Results of the search
After removing duplicates, 663 records were identified. Title and abstract screening review resulted in 299 publications that fulfilled the inclusion criteria. 79 studies were included in the review. 14 articles were identified from the grey literature search and 1 article obtained via hand searching. In total, 94 articles were included in the review (see Figure 1).
Studies were excluded at the full-text review stage because they did not meet the inclusion criteria in that no clinician experience data were collected (n=162), not being primary research or theoretical papers (n=11) or had a wrong focus (n=33) or focused on only psychological impacts of clinical work (n=10) or were not available (n=4).
Articles emerged from Articles emerged from Australia (n=21), UK (n=16), US (n=13), Canada(n=10), Denmark (n=8) , Sweden (n=6), Spain (n=2), Switzerland (n=2), Italy (n=2), Norway (n=3), France (n=2), New Zealand (n=2), The Netherlands (n=2), Singapore (n=1), Hong Kong (n=1), Northern Ireland (n=1), Israel (n=1) and Germany (n=1). Articles reported data from the health system level (n=8), across multiple areas within one or more hospitals (n=60), specific specialities within hospitals (n=10), integrated care settings (n=8), primary care (n=6), community health care (n=1), and ambulance (1). Diverse health care settings were utilised, comprising mainly inpatient hospital settings which included intensive care, perioperative care, emergency care and maternity settings. Articles were qualitative (n=41), quantitative (n=24) or mixed- or multi-methods (n=31). Health professional groups examined in the studies mainly involved nurses and doctors, but a number of studies also included allied health professionals or pharmacists. Other health professional discipline groups examined involved midwives, and dietitians.
Past research on clinician experience comprised qualitative research designs involving the conduct of interviews and focus groups. Few studies involved the conduct of observational work (n= 6), which would have enabled examination of clinical experiences in actual practice. Similarly, there were few studies that involved the conduct of survey studies (n = 24) which often examined the psychometric properties of variables underpinning clinician experiences.
Question 1: How has clinician experience of delivering health care been defined in the literature?
Clinician experience has largely been understood as self-reported information presented by clinicians about how they practise patient care, the activities they undertake and how providing care makes them feel. In some instances, observational data were also collected and synthesised to capture the events that occurred within care provision(17-21). Two dominant approaches to conceptualising clinician experience emerged, which included subjective reports of past experiences and of the process of undertaking a change that were evident from the question scope and content of the included studies. Questions commonly explored clinicians’ perception of the need or justification for change, their perceived impact of change on personal care practices, and their impressions of contributing to change. For example, this impact was considered when examining clinician experiences to meet a four-hour target in the Emergency Department through a new model of care(22). Similarly, when redesigning post-natal care, midwives were asked to discuss their experiences of the changes made(23).
The literature indicated there was overlap between, 1) clinician experience of delivering care, 2) health workforce job satisfaction and 3) clinician engagement. It was apparent that self-reported experiences of providing care were closely linked to both resulting job engagement and satisfaction(18, 24-28). The nature of this relationship was not sufficiently examined to draw conclusive findings regarding the relationships between these variables. For example, lack of clinician engagement was identified in the negotiation of professional boundaries among clinicians’ during health services change (29). This lack of engagement reproduced inequalities among professional groups and prevented some groups from participation in service change. However, there was little information about the relationship between engagement and experience, such as if clinicians’ experiences had led to a lack of engagement or whether lack of engagement further affected clinician experience(29) Interviews with doctors in cancer care services demonstrated their organization comprised a work system, which consisted of a set of specific actions and narrow-focused tasks. This experience underestimated the emotional components of patient-doctor encounters, which impacted job satisfaction. The creation and maintenance of genuine patient-doctor relationships were therefore more difficult to attain, leading to perceptions of failed doctor encounters with patients, on behalf of the doctors(30).
