Study Design - Protocol and registration
This scoping review protocol is part of a more extensive study [Details of the bigger project goes here], and the protocol for the complete review is available in the PROSPERO data repository registries – ID CRD42023481892 https://www.crd.york.ac.uk/prospero/export_details_pdf.php.
As part of the more extensive study, a scoping review was chosen as the best method to systematically synthesise qualitative and quantitative evidence on the nature and effectiveness of currently available educational interventions to improve palliative care education for health and social care professionals in the undergraduate curriculum. The protocol for the scoping review was developed per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol extension for a scoping review (PRISMA-P-ScR), which permitted the forwarding of a six-step scoping review protocol (see Supplementary Appendix for the completed PRISMA-P Checklist).10
The proposed comprehensive systematic scoping review of the literature will be conducted according to the Levac et al. (2010) adaptation to Arksey and O’Malley (2005) framework for scoping review methods and experts in the field.11, 12 The review findings will be reported per the PRISMA 2020 statement - an updated procedure for reporting review studies (see Fig. 1 for the PRISMA-2020 flowchart).13
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Step 1: Identifying the review question
As an integral component of the framework’s preliminary phase, the research team received guidance from the expert team in formulating comprehensive and specific research questions. Additionally, the study protocol’s design, the selection of search terms for the literature review, and the identification of relevant databases were established through a collaborative process involving iterative consultations with our research team, key informants possessing expertise in curricular design, implementation, and assessment of healthcare professional qualifications in both general and specific contexts related to palliative and end-of-life care. Furthermore, the input of an experienced medical librarian was sought in this process.
To determine whether the research question qualified for a scoping review project, we utilised the PICO (participants; interventions; comparator; outcomes) nomenclature framework recommended by the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis: 2020 Edition (Fig. 2).14
The main research question that the proposed scoping review will address:
What is the nature and effectiveness of teaching palliative and end-of-life (EOL) care to students in the undergraduate health and social care professionals qualifications curriculum?
More specifically, the scoping review seeks to address the following research sub-questions:
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What is the evidence on the nature of educational interventions to improve palliative and end-of-life (EOL) care teaching in the undergraduate curriculum for health and social care professionals qualifications?
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What is the effectiveness of educational interventions to improve palliative and end-of-life (EOL) care teaching in the undergraduate curriculum for health and social care professionals qualifications?
The eligibility criteria for including studies in this review in order to answer the aforementioned questions are based on the relevant components of the PICOd-T (Study Design - Time) framework and the research question. Thus, the PICOd-T framework is employed to ensure that the boundaries of the proposed scoping review research question are clearly defined.
The eligible studies will be included once they have been evaluated independently, reproducibly, and systematically by two reviewers. For studies to be considered eligible, studies must provide evidence of one of the factors listed in Table 3. A third reviewer will resolve disagreements between the two reviewers; reviewers will also pilot-test the inclusion/exclusion criteria to reach a consensus before beginning the study selection process (Step 3: Study selection and eligibility screening).
Step 2: Identifying relevant studies - Search Strategy and Data Sources
The systematic, comprehensive, and reproducible searches to identify relevant studies will initially be conducted via electronic search sources – searching reputable bibliographic databases and indexing services (and platforms) – followed by searches of supplementary information sources to capture primary studies addressing the main review question. With the assistance of a professional medical librarian, the first author will conduct all direct electronic and supplementary information source systematic searches, using a pre-defined and piloted search strategy (see Table 1), to capture both published and unpublished (grey) literature to be screened for eligibility for inclusion in this review.
Search Strategy
The first author, a medical librarian and subject specialist with experience in designing, implementing, and assessing HCP qualifications in general and in the palliative and EOL care domain, co-developed the comprehensive search strategy (see Table 1 for details of the search strategy metrics). All authors were given an equal opportunity to review the draft to ensure the correct use of indexing terminology and Medical Subject Headings (MeSH) descriptors before it was pilot-tested on a subset of records from the PubMed database (see Table 1 pilot test results).
In accordance with the approach of Bethel et al., (2021), a search summary table (SST) will be used to report on the performance of the search strategy in effective searching databases. The SST is a viable and reproducible method for reporting and evaluating the search strategy’s effectiveness (see Table 2 for the example of the SST metrics that will be used for this purpose).15
Data Sources
Electronic search sources
The systematic and comprehensive searches will be conducted from the following electronic databases to source articles published on the topic of teaching palliative and end-of-life (EOL) care to students in the undergraduate curriculum of HCPs qualification, using the pilot-tested search strategy:
WEB of Science, PubMed, and EBSCOHost Web (Academic Search Complete, PyscInfo, MEDLINE with Full Text, and Health Source: (Nursing/Academic Edition)). Furthermore, evidence on palliative care teaching interventions will be sourced from the South African National Clinical Trial Register and the ISRCTN registry. The mentioned databases will be searched from their inception to the present, regardless of the publication language. This procedure aims to obtain as many articles as possible from electronic search sources and to ensure that all relevant articles or reports are captured before the study selection and eligibility screening process begins.
