Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: A Meta-Ethnography Protocol

Version Changes

Revised. Amendments from Version 1

The following amendments have been made in line with peer-review recommendations: -The ' Introduction' section has been supplemented with additional references to better describe and contextualise the research issue. - The ' Aim' and ' Research Question' have been reframed for greater clarity.  - ' Table 1' has been updated with clarifications.  - Additional context and descriptions have been added to the ' Study Design' section to better explain the process of conducting QES meta-ethnography.  -Clarifications have been provided within the ' Eligibility Criteria' section (language and publication year filters).  -Author/reviewer initials have been added to define who is responsible for each screening and reviewing/appraisal step. -Clarifications and a more elaborate explanation of the steps involved in data selection, extraction, analysis and synthesis have been added to sections ' Screening/data management & selection process','Data extraction process and analysis', 'Data Items', and 'Data Synthesis'. -Primary outcomes have been revised in the ' Outcomes and prioritisation' section. -Steps involved in the ' Confidence in cumulative evidence' section / GRADE-CERQual approach for assessment of confidence in final QES findings have been expanded upon.  -Minor edits/ clarifications have been made to the ' Discussion' and ' Limitations' sections.  -References have been edited as additions have made.

Abstract

Negative healthcare professional experiences of work can undermine health system stability by contributing to shortages, burnout and poor retention. Research into doctors’ and nurses’ working conditions indicates the important role of 'solidarity' to their working experience. There is limited understanding of formal (trade unions, industrial action) and informal (peer-support, camaraderie) solidarity in shaping doctors’ and nurses’ working experience. This study aims to conceptualise both forms of solidarity as perceived by doctors and nurses to understand its potential on their working experience. This qualitative evidence synthesis (QES) protocol is reported following PRISMA-P recommendations. A search strategy has been developed using controlled vocabulary and free terms (MEDLINE, CINAHL, Scopus Embase, PubMed databases), following the Peer Review of Electronic Search Strategies (PRESS) process. English language articles will be included if they report primary, conceptually rich and contextually thick qualitative data, exploring the perceptions of informal and formal solidarity as experienced by qualified doctors and/or nurses. Its influence on the working experience, as reported by included studies, will be explored. Initial title and abstract screening, followed by full-text screening of included articles, will be completed independently by two reviewers. A grey literature search will be employed, including a targeted, domain-specific Google search of doctor and nurse national unions within ten countries with highest union density, and websites of intergovernmental organisations/agencies. Piloted data extraction forms will be used to extract study characteristics and qualitative data. The CASP (Critical Appraisals Skills Programme) tool will be used to assess the quality of included studies by two reviewers, independently. Confidence in cumulative findings will be assessed using GRADE-CERQual guidelines. The QES will be reported using eMERGe guidelines and will follow the Noblit and Hare meta-ethnography approach. Registration Number: This protocol has been registered via the PROSPERO database, the International Prospective Register of Systematic Reviews. The protocol can be found on the register under the following number: CRD420251150676. Available from: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251150676. PROSPERO Registration: CRD420251150676

1. Introduction

1.1. Introduction & background

Healthcare workforce retention is a global population health challenge. As argued by the World Health Organization (WHO), there is ‘no health without a workforce’, highlighting the need for research exploring frontline healthcare staff workplace experiences. ¹ Negative healthcare professional (HCP) experiences of work (such as prolonged exposure to occupational stress, high workloads, unfavourable conditions, emotional trauma, a lack of preparedness in the face of newly emerging diseases, or horizontal violence) are a chronic health system issue undermining system stability, being consequential for healthcare access, patient care quality and continuity – further perpetuating the workforce crisis. ^{2– 5} This crisis is multifaceted, and exists internationally, comprising of labour (recruitment and retention), mental health (high levels of anxiety, stress and burnout), education (inadequate institutional training and development to meet system demands) gender equality (pay gap, sexual harassment), and financial (austerity, unstable economies and a lack of funding) crises. ^{3, 4} It is reflected in staff shortages, burnout and poor retention. ^{3, 4, 6– 8} Increased workplace pressure faced by HCPs from the demands of ageing populations, and the coronavirus (COVID-19) pandemic especially, have highlighted the importance of ‘solidarity’ in shaping their working experience. ^{4, 5}

