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Nurses’ experiences of working in organizations undergoing restructuring: A metasynthesis of qualitative research studies
Accepted Manuscript Title: Nurses’ experiences of working in organizations undergoing restructuring: A metasynthesis of qualitative research studies Author: Anne Sofie Bøtcher Jensen Dorthe Sørensen PII: DOI: Reference:
S0020-7489(16)30239-5 http://dx.doi.org/doi:10.1016/j.ijnurstu.2016.12.002 NS 2867
To appear in: Received date: Revised date: Accepted date:
14-4-2016 20-11-2016 3-12-2016
Please cite this article as: Jensen, Anne Sofie Bøtcher, Sørensen, Dorthe, Nurses’ experiences of working in organizations undergoing restructuring: A metasynthesis of qualitative research studies.International Journal of Nursing Studies http://dx.doi.org/10.1016/j.ijnurstu.2016.12.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title page Nurses' experiences of working in organizations undergoing restructuring: a metasynthesis of qualitative research studies First author and corresponding author: Anne Sofie Bøtcher Jensen, RN, master in nursing science Affiliations: VIA University College, Center for Research in Health Promotion and Rehabilitation Address: Hedeager 2, 8200 Aarhus N, Denmark E-mail: [email protected] Telephone: 0045 22309201 Second author: Dorthe Sørensen, RN, PhD Affiliations: VIA University College, Center for Research in Health Promotion and Rehabilitation Address: Hedeager 2, 8200 Aarhus N, Denmark E-mail: [email protected]
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Contribution of this paper What is already known about this topic -
Structural changes are common and every nurse experiences this phenomenon.
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Quantitative research has shown that structural changes can have a negative impact on job satisfaction among nurses.
What this paper adds -
The paper provides an exhaustive description of nurses’ collected experiences working in organizations undergoing structural changes.
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Nurses experience an increased workload due to structural changes but still experience a joy associated with the nursing work.
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Nurses' experiences of working in organizations undergoing restructuring: a metasynthesis of qualitative research studies
Introduction In order to optimize the use of resources, reduce costs, and improve the quality of patient treatment, many health care organizations undergo continual reconfiguration (BilleterKoponen and Fredén, 2005; Johnston, 1997; Kivimäki et al., 2007; Kuokkanen et al., 2009; Hjort, 2012). This reconfiguration often results in structural changes in the health care organization. An example of such a development is currently occurring in Denmark. In April 2015, the Danish government announced that a new health care reform would be launched during 2016 (Department of Health and Prevention, 2015). The reform intends to achieve economic cost savings, higher quality services, and a general improvement of health status among the citizens. In addition, Canada, Sweden, Australia, England, Norway, and the United States have also undergone such developments in order to reduce costs (Ardern, 1999; Bakker et al., 2006; Blythe et al., 2001; Cloutier et al., 2008; Debesay et al., 2014; Hertting et al., 2004; Ingersoll et al., 2001; Kristiansen et al., 2010; Montour et al., 2009; ShindulRothschild, 1994; Venturato et al., 2007; Wynne, 2004). These developments have greatly influenced the structure of the health care organizations in these countries by restructuring hospital units, standardizing work tasks, creating redundancies, and reorganizing the hospital hierarchy. Nevertheless, research has shown that structural changes can have a negative impact on nurses’ job satisfaction (Kuokkanen et al., 2009) and that the work environment is eroded by these changes (Johnston, 1997). One study reported that one of the reasons for nurses being stressed and burned out is the organizations undergoing constant structural changes (Grønkjær, 2013). Furthermore, these changes can lead to physical and mental illness
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among nurses (Kristensen, 2012) and influence the use of drugs and disease-related mortality (Erikssen et al., 1990; Ferrie et al., 2002; Iversen et al., 1989; Kivimäki et al., 2007; Vahtera et al., 2004). To prevent these negative effects, a study focusing on structural changes and nurses’ experiences with these changes is highly relevant. The American management psychologist Harold Leavitt (1974) believed that when the structures in an organization are changed, it will affect the remaining elements of the organization, such as the people involved. Theoretically, nurses can be assumed to be affected when the structures in organizations are changed. Using a qualitative approach to explore nurses’ experiences with structural changes in health care organizations can capture a deeper understanding of the burdens of structural changes. Qualitative studies discover patterns and variations from which hypotheses and theories can be developed and practice kept up-to-date (Sandelowski and Barroso, 2007). However, to the best of our knowledge, no metasynthesis exists on the burdens of structural changes. The purpose of this article was to conduct an exhaustive review of synthesized findings from qualitative studies on the burdens of structural changes experienced by nurses in health care organizations. The findings suggest a direction for future developments.
