Assessment of culture of care in health services: a scoping review protocol

Abstract

Introduction

The term ‘culture of care’ began to be used following the Francis Report in the UK in 2013. This concept involves three dimensions: personal care, leadership care and co-worker care. Personal care focuses on employees’ attitudes and behaviours. Co-worker care relates to a sense of community, and leadership care relates to how employees perceive leaders and managers as caring individuals dedicated to ensuring the well-being of others. Previous studies investigating culture assessment tools used in the healthcare system reported that although organisations are increasingly using culture assessment instruments, there is a focus on assessing safety and quality cultures rather than on caring perspectives. This scoping review aims to map existing studies related to the assessment of culture of care.

Methods and analysis

This scoping review will be conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews. The search strategy will include four indexed databases (PubMed, EMBASE, Cochrane Library and Latin American and Caribbean Literature in Health Sciences) and additional sources not retrieved with the adopted search strategy. The search strategy will be constructed using the controlled vocabulary in Health Sciences Descriptors, Medical Subject Headings and Emtree. Relevant articles in all languages, without restrictions related to date of publication, will be considered eligible for inclusion. Two independent researchers will select articles based on the inclusion criteria, and a third author will be consulted to establish consensus, if necessary. Data extraction will involve a form with information on the study characteristics, methodological issues and main results from the evidence sources. The extracted data will be analysed using descriptive and content analysis.

Ethics and dissemination

Ethics approval is not required, as this review will use data from publicly available bibliographic sources. The results will be disseminated through publications in scientific journals and presentation of the evidence to interested parties.

Study registration

The protocol was registered in the Open Science Framework (DOI: 10.17605/OSF.IO/U9Q53).

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The scoping review will use a well-established methodological framework to ensure rigour and transparency.

• No language or date restrictions will be set, ensuring the broadest possible inclusion.

• Given that only four different databases will be searched, some relevant publications indexed elsewhere may be missed.

• The subjectivity of the concept, as well as its similarity to organisational culture, may be a limiting factor in the development of the study.

• The study will not specifically address clinician engagement, assessment of professional standards or aiming for excellence in care delivery.

Introduction

Gillin, Taylor and Walker¹ explored the definition of culture of care, and they argued that to better understand this concept, ‘culture’ must be defined within organisations. The importance of culture in providing high-quality and patient safety has been emphasised in many studies on failures in healthcare systems. One of the attributes of quality in healthcare is safety in the provision of care, which is related to minimising risks and harm to healthcare users. One of the greatest challenges of this attribute is that it must be considered systematically, encompassing organisational factors beyond human and technological factors. This requires reflecting that true change lies in the organisational culture of safety in healthcare services.²

In the UK, the term ‘culture of care’ began to be used following the Francis Report in 2013, with a negative attribute involving fear, bullying and the acceptance of inappropriate standards; it was later reworked in a positive way by The King’s Fund (2014) and the Culture of Care Barometer tool.^{1 3}

The culture of care has three dimensions: personal care, leadership care and co-worker care. Personal care focuses on workers’ attitudes and behaviours. Coworker care relates to a sense of community, and leadership care relates to how workers perceive leaders and managers as caring individuals dedicated to ensuring the well-being of others.⁴

Mensik, Leebov and Steinbinder⁴ conceptualised a culture of care as a place where leaders, managers, supervisors and all staff demonstrate compassion, dignity and respect for each person they interact with, even when this is not evident. A culture of care is related to beliefs, norms and values shared by members of the healthcare organisation that ‘motivate, facilitate and direct these professionals to act structurally in caring for patients and families’, according to Hesselink et al.⁵ Rafferty et al⁶ define a culture of care as an environment where employees feel supported, respected and valued, connect and communicate with empathy and compassion while performing the tasks and responsibilities inherent to their work.