Recent studies have highlighted two key points of relevance to health research: the exacerbation of the unfavourable working conditions (extensive working hours and unreasonable shift patterns, resource shortages, pressure, stress, unsafe staffing) faced by HCPs, ^{4– 9} as well as the role of solidarity in the management of these conditions. ^{4, 5, 9} Solidarities in work have been broadly described as a collective sense of representation, shared vision and purpose that develop within work environments. Beck and Brook ¹⁰ define solidarity, broadly, as a phenomenon of ‘fellow-feeling’, which develops informally in the workplace as a collective sense of togetherness and mutually shared experiences and understanding. Solidarity (especially informal) refers to peer support or camaraderie – organic and mutually beneficial interpersonal support between colleagues with a shared sense of identity, ^{5, 10– 13} an example being illustrated by Korczynski’s communities of coping, ¹⁴ where two or more healthcare practitioners support one another in the workplace. Specific definitions of solidarities which will guide our research are presented in Table 1.

Table 1. Research question as defined and formulated using the SPIDER framework. ²⁵ .

Each aspect of the question is mapped on to and explained in the context of each element of SPIDER, while providing a summary of study search strategy inclusion and exclusion criteria (see ‘Study Design’ below).

Sample	Doctors and nurses of any grade/register (including intern but excluding undergraduate student or not fully qualified groups) or specialty, working in any healthcare setting (hospital, community, public or private etc.). Doctors and nurses can be either active union members or non-members and be actively practicing or retired. Doctors and nurses who have exited the system but have healthcare work experience will also be included. The study is limited to medical, qualified (licensed) doctors (i.e. not doctorates, PhDs or similar) and nurses. Patient peer-support groups, or support groups for various morbidities/diseases (either communicable or non-communicable) will be excluded, to limit the number of irrelevant search results being returned, the research focus being doctors and nurses only. Articles exploring the experiences of other allied HCPs only will be excluded (due to the nature of other HCPs often being members of multi-professional unions, as opposed to single-profession unions, such as doctor and nurse unions). Articles where data specifically related to the perceptions and experiences of nurses and doctors can be extracted will be included.
Phenomenon of Interest	Solidarity comprising: a. Formal collective representation (e.g., trade unions, unionisation & union membership - representative bodies) of doctors and nurses, most frequently involving a contractual, paid subscription to access services such as legal support/advice, organised collective bargaining, safeguarding of interests and well-being, adequate renumeration etc., via negotiation with an employer. 26 , 27 b. Informal solidarity (e.g., peer support, shared experiences, camaraderie), defined as voluntary, mutual (ly beneficial), organic, interpersonal support and camaraderie between peers/colleagues who have a shared sense of experience, justice, purpose, and identity. 5 , 10 – 13 This can involve peer-to-peer support through institutionally organised programmes. To meet inclusion criteria, studies must specifically address either a or b above in depth, i.e., literature must include contextually thick and conceptually rich qualitative data, assessed using a QES assessment tool developed for this purpose. 28
Design	Qualitative evidence synthesis of primary, qualitative data studies using: - focus groups - interviews - fieldwork observations and notes - diaries and other qualitative data Included literature types: - articles published in peer-reviewed journals - ‘grey’ literature (reports and websites of international, representative agencies/bodies) Ethnographic studies, including digital book chapters with thick/rich qualitative data Excluded research designs and literature types: - Quantitative primary studies - Reviews (qualitative or quantitative, of any nature, including systematic reviews), - Mixed-methods studies (meta-ethnography being applicable to qualitative studies exclusively) - Grey literature in the form of expert opinions, editorials, news articles, commentaries, abstracts in proceedings, theses, dissertations. - Ethnographic books (hard copies only, due to possible access restrictions and specificity to research question) - Full-text studies not written in the English language
Evaluation	Experiences and perceptions
Research Type	Original qualitative research articles using designs noted above. Full-text, English language only (for the sake of preserving context/accurate interpretation of qualitative data).