Methods This review was designed as a meta-ethnographic metasynthesis investigating how nurses experience working in organizations undergoing structural changes. A meta-ethnographic metasynthesis is an interpretive integration of qualitative findings that offers a fully integrated description of an experience and not just a summary of unlinked features of that experience (Sandelowski and Barroso, 2007), which implies an inductive approach. This review followed Sandelowski and Barroso’s guidelines for synthesizing qualitative research
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and was conducted in the following six steps: formulating a purpose, searching for and retrieving qualitative research reports, appraising the reports, classifying the findings in the included reports, conducting a metasummary, and developing a metasynthesis by synthesizing the qualitative research findings (Sandelowski and Barroso, 2007). We used an ENTREQ statement consisting of 21 items (Tong et al., 2013) to ensure methodical rigor in this metasynthesis.
Analysis Searching for and retrieving qualitative research reports The search was performed systematically based on three parameters: the topic, the population, and the methodology. The search terms were “organizational changes OR reorganization OR organizational restructuring” AND “experience OR perception” AND “nurses OR nursing staff OR RN” AND “qualitative research”. These search terms were used in three different databases: CINAHL, PubMed, and ProQuest. For each database the search terms and strategy were modified to fit the different search systems, which included using MeSH, thesaurus, and free text searching. In addition, a search was carried out in MedNar to cover grey literature. An inclusion criterion was that the articles should be published in English, German, Norwegian, Swedish, or Danish to fit our multilingual skills and limitations. The search was not limited by date. The search was conducted by the first author (XX) in collaboration with a librarian, identifying a total of 669 articles (Figure 1). Twelve of these articles were included in the present review. To optimize the validity of the metasynthesis, the searches were performed as comprehensively and completely as possible. The search process lasted from January to April 2015 and covered studies carried out in the period from 1994 to 2014.
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Figure 1. Flow diagram, showing the inclusion of studies by a systematic literature review.
Appraising the reports After searching for and finding research reports, we screened each title; if it was appropriate we also read the abstract. A total of 114 abstracts were read. Fourteen articles were appraised using a specially designed Reading Guide for Appraisal (Sandelowski and Barroso, 2007) and the tool COREQ (Tong et al., 2007). The reading guide was designed to fit the research purpose and was used to determine whether the reports met the inclusion criteria. That is, if the reports described qualitative studies concerning nurses’ experiences with structural
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changes. The results from the reading guide were reviewed by the first author (XX), who was the first reviewer, in discussion with the second author (XX), who was the second reviewer. The reading guide was accompanied by a schematic comparative appraisal in which the key elements of the 12 included studies were shown in order to illuminate whether the articles had something specific in common or if information was missing (Table 1).
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First author, year of publication Ardern, P., 1999
Bakker, D., 2006
Blythe, J., 2001
Cloutier, E., 2006
Debesay, J., 2014
Hertting, A., 2004
Ingersoll, G., 2001
Kristiansen, L., 2010
Country of study
Participants
Method
Types of structural changes
England
4 RNs employed in day hospital
Qualitative method: semistructured interviews, observations
Closing hospital units, restructuring hospital units
Canada
Canada
Canada
Norway
Sweden
New York, USA
Sweden
51 RNs employed in a hospital 59 RNs employed in a hospital
24 registered nurses (RNs) are group interviewed, 11 RNs are observed
19 RNs employed in home care services
14 RNs employed in a hospital
48 RNs employed in two different hospitals
13 RNs employed in home
Qualitative method: observations and telephone interviews Qualitative method: focus group interviews, interviews
Mixed methods: interviews, focus group interviews, observations, document analysis, questionnaire
The structural changes were implemented because of cost reductions Reforms, cutbacks The structural changes were implemented because of cost reductions Personal reductions, closing hospital units, restructuring hospital units The structural changes were implemented because of cost reductions Reforms, closing hospitals, shift to ambulatory care, removal of care from hospitals to home
Qualitative method: semistructured interviews
The structural changes were implemented because of cost reductions Reforms, demographic changes, lack of resources, standardization of work tasks
Qualitative method: semistructured interviews
The structural changes were implemented because of cost reductions Personnel reductions, new treatment methods