A number of indicators emerged from the literature as contributing to positive or negative clinician experiences. Indicators of positive clinician experiences were linked to clinicians’ attributes, the environment in which they worked and system changes. Active patient participation in health care contributed to positive clinician experiences, while clinicians’ respect for each other’s competencies and valuable contributions to patient care influenced their ability to collaborate effectively(25, 31). The development of trust among team members of different disciplines was regarded as essential for effective clinician experience(32). The leadership style of clinicians was a positive indicator of experiences, especially when promoting interdisciplinary practice(32, 33). Senior management support for how clinicians conducted their work(34), the availability of ongoing education and training tailored to the needs of various professional groups(35), and the presence of an organisational culture that addressed patient care needs facilitated positive clinician experiences(36). In addition to this support, clinicians who practised patient-focused models of care expressed enhanced clinicians’ experiences. For example: pharmacists who were in patient-focused practice settings were more likely to seek opportunities to collaborate with physicians to discuss prescribing practices(37).
Indicators of negative clinician experiences included tensions when balancing professional responsibilities and quality of patient care. Clinicians reported that complex arrangements in which professional responsibilities were unclear negatively impacted the quality of the care they could provide and their experience of providing care(26). In addition to this, there was a discussion on the impact of a fragmented system of care in which interprofessional members constituted a team or that multiple teams were responsible for patient care. This fragmented care system often created confusion regarding patient responsibility and clinical decision making, which had a negative impact on the clinicians’ experience(38, 39). The hierarchical structure that was particularly apparent in hospital settings was reported to adversely affect clinician experience; such that communication practices were ineffective in terms of disseminating information about project awareness and knowledge transfer which as a result impacted clinician engagement(34).
Question 2: What survey instruments and measures of clinician experience have been developed, and applied to evaluate the impact of a health system change or monitor health system performance?
The under-developed conceptualisation of clinician experience was reflected in the lack of survey research in this field. Twenty studies (18 from the database search and two from the grey literature) included survey methods to capture clinician experience data, with no single survey instrument widely adopted within these studies (27, 28, 40-56). Of the identified studies, only two survey studies sought to assess clinician experience of providing care beyond a specific change event and using a survey instrument explicitly capturing experience outcomes (41, 56). Surveys were cross-sectional or over short time, with no longitudinal research emerging.
Only one study sought to develop and validate a clinician experience measure(56). This survey was also utilised in the grey literature(57). Experience of work was defined as encompassing a number of facets which are included in the Picker Staff/Employee Questionnaire(58). The items within the Picker surveys indicate that work experience data comprise a range of self-reported information about the work environment interactions within this experience, perceptions of environment and interactions, and satisfaction with the work environment. The United Kingdom (UK) National Health Service (NHS) has engaged Picker Europe to undertake a staff survey across the NHS each year, which comprises a core composite and additional optional elements for individual services or groups within the NHS to use such as leadership assessments(59).
Studies often reported experience data within another outcome including: clinician engagement, team climate, emotional exhaustion, information systems expectations or safety attitudes, with some degree of experiential data within each of these studies(27, 47) (28, 46, 60) (49). Definitions of clinician engagement varied substantially, and its relationship with experience was poorly defined. Some studies therefore captured engagement using validated measures and then added on specific items to capture experiential data that were linked to engagement. For example, in a study by Dellve et al (2018), clinician engagement was conceptualised as ‘attitudes toward engagement in organizational development, work engagement as a cognitive state, and clinical engagement behavior in developing patient safety and quality of care in practice(27). Clinician engagement behaviour was captured on two scales; a patient safety scale (consisting of four items) and a quality of care scale (consisting of three items)(27). The items in each scale ask clinicians about their experiences of engagement in safety and quality activities or programs, but are limited to key behaviours, which do not encapsulate the holistic clinician experience of providing care.