Solidarities can also be formal – traditionally, as labour mobilisation or trade unions, commonly involving union membership of organised workers with similar material interests, ideas, or a sense of (in) justice. ¹⁰ With respect to formal solidarity, appropriate management of labour relations via engagement of healthcare workers’ trade unions and professional representative bodies has a documented influence on addressing and safeguarding workers’ wellbeing. ^{3, 15} Trade unions, e.g., the Irish Nurses and Midwives Union (INMO) and the Irish Medical Organisation (IMO) representing Irish nurses and doctors, respectively, act as key stakeholders of formal, collective representation. Having the power to negotiate reform recommendations for more sustainable working contracts, conditions and pay through industrial action, workers’ unions shape the industrial and labour relations landscape, and thus, the experience of work for doctors and nurses. ^{15, 16}

In the Irish context, Byrne et al. ¹⁷ and Creese et al. ^{18, 19} highlight how doctors’ experiences of work are shaped by informal peer support in a situation of a perceived ‘lack of voice’. In the US, Andrews et al., ²⁰ describe “co-worker support” as a mediating factor to turnover nurses, influencing job satisfaction. Similarly, a survey of GPs in England conducted by Jefferson et al. ²¹ found that a lesser ‘sense of belonging’ (described as a factor of ‘job satisfaction’) negatively influenced retention. However, evidence coherency as to the influence of informal solidarity on the working experience of doctors and nurses remains limited. As with informal solidarity, there is a lack of coherency as to the perceived influence trade unions and other collective forms of representation have on the experience of work from the viewpoint of doctors and nurses. ^{3, 15}

Following the consultation of the ‘RETREAT’ criteria developed by Booth et al., ²² we identified qualitative evidence synthesis (QES) as the best methodology to explore this topic and address this evidence gap. Doctors and, in particular, nurses, were chosen due to historically high unionisation rates ^{23, 24} and a tendency for these HCP unions to be single-profession (al) unions (as opposed to unions representing other allied HCPs, which tend to be mulit-professional). Additionally, the COVID-19 pandemic has highlighted the importance of solidarity for both professions. ^{4, 5} As established, negative work experiences have the potential to exacerbate the workforce crisis by undermining HCP retention, and contributing to burnout and shortages. ^{4– 9} Meanwhile, research has shown that solidarity shapes the working experience of HCPs, particularly that of doctors and nurses profoundly. ^{17– 21} However, there is no universal consensus on whether doctors and nurses perceive both informal or formal solidarity (mainly trade union support) as effective in mediating negative work experiences. The specifics of the nature of the influence of solidarity for this group of professionals are also not fully conceptualised. It is worthwhile, therefore, to synthesise existing literature exploring these perceptions to better inform and support health workforce policies. The objective of this QES is to synthesise existing primary, qualitative literature defining the experience of solidarity (formal and informal) as perceived by, and from the viewpoint of doctors and nurses, to describe how exactly do both forms of solidarity influence their working experience.

1.2. Aim

This QES aims to conceptualise how doctors and nurses experience both formal and informal solidarity in work. Findings of this review can inform strategies for improving health system sustainability by addressing the workforce crisis, leveraging the priorities of the World Health Organization’s (WHO) ‘Framework for action on the health and care workforce in the WHO European Region 2023–2030’, which is to safeguard the wellbeing of staff. ¹ Additionally, a better understanding of working experiences of frontline health workers has the potential to influence workforce policy and improve retention. The research findings may also be beneficial in redefining or adding to the understanding of the definition or concept of solidarity, specifically in healthcare work for both doctors and nurses.

1.3. Research questions

What are doctors’ and nurses’ experiences or perceptions of formal and informal solidarity, and how do both solidarity types influence the experience of work for these two professions.

2. Methods

The SPIDER ²⁵ (Sample, Phenomenon of Interest, Design, Evaluation, Research Type) framework informed the review question, search terms and inclusion and exclusion criteria, which are outlined in Table 1 below. See also the ‘Study Design’ section, ‘ Step 1: Getting Started’.

