Registered nurses’ experiences of organizational change in acute care settings: a qualitative systematic review

The objective of this review was to describe the experiences of registered nurses (RNs) providing direct patient care in acute care settings undergoing organizational change. RNs, comprising the largest group of health care professionals in the hospital setting, are directly influenced by organizational change. Exploring their experiences will contribute to better strategic planning within hospital systems. An understanding of both the positive and negative experiences of ubiquitous organizational change, and the factors that mitigate negative effects, is essential to retaining precious health human resources, specifically nurses in acute care. Qualitative studies of RNs working in direct patient care in acute care settings with experiences of organizational change were included. Quantitative studies and studies of other health care professionals, including those where midwives are not RNs, were excluded. Studies limited to organizational change that involved planned, purposeful change impacting daily nursing practice were included. An initial search was conducted in MEDLINE (EBSCOhost) and CINAHL (EBSCOhost), followed by a full search in CINAHL, MEDLINE, PsycINFO, Business Source Complete, ERIC (all via EBSCOhost), PubMed (January-June 2017, January-July 2023), and gray literature sources (June 2017, updated July 2023). There were no search limits. We followed the JBI approach for study selection, critical appraisal, data extraction, and synthesis. Synthesized findings were assessed using ConQual. Seventy-nine studies were included in the review but, after assessing methodological quality, 5 were excluded, leaving 74 studies with 561 findings. The earliest study was from 1987, with the majority published between 2013 and 2023. Most were phenomenological, hermeneutic, or grounded theory studies. Sixteen countries were represented in the included studies, with almost half from the US and England. The 5 synthesized findings are: i) Nurses experienced a lack of meaningful participatory approaches and effective planning and preparation; ii) Nurses identified facilitators to help them navigate change at intrapersonal, leadership, and organizational levels, with two-way communication an overarching facilitator; iii) Nurses experienced a range of affective responses in direct response to organizational change; iv) Nurses experienced impacts on their care practices, nursing identity, workload, roles, and everyday responsibilities, which influenced the quality and safety of patient care; v) Organizational change led to altered relationships at organizational, unit, team, and nurse-patient levels. The quality of the included studies was high, giving strength to this review. Engaging nurses from the point of care prior to any health care change is essential for minimizing the negative impact on the quality of patient care and for increasing effective, efficient, and respectful change. Nurses are affected by chaotic, non-participatory initiatives that fail to improve the quality of patient care. Early, ongoing, and effective 2-way communication across the process of change is essential. Health care leadership can contribute to positive experiences of change by engaging with nurses' commitments to high-quality patient care. Practice recommendations include participatory approaches with ongoing 2-way communication across all levels of organizational change. A quantitative systemic review and evaluation research related to organizational change is recommended. PROSPERO CRD42023442473.