'Strategy-as-practice' by hospital personnel in hospitals: a scoping review protocol [version 1; peer review: 1 approved with reservations]

Background: Strategy in hospitals is based on distinct principles and rules which lead organisations to act on chosen priorities. Hospitals are struggling to cope with increasing service demands and activity and need to become more responsive to changing environments while demonstrating effective use of resources. Strategizing involves the active process of sensing, planning, implementing and evaluating strategy. Strategy-as-practice is concerned with what people do about strategy in an organisation, as opposed to the traditional focus on what the organisation has as a strategy. It is recognised that there is a disconnection between strategic planning and implementation, however little is known about how organisational context influences the strategic process or how hospital personnel engage in strategic activities. The aim of this scoping review is to explore the literature on strategizing by hospital personnel in hospitals, and will include literature for hospital both professional and managerial backgrounds, to establish the extent and breadth of strategizing or as it is often termed ‘strategy-as-practice’ in hospitals. Methods: The systematic scoping review will search the literature within the databases of PubMed, Embase, CINAHL, PsycINFO, ABI/INFORM (Proquest) and OpenGrey.net to explore the scientific evidence on strategizing in hospitals. The review will be based on the Arksey & O’Malley (2005) framework of five mandatory steps which was updated (Levac et al 2010, Colquhoun et al 2014 & Peters 2015) and is published online by the Joanna Briggs Institute. It will follow the PRISMA-ScP reporting guidelines. Conclusion: A scoping review methodology will provide a framework to explore strategizing in hospitals


Introduction
According to the World Health Organisation, hospitals matter to people and play a pivotal role in providing and coordinating care and integrating services with primary care, outreaching into the community and into people's homes (World Health Organisation, 2021).The future is uncertain with continuous change in the health system environment, so hospitals' main challenge is to develop strategic capacity and functionally flexible to readily adapt to the changing definition of services in the future (Rechel et al., 2009;Saltman et al., 2011).One of the healthcare system's main goals is to improve the value delivered to its customers as measured by patient outcomes in proportion to expenditure (Kaplan & Porter, 2011).As large proportions of the national healthcare budgets are spent on hospital care (OECD, 2019) with between 60-70% of health system resources allocated to hospitals (World Health Organisation, 2021), there is an onus on hospitals to perform.However, as we enter a new decade, hospitals are already struggling to cope with increasing service demands and activity.They need to become more responsive to changes in their environment and demonstrate more effective use of available resources (Bowman et al., 2020;Staib & Small, 2020;Steier & Moxham, 2020;Whitwell et al., 2020;Zeng et al., 2020).On an international level, growing numbers of hospitals within the public sector are empowered to develop their own strategic, financial and clinical directions, so they must be ready to redefine roles and set clear goals for service delivery (Saltman et al., 2011).This requires good strategy.
Good strategy is seen as the holy grail for most organisations including healthcare.It is seen as providing a good road map to achieve identified goals (Watkins, 2007).This is based on distinct principles and rules which lead the organisation to act on defined priorities.Throughout the organisation, people should choose when and when not to act, taking into account trade-offs and resource allocation, to realise top priorities.Strategy is most commonly operationalised using a strategic planning process.In the context of the public sector, according to Bryson (2004) strategic planning is a structured decision-making process which leads to actions that direct and forms the characteristics of an organisation; essentially what it is, does and why it does it.Strategizing encompasses the activity across the whole spectrum, from sensing, planning, implementing, and evaluating (Stigter & Cooper, 2015).This preliminary review will present the literature from different organisational backgrounds such as healthcare, the public sector, and the most established area of business strategy.This will be followed by examining approaches to the process of strategizing, to then refine the area of study for a full systematic review.