Table 1 outlines the research team’s definition of both formal and informal solidarity for the purpose of the proposed search strategy, inclusion criteria, and primary outcome measures of the prospective QES.

2.1. Study design

This QES will employ Noblit and Hare’s ²⁹ 7‐step meta-ethnography, a systematic approach to the synthesis of findings of relevant qualitative studies, translating them into one another. Meta-ethnography was chosen to address our research question for its ability to help synthesise various qualitative, social and cultural interpretations (primary data) by way of producing a cohesive review. By synthesising primary interpretations, the authors of the QES themselves add to the body of knowledge by providing their own interpretations and by mapping how reviewed literature relates to one another. Literature, when synthesised using meta-ethnography, can be shown to align in agreement, but it can also be refutational, where different or conflicting sentiment can be evaluated against each other across different studies. This ensures that new insights are not simply one dimensional. As such, a meta-ethnography QES is an interpretation (by the research team) of interpretations (made by primary study authors) of interpretations (as expressed by the subjects of individual primary studies) ( 29). In the context of our study, meta-ethnography will address aforementioned research gaps by clearly defining the perceptions and working experience influences of formal and informal solidarity as understood by doctors and nurses – for example, whether these professions perceive solidarity as effective in maintaining positive working experiences, or conversely, whether it has no benefit or undermines working morale in some cases. The 7 steps (or “phases”, as described by Noblit and Hare) include:

• 1. Getting started – identifying a novel research question or ‘intellectual interest’ which could be answered using qualitative methods (see ‘3. METHODS’ section and Table 1).
• 2. Deciding what is relevant – identifying articles, literature, and data which meet researcher-established criteria to answer the research question (described in ‘3. METHODS’).
• 3. Reading the studies – taking time to analyse and interpret the data selected in Step 2 above (please refer to the ‘Search Strategy 'subsection of section ‘3. METHODS’).
• 4. Determining relatability across selected studies – finding similarities, but also differences, across concepts, themes and author interpretations which complement or refute each other throughout the selected studies (specifically ‘Data Extraction Process and Analysis & Data Synthesis’ under ‘3. METHODS’).
• 5. Translating studies into one another – analysing the data of each selected study (both first-order constructs, or raw participant data such as quotes, as well second-order constructs, or original article author interpretations of participant data, such as analytical themes), through line-by-line coding, followed by the grouping of this coding into descriptive codes. This will be done on the basis ofthe similarities and differences in themes and concepts present in the data (‘ Data Synthesis’).
• 6. Translation synthesis – generating novel analytical themes based on descriptive themes, as understood and interpreted by the researcher, with the help of existing theoretical frameworks to further the body of evidence related to the research question. This is known as reciprocal translation and generates ‘third-order constructs’. Translation can also be refutational, should some constructs or concepts be conflicting. Also, ‘line-of-argument' translation can build an inference to address a large issue as a whole, based on the study of its individual parts (explained further in the ‘ Data Synthesis’ section).
• 7. Synthesis expression – achieved by discussing and reporting the synthesised, translated interpretations from Steps 4 to 6 (‘third-order constructs’) as a systematic review of included qualitative literature, while following appropriate reporting guidelines such as eMERGe ^{29, 30} (‘3. METHODS – Dissemination' and ‘4. CONCLUSION’).

The protocol for this QES is reported using the PRISMA-P protocol checklist and guidelines. ³¹ The final synthesis and analysis will be reported in line with the ‘Improving reporting of meta-ethnography (eMERGe)’ guidelines. ³⁰

2.2. Eligibility criteria

Inclusion/exclusion criteria of study types, properties and study participants/population sampled are set out in the SPIDER framework ²⁵ of Table 1 and addresses ‘Step 2: Deciding what is relevant’ of the 7-step Noblit and Hare meta-ethnography approach. ²⁹

Studies for which there is no English language translation will be excluded. However, to avoid excluding studies with non-English titles which are otherwise supplemented with an original English translation (provided by the authors/publishing journal), no English language filter will be applied to the search. Studies not written in English (title or otherwise), without a full-text English translation from the authors of the study or the publishing journal, will be excluded manually - the rationale being the importance of context (for example, direct participant quotes) in qualitative studies, which may be impacted by poor or unoriginal manual translation by the research team. The search will not include non-English language terms. Neither the search string nor the strategy will be translated.