Rafferty et al⁶ researched culture assessment tools used in the English healthcare system and reported that although organisations are increasingly using culture assessment instruments, there is a focus on assessing safety and quality culture rather than on care perspectives. The attributes of care culture for patients or workers are not assessed in existing measures of quality and performance in healthcare organisations.⁵ In this context, a culture of care has been established as ideal when workers feel valued, respected and supported and when relationships are good between managers, workers, teams, departments and across institutional boundaries.^{6 7}

This study aims to map existing studies related to the assessment of culture of care through a scoping review. The study is justified by the lack of such reviews in the Brazilian context. The goal is to understand the constructs related to the assessment of culture of care, compare application scenarios and analyse the need for and feasibility of using a specific instrument applied to the Brazilian context. The ultimate goal is to identify the factors that influence the culture of care in healthcare services, which can inform effective measures to improve the work of professionals in these services, impacting the efficiency of care.

Methods and analysis

This scoping review protocol was developed according to criteria of the Joanna Briggs Institute (JBI) Reviewer’s Manual,⁸ based on a theoretical framework developed by Arskey and O'Malley⁹ and Levac, Colquhoun and O'Brien,¹⁰ and guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR).¹¹ The Rayyan software will be used for reference management. The protocol was developed and registered on the Open Science Framework and can be accessed through the following link: https://osf.io/u9q53/ (accessed on 30 July 2025).

The review will be conducted based on the following steps: formulation of the research question, search strategy and identification of relevant studies, study selection, data extraction and coding, analysis and interpretation of results and synthesis of results.^{9 10}

Formulation of the research question

The research question was formulated using the mnemonic PCC (population, concept and context).⁸ This model allows for a broader mapping of information to identify knowledge gaps, present key concepts, quantify aspects of interest and expose practices and evidence on a given topic.¹²

For this analysis, ‘P’ was defined as health service workers and managers, ‘C’ as culture of care and the other ‘C’ as health services.

Therefore, the review will be guided by the following research question: ‘What studies exist in the literature on assessing the culture of care among health service workers and managers?’ The reference concepts for the mnemonic elements adopted in this review are shown in table 1.

Table 1. Definition of concepts used in the review.

		Concept	Definition
P	Health service workers and managers	Health service workers	Individuals working in the provision of health services, whether as individual practitioners or employees of health institutions and programmes, whether trained or untrained health professionals and whether or not subject to public regulation.
		Health service managers	Individuals responsible for formulating, implementing and evaluating health policies, programmes, projects and services, depending on the level of activity (federal, state or municipal). They are also known as ‘decision-makers’ in the health field.
C	Culture of care	Culture of care	It’s about creating a space where people feel valued and supported as part of a broader organisation. A culture of care has three dimensions: personal care, leadership care and co-worker care.
C	Health services	Health services	They constitute an organised system for providing healthcare within a country. The range of services varies by country and includes everything from preventive services to inpatient and outpatient care.

Search strategy

To identify relevant studies, the search strategy will be constructed using the controlled vocabulary in Health Sciences Descriptors, Medical Subject Headings (MESH) and Emtree. In conjunction with the controlled language (descriptors), we will use natural language considering the need for greater sensitivity and to expand the search results.^{13 14}

The search strategy will be developed using the extraction, conversion, combination, construction and use model.¹³ This model allows for the development of a highly sensitive strategy, as it follows a set of complementary steps. Table 2 shows the conversion of mnemonic elements into primary keywords.

Table 2. Conversion of adopted mnemonic elements.

Mnemonic	Extraction	Conversion
Population	Health service workers and managers	Health personnel Healthcare professionals Manager Healthcare employees Nursing managers
Concept	Culture of care	Organisational culture Attitude of health personnel Organisational development Culture of care Caring culture Caring cultures Culture of care barometer
Context	Health services	Health services Healthcare organisations Professional patient relations Hospitals Healthcare institutions Patient care

Initially, an exploratory search will be conducted in PubMed/Medline to identify the main MeSH terms and all fields related to the topic. A search strategy will be developed based on the exploratory search, combining descriptors and keywords using the Boolean operators AND and OR, and will be adjusted according to each database, as shown in table 3.

Table 3. Database search strategy.