Strategy in different organisational sectors
Healthcare.Strategy in healthcare has been researched from several perspectives.Powell et al. (2019) reviewed the literature from an implementation science perspective.They detailed the progress of implementation science for clinical evidence-based practice uptake in healthcare; however, the focus was not on strategy's organisational practice.A scoping review of a specific strategic planning tool was conducted by Vollmar et al. 2015, which identified the breath of empirical evidence available for scenario planning as a method of strategizing to outline possible futures.The review found that project methods and activities varied widely and were poorly reported.Improved criteria were needed for reporting scenario methods, and if these criteria were achieved, it could be a useful tool for healthcare planning.The gap identified from the review highlighted a need to focus on reviewing healthcare workers about who, how, and why they conduct strategy in hospitals.In light of the coronavirus disease 2019 (COVID-19) pandemic becoming the major disruptor for healthcare and hospital sites in particular (Bowman et al., 2020;Pellino et al., 2020;Staib & Small, 2020;Steier & Moxham, 2020;Whitwell et al., 2020;Zeng et al., 2020), it would be of benefit to examine the literature to see how hospitals conduct strategy, to inform future research in the field.
Public sector strategy.Not-for-profit public organisations including hospitals, have a greater strategic focus on goal alignment, within the context of more accountability and complex stakeholder settings than private-sector sites (Bryson, 2004).Public sector strategic planning was researched by Bryson et al. (2018).They concluded a scarcity of empirical research on public-sector strategic planning and links with implementation and performance.They noted in particular the lack of wellconducted research with regard to the impact of various levels of strategy and different strategy implementation and organisational performance contexts.Context was an area that Bryson et al. (2018) found challenging to conceptualise and match to processes creating appropriate outcomes.Strategic planning was noted to be a key element in achieving a strategic mission for stakeholders and interested parties in a study based in an educational institution (McHatton et al., 2011).The relationship between strategic planning and implementation success was examined by Elbanna et al. (2016).Using an online survey for senior staff with responsibility for strategic planning in Canada in over 150 public organisations, they reported positive results when formal strategic planning processes were used to enhance implementation.Elbanna et al. (2016) concluded that strategic planning had a favourable and significant effect on managerial involvement, improving some leader's commitment to public policy and organisational goals.They also found that managers obtained a greater understanding of strategy implementation with the potential to improve strategy success.A limitation reported was the low survey response rate of 12%.On examination of the participant profile, it was noted that only 2.6% of respondents (n=5) were healthcare-related, so further research in this area concentrating on healthcare systems as a target population.
A systematic literature review by Laurett & Ferreira (2018) examined strategy and strategic management in non-profit organisations which characterised the literature by decade and themes.This review looked at all non-profit organisations including healthcare but also education, animal and environmental protection alongside issues for religion, housing, agriculture, recreation and culture.They found a growth in research and diversification in the approach to the themes under study.They concluded that non-profit organisations were adopting and implementing strategic approaches from the profit-making sector.Of the 62 articles analysed, there were 13 different approaches catalogued regarding strategic planning; however, no articles examined the factors for success, challenges or benefits after implementing strategic planning in organisations.The authors identified this as a gap in the literature.The cultural factors in implementing and adopting models and tools for managers were highlighted as worthy of further research using a qualitative methodology to gather more detail on these research themes.As the review examined a wide range of not-for-profit organisations, it would be beneficial to focus on healthcare settings in greater detail.

Business sector strategy.
Strategy in business must first be understood to be implemented; however, this is not always the case.Implementation of strategy was highlighted as an area which could be improved.In a large-scale McKinsey Quarterly survey of over 2,000 global executives (Bradley et al., 2011), many perceived 'good' strategies fell short at the implementation stage because of an absence of follow-through from the organisation.Bradley et al. (2012) noted three themes that organisational leaders needed to address to undertake the strategy journey, namely setting aspirations and direction, establishing a strong ongoing process, and translating strategy into a workable operational reality.They described one of the top priorities to be the meticulous implementation of key strategic objectives.Collis & Rukstad (2008) reported a surprising number of organisations, from executive down to frontline staff level, who were frustrated due to the apparent lack of clear strategy, in the context of needing strategy to assist in the alignment of behaviours to goals.Leaders did not always know which elements of strategy were essential for both planning and implementation, which could significantly impact the strategic success of long-term financial performance for organisations.The studies highlighted here from the business sector lacked some detail in the methodological section which was a limitation of the reported research.