There will be no publication year restrictions applied to the search, the justification being that solidarity is a traditional concept in the social sciences and the likelihood of studies from the 70s and 80s in industrial relations being potentially relevant to our conceptualisation and research question. Although previously cited studies describe examples of recently emergent solidarity (for example, in the context and face of the COVID-19 pandemic), the relevance and impact of solidarity for both doctors and nurses is likely to be a concept dating back in time. Therefore, in order to broadly address the research question, to note any historical differences in sentiment towards or the manifestation of solidarity, and to minimise the risk of excluding older, but highly relevant literature, no publication year restriction filter will be applied.

2.3. Search strategy

The search strategy was devised, using the PRESS Peer-Review process, to address ‘ Step 2: Deciding what is relevant’ of the Noblit and Hare 7-step meta-ethnography approach. ²⁹

An independent, expert health librarian affiliated with the 1 ^st Author’s host institution was consulted to develop the search strategy and search strings for each relevant database. An initial search was developed with the help of the host institution librarian ('searcher'). A second, independent, university librarian ('reviewer') affiliated with the 2 ^nd Author’s host institution produced a PRESS Peer-Review ³² of the initial search, to finalise the search string, strategy, and increase rigour and transparency throughout the QES.

Upon meeting and discussing with both librarians, any amendments advised as part of the PRESS peer-review were clarified and implemented across the search strategy and search strings for all databases used. The finalised search strings and strategy used for the purpose of this review, as well as the PRESS peer-review form completed by both librarians, is available under the ‘Extended Data’ section. The PRESS peer-review proved to be a very beneficial exercise, both in formalising the search strategy, as well as increasing the rigour and transparency of study search methodology. Additionally, both librarians offered invaluable amendments and suggestions for a more precise database search by pointing to some minor omissions and errors.

Preliminary search terms were developed to reflect the research question, using both keywords and controlled vocabulary of MeSH terms. MeSH terms were used for term refinement. The final search string will be translated and applied to MEDLINE (Ovid; doctor focus), CINAHL (Cochrane; nurse focus), Scopus (Elsevier; a multidisciplinary database, with coverage of social sciences and humanities research), and Embase (Ovid/Elsevier). PROSPERO will be searched for similar, prospective reviews. Article authors may be contacted for clarifications.

The search terms have been designed to capture international spelling variants and titles, using MeSH terms, controlled database-specific vocabulary and appropriate terms and truncations (e.g. “physician*”).

Search results will be subject to initial title and abstract screening carried out independently by two reviewers (MD, and a second, appointed reviewer) and selected based on relevance and meeting inclusion criteria outlined above. Disagreements and conflicts will be resolved by consulting a third reviewer (JPB).

Grey literature search strategy. A two-step, grey literature search will be carried out via a targeted, domain specific Google search using the following keywords: “nurse”, “doctor”, “physician”, “midwife”, “frontline worker”, “union”, “experience”, “solidarity”, “peer support”, “employee morale”, “workplace support”, “strike”, “collective organisation”, “camaraderie” of:

• a)doctor and nurse-specific unions in the ten countries with the highest union density as per OECD data ³³ : Iceland, Sweden, Denmark, Finland, Norway, Belgium, Italy, Luxembourg, Canada, Ireland. It is hoped that countries where union density and activity is highest will have published reports on union-member experiences.
• b)the websites of the following intergovernmental organisations and agencies will also be searched: Eurofound, WHO, OECD (Organisation for Economic Co-operation and Development), ILO (International Labour Organization) for key data relevant to the research question and inclusion criteria.

Neither the search terms nor search string for the primary and grey literature search will be translated to non-English language phrasing.

The reference list of all included documents will be screened (by MD) for additional studies using forward and backward citation (citation chasing via ‘Citationchaser’), supplemented by hand-searching reference lists where necessary. ³⁴

Screening/data management & selection process. Following the search, all identified citations will be collated and imported into Zotero. After deduplication, citations will be uploaded into Covidence. The title and abstracts will be screened independently by two reviewers (MD and a second, appointed reviewer) against the inclusion criteria outlined in Table 1.