Qualitative method: focus group interviews
The structural changes were implemented because of cost reductions Reforms, changes in management structure, personal reductions
Qualitative method: focus
The structural changes were implemented because of cost reductions Reforms, removal of hospital units to
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care services (psychiatry)
Montour, A., 2009
Shindul-Rothschild, J., 1994 Venturato, L., 2007
Wynne, R., 2004
Canada
Massachusetts, USA Australia
Australia
21 RNs employed in hospitals
29 RNs employed in different hospitals 14 RNs employed in home care services
10 RNs employed in a hospital
group interviews
Qualitative method: semistructured interviews, telephone interviews, e-mail interviews Qualitative method: focus group interviews, telephone interviews Qualitative method: interviews
Qualitative method: semistructured interviews, document analysis, policy analysis, author’s experiences
home care services The structural changes were implemented because of a wish to improve the quality of life for psychiatric patients, but the nurses experienced the structural changes as an excuse for cost reductions. Reforms, changes in management structure The structural changes were implemented because of cost reductions Reforms, personal reductions, cutbacks The structural changes were implemented because of cost reductions Reforms, changes in the hospital hierarchy, improving the quality in care, accreditation The structural changes were implemented because of cost reductions Reforms, changes in the hospital hierarchy, relocating hospitals, personnel reductions, closing hospitals, cutbacks The structural changes were implemented because of cost reductions
Table 1. The schematic comparative appraisal, showing the characteristics of every study.
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Table 1 summarizes the characteristics of the 12 included articles by explicating similarities and differences. The review represents 317 participants from six different countries. Furthermore, the majority of the articles describe the structural changes as the result of cost reductions, but one (Kristiansen et al., 2010) claimed that the structural changes were implemented to improve the quality of life for the patients, though the nurses believed that the changes were an excuse for reducing costs. Notably, the 12 articles are distinct from each other. In other words, we have not included articles based on the same study.
Classifying the findings in the included studies Study findings have to be interpreted to some extent if they are to be considered real findings. In order to understand what the researchers actually did in their analyses and gain knowledge about the interpretations the findings went through, we classified the findings from the included studies into one or two of the following classifications: thematic surveys, conceptual/thematic descriptions, or interpretive explanations.
Conducting a metasummary A metasummary was conducted to achieve quantitative aggregation of the qualitative findings. The metasummary illuminated which findings were the most frequent across the studies and which study contributed the most to the analysis. All findings from every study were extracted, edited, grouped, and abstracted.
Development of a metasynthesis by synthesizing the research findings There are many different ways to synthesize research findings. We used the constant targeted comparison because the purpose of this type of analysis is to identify similarities and
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differences in the included studies (Sandelowski and Barroso, 2007). This identification can contribute to increasing our understanding of nurses’ experiences working in organizations undergoing structural changes.
Findings The findings of the review are reported in a metasummary and a metasynthesis.
Metasummary The metasummary is shown in Table 2; the results are quantitative aggregations describing the frequency of each finding. The subcategory increased workload was the most frequent finding in every study (100%), whereas compromising ideal nursing was present in 83.33% of the included studies. Therefore, these two findings are the top findings in the metasummary. The metasummary also clarified which studies we used the most. The study conducted by Venturato et al. (2007) was used in 81.25% of all subcategories, which means that the findings of this review are strongly influenced by the findings in that study.
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Figure 2. Metasummary showing the intensity of every study used and the frequency of every subcategory.
Metasynthesis The metasynthesis contributes to the review by using a more qualitative approach to the categories and subcategories. The metasynthesis shows how findings from the different studies relate to each other in the same subcategory and how they contribute to illuminating nurses’ experiences working in organizations undergoing structural changes. The overall findings are four categories: nursing management, emotional responses, nursing work, and colleagues. The subcategories are 16 different types of experiences.