Searching other resources – supplementary information search
In addition, supplementary search methods will include hand-searching of relevant journals, reference lists of identified peer-reviewed articles and grey literature, and as well as forward and backwards citation chasing. The reviewers will further browse through the link entitled “Related Articles” option, which searches for similar citations using an intricate algorithm that scans titles, abstracts, and MeSH terms to detect more studies (Table 3).
Systematic reviews and other review papers are not eligible for inclusion; however, reference lists of relevant reviews, preprints, and conference abstracts will be screened for more relevant primary studies not captured by the search strategy. Furthermore, the appropriate trial publications reference lists will be checked for unidentified randomised clinical trials.
The systematic search management
The SST will also be used to present and keep records of the systematic searches retrieved information, such as the summative metrics of effective searching suggested by Cooper et al., (2018), and additional metrics providing further useful search-related information for the librarian or information specialist.16
The SST will be completed in two stages. In stage one, all the references that the search strategy retrieves from each electronic database, including all duplicates, will be exported to EndNote X9 (version 19.1.0.12691) – a reference management software, which will be used to create a virtual library (Thomson Reuters, Stamford, CT, USA).17 Every record in the virtual library will be given a code for the database name where the record was found.
Stage two involves re-running the searches in the databases where most of the included references were found to determine whether references not found during the original search were in the database and, if so, whether the search strategy retrieved them.
Step 3: Study selection and eligibility screening
The study selection and eligibility screening method is multi-step and involves two reviewers. The eligibility screening approach for eligible articles will be carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) criteria, as represented in the PRISMA 2020 Flow Diagram Fig. 1.
First, two reviewers will screen the title and abstracts for relevance independently and in duplicate, and articles that pass initial screening by either reviewer will undergo full-text review independently and in duplicate by the same two reviewers. Standardised, pilot-tested eligibility forms will be used for both title and abstract screening and for full-text review (see Supplementary Appendix for the completed screening tool).
Disagreements about study eligibility will be resolved through consensus discussion or will be resolved by a third reviewer in the case of ongoing disagreement. Kappa statistics will be calculated to assess the inter-rater reliability of full-text review, using Cohen’s Kappa coefficient (κ) statistic on Stata 13.0SE (StataCorp College Station, TX, USA), a robust statistic used for inter-rater reliability testing.18
Step 4: Data extraction/ or collection process
A standardised data extraction form informed by the template for intervention description and replication (TIDieR) checklist and guide for describing interventions will be created to capture relevant information from the included studies (see Supplementary Appendix for the data extraction form).19 The form will consist of fields for study characteristics, participant demographics, teaching/ or communication strategies employed, outcome measures, and key findings
Two independent reviewers will extract data from the included studies using the standardised data extraction form to detect inter-rater errors and decrease data errors and bias. The reviewers will extract data from the included articles independently and in duplicate. A third reviewer will verify the data related to study characteristics, such as publication information, study dates, population characteristics, interventions, outcomes, and study methods, which are required to assess the risk of bias.
In the meta-analysis, the nature of the data, such as continuous outcomes (mean differences or standardised mean differences) or dichotomous outcomes (odds ratios or risk ratios (ORs)) will be calculated if necessary, and if the data is available, only measures most adjusted for one or more sets of potential confounders such as socio-demographic and lifestyle factors will be extracted by the two reviewers to reduce confounding and measurement errors and to ensure consistency across studies and reduce bias.
Requests for missing data
Missing data will be identified and recorded within the review. Where papers provide insufficient details about the intervention, such as what is delivered and by whom, an effort would be made to contact the authors to obtain previously unpublished information and clarify any missing data. In cases of non-response or inadequate clarity from contacted authors (i.e. retrieval of missing data is not possible), that study/outcome will be eliminated from the review.