Two reviewers (MD and a second, appointed reviewer) will review the first 100 titles/abstracts as part of a pilot test. Disagreements will be resolved by consulting a third reviewer (JPB).

Remaining articles will be subject to independent, full-text screening by two reviewers (MD and JPB) - disagreements will be resolved by consulting a third reviewer (SOR) ( Steps 2 and 3 of the meta-ethnography approach). ²⁹

The QES screening tool developed by Ames et al. will be implemented during full-text screening. ²⁸ Studies containing large volumes of data addressing the research question specifically will be selected for inclusion. Following these inclusions, studies will be screened further by way of sampling (independently, by two reviewers - MD and JPB), against the QES tool on the basis of contextual thickness and conceptual richness. Contextual richness refers to the depth to which the study has been contextualised (background, population/sample characteristics, description of methodology used by the study). Meanwhile, conceptual richness refers to the level of which the study findings or data have been transformed (by way of analysis, using existing, appropriate theoretical frameworks). ²⁸ Appropriate thickness and richness cut-off points will be agreed upon by the research team prior to sampling but following full-text inclusions based, at this stage, on data volume only. The tool and cut-off points will be piloted by the research team on a small number of said full-text inclusions. For increased reproducibility and transparency, exclusion decisions based on the screening tool will be noted and made available as part of the supplementary material of the published QES review.

2.4. Data extraction process and analysis

For the purpose of collecting both descriptive characteristics of studies included in this review, as well as qualitative data reported in each, data extraction forms will be drafted, piloted, and finalised. Data will be extracted using said preconceived extraction forms and the qualitative data (such as interview or focus group quotes/statements, observational notes and author analysis) generated from each included study will be imported into the latest NVivo software available to the 1 ^st Author, for further synthesis and analysis. This will be done independently by MD, with review from JPB – disagreements, should they arise, will be resolved by consulting SOR. This will address Steps 3 and 4 of the 7-step meta-ethnography process. ²⁹

Data items. Data items collected will reflect the requirements proposed in data extraction forms. Data extraction forms (Microsoft Excel format) will be piloted by the research team, and will include:

- Sample demographics and sample size.

- Country of origin of each study.

- Year of publication.

- Author name(s).

- Qualitative data generated and the authors’ interpretation of this data. This could include sections/paragraphs or transcripts, or direct study participant quotes interpretations, and analyses from grey literature. Extracted raw data will be grouped as first-order constructs (e.g. participant data such as direct quotes) and second-order constructs (e.g. primary study author interpretations of participant quotes by way of analytical themes). Both first-order and second-order constructs constitute primary data from individual articles, while third-order constructs will be the researcher’s novel, original analysis and synthesis of first and second-order constructs.

2.5. Data synthesis

Using the latest version of NVivo available to the research team, original, full-text articles will be uploaded and stored as documents once data extraction (using piloted, Excel forms imported to NVivo) is complete. A translation table of first and second-order constructs will then be created. This will allow for constant comparison within and between first and second-order constructs, and for the research team to refer back to original data when developing third-order constructs.

Meta-ethnography as described in the 7-step process developed by Noblit and Hare will be used to analyse both first and second-order constructs, through line-by-line coding ( Step 4 of the process), followed by descriptive coding of both construct groups (including any contradictory findings and addressing Step 5 of the process). This will be achieved with the help of node and memo generation features of NVivo – original articles and constructs will be indexed and linked to specific article sections or participant quotes. The research team will then generate novel analytical themes and interpretations (third-order constructs, using any existing conceptual or theoretical frameworks in this specific research field if applicable, for example Durkheim’s sociological foundations and mechanical and organic solidarity, ^{10, 35} or the Social Exchange Theory). ^{24, 36}

Individual study results (i.e. raw data, authors’ interpretations) will be translated into one another to create/synthesise novel themes, adding to the body of knowledge. This has the effect of adding cohesiveness to pre-existing knowledge, summarising how results from one existing study can relate to another (Step 6). ²⁹ Third-order constructs will be linked to quotes and other data from original articles in NVivo to help ensure novel interpretations remain grounded. To further ensure that third-order constructs are grounded in first and second-order constructs, the research team will discuss third-order interpretations. The author (MD) will maintain a data synthesis diary to challenge and reflect on their interpretations of first and second-order constructs..