Nursing management
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This category consists of four types of experiences describing how structural changes influence nurses’ relationships with the nursing management. The need for visible nursing management, the relationship between nurses and managers, the feeling of being torn between conflicting demands, and the feeling of being imposed upon by top-down decisions are experiences that contribute to illuminating how nurses experience nursing management when working in organizations undergoing structural changes. The nurses describe a serious lack of communication from management when restructuring (Kristiansen et al., 2010; Montour et al., 2009; Wynne, 2004). Some nurses see management as representatives of the changes and distance themselves from managers and leaders (Ardern, 1999). For some nurses, the feeling of being torn between conflicting demands is due to a rigid organizational system that limits the nurses in their daily work. On the other hand, there is an expectation of high-quality care in which the nurses should be flexible and independent (Venturato et al., 2007). Top-down decision making is perceived by nurses as a way of excluding them from decisions, thereby taking away their co-determination (Blythe et al., 2001; Cloutier et al., 2008; Debesay et al., 2014; Ingersoll et al., 2001; Venturato et al., 2007; Wynne, 2004).
Emotional responses This category consists of six types of experiences describing how structural changes impact nurses emotionally. Generally, the feelings associated with structural changes are negative, despite the feelings described in the subcategory the joy associated with nursing work. Nurses in half of the included studies indicated that, despite all negative outcomes from structural changes, some nurses enjoy their job and caring for patients (Bakker et al., 2006; Hertting et al., 2004; Kristiansen et al., 2010; Montour et al., 2009; Shindul-Rothschild, 1994; Venturato et al., 2007). The joy associated with nursing work should not be seen as a result of structural
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changes, but as some nurses managing to maintain the joy despite the negative consequences of the structural changes. Nevertheless, many nurses also feel frustrated, without influence, and “emotionally drained” (Shindul-Rothschild, 1994, p. 551) because of the restructuring. In one of the studies the nurses experienced a need for “mentally turning work off (when going home) in order to safeguard their own health” (Hertting et al., 2004, p. 150), which can be perceived as a disturbance in the balance between the nurses’ working lives and their private lives. It can also be understood as a way of “surviving” the restructuring (Bakker et al., 2006, p. 84) or that the desire to be a nurse was more important.
Nursing work This category consists of four types of experiences describing how nursing work is affected by structural changes. All of the included studies are represented in this category. Nursing work comprises the daily work tasks that nurses perform when they are on the job, including patient care, drug administration, documentation, patient guidance and education, monitoring patients, and screening tasks. The nurses experience that an increase in nursing tasks has consequences on the quality of the basic nursing work (Ardern, 1999; Bakker et al., 2006; Blythe et al., 2001; Cloutier et al., 2008; Debesay et al., 2014; Hertting et al., 2004; Ingersoll et al., 2001; Kristiansen et al., 2010; Montour et al., 2009; Shindul-Rothschild, 1994; Venturato et al., 2007; Wynne, 2004). During reorganization, nurses experience an increased amount of administrative work, which makes the nurses feel that they have to take on extra work tasks (Montour et al., 2009; Shindul-Rothschild, 1994). However, some nurses also see the administrative work as “a chance to unwind and relax, as the constant empathy required of them in their job could be emotionally draining” (Hertting et al., 2004, p. 149).
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Colleagues This category consists of two types of experiences describing how structural changes significantly influence nurses’ collegial relationships in both a negative and positive way. Most structural changes imply redundancies and, therefore, an increased workload for the remaining nurses. The redundancies also result in hiring “unlicensed personnel” (ShindulRothschild, 1994, p. 500), which compromises the quality of the nursing care and creates frustrations among the nurses. However, it also fosters a feeling of team spirit and a desire to help one’s colleagues (Ardern, 1999; Bakker et al., 2006; Blythe et al., 2001; Ingersoll et al., 2001; Kristiansen et al., 2010; Montour et al., 2009; Shindul-Rothschild, 1994; Venturato et al., 2007).
Interpretive integration We also found that the 16 different types of experiences are linked to each other in a way that goes beyond the four categories, which is the interpretive integration of this study (Figure 3). While systematizing the findings in the metasynthesis, we were surprised to find increased workload and the joy associated with nursing work because they represent a paradox in the nurses’ descriptions of their experiences working in organizations undergoing structural changes. Therefore, these findings are placed as the outset for the interpretive integration (Figure 3). To conduct the interpretive integration of this study, we used a meta-ethnographic method in order to integrate the findings from the reports. This method implied an inductive approach, where the findings from the reports were integrated with each other in order to produce a new interpretated wholeness and not just a summary of the findings.
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Figure 3. Metasynthesis, the interpretive integration, showing the relations between the study’s findings.
