Since the mid-20th century shift to hospital-focused health care, registered nurses have played an increasingly significant role in providing safe, competent and caring health care.1 Over the past decades, many organizational and healthcare innovations and changes to service delivery have altered the registered nurses’ workplace. For example, increasingly specialized medical care and technological developments have resulted in the development of specialized practice at the point of care. More recently, the demand for fiscal efficiencies, in both private and public healthcare systems, and broad reaching austerity measures have also impacted healthcare organizations. The current emphasis on shifting to primary health care, community-based health care and a developing commitment to support aging in place, which has been led and strongly supported by registered nurses,2 is creating significant changes to nursing practice. These innovations, adjustments and developments have translated into organizational change, which has shaped and altered nursing practice and the registered nurses’ workplace.
As with many contemporary systems and institutions, change is ubiquitous in health care globally. Fiscal efficiencies and a collective desire to improve the quality and safety of patient (client) care have driven much of the constant change in health care. Healthcare reform in the late 1990s and early 2000s, driven by neoliberal governments and globalization, impacted all healthcare practitioners, including registered nurses.3-5 More recently, various approaches to transforming nursing practice, stemming from a series of reports from the Institute of Medicine6 in the United States, and increasingly energetic initiatives related to patient safety have resulted in organizational change that has shaped nursing practice. These initiatives include, but are not limited to, Transforming Care at the Bedside,7Productive Ward – Releasing Time to Care,8Care Delivery Model Redesign (CDMR)9 and other changes in nursing care delivery informed by Lean design, originating with Toyoto.10
In the first decade of the 21st century, quality improvement initiatives, often based on business models,8 have resulted in a significant increase in organizational change and have affected nursing practice. White et al.8 acknowledge that these types of changes are “very complex social interventions”8(p.1635) implemented with little supporting evidence for their effectiveness. Reasons for organizational change include responding to increased acuity of patients; however, the most common reason for changes in skill-mix is a real or anticipated shortage of registered nurses.11 In addition to these widespread initiatives, healthcare organizations undergo change such as amalgamation, re-structuring, program and unit closures, renovation and “improvements” ranging from revised organizational philosophy and vision statements to adoption of new nursing practice models.
Organizational change driven by advances in technology has also contributed to significant change across levels and areas of practice. The addition of new skills and new nursing roles to match technological advances and innovations is remarkable. For example, the development of telehealth, whereby registered nurses are able to assess or monitor patient status and implement interventions remotely, has created a new area of nursing practice. The implementation of an increased scope of practice and the addition of other healthcare providers, including personal support workers, licensed practice nurses and care aides, have shifted the role of the registered nurse in many highly acute healthcare settings.
Organizational re-design often results in turbulence for nurses in direct care related to changes in roles and responsibilities. This can negatively impact working relationships and the quality of care12 and create confusion in terms of role identity of the caregiver.3 Drawing on a common commitment and high expectations for patient care, organizational change is often presented as a means to improve the quality of delivery of services to patients; however, it is often seen by healthcare professionals as a direct threat to patient safety and quality of care.11 Poorly implemented change also has a negative impact on workplace engagement and employee attitudes and beliefs.8
A number of studies have evaluated changes to models of nursing care delivery. These studies, together, highlight the importance of empowerment of staff for success.12 Staffs’ attitude, perceived support (or lack of support) and emotional responses to change, including uncertainty and perceived loss of control, all affect the implementation and response to organizational change.11,13 Registered nurses should and want to be involved throughout change process including identifying common desirable outcomes along with maintaining effective communication, education and de-briefing.11 A collaborative approach across levels in the organization is recommended.