Broader use of the term ‘engagement’ was demonstrated in a study that discussed nurse engagement with an initiative utilising a survey(60). In this survey study, outcome variables included data of clinicians perceptions of the change, buy-in, experiences of impacts on the caregiving process and satisfaction(60). Press Ganey (2017) made a link between patient experience, workforce engagement and financial outcomes for health care organisations in their strategic paper on investigation of engagement, morale and working conditions of staff in Perth Children’s Hospital(48). Their research utilised two survey tools that contributed to the Perth Children’s Hospital Investigation: physician engagement and the Practice Environment Scale–Nursing Work Index (PES–NWI)(61, 62). The PES-NWI was derived from the Nursing Work Index (NWI) and developed specifically to capture the hospital practice environment. Items of the PES-NWI consist of five subscales that capture experiences in relation to key aspects of the work environment of hospitals: “Participation in Hospital Affairs,” “Foundations for Quality of Care,” “Manager Ability, Leadership and Support of Nurses,” “Staffing and Resource Adequacy,” and “Collegial Nurse‐Physician Relations” (63). The Press Ganey report focuses on subscale data in relation to safety and quality outcomes, reporting a relationship between a positive work environment, engagement and safety and quality of care(48).
In a group of nine studies, authors developed their own surveys in the absence of existing validated measures to capture experiential data from clinicians about current processes of care provision or specific changes to care provision, including the introduction of an electronic health record (EHR), the treatment of sepsis, and redesign of observational charts(43) (44, 45) (52) (23, 50, 51, 53, 55). In these studies, surveys were often lengthy, with multiple components. Two multi-instrument studies combined validated measures and purposively developed items(42). In the first, the Karasek Job Content Questionnaire, the Nursing Work Index-Extended Organization (NWI-EO), the SF-12 Health Survey, 51 researcher-developed items were used to explore the impact of a departmental relocation on psychosocial job characteristics, perceived health, and psycho-organisational constraints amongst health care workers(42). By including validated measures incorporating clinician engagement, impact of work on health and job satisfaction, this study provided a more thorough assessment of clinician experience. The study highlighted that in order to capture holistic experience data, it was important to synthesise a range of validated and purposively developed survey instruments. Similarly, a study of staff experiences of closing a psychiatric ward captured uncertainty and self-efficacy using validated tools, and experiences of perceived functioning on the ward through a researcher-developed tool(54).
Question 3: How have clinician experience measures been used to assess the impact of health system change on the experience of giving care?
Clinician experience was primarily captured for the purpose of providing feedback on a single change project or issue, to understand its perceived value, impacts on care delivery and factors that may impact its uptake and ability to achieve maximum benefits realisation. For example introduction of a new technology such as electronic medical record (EMR) across a health service(55) or to local-level quality improvement projects(53) was captured. Far fewer studies examined holistic clinician experience and focused on exploring experience of providing care across a range of events, interactions and points in the care-giving process(56).The body of evidence strongly indicated that clinician experience was captured and valued appropriately for the purpose of improving care, but that consideration of the experience of providing care on clinician’s personal and professional lives was not a key driver of the data collection(64). In qualitative work, clinicians were recruited as key informants about the use of a new system, technology or model of care(65, 66).
The grey literature provided several examples of evaluations of system level changes and the way that clinician experiences were measured. These evaluations were used to assess the impacts beyond a specific context such as a single ward, department, or service. Research designs that included a survey around benefits realisation in terms of clinical and process outcomes, coupled with qualitative interviews to capture experience data were apparent in many articles as a strategy to capture data from clinicians about change projects(67)(68). Other reports included interviews with system-level stakeholders and clinicians were used, along with document and observational analysis, to understand the model of change applied, its value and the factors impacting implementation(69).
Five articles from the retrieved literature captured clinician experience more broadly, rather than in relation to a change project (56, 62, 70)(30)(59). The focus of this work was primarily around the changing role of clinicians in contemporary health care. Several reports of investigations into poor quality care or stemming from such investigations were identified in the grey literature that discussed the issue of clinician experience of care provision and its intersection with safety, quality and patient experience(62).