The main finding increased workload is the ultimate result of structural reorganization. Nurses also experience a connection between increased workload and lack of nurses, which causes the remaining nurses to experience a neglect of professional development due to a lack of resources. In addition, nurses feel that the lack of nurses generates a significant change in the collegial relationship and a need for role clarification among the remaining nurses. As seen in Figure 3, the increased workload also contributes to nurses feeling torn between conflicting demands. On one hand, they should cope with new economic demands coming from the reorganization, but on the other hand they should give the best nursing care to
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patients. According to the nurses, this results in compromising the ideal nursing, as the system defined by the reorganization does not allow them to perform the care they hoped for professionally and for which they were educated. Therefore, some nurses apply survival strategies in order to endure in jobs in which their job satisfaction is challenged by structural reorganization. The feeling of being torn between conflicting demands also results in some nurses having a problematic relationship with their managers, as the nurses see them as representatives of the structural changes and, therefore, as threats. Consequently, there is a need for visible nursing management. The nurses’ experiences with imposed top-down decisions also challenge the relationship with their managers, as the nurses do not feel that they have opportunities to ask questions or debate the structural reorganization. Some nurses see this as a control form exercised by managers, and some nurses describe physical and emotional responses as a consequence of imposed top-down decisions because they feel frustrated and unable to adequately stand up for their nursing ideals. The result of this is that some nurses experience negative development in their professional status, as they do not feel that they are seen as competent coworkers in the implementation of the structural reorganization. The physical and emotional responses also contribute to the threat to the normal balance between working and private lives because the nurses feel so affected by the structural reorganization, even when they are at home. The additional finding, the joy associated with nursing work, is notable because it is not associated with the main findings of this metasynthesis. This presentation was chosen to show that, despite the other rather negative findings, some of the nurses describe a joy associated with being a nurse. We found that some nurses describe being so satisfied by
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working with patients that it compensates for the negative consequences of the structural reorganization.
Discussion This metasynthesis based on interpreted findings from 12 qualitative studies offers a thorough understanding of how nurses experience being employed in organizations undergoing structural changes. 16 different types of experiences were found, organized into four categories. Figure 3 shows the interrelations between the experiences, including the paradox in the main findings.
Increased workload and joy The findings increased workload and the joy associated with nursing work contradicted nurses’ experiences working in organizations undergoing structural changes. The findings show, that while all the nurses in the included studies experience the reorganizations as frustrating and challenging, some nurses also experience a joy. As a heavy workload usually reduce employee job satisfaction (Billeter-Koponen and Fredén, 2005; Grønkjær, 2013; Kristensen, 2012), it is paradoxical that some nurses experience this joy associated with nursing work. Thus, some nurses from the included studies accepted the negative consequences of structural changes because working with patients is considered more valuable. Furthermore, some nurses experienced a joy associated with nursing work despite the fact that an increased workload reduces job satisfaction (Billeter-Koponen and Fredén, 2005; Grønkjær, 2013; Kristensen, 2012). During the appraisal it became clear that when the structural change occurred relative to when the study was carried out was different from study to study. Studies were performed in
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the middle of the change, a few months after the change, or years after the change. Therefore, it is not possible to determine whether nurses are able to put their needs aside for shorter or longer periods of time. However, when in the process of structural change nurses are asked about their experiences seems to be important. In a 3-year follow-up study, Hertting et al. (2004) found that nurses felt reverted to a resigned approach due to recurrent demands. The nurses felt trapped because they realized that the structural changes were a basic condition. Consequently, nurses can be sceptical of structural changes argued to improve the quality of care. Kristiansen et al. (2010) found that nurses see the structural changes as an excuse for reducing costs despite the policy makers’ statement about improving the quality of care. Another finding in the metasynthesis is the need for visible nursing management. This need is supported by an international research team working with the PSYRES-project that recommended management be visible and in dialog with employees when a company is going through structural changes (Pahkin et al., 2012). Therefore, visible nursing management can contribute to increasing job satisfaction among nurses working in organizations undergoing structural changes. The significance of paying attention to structural changes in an organization was also described by Leavitt (1974), who developed a theory concerning changes in an organization. Through his research, Leavitt concluded that managers have to include every part of an organization when implementing structural changes (Bakka and Nielsen, 1990; Danielsen and Lange, 2013; Leavitt, 1974). The parts that comprise an organization are tasks, structure, people, and technology. In addition, society will also influence an organization’s structure. Recognizing the interactions between every part is essential when understanding the dynamic of an organization undergoing structural changes (Leavitt, 1974). Society can be seen as health care reforms, which affect the structures (i.e., structural changes), which again affect
