S YS T E M AT I C R E V I E W P R O T O C O L
Registered nurses’ experiences of organizational change
in acute care settings: a systematic review protocol
Darlaine Jantzen 1  Lorelli Nowell 2  Patricia Scott 3
1
Department of Nursing, Camosun College, Victoria, Canada, 2Faculty of Nursing, University of Calgary, Calgary, Canada, and 3Learning Services,
Camosun College, Victoria, Canada
Review objective: The objective of this review is to explore how registered nurses working in acute care settings
experience organizational change.
Downloaded from https://journals.lww.com/jbisrir by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 08/22/2021
Keywords Acute care; experiences; nurses; organizational change
JBI Database System Rev Implement Rep 2017; 15(4):855–861.
Background
ince the mid-20th century shift to hospital-
S 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 health-
care 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 effi-
ciencies, 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 develop-
ing 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 institu-
tions, 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.
Correspondence: Darlaine Jantzen, jantzend@camosun.bc.ca
There is no conflict of interest in this project.
DOI: 10.11124/JBISRIR-2016-003043
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©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
Healthcare reform in the late 1990s and early 2000s,
driven by neoliberal governments and globalization,
impacted all healthcare practitioners, including regis-
tered 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,7 Productive Ward – Releasing Time to
Care,8 Care 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 interven-
tions’’8(p.1635) implemented with little supporting
evidence for their effectiveness. Reasons for organ-
izational change include responding to increased
acuity of patients; however, the most common
reason for changes in skill-mix is a real or anticip-
ated shortage of registered nurses.11 In addition to
these widespread initiatives, healthcare organiz-
ations undergo change such as amalgamation, re-
structuring, program and unit closures, renovation
and ‘‘improvements’’ ranging from revised organ-
izational philosophy and vision statements to adop-
tion of new nursing practice models.
Organizational change driven by advances in
technology has also contributed to significant change
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across levels and areas of practice. The addition of
new skills and new nursing roles to match techno-
logical 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 imple-
mentation 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 turbu-
lence 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, organiz-
ational 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, edu-
cation 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 learn-
ing 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, concen-
tration, knowledge and skill of the nurses create
challenges to maintain the nurses’ high standards
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D. Jantzen et al.
of patient care when hampered by changes in organ-
izational structure, protocols, practice requirements
and administrative discourses in the workplace.15
Registered nurses have a pivotal role in the pro-
vision 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 stake-
holders throughout organizations. The results of this
systematic review will provide healthcare administra-
tors, nurse leaders and those implementing changes in
healthcare organizations (including CDMR, health-
care restructuring and quality improvement initiat-
ives) with a clearer understanding of how registered
nurses experience organizational change and inform
efforts to ameliorate the negative effects of organiz-
ational 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 Imple-
mentation Reports, Scopus, PROSPERO, MED-
LINE, CINAHL and Epistemonikos were sear-
ched, 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 effective-
ness of organizational structures to support nursing
practice. The authors of these quantitative reviews
suggest that if policy makers and healthcare organ-
izations aim to promote evidence-based nursing
practice, more funding and support must be pro-
vided 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 explo-
ring nurses’ experiences with organizational
change,12,18-23 with no current synthesis of high-
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quality evidence to guide practice. It is this gap
in literature that we aim to fill with this
systematic review.
Inclusion criteria
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 prac-
titioners, 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 organ-
izational change. Organizational change is defined as
alteration in nature, content or course of a (health-
care) organization including but not limited to re-
structuring, transformation and CDMR.
Context
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.
Search strategy
The search strategy aims to find both published and
unpublished studies. A three-step search strategy will
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©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
D. Jantzen et al.
be utilized in this review. An initial limited search of
MEDLINE and CINAHL will be undertaken fol-
lowed 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 ident-
ified keywords and index terms will then be under-
taken across all included databases. Third, the
reference list of all identified reports and articles
will be searched for additional studies. Studies pub-
lished in English will be considered for inclusion in
this review. Studies published in other languages will
be tallied (but not translated) to provide an indica-
tion 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 Collec-
tion, The Canadian Health Research Collection,
Grey Matters CADTH, Open Grey, British Library
Ethos and Trove.
Initial keywords to be used will be ‘‘nurs,’’ ‘‘atti-
tude,’’ ‘‘perspective,’’ ‘‘perception,’’ ‘‘view,’’
‘‘experience,’’ ‘‘reaction,’’ ‘‘organizational cha-
nge,’’ ‘‘organizational reform,’’ ‘‘organizational
transforming’’ and ‘‘hospital restructuring.’’
Assessment of methodological quality
Qualitative papers selected for retrieval will be
assessed by two independent reviewers for methodo-
logical 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).
Data extraction
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 out-
comes of significance to the review question and
specific objectives. Authors of primary studies will
be contacted if information is missing or unclear.
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Data synthesis
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 catego-
rizing 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.
Acknowledgements
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.
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Appendix I: Critical appraisal instruments

QARI appraisal instrument

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Appendix II: Data extraction instruments

QARI data extraction instrument

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SYSTEMATIC REVIEW PROTOCOL D. Jantzen et al.

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