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Learn more: PMC Disclaimer | PMC Copyright Notice BMJ Open . 2026 Apr 15;16(4):e116205. doi: 10.1136/bmjopen-2026-116205 Search in PMC Search in PubMed View in NLM Catalog Add to search Clinician factors influencing decision-making in emergency general surgery (EGS): a scoping review protocol Ellen Groundwater Ellen Groundwater 1 Department of Surgery, NHS Greater Glasgow and Clyde, Royal Alexandra Hospital, Paisley, UK 2 University of Glasgow, Glasgow, UK Find articles by Ellen Groundwater 1, 2, ✉ , Carly Nichola Bisset Carly Nichola Bisset 2 University of Glasgow, Glasgow, UK 3 Department of Surgery, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, Glasgow, UK Find articles by Carly Nichola Bisset 2, 3 , Rebecca Bradley Rebecca Bradley 2 University of Glasgow, Glasgow, UK 4 Department of Surgery, Golden Jubilee National Hospital, Clydebank, UK Find articles by Rebecca Bradley 2, 4 , Rachel John-Charles Rachel John-Charles 1 Department of Surgery, NHS Greater Glasgow and Clyde, Royal Alexandra Hospital, Paisley, UK 2 University of Glasgow, Glasgow, UK Find articles by Rachel John-Charles 1, 2 , Yasuko Maeda Yasuko Maeda 2 University of Glasgow, Glasgow, UK 5 Department of Surgery, NHS Greater Glasgow and Clyde, Queen Elizabeth University Hospital, Glasgow, UK Find articles by Yasuko Maeda 2, 5 , Tracey McKee Tracey McKee 6 Knowledge Services, NHS Greater Glasgow and Clyde, Glasgow, UK Find articles by Tracey McKee 6 , Susan Joan Moug Susan Joan Moug 1 Department of Surgery, NHS Greater Glasgow and Clyde, Royal Alexandra Hospital, Paisley, UK 2 University of Glasgow, Glasgow, UK 4 Department of Surgery, Golden Jubilee National Hospital, Clydebank, UK Find articles by Susan Joan Moug 1, 2, 4 Author information Article notes Copyright and License information 1 Department of Surgery, NHS Greater Glasgow and Clyde, Royal Alexandra Hospital, Paisley, UK 2 University of Glasgow, Glasgow, UK 3 Department of Surgery, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, Glasgow, UK 4 Department of Surgery, Golden Jubilee National Hospital, Clydebank, UK 5 Department of Surgery, NHS Greater Glasgow and Clyde, Queen Elizabeth University Hospital, Glasgow, UK 6 Knowledge Services, NHS Greater Glasgow and Clyde, Glasgow, UK Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. None declared. ✉ Ellen Groundwater; [email protected] Received 2026 Jan 2; Accepted 2026 Mar 20; Collection date 2026. Copyright © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ . PMC Copyright notice PMCID: PMC13084799 PMID: 41985950 Abstract Abstract Introduction Emergency general surgery (EGS) decisions often occur under time pressure and with reduced patient involvement in comparison to the elective setting. Variation in decision-making in the field of EGS is partly attributable to patient and contextual factors, but clinician factors also likely shape decisions. This scoping review aims to clarify which clinician factors have been investigated in relation to decision-making in adult EGS, which have been identified as influential, and the methods used to measure them. Methods and analysis Any studies reporting on individual clinician factors and decision-making in EGS will be eligible. Studies must be only in adult populations (patients aged 18 and over). This review will consider quantitative, qualitative and mixed-methods study designs. This scoping review will be conducted in accordance with the methodology developed by the Joanna Briggs Institute and reported in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. This protocol was prospectively registered with the Open Science Framework: https://osf.io/xcqp4 . We will search MEDLINE, EMBASE, CINAHL, CDSR and CENTRAL. The search strategy will be adapted for each database, and no time or language restrictions will be applied. Two independent reviewers will screen studies for eligibility and extract data using a purpose-designed data extraction form, with disagreements resolved by a third reviewer. Extracted data will be synthesised using a narrative approach to map key concepts, describe study characteristics and identify gaps in the literature. Ethics and dissemination Ethical approval is not required as this review will use publicly available data. Findings will be disseminated through peer-reviewed publication and conference presentations. Keywords: Adult surgery, SURGERY, Decision Making, Clinical Decision-Making Strengths and limitations of this study. This protocol follows methodological guidance from the Joanna Briggs Institute and is reported in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. Quantitative, qualitative and mixed-methods studies will be included, allowing for a broad exploration of how clinician factors are conceptualised and measured. The existing literature examining clinician factors in emergency general surgery decision-making may be limited. Variation in definitions of emergency general surgery and clinician factors across studies and healthcare systems may affect comparability of findings. Introduction Emergency general surgery (EGS) is defined as ‘any patient requiring emergency surgical evaluation (operative or non-operative) for diseases within the realm of general surgery’. 1 Some patients will require emergency surgical intervention for their presenting pathology, while others will be appropriately managed with medical therapy alone. Among patients whose pathology indicates the need for surgical intervention, two key groups can be identified: those who proceed to emergency laparotomy and those who do not, the NoLap population. 2 EGS encompasses a vast array of surgical pathology and contributes to a significant proportion of admissions under the banner of general surgery. 3 EGS also forms a substantial proportion of the mortality observed in surgical patients, with 80% of surgical mortality arising as a result of emergency surgical intervention. 4 Understanding and optimising the decision-making process for EGS patients is crucial for improving patient outcomes and mortality rates. The decision-making in EGS often occurs under time pressure and uncertainty, which impacts the ability to engage in effective shared decision-making. 5 In this review, we considered all clinicians involved in EGS decision-making. Clinicians involved in EGS encounter numerous decision-making points in the management of their patients and there remains a large variation in this decision-making. 