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the people (i.e., nurses). Therefore, health care reforms affect the tasks (i.e., nursing care) and the technology (i.e. new treatment methods). This means that health care reforms start an avalanche of interactions between every part of the model. Consequently, a combination of the PSYRES-project and Leavitt can contribute to our understanding of why nurses in this metasynthesis have a need for visible nursing management when the nurses are seen as part of a system. Nurses need someone to guide them when structures are changing. If Leavitt’s theory is used when organizations are restructuring, the challenges may be dealt with in a more systematic and comprehensive manner and contribute to preventing some of the problems nurses described in this metasynthesis. A study investigating the impact of the Productive Ward-Releasing Time to Care program (Van Bogaert et al., 2014) showed that, when restructuring, it is important to ensure that the new strategies are aligned with the daily practices of health care workers so that the employees have the best possibility of doing their jobs and feeling satisfied with it. These findings support the results of the metasynthesis, in which we found that nurses experience an increased workload, including extra administrative work and extra nursing tasks (Ardern, 1999; Bakker et al., 2006; Blythe et al., 2001; Cloutier et al., 2008; Debesay et al., 2014; Hertting et al., 2004; Ingersoll et al., 2001; Kristiansen et al., 2010; Montour et al., 2009; Shindul-Rothschild, 1994; Venturato et al., 2007; Wynne, 2004). This increased workload is something the nurses cannot see the point in because it takes away time from patient care and, therefore, is not aligned with their daily work, causing the nurses to feel that they have to compromise the ideal nursing (Ardern, 1999; Bakker et al., 2006; Blythe et al., 2001; Cloutier et al., 2008; Debesay et al., 2014; Ingersoll et al., 2001; Kristiansen et al., 2010; ShindulRothschild, 1994; Venturato et al., 2007; Wynne, 2004). The experiences described in this
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metasynthesis show that nurses do not feel that management has taken daily practice into account, which may be why the nurses practically see the structural changes as burdens.
Strengths and limitations This study has some limitations. First, we tried to identify every study relevant to this metasynthesis by searching different databases covering the period from 1994 to 2014. However, we cannot be sure to have discovered all published studies in this field, despite consulting a librarian and using a comprehensive search strategy. In April 2015, no further studies were found, so we stopped the search. Another limitation of this metasynthesis is that we did not include studies from non-Western countries. Also, our metasynthesis was based on studies from Sweden, Norway, Australia, Canada, England, and the United States and our findings are not necessarily transferable to nurses in other Western countries. However, the findings from this metasynthesis are deeply rooted in Western nurses’ experiences and, therefore, to some extent, transferable to Western nurses, which strengthens the review. Despite a wish to conduct an extensive metasynthesis, we chose to exclude the one study we found that was conducted in Asia. The study was from Taiwan and excluded because it clearly argued that the working conditions for Taiwanese and Western nurses could not be compared (Su et al., 2009). Supplementing our findings with other methodical studies, such as a qualitative interview study exploring nurses’ experiences working in organizations undergoing structural changes at the present time, would be relevant.
Conclusion
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We demonstrated how nurses experience structural changes and how an interpretive integration of the qualitative findings can increase our understanding of nurses’ experiences being employed in organizations undergoing structural changes. The nurses from the included studies tended to put their own needs aside when an increased workload pressed them physically and emotionally because they experience joy in their daily work with the patients despite the negative consequences of the structural changes. This enlightening of the circumstances is central for hospital management if they wish to secure a good working environment and job satisfaction for nurses in the long-term when restructuring the organization. The implementation of changes is challenging, but research shows that a well-organized approach to implementation increases the success rate (Dulko, 2007). For example, the hospital management could benefit from using some of the components from Leavitt’s theory to ensure that they deal with every aspect of the restructuring and its consequences. In addition, the management could take into account whether the structural changes actually improve the daily work of the nurses and, if not, how they can achieve this. According to the Productive Ward-Releasing Time to Care program, this would increase nurses’ job satisfaction and patient care (Van Bogaert et al., 2014). Future studies should explore the long-term consequences of nurses working in organizations undergoing structural changes, thereby setting their own needs aside, as seen in this metasynthesis. Some nurses burnout because of the pressure (Grønkjær, 2013), but it would be interesting to know how large of a proportion of nurses is affected. According to this review, many nurses exhibit signs of burnout, and if every nurse working in the context of restructuring is at risk of burning out, our hope is that it is taken serious by politicians and managers for the sake of both the nurses and patients.