Organizational change, intended to respond to healthcare reform, often results in significant learning for nurses in direct care.14,15 In a recent grounded theory, organizational change was found to be the most common, and the most challenging, trigger for professional development, including formal and informal workplace learning.15 The constant, often seemingly random, nature of change and the resulting demands on the time, energy, concentration, knowledge and skill of the nurses create challenges to maintain the nurses’ high standards of patient care when hampered by changes in organizational structure, protocols, practice requirements and administrative discourses in the workplace.15
Registered nurses have a pivotal role in the provision of health care and are exposed to vulnerabilities in the midst of continuing organizational change. Given the ubiquitous nature of organizational change in healthcare systems and registered nurses ongoing commitment to improving patient care, we are interested in understanding the experience of organizational change for registered nurses. We believe that this systematic review is timely and potentially valuable for decision makers and stakeholders throughout organizations. The results of this systematic review will provide healthcare administrators, nurse leaders and those implementing changes in healthcare organizations (including CDMR, healthcare restructuring and quality improvement initiatives) with a clearer understanding of how registered nurses experience organizational change and inform efforts to ameliorate the negative effects of organizational change on nursing practice and the provision of quality health care.
A search of the literature was undertaken to find literature relating to registered nurses experiences with organizational change. The Cochrane Library, JBI Database of Systematic Reviews and Implementation Reports, Scopus, PROSPERO, MEDLINE, CINAHL and Epistemonikos were searched, and no previous systematic reviews on this specific topic were identified as published or currently underway. Two quantitative systematic reviews have explored organization structures and their impact on nursing practice and behavior.16,17 However, due to the very narrow inclusion criteria, only a maximum of two studies were included in these reviews. The paucity and poor quality of literature included in these reviews resulted in no firm conclusions being drawn about the effectiveness of organizational structures to support nursing practice. The authors of these quantitative reviews suggest that if policy makers and healthcare organizations aim to promote evidence-based nursing practice, more funding and support must be provided to ensure that rigorous research is conducted to generate the required evidence to guide policy. Interestingly, initial examination of the literature revealed a number of qualitative studies exploring nurses’ experiences with organizational change,12,18-23 with no current synthesis of high-quality evidence to guide practice. It is this gap in literature that we aim to fill with this systematic review.
Types of participants
The current review will consider studies that include registered nurses who work in direct patient care in an acute care setting. Registered nurses are educated in state-approved institutions and write a licensing exam on completion of their education, either at the diploma or Baccalaureate degree level. Acute care settings provide a range of services, generally in a time-sensitive manner, aimed at diagnosis, urgent care, stabilization or cure.24 Nurse managers, nurse administrators, nurse educators and nurses working in primary care will be excluded. Nurse practitioners, clinical nurse specialists and advanced practice nurses who work in direct patient care in an acute care setting will be included.
Phenomena of interest
The current review will consider studies that explore nurses’ experiences of organizational change. The experiences include nurses’ perceptions, perspectives, views, challenges, feelings and thoughts about organizational change. Organizational change is defined as alteration in nature, content or course of a (healthcare) organization including but not limited to re-structuring, transformation and CDMR.
Acute care settings will be considered. This review will exclude aged care and primary care settings. The context of nursing work in these settings occurs under a different model of care to the acute care setting; therefore, the research findings generated from aged care and the primary care setting are considered to be outside the scope of this review.
Types of studies
The current systematic review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. Studies published in other languages will be tallied (but not translated) to provide an indication of the range of international literature available on this topic. No limitations will be placed on dates of publication.
The databases to be searched will include CINAHL, ERIC, PubMed, PsycINFO and Embase.
The search for unpublished studies will include ProQuest Dissertations and Theses Global, The New York Academy of Medicine Grey Literature Collection, The Canadian Health Research Collection, Grey Matters CADTH, Open Grey, British Library Ethos and Trove.
Initial keywords to be used will be “nurs∗,” “attitude,” “perspective,” “perception∗,” “view,” “experience∗,” “reaction,” “organizational change,” “organizational reform,” “organizational transforming” and “hospital restructuring.”
Assessment of methodological quality
Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer (PS).
Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Authors of primary studies will be contacted if information is missing or unclear.
Qualitative research findings will, where possible, be pooled in JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent aggregation, through assembling of findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories will be subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in a narrative form.
Appendix I: Critical appraisal instruments
QARI appraisal instrument
Appendix II: Data extraction instruments
QARI data extraction instrument
The authors express their gratitude for the excellent assistance of Dr Christina Godfrey, Deputy Director/Methodologist for the Queen's Collaboration for Health Care Quality for providing methodological support, and to Dr Alix Hayden, Librarian at the University of Calgary, for assisting in developing the database searches.