6 These decisions may include, but are not limited to, decisions regarding initial assessment and investigations, whether to pursue operative or non-operative management (including NoLap patients), the type of operation or anaesthetic, the timing or prioritisation of surgical intervention, decisions regarding escalation of care or referral, palliative management, in addition to intraoperative and postoperative management decisions. The variation seen in decision-making is partly attributable to patient and contextual factors, but these factors alone do not account for the significant variation seen in current practice. It is likely that clinician factors also influence decision-making. A clinician factor is defined as ‘a trait or attribute related to a clinician which influences the assessment and/or treatment of a patient’. 7 In this review, we considered clinician factors in three categories: Demographic factors. Training experience. Psychosocial factors. Demographic factors include a clinician’s gender, age and ethnicity, as well as their cultural background. In addition, the type of hospital in which a clinician practises may expose them to different cases and institutional cultures. 8 The training experience of a clinician refers to the experience and expertise accumulated over their career. The career stage of the clinician reflects their level of experience within a specific medical field and encompasses medical students, junior doctors and consultants (or their international equivalents). Training factors also include a clinician’s specialty and sub-speciality. In the modern era of medicine, sub-specialisation is becoming ever more complex due to advancing medical knowledge and technologies. 9 Clinicians involved in EGS will have varying degrees of their workload dedicated to the field, ranging from infrequent involvement on-call to dedicated EGS clinicians. This review seeks to establish whether clinician experience or expertise has been examined in relation to EGS decision-making. Psychosocial factors are perhaps the least studied of these clinician factors. Psychosocial factors are the combined effects of individual psychology and the social environment on behaviour, attitudes and decision-making. 10 This review aims to identify whether personality or individual personality traits of the clinicians involved in EGS decision-making have been studied. Heuristics, which can be seen as mental shortcuts, can aid in making rapid decisions and are often employed in time-pressured situations in medicine. The use of heuristics can improve efficiency but introduces the potential for cognitive bias, which is unconscious and systematic errors in thinking that can influence decisions and judgement. 11 This review will identify and synthesise the current evidence on heuristics and biases in EGS decision-making. There is limited evidence examining clinician factors and their influence on decision-making in the realm of EGS. The current evidence spans multiple disciplines, including medical literature and psychological research, and is characterised by a wide variety of study designs and methods. This scoping review aims to map the current literature and identify gaps, with the hope of informing future study. Review question Which clinician factors have been investigated in relation to decision-making in adult EGS, which have been identified as influential and by what methods are these factors measured? Objectives To identify and map clinician factors studied in relation to decision-making in adult EGS. To describe decision points and/or outcomes examined. To summarise study designs, measures and analytical approaches. To identify knowledge gaps and priorities for future research. Definition Clinician factor ‘A trait or attribute related to a clinician which influences the assessment and/or treatment of a patient’. 7 Examples of clinician factors Detailed below is a comprehensive, but not exhaustive, list of clinician factors. Demographic factors Age. Sex (most often available), gender (if available). Country of practice. Country of study/training. Native language/language of clinical practice. Hospital setting (eg, teaching hospital, district general hospital). Work setting (eg, private practice, public sector, rural vs urban). Ethnicity. Cultural background/cultural influences. Training Experience, career stage (eg, consultant/attending, registrar/resident, trainee, intern, student), level of training, grade of training, years of surgical experience. Sub-speciality (eg, general surgery, EGS, trauma surgery, colorectal surgery, upper gastrointestinal surgery, hepatobiliary surgery). Psychosocial factors (with attached definitions) Personality/personal traits—defined as personal qualities and emotions that shape a person’s characteristic behaviour and thoughts. 12 Propensity to risk, risk-taking behaviour, risk tolerance, risk perception—these words describe an individual’s overall approach to uncertainty. 13 Self-awareness—defined as the ability of an individual to recognise their own emotions and/or behaviours and the subsequent effect on others. 14 Coping style—defined as strategies an individual can employ to manage stress. Cognition, cognitive bias, heuristics—these words describe mental processes involved in acquiring knowledge and making decisions. 11 Fatigue, stress, burnout—these words describe physical and/or emotional exhaustion which has resulted from persistent stressors. Attitude, behaviours, beliefs—these words describe the personal viewpoints that shape responses. Personal bias—defined as preconceived notions held by an individual. 