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Van Bogaert, P., Van Heusden, D., Somers, A., Tegenbos, M., Wouters, K., Van der Straeten, J., Van Aken, P. & Sullivan Havens, D. 2014, “The Productive Ward Program: a longitudinal multilevel study of nurse perceived practice environment, burnout, and nurse-reported quality of care and job outcomes”, The Journal of Nursing Administration, vol. 44, no. 9, pp. 452-461. Vahtera, J., Kivimäki, M., Pentti, J., Linna, A., Virtanen, M., Virtanen, P. & Ferrie, J.E. 2004, “Organisational downsizing, sickness absence, and mortality: 10-town prospective cohort study”, British Medical Journal, vol. 328, no. 7439, pp. 555-558. Venturato, L., Kellett, U. & Windsor, C. 2007, “Nurses’ experiences of practice and political reform in long-term aged care in Australia: implications for the retention of nursing personnel”, Journal of Nursing Management, vol. 15, no. 1, pp. 4-11. Wynne, R. 2004, “Ten Australian ICU nurses’ perceptions of organisational restructuring”, Australian Critical Care, vol. 17, no. 1, pp. 16-24.
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S0020-7489(16)30239-5 http://dx.doi.org/doi:10.1016/j.ijnurstu.2016.12.002 NS 2867
To appear in: Received date: Revised date: Accepted date:
14-4-2016 20-11-2016 3-12-2016
Please cite this article as: Jensen, Anne Sofie Bøtcher, Sørensen, Dorthe, Nurses’ experiences of working in organizations undergoing restructuring: A metasynthesis of qualitative research studies.International Journal of Nursing Studies http://dx.doi.org/10.1016/j.ijnurstu.2016.12.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title page Nurses' experiences of working in organizations undergoing restructuring: a metasynthesis of qualitative research studies First author and corresponding author: Anne Sofie Bøtcher Jensen, RN, master in nursing science Affiliations: VIA University College, Center for Research in Health Promotion and Rehabilitation Address: Hedeager 2, 8200 Aarhus N, Denmark E-mail: [email protected] Telephone: 0045 22309201 Second author: Dorthe Sørensen, RN, PhD Affiliations: VIA University College, Center for Research in Health Promotion and Rehabilitation Address: Hedeager 2, 8200 Aarhus N, Denmark E-mail: [email protected]
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Contribution of this paper What is already known about this topic -
Structural changes are common and every nurse experiences this phenomenon.
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Quantitative research has shown that structural changes can have a negative impact on job satisfaction among nurses.
What this paper adds -
The paper provides an exhaustive description of nurses’ collected experiences working in organizations undergoing structural changes.
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Nurses experience an increased workload due to structural changes but still experience a joy associated with the nursing work.