The specific type of synthesis approach (i.e. reciprocal, refutational or line-of-argument synthesis) will be dependent on the alignments, similarities or differences across first and second order-constructs . ^{29, 37} However, a gold-standard approach to meta-ethnography translation considers and applies all possible types of syntheses. The research team will pay additional attention to differences and disconfirming cases across first and second-order constructs (if applicable) in which case refutational translation will be considered for these cases, alongside reciprocal translation of aligning constructs. A line-of-argument synthesis will also be applied to translate different accounts addressing various aspects of solidarity to produce a whole greater than the sum of its parts, as described by Noblit and Hare when referring to this type of synthesis. ²⁹

Outcomes & prioritisation. In line with the research question and qualitative nature of this review, outcome data will include doctors’ and nurses’ experiences and perceptions of formal and informal solidarity, as well as the impact and influence of solidarity on their working experience. Outcome measures of solidarity impact may be inductive, but could include staff expressions of engagement, intention to leave current post or health system, workplace satisfaction, satisfaction with the representativeness of trade unions or consequences of industrial action, and the perceived ability of formal and informal solidarity to enforce, promote or enable workplace wellbeing and the voicing of staff concerns.

There is also scope to examine any existing relationships or tensions between formal and informal solidarity, perceived in the context of work in medicine and nursing. However, this will largely depend on the data gathered as part of the QES.

2.6. Risk of bias in individual studies, meta bias (es)

Studies will be independently assessed for risk of bias (in both study methodology and outcomes reporting) by MD and JPB (with input from SOR should discrepancies arise) using the’Critical Appraisal Skills Programme (CASP) Qualitative Studies Checklist’. ³⁸ Studies will not be excluded or included based on quality, but as previously stated, based on the richness and thickness of qualitative data. Contextual thickness and conceptual richness will be determined using a QES assessment tool developed by Ames et al.. ²⁸

2.7. Confidence in cumulative evidence

To assess the overall level of confidence to be placed in the overall findings of this review, and to increase reporting transparency, the (GRADE-CERQual) approach ³⁹ will be applied to the cumulative evidence synthesis. Confidence in the cumulative evidence will be graded, assessed independently by two reviewers (MD and JPB) and will be presented and discussed by the research team using a summary table to address all four components of the guideline. The research team will determine a level of confidence to which each GRADE-CERQual component has been appropriately addressed. The ‘Methodological Limitations’ component will examine the rigour of study methodology, such as, for example, data collection and analysis. The ‘Coherence’ component will examine whether individual, primary study findings appropriately and adequately address the research question and findings of the QES, including any conflicting findings – or whether the QES as a whole is grounded in the findings of individual studies. ‘Adequacy of Data’ will be used to assess the conceptual richness (the level and depth of synthesis, using and applying appropriate frameworks to conceptualise findings), as well as the volume of data which supports the review findings. ‘Relevance’ will be used to determine the generalisability of results by evaluating whether the context of primary studies matches that of the study and research question, including, for example, the setting, population (doctors and nurses) or phenomenon of interest (solidarity). ³⁹

2.8. Reflexivity

To ensure an unbiased approach, especially during the data analysis and the presentation of study findings, the research team will reflect on individual preconceptions and past experiences which could interfere with the validity of this study. The 1 ^st Author (MD) has a background in microbiology and public health, with some experience in the administrative aspect of healthcare management and teaching, but little experience in sociology or industrial relations. Two of the remaining authors (JPB and SOR) have an extensive background in sociology, with experience in the field of healthcare management. JPB’s previous work has largely focused on the working conditions and experiences of frontline healthcare workers (especially doctors). All authors have carried out research in both an Irish and an international context. However, none of the authors are qualified doctors, nurses, or other allied healthcare professionals. The research team will reflect on any possible preconceptions at each stage of producing this review, which may affect the interpretation of data and research results.