15 Methods The proposed scoping review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews and is reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines. 16 , 18 Registration This scoping review protocol was prospectively registered on the Open Science Framework: https://osf.io/xcqp4 . Inclusion and exclusion criteria The population/concept/context (PCC) framework, recommended by the JBI, has been employed in this review to identify the main concepts in the primary review question and construct the eligibility criteria. In this review, the PCC framework has been employed as such: Population—clinicians involved in adult EGS. Concept—individual clinician factors. Context—decision-making in EGS. Inclusion criteria Any studies reporting on clinician factors (as detailed in introduction) and decision-making in EGS will be eligible. Only studies undertaken in adult populations (patients aged 18 and over) will be eligible for inclusion. We will search for peer-reviewed published articles and selected grey literature resources (conference abstracts, theses and pre-publication texts) provided sufficient methodology is available. The inclusion of selected grey literature aims to reduce publication bias and ensure a comprehensive review of available literature. This review will consider quantitative, qualitative and mixed-methods study designs. There will be no time limit applied to the studies when searching. There will be no language limit applied to the search. If non-English language articles are found, we will use Google Translate to assess the abstract and, if seemingly relevant, will use a professional translation service to translate the articles in question. Exclusion criteria Studies in paediatric populations (patients aged under 18 years old) will be excluded; this is primarily due to differences in decision-making between adult and paediatric populations. In paediatric patients the patient primary decision makers are often parents/caregivers on behalf of their children, and this duly impacts the decision-making process. Studies examining elective surgeries only will also be excluded. This review is focusing on decision making in the high acuity and time-pressured environment of EGS. The inclusion of elective surgery is out with the scope of this review. Studies examining solely trauma surgery or non-general surgical specialities will be excluded. Selected grey literature, such as editorials and book chapters, will be excluded as they do not provide primary research data to analyse. Search strategy Here we present the full electronic search strategy for MEDLINE (via OVID), including any limits used, such that the search could be repeated. Full search strategy for MEDLINE detailed in online supplemental appendix 1 . Information sources Databases to be searched: MEDLINE (via OVID), EMBASE (via OVID), Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL) and Cumulative Index to Nursing and Allied Health Literature (CINAHL via EBSCOhost). The search will be adapted for each included database and/or information source. The reviewers will also check the reference list of eligible studies to look for other potentially appropriate studies for inclusion, a technique known as snowballing. We will conduct an online search to assess for relevant conference abstracts and theses. Selection of sources of evidence and data charting process Articles identified in searching will have their citation details imported into Covidence. Covidence is an online, collaborative software platform which will provide a structured framework to this review and allow for the collaboration of multiple reviewers. 19 Covidence will be used to perform deduplication of articles. Screening will be completed by two independent reviewers (EG, RB) who will assess titles and abstracts of articles against the pre-determined inclusion and exclusion criteria to determine which abstracts will be retrieved in full. Full text articles will be reviewed against inclusion criteria by two independent reviewers (EG, RB). If any disputes arise during the screening and selection process, a third independent reviewer (RJ-C) will decide any disputes. The results of the search and the study inclusion process will be reported in full in the final scoping review and presented in a PRISMA flow diagram. 17 Data extraction Data will be extracted from sources of evidence included in the scoping review by two independent reviewers (EG, RB) using a data extraction form created by the reviewer (EG). Data extracted will include study bibliographic details, specific details about study design, clinician factors studied, data collection measures used and the key results. A draft data extraction form is included ( online supplemental appendix 2 ). Data analysis and presentation The extracted data will be displayed in a table form. A narrative summary will be provided which will aim to map key concepts, describe study characteristics and identify gaps in the literature. The review does not aim to perform a risk of bias assessment, as this is typically not undertaken during a scoping review. The aim of this scoping review, in alignment with the intention of scoping reviews in general, is not to seek the best available evidence, but instead provide a comprehensive description of the available evidence related to the question of interest. Patient and public involvement Patients and the public were not involved in the design of this scoping review protocol. Ethics and dissemination Ethics approval is not required for this scoping review, as this review will use publicly available data. Results will be disseminated via presentation at surgical conferences and submission for publication at peer-reviewed journals. Supplementary material online supplemental file 1 bmjopen-16-4-s001.docx (730KB, docx) DOI: 10.1136/bmjopen-2026-116205 Footnotes Funding: EG is Emergency Laparoscopic and Laparotomy Scottish Audit (ELLSA) PhD Fellow and receives funding towards her PhD study. The funder had no influence upon the development of this protocol. Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online ( https://doi.org/10.1136/bmjopen-2026-116205 ). Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent for publication: Not applicable. Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. References 1. Gale SC, Schuster KM, Crandall ML, et al. In: Emergency general surgery. Brown CVR, Inaba K, Martin MJ, et al., editors. Cham: Springer International Publishing; 2019. 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Supplementary Materials online supplemental file 1 bmjopen-16-4-s001.docx (730KB, docx) DOI: 10.1136/bmjopen-2026-116205 Articles from BMJ Open are provided here courtesy of BMJ Publishing Group ACTIONS View on publisher site PDF (350.0 KB) Cite Collections Permalink PERMALINK Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM Add to Collections Create a new collection Add to an existing collection Name your collection * Choose a collection Unable to load your collection due to an error Please try again Add Cancel Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top