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Nurses' experiences of working in organizations undergoing restructuring: a metasynthesis of qualitative research studies
Introduction In order to optimize the use of resources, reduce costs, and improve the quality of patient treatment, many health care organizations undergo continual reconfiguration (BilleterKoponen and Fredén, 2005; Johnston, 1997; Kivimäki et al., 2007; Kuokkanen et al., 2009; Hjort, 2012). This reconfiguration often results in structural changes in the health care organization. An example of such a development is currently occurring in Denmark. In April 2015, the Danish government announced that a new health care reform would be launched during 2016 (Department of Health and Prevention, 2015). The reform intends to achieve economic cost savings, higher quality services, and a general improvement of health status among the citizens. In addition, Canada, Sweden, Australia, England, Norway, and the United States have also undergone such developments in order to reduce costs (Ardern, 1999; Bakker et al., 2006; Blythe et al., 2001; Cloutier et al., 2008; Debesay et al., 2014; Hertting et al., 2004; Ingersoll et al., 2001; Kristiansen et al., 2010; Montour et al., 2009; ShindulRothschild, 1994; Venturato et al., 2007; Wynne, 2004). These developments have greatly influenced the structure of the health care organizations in these countries by restructuring hospital units, standardizing work tasks, creating redundancies, and reorganizing the hospital hierarchy. Nevertheless, research has shown that structural changes can have a negative impact on nurses’ job satisfaction (Kuokkanen et al., 2009) and that the work environment is eroded by these changes (Johnston, 1997). One study reported that one of the reasons for nurses being stressed and burned out is the organizations undergoing constant structural changes (Grønkjær, 2013). Furthermore, these changes can lead to physical and mental illness
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among nurses (Kristensen, 2012) and influence the use of drugs and disease-related mortality (Erikssen et al., 1990; Ferrie et al., 2002; Iversen et al., 1989; Kivimäki et al., 2007; Vahtera et al., 2004). To prevent these negative effects, a study focusing on structural changes and nurses’ experiences with these changes is highly relevant. The American management psychologist Harold Leavitt (1974) believed that when the structures in an organization are changed, it will affect the remaining elements of the organization, such as the people involved. Theoretically, nurses can be assumed to be affected when the structures in organizations are changed. Using a qualitative approach to explore nurses’ experiences with structural changes in health care organizations can capture a deeper understanding of the burdens of structural changes. Qualitative studies discover patterns and variations from which hypotheses and theories can be developed and practice kept up-to-date (Sandelowski and Barroso, 2007). However, to the best of our knowledge, no metasynthesis exists on the burdens of structural changes. The purpose of this article was to conduct an exhaustive review of synthesized findings from qualitative studies on the burdens of structural changes experienced by nurses in health care organizations. The findings suggest a direction for future developments.
Methods This review was designed as a meta-ethnographic metasynthesis investigating how nurses experience working in organizations undergoing structural changes. A meta-ethnographic metasynthesis is an interpretive integration of qualitative findings that offers a fully integrated description of an experience and not just a summary of unlinked features of that experience (Sandelowski and Barroso, 2007), which implies an inductive approach. This review followed Sandelowski and Barroso’s guidelines for synthesizing qualitative research
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and was conducted in the following six steps: formulating a purpose, searching for and retrieving qualitative research reports, appraising the reports, classifying the findings in the included reports, conducting a metasummary, and developing a metasynthesis by synthesizing the qualitative research findings (Sandelowski and Barroso, 2007). We used an ENTREQ statement consisting of 21 items (Tong et al., 2013) to ensure methodical rigor in this metasynthesis.
Analysis Searching for and retrieving qualitative research reports The search was performed systematically based on three parameters: the topic, the population, and the methodology. The search terms were “organizational changes OR reorganization OR organizational restructuring” AND “experience OR perception” AND “nurses OR nursing staff OR RN” AND “qualitative research”. These search terms were used in three different databases: CINAHL, PubMed, and ProQuest. For each database the search terms and strategy were modified to fit the different search systems, which included using MeSH, thesaurus, and free text searching. In addition, a search was carried out in MedNar to cover grey literature. An inclusion criterion was that the articles should be published in English, German, Norwegian, Swedish, or Danish to fit our multilingual skills and limitations. The search was not limited by date. The search was conducted by the first author (XX) in collaboration with a librarian, identifying a total of 669 articles (Figure 1). Twelve of these articles were included in the present review. To optimize the validity of the metasynthesis, the searches were performed as comprehensively and completely as possible. The search process lasted from January to April 2015 and covered studies carried out in the period from 1994 to 2014.
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Figure 1. Flow diagram, showing the inclusion of studies by a systematic literature review.
Appraising the reports After searching for and finding research reports, we screened each title; if it was appropriate we also read the abstract. A total of 114 abstracts were read. Fourteen articles were appraised using a specially designed Reading Guide for Appraisal (Sandelowski and Barroso, 2007) and the tool COREQ (Tong et al., 2007). The reading guide was designed to fit the research purpose and was used to determine whether the reports met the inclusion criteria. That is, if the reports described qualitative studies concerning nurses’ experiences with structural
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changes. The results from the reading guide were reviewed by the first author (XX), who was the first reviewer, in discussion with the second author (XX), who was the second reviewer. The reading guide was accompanied by a schematic comparative appraisal in which the key elements of the 12 included studies were shown in order to illuminate whether the articles had something specific in common or if information was missing (Table 1).
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First author, year of publication Ardern, P., 1999
Bakker, D., 2006
Blythe, J., 2001