Step 5: Assessment of study methodological quality, risk of bias, and the certainty of evidence
The methodological quality and risk of bias of each included study will be assessed by two reviewers independently, using appropriate methodological quality assessment tools depending on the design of the included studies using the guidance produced by the NHS Centre for Reviews and Dissemination and the Cochrane Collaboration.20, 21
Tools to assess the methodological quality
As recommended, the MERSQI (Medical Education Research Study Quality Instrument) Scale and Newcastle-Ottawa Scale Education (NOS-E) [19, 20] will be used to determine the methodological quality of the included studies.22, 23 The two instruments will be used as they assess different aspects of quality and risk of bias, acting in a complementary fashion. As described in previous studies, a score above the sample median MERSQI score (12.5) and NOS-E score (2.5) will be considered the threshold for high methodological quality.22
Furthermore, the risk of bias for RCTs will be assessed using the Cochrane risk of bias tool, which will take into account random sequence generation, allocation concealment, participant and personnel blinding, insufficient outcome data, and selective reporting. Each domain will be evaluated independently by both reviewers and classified as ‘high,’ ‘low,’ or ‘uncertain’ regarding bias. Studies will be considered to be at an overall ‘high’ risk of bias if they are judged to be at ‘high’ risk of bias in any domain, ‘uncertain’ risk of bias if they are judged to be at an uncertain risk of bias in any one domain, with no domains at high risk of bias, and an overall ‘low’ risk of bias if they are not judged to be at ‘high’ or ‘uncertain’ risk of bias in any domain. All risk of bias assessment will be judged at the outcome level.
Tools to assess the risk of bias (or publication bias)
Publication bias will be assessed using visual inspection of funnel plots, where sufficient numbers of studies will exist to permit interpretation.24
Tools to assess the certainty of evidence (quality of evidence/ the strength of the body of evidence)
The overall quality of evidence (or certainty in the findings) for each outcome obtained will be evaluated using the five GRADE principles (trial bias risk, consistency of effect, imprecision, indirectness, and publication bias). The completed GRADE checklist and reasons for up- or down-grading assess the quality of a body of evidence based on study methodological quality, results from sensitivity analysis, and by downgrading and upgrading the baseline quality score according to the domains specified in the GRADE guidelines.25 We will generate a table that summarises our findings using GradePRO software.26
Step 7: Collating, summarising, and reporting the results
Systematic scoping reviews provide an executive overview of current evidence by answering broad questions.27 Thus, following the completion of the data extraction step, we will generate a comprehensive summary of the data extracted from the included studies. The summary will consist of two key presentation components:
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Numerical presentation: We will create a compiled findings table that provides a descriptive overview of the key pre-specified study outcomes and type of included studies, as depicted in Fig. 2. Additionally, we will employ an interactive web-based graphic design tool, specifically Canva version 2.93.0, to generate a world map.28 This map will help visualise the geographical distribution of the summary of the included studies, offering insight into global patterns.
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Narrative presentation: To ensure a holistic analysis, we will synthesise the essential characteristics of all the included studies. We will archive this by documenting the structure of the intervention of interest – all educational interventions used to teach palliative and end-of-life (EOL) care education to health and social care professionals in the undergraduate curriculum – will be captured by recording pedagogy, course content and learning outcomes. This will consist of data including, but not limited to, educational method, educational content, length/duration, outcome measures, outcome results and implementation ‘barriers and facilitators’ such as financial support.
Strategy for data synthesis
The data synthesis process will involve the following steps:
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Thematic Analysis: We will conduct a thematic analysis of the extracted data to identify recurring themes, concepts, and patterns related to key characteristics of teaching palliative and end-of-life (EOL) care to students in the undergraduate health and social care professionals qualification curriculum. This will involve coding and categorising the extracted data into meaningful themes and sub-themes;
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Qualitative Summary: We will provide a qualitative summary of the key findings from the included studies. This will involve synthesising the results narratively, highlighting similarities, differences, and trends in the effectiveness of a series of identified interventions to improve palliative care education for health and social care professionals in the undergraduate curriculum;
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Subgroup Analysis: If a sufficient number of studies with similar characteristics and outcomes are identified, we may conduct subgroup analyses based on factors such as study design, geographical location, or types of Educational methods/ Pedagogies employed in the Teaching of PC. This will enable us to explore potential variations in the effectiveness of different interventions – to improve palliative care education for health and social care professionals in the undergraduate curriculum – within specific subgroups; and
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Meta-analysis (if applicable): If the included studies are deemed suitable and homogeneous, we will consider conductinga meta-analysis to provide a quantitative synthesis of the data.
Furthermore, the authors will delve into the implications of these findings for future research, practice, and policy.12 Stage 7 details are still being worked out, and they may be repeated or changed if reviewers deem them necessary.
Ethics and dissemination
No ethical clearance is required for this study. The results of the proposed systemic scoping review will be disseminated electronically, in print, and through conference presentations as well as key stakeholder meetings.