Strategic approaches
Strategic flexibility.Deliberate as opposed to emergent strategy concepts were first published by Mintzberg and Waters in the mid-1980's and continue to be referenced today.Deliberate strategy was defined as a formal planned strategic approach found in stable environments and strongly influenced by corporate objectives.In contrast, emergent strategy was the reality of what happened when an organisation responded to changes in the environment as they occurred and was much less formal in its approach (Mintzberg & Waters, 1985).The journey from the initial intended strategy to the realization of strategy could take two routes, the more direct deliberate route which was planned, or the more often travelled route where the intended strategy was unrealized.An emergent adapted strategy came to the fore.The benefits of an emergent strategy was described as learning and feedback to ensure strategy was a continuous process, not an annual event (Mintzberg & Lampel, 1999).They proposed that emergent strategy may lead to a more flexible and responsive organisation which was suited to changing environments and encouraged inputs from all levels of management rather than the traditional top-down approach.
Strategic flexibility is a concept which has emerged more prolifically within the strategic management literature in the last two decades.It relates to the ability of an organisation to handle uncertainty and change by creating strategic options to respond or proactively lead to change (Brozovic, 2018).This is an area of practice relevant in the current uncertain time of the COVID-19 pandemic and in preparation for the "next normal" of the post-pandemic era (Yawson, 2020).Following a comprehensive literature review Brozovic noted that triggers, barriers and enablers are essential areas to consider in understanding organisational strategic management, competencies and social networks.Strategic planning and organisational processes were identified as categories for enablement, but he noted a paucity of research of a qualitative nature, which would help in the understanding of context and generate further knowledge in this area.Operational flexibility was noted within the review to be an important link to strategic flexibility.It did not always come from just strategic level actors but also operational level managers, so was worth investigating further (Combe et al., 2012).As COVID-19 has become the major worldwide disruptor of healthcare, agility in strategic activities was an area for consideration as outlined by strategic flexibility (Sneader & Singhal, 2020).By examining strategy as practised in hospitals within the literature, the extent of the engagement by personnel including hospital managers and professionals will be identified and lead to mapping of this important evidence.
Strategy for professional disciplines.The strategic approach of operational managers is one area that warrants attention within the healthcare strategy literature, including healthcare professionals such as doctors and nurses.The importance of strategic management in nurse managers' role in healthcare was examined by a review of the published literature over a 10-year period from 1997 to 2007 by Carney (2009).It found that less than 10% of the literature referred to strategy or strategic management in the journal title which led to the conclusion that these terms were not used to any significant degree.Carney (2009) proposed that if strategy in healthcare was understood better by nurse managers and the engagement of nurse managers was promoted more; they could have a greater role in the overall strategy development as well as its delivery.Nursing managers were also examined by Mintzberg (2002) alongside medical professionals and executive-level managers in healthcare settings.Having reviewed seven different approaches and levels of managers in Healthcare, both in the NHS England and Canadian healthcare, they found disconnections at every level, especially between clinical operations and management.The study noted that hierarchy was an influential factor in hospitals and nursing management demonstrated an appropriate model for managing healthcare and disease care and could be looked at further.Networking was appreciated better as an approach to engaging with professional groups rather than a top-down management control method.
A recent empirical study examined the practice of strategy for a group not widely researched in the literature; medical managers in directorate roles (Begkos et al., 2019).The research focused on the strategic planning approach taken in four English NHS hospitals.Using an exploratory and interpretive approach with interviews and documentary analysis, they examined the practice of clinical medical directors, medical consultants, business managers, finance directors and chief executives.They found three key practices existed.These were defined as practice through controlling, contesting and competing.The implications arising from the findings were identification of some conflicting strategic objectives between individual medical specialities and the hospital and public sector brief overall.Finally, engagement and training for medical managers in strategic planning endeavours would be advisable for policymakers due to the significant role medical managers play in healthcare strategic management.Begkos et al. (2019) suggested further research in comparative cross-country analysis and further contextual research in this area.Although the primary focus of the research was on medical directors which gives valuable insight into hospital strategizing for this group, it would be beneficial to consider all individuals within a hospital environment and examine who, how and what each subgroup may contribute to strategy in this arena.Begkos et al. (2019) used the 'strategy-as-practice' perspective as a framework for the research.