2.9. Dissemination of information

It is hoped that this review will be published in a relevant peer-reviewed journal. The published review and its findings will be incorporated as part of the 1 ^st Author’s PhD research and disseminated at relevant conferences, PhD research showcases (internal and external to the 1 ^st Author’s host institution) and presented to policymakers and stakeholders of interest as relevant (‘ Step 7: Synthesis Expression’). ²⁹

3. Discussion

COVID-19 highlighted a number of key points: there is no healthcare without a health workforce, ¹ already strained working conditions and staff wellbeing were exacerbated by the pandemic experience, and solidarity was a key influence on the experience of healthcare delivery. ^{5, 9, 11– 13} The findings of this QES can inform strategies for improving health workforce sustainability by leveraging the priorities of the WHO’s 'Framework for action on the health and care workforce in the WHO European Region 2023–2030’ to safeguard the wellbeing of health workforce staff. ³ A better understanding of the working experiences of frontline health workers, and the role of solidarity on this experience, has the potential to inform health workforce retention strategies and policies. Representative bodies and organisations will be informed of key findings regarding how solidarity can encourage workforce retention, amplify employee voice and belonging, and address some elements of the workforce crisis through appropriate research dissemination.

4. Limitations, final considerations

4.1. Limitations

This review will examine the experiences of qualified doctors and nurses only – undergraduate student doctors and nurses, and other allied healthcare professionals (be they students or fully qualified professionals) will not be considered, as this would fall far beyond the scope of a PhD research project QES. Therefore, this review will not capture the phenomena of solidarity, formal or informal, as perceived by other types of HCPs, or future frontline health workers. Due to the current political, social, and industrial relations landscape, views of those who practice in countries where trade union membership is considered unprofessional, taboo, or perceived to have consequences for one’s employment security (e.g. USA currently – especially in terms of the possibility of newly emerging research being limited, Belarus, Hungary, Turkiye) may not be captured fully despite this study aiming to capture an international perspective. Research emerging from countries where union density tends to be high (for example, Nordic and Benelux countries), may be overrepresented in this review.

Additionally, articles not published in the English language are excluded, which, despite all efforts to include international literature, does not fully encapsulate the international perspective of doctors and nurses surrounding the concept of solidarity in the workplace. Although meta-ethnography is a powerful evidence synthesis tool for qualitative research, it often necessitates an exclusion of mixed-methods and quantitative studies such as research which utilises questionnaires or surveys with an explanatory or open-text element. Therefore, “thinner” qualitative data and quantitative data fall outside the scope of this review. However, this is partially justified with the primary aim of meta-ethnography being the synthesis of valuable rich and thick qualitative data only, which tends to be reported on and generated more transparently and rigorously in a fully qualitative study, as opposed to being an adjunct of a primarily quantitative study (which oftentimes yields ‘thin’ qualitative data). ^{28, 29}

5. Study status

On publication of this protocol, the review has commenced with the initial title and abstract screening phase.

Data availability

Underlying data

No data associated with this article.

Extended data

PORSPERO Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251150676 .

The following extended data is available for this protocol under the Open Science Framework and the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication): https://doi.org/10.17605/OSF.IO/DGMK4. ⁴⁰

• •Preliminary Search Strategy.docx (Provisional search string, exploring relevant MeSH terms prior to peer-review by a second, independent librarian.)
• •PRESS Peer-Review Form.docx (Fully completed search string and search strategy peer-review document completed by librarian one and two.)
• •Finalised Search Strategy.docx (Full, peer-reviewed search string applied as part of the search strategy, applied to databases PubMed, MEDLINE, CINAHL, Scopus and Embase)

Protocol reporting guidelines

PRISMA-P 2015 Checklist ³¹ for ‘Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: A Meta-Ethnography Protocol’ is available as extended data as ‘PRISMA-P Checklist’.docx under the Open Science Framework and the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication): https://doi.org/10.17605/OSF.IO/DGMK4. ⁴⁰

Funding Statement

Health Research Board [SPHeRE-2022-1 ]

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.