1. Wall S. “We inform the experience of health”: perspectives on professionalism in nursing self-employment. Qual Health Res
2013; 23 7:976–988.
2. Canadian Nurses
Association. A nursing call to action. Ottawa, CA: Canadian Nurses
3. Ardern P. Safeguarding care gains: a grounded theory study of organizational change
. J Adv Nurs
1999; 29 6:1370–1376.
4. Laschinger S, Leiter M. The impact of nursing work environments on patient safety outcomes: the mediating role of burnout engagement. J Nurs Adm
2006; 36 5:259–267.
5. Cartier C. From home to hospital and back again: economic restructuring, end of life, and the gendered problems of place-switching health services. Soc Sci Med
2003; 56 11:2289–2301.
6. Institute of Medicine of the National Academies. The future of nursing: leading change, advancing health. United States of America: The National Academies Press; 2011.
7. Dearmon V, Roussel L, Buckner EB, Mulekar M, Pomrenke B, Salas S, et al. Transforming Care at the Bedside (TCAB): enhancing direct care and value-added care. J Nurs Manag
2013; 21 4:668–678.
8. White M, Wells JSG, Butterworth T. The impact of a large-scale quality improvement programme on work engagement: preliminary results from a national cross-sectional-survey of the ‘Productive Ward’. Int J Nurs Stud
2014; 51 12:1634–1643.
9. Stevenson L, Parent K, Purkis M. Redesigning care delivery in British Columbia. Healthc Manage Forum
2012; 25 1:16–19.
10. Kinsman L. “The largest Lean transformation in the world”: the implementation and evaluation of lean in Saskatchewan healthcare. Healthc Q
2014; 17 2:29–32.
11. Hayman B, Wilkes L, Cioffi J. Change process during redesign of a model of nursing practice in a surgical ward. J Nurs Manag
2008; 16 3:257–265.
12. Ingersoll GL, Fisher M, Ross B, Soja M, Kidd N. Employee response to major organizational redesign. Appl Nurs Res
2001; 14 1:18–28.
13. Hall LM, Doran D, Sidani S, Pink L. Teaching and community hospital work environments. West J Nurs Res
2006; 28 6:710–725.
14. MacIntosh J. Reworking professional nursing identity. West J Nurs Res
2003; 25 6:725–741.
15. Jantzen D. Refining nursing practice: a grounded theory of experienced nurses
’ lifelong learning. Alberta: University of Alberta; 2012.
16. Flodgren G, RojasReyes X, Cole N, Foxcroft DR. Effectiveness of organisational infrastructures to promote evidence-based nursing practice. Cochrane Database Syst Rev
17. Flodgren G, Pomey M, Taber S, Eccles MP. Effectiveness of external inspection of compliance with standards in improving healthcare organisation behaviour, healthcare professional behaviour or patient outcomes. Cochrane Database Syst Rev
18. Wells J, Manuel M, Cunning G. Changing the model of care delivery: nurses
’ perceptions of job satisfaction and care effectiveness. J Nurs Manag
2011; 19 6:777–785.
19. White M, Waldron M. Effects and impacts of Productive Ward from a nursing perspective. Br J Nurs
2014; 23 8:419–426.
20. Cumming E, Clancey IL, Cumming J. Improving patient care through organizational changes in the mental hospital. Psychiatry
1956; 19 3:249–261.
21. McMillan K, Perron A. Nurses
amidst change: the concept of change fatigue offers an alternative perspective on organizational change
. Policy Polit Nurs Pract
2013; 14 1:26–32.
22. Rhéaume A, Dionne S, Gaudet D, Allain M, Belliveau E, Boudreau L, et al. The changing boundaries of nursing: a qualitative study of the transition to a new nursing care delivery model. J Clin Nurs
2015; 24 (17/18):2529–2537.
23. Irwin M, Bergman R, Richards R. The experience of implementing evidence-based practice change: a qualitative analysis. Clin J Oncol Nurs
2013; 17 5:544–549.
24. Hirshon JM, Risko N, Calvello EJ, Stewart de Ramirez S, Narayan M, Theodosis C, et al. Health systems and services: the role of acute care
. Bull World Health Organ
2013; 91 5:386–388.