Strategy-as-practice. Strategy-as-practice was defined by Johnson et al. (2007) as a concern with what people do about
strategy and how the organisational and institutional context influences this.The strategy-as-practice research is influenced by a social theoretical paradigm framed in a pragmatic practice perspective (Schatzki, 2001).There are opportunities to understand how people translate strategy into action through the study of their activities.According to Vaara & Whittington (2012) in their review of Strategy-as-Practice in the wider academic literature, there was a value in exploring the field in relation to focussing on people beyond the top and middle managerial ranks which was backed up by Mantere's study (2005) on strategic practice enablers.Vaara & Whittington (2012) maintained there was knowledge to be gained by studying the contribution to strategy-making of organisational characters such as 'professionals' and 'shop floor workers'.Within the healthcare context, this may be suggestive of frontline clinical staff, managers and leaders.The challenge according to Stigter & Cooper (2015) was in establishing how to harness energy from leaders to gain a critical mass of people at various levels of the organisation who can combine their capabilities, engagement and alignment to achieve strategic level change.The Strategic-as-practice perspective is a research framework that focuses on emergent strategy understood in day-to-day situations and circumstances (Mantere, 2005;Chia & Holt, 2006;Tsoukas, 2010;Varra & Whittington, 2012), so it would be worthwhile to gain an understanding of strategizing within hospital settings to capture the contribution of all levels of staff in the organisation.
The aim of this scoping review is to explore the literature on strategizing in hospitals by hospital personnel.The review will include literature on hospital staff with professional and managerial backgrounds to establish the extent and breadth of strategizing or as it is often termed 'strategy-as-practice' in hospitals.A scoping review is an appropriate review methodology as it will explore strategizing in hospitals comprehensively and map the body of literature for this subject matter, which has not been conducted previously.This review will contribute to collating a body of knowledge on the strategic practice reported in hospitals to highlight knowledge gaps and inform potential research opportunities going forward.

Protocol
Design A scoping review is the most appropriate review to base the search upon to address the review question (Grant & Booth, 2009).The framework will be based on the Arksey & O'Malley (2005)  This will follow the PRISMA-ScP reporting guideline (Tricco et al., 2018), using the steps outlined during the protocol development alongside the PRISMA-P guideline (Moher et al., 2015;Shamseer et al., 2015) which will be adapted for a scoping review rather than the standard systematic review and meta-analysis guideline steps.
As per Arksey & O'Malley (2005) the review steps will be: Assessment of methodological quality is not applicable in scoping reviews as per Peters et al. (2015).

STAGE 1 -Identifying the research questions
The review aims to determine and describe the extent and nature of the literature on strategizing in hospitals and identify gaps for future research.
Objectives to guide the scoping review: 1. To map the literature on strategizing in hospitals for volume, types of studies, years, settings and geographical distribution.

2.
To map what theoretical frameworks or models are used in the strategizing in hospitals literature.

3.
To explore what is known about hospital strategic planning and strategy implementation activities in hospitals 4. To establish who engages in strategic planning and implementation in hospitals Population -Hospital personnel, from frontline upwards and any discipline or group within the hospital.This includes managers at the frontline, middle management, executive management and also nursing, medicine, allied health professionals, administration and corporate personnel.
Concept -Strategizing, strategy to include the strategic planning process (strategic planning, assessment and development of the strategy for the organisation, strategic implementation and communication and review evaluation of the plan) Context -setting will be hospitals in any country.

Inclusion and exclusion criteria
The inclusion and exclusion criteria are summarised in Table 1.

STAGE 2 -Identifying relevant studies
As the research is varied, all types of studies will be included in the review, including systematic reviews: • Quantitative studies and qualitative studies.
• Primary and secondary studies that report empirical research data.
There will be no limits imposed on the timeframe for the studies as the approach to strategy is a subject researched over many decades.As 'strategy-as-practice' is a field of study which has emerged over the last two decades, there are studies using various methodological types reported, so all will be included.