Database	Research strategy
PubMed/MEDLINE (http://www.ncbi.nlm.nih.gov/pubmed/)	(((((“Health personnel”(MeSH Terms))OR “healthcare professionals”(MeSH Terms))OR “Manager”(MeSH Terms)) OR (“health personnel”(tiab))OR “healthcare professionals”(tiab))OR “manager”(tiab))OR “nursing managers”(tiab))OR “healthcare employees”))) AND (((“Organisational culture”(tiab))OR “Attitude of health personnel”(tiab))OR “Organisational development”(tiab))OR “Culture of care”(tiab))OR “culture of care barometer”(tiab))OR “caring culture”(tiab))OR “caring cultures”(tiab))))) AND (((“Health services”(MeSH Terms))OR “Healthcare organisations”(MeSH Terms))OR “Professional patient relations”(MeSH Terms)) OR (“health services”(tiab))OR “healthcare organisations”(tiab))OR “professional patient relations”(tiab))OR “healthcare institutions”(tiab))OR “hospitals”(tiab))OR “patient care”(tiab)))))
LILACS (https://lilacs.bvsalud.org/)	((“Pessoal de saúde” OR “Profissionais de saúde” OR “Gestor” OR “Gestores de enfermagem” OR “Trabalhadores da saúde”) AND (“Cultura organizacional” OR “Atitude do pessoal de saúde” OR “Desenvolvimento organizacional” OR “Cultura de cuidado” OR “barômetro da cultura de cuidado” OR “culturas de cuidado”) AND (“Serviços de saúde” OR “Organizações de saúde” OR “Relações profissionais-paciente” OR “Hospitais” OR “Atendimento ao paciente”))
Cochrane (https://www.cochranelibrary.com/)	((“Health personnel” OR “healthcare professionals” OR “manager” OR “nursing managers” OR “healthcare employees”) AND (“organisational culture” OR “attitude of health personnel” OR “culture of care” OR “Organisational development” OR “culture of care barometer” OR “caring culture” OR “caring cultures”) AND (“health services” OR “healthcare organisations” OR “professional-patient relations” OR “healthcare institutions” OR “hospitals” OR “patient care”))
EMBASE (https://www-embase.ez292.periodicos.capes.gov.br/search/quick)	('health personnel’/exp OR 'healthcare professional’ OR 'manager’) AND ('organisational culture’/exp OR 'attitude of health personnel’ OR 'organisational development’ OR 'culture of care’ OR 'culture of care barometer’ OR 'caring culture’) AND ('health service’ OR 'healthcare organisation’ OR 'professional patient relation’ OR 'healthcare institutions’)

LILACS, Latin American and Caribbean Literature in Health Sciences ; MEDLINE, Medical Literature Analysis and Retrieval System Online.

Sources of evidence

The following databases will be used: Cochrane, Latin American and Caribbean Literature in Health Sciences (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE/PubMed) and EMBASE.

Using the reference list, additional sources not retrieved using the adopted search strategy will be searched. If necessary, the review authors will contact the study authors for additional information.

Study selection

Duplicate studies will be extracted using the Rayyan platform (https://www.rayyan.ai/), a free and validated review application developed to facilitate collaborative citation screening. With integrated machine learning and artificial intelligence, Rayyan’s developers aim to reduce the time and workload of screening. There are no relevant ethical implications, as the platform requires manual input of data generated by the databases into the search using the defined search key.¹⁵

Two researchers with access to the spreadsheet will then independently review the title and abstract based on the established criteria. In the case of disagreement, a third reviewer will be consulted to reach a consensus.

Relevant studies will be retrieved in full and exported to a Microsoft Excel database (2020 update). Full texts will be analysed in detail according to the eligibility criteria, and the reasons for exclusion will be recorded and reported in the review. A pilot test will be conducted among the reviewers, in which a random sample of 25 studies will be evaluated by title and abstract to verify their consistency with the inclusion criteria defined in the protocol and achieve a minimum agreement percentage of 75% between them, to proceed with independent collection, as recommended by the JBI manual.⁸

Eligibility criteria

Articles that cited or used the concept of culture of care in healthcare services, both quantitative and qualitative, and available in full will be included.

Regarding language, articles in all languages will be considered, with no time restrictions, for a broader mapping. Duplicate publications, letters, editorials, theoretical essays, opinion pieces and publications related to the concept of culture of care not applied to human beings or associated with healthcare services will be excluded.

Data extraction

The data extraction and coding stage will be performed by two independent reviewers, using a Microsoft Excel data extraction form based on the JBI model⁸ and adapted by the authors, as shown in table 4.

Table 4. Instrument for data extraction.

Variable	Standardisation	Data extraction from publications
Title	Complete specification of title and subtitle, if any.
First author	Name of the author who appears in the first position.
Type of study	Article, dissertation, thesis, etc.
Year of publication	Year the study was published
Institution	Institution to which the first author is linked
Objective	Detail the objective of the study
Research design	Detail the research design described by the author(s)
Data collection procedures	List data collection technique(s) used
Study population	Health professionals with whom the study was conducted
Publication context	Location where the study was conducted
Tool used	List tool or scale used in assessing the culture of care
Results	Main results of the study

Data analysis and interpretation of results

Analysis and interpretation of results will be performed quantitatively and qualitatively, as appropriate. Quantitative data will be analysed using simple descriptive statistics, presenting absolute frequencies and percentages. Qualitative analysis will be conducted through thematic analysis to identify meanings and patterns to answer the research question.¹⁶

All results will be discussed based on relevant literature and presented in flowcharts, graphs and tables.

Table 5 presents the phases of the review that have already been completed and the steps that are still to come. Started in April 2025 with the protocol, the aim is to finalise and publish the review by February 2026.

Table 5. Review stage.

Stage	Start	Conclusion
Pilot research to verify the review protocol and define the research strategy.	April 2025	July 2025
Construction of the review protocol	April 2025	August 2025
Protocol registration in the Open Science Framework	July 2025	August 2025
Study selection	August 2025	No
Data extraction and coding	No	No
Analysis and interpretation of results	No	No

Patient and public involvement

None.

Ethics and dissemination

Ethics approval is not required, as this review will use data from publicly available bibliographic sources. The results of this review will be shared with stakeholders and published in renowned, open-access, peer-reviewed journals of major public health importance, fostering and expanding the dissemination of knowledge within the scientific community. Any changes to this protocol will be appropriately reported in the final publication, including dates and justifications.

Discussion

This scoping review will map the existing body of evidence on the topic of assessing the culture of care, including a wide range of healthcare services and the various categories of healthcare professionals and managers. The aim is to locate studies that analyse the barometer of the culture of care in various settings and across different national contexts.

This review report will follow the PRISMA-ScR, which will ensure that the review objectives are met and that the review steps can be replicated.¹¹ This well-established methodological framework will ensure rigour and transparency. However, even with rigorous reporting, it is still possible that the search strategy is not sensitive enough or that some keywords/terms may be missing, which would lead to an incomplete evidence map.

To minimise the possibility of bias in the research, collation, analysis and data synthesis process, peer review will be conducted to obtain an agreement index. This will involve independent evaluation by two researchers.

One potential limitation of the scoping review is that, although our search will use four databases, some relevant publications indexed elsewhere may not be identified. The number of databases was defined according to the reviewers’ ability to evaluate the studies in a timely manner.

The results will contribute to the assessment of the current state of scientific evidence on the culture of care and its measurement in health services worldwide. The subjectivity of the concept, as well as its similarity to organisational culture, may be a limiting factor in the development of the study. Another challenge concerns the approach to clinician engagement, evaluation of professional standards and aiming for excellence in care delivery, which are not present in the protocol. However, these concepts are embedded in the context of the culture of care; therefore, it is presumed that they will emerge when the review is conducted.

Ultimately, the review will inform on the available knowledge on the topic so that instruments for culture of care assessment can be developed and applied in the Brazilian context.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.