Search strategy for identification of studies
The databases to be searched are as follows: PubMed -Biomedical and life sciences database Using the PCC framework (Population -Concept -Context) concepts will be expanded on using search terms and database appropriate thesaurus terms.Sample search strings for the Pubmed database are outlined in Table 2.The search terms will be modified as required for other databases and reviewed by a librarian information specialist.

STAGE 3 -Study selection
Identified studies will be entered into Endnote X8 from the database searches from separate files.Duplicates will be identified and removed within Endnote X8.A screening process will then be undertaken by two researchers independently for titles and abstracts, to remove studies not relevant based on the criteria with the assistance of Covidence management software.The eligibility criteria may be refined after familiarity is gained with a sample of the literature by the two researchers and the final criteria will be adhered to for all study selections.In advance of starting the screening process a small percentage of the studies will be screened independently by each reviewer and then a comparison will be reviewed for consistency.The full text review will be undertaken using the same iterative process with researchers reviewing the full texts independently initially and then meeting to agree criteria and then finalising criteria.Disagreements will be settled if needs be by a third independent researcher.

STAGE 4 -Charting the data
Data extraction will be conducted using a data extraction form devised by the researchers within EXCEL software as recommended by Joanna Briggs Institute (Peters et al., 2017).
Using the elements identified in the population, concept and context framework as a guide, the initial fields will include:

Gaps in research
This form will be revised when the researchers are more familiar with a sample of the studies, to elicit if further information is required or if fields are not relevant and should be deleted.

STAGE 5 -Collating, summarising and reporting the results
There will be forms of synthesis from a numerical and qualitative perspective.The studies will be mapped according to the types, locations and years of publications.Then there will be a thematic analysis of barriers and enablers for engaging with strategic planning in hospitals and an analysis of what level of staff engages with strategic activities.Finally gaps in the literature will be explored and reported.The PRISMA-ScP guideline will be used for reporting the outcomes of the review (Tricco et al., 2018).Key concepts will be summarised using descriptive content analysis.The report findings will be disseminated in graphic and tabular formats according to the findings and gaps identified.Full adherence to ethical procedures in disseminating information will be adopted by the researchers.Arrangements will be made to share findings with key stakeholders including local hospital personnel and management, regional hospital groups, the hospital division of the national health service executive and in the researchers affiliated university.The report will be submitted for peer review publication.The findings will be presented both orally and through poster presentations at national and international healthcare conferences.

Study status
At the time of publication of this protocol, preliminary database searches were commenced.

Discussion / conclusion
Hospitals are under increasing pressure to use valuable resources most effectively in the current dynamic and complex environment.A clear strategy is vital to ensure that all hospital personnel understand the strategic plan to implement the objectives successfully.This scoping review will systematically explore what is known about strategizing in hospitals.Based on the review findings and knowledge gaps uncovered, future research recommendations can be put forward.Findings from the review will be shared widely with hospital personnel and policymakers both locally and nationally, and also through presentations and publication of the review in an open-access journal.
framework of five mandatory steps which was updated and expanded on by Levac et al. (2010) and Colquhoun et al. (2014) and Peters et al. (2015) as advocated by the Joanna Briggs Institute and published on their website (Peters et al., 2017).
Collating, summarising and reporting the results.

5.
To establish what factors facilitate or hinder strategizing in hospitals 6. Explore what is known about strategic flexibility in hospitals 7. Identify gaps in the literature to inform future research opportunities in this field Review question How do hospital personnel strategize from planning to implementation in hospitals?The framework to be used is PCC -Population, Concept and Context as used by Peters et al. (2015) -Biomedical and pharmaceutical database CINAHL -Nursing and allied health database Psycinfo -Psychology database ABI/INFORM (Proquest) -Business databaseOpenGrey.net-Open Grey literature repositoryAs the research question is broad, the list of databases must reflect this by exploring the literature in standard healthcare databases such as Pubmed and CINAHL, but also psychology databases such as PsycInfo, and business databases such as ABI/INFORM to gain the full extent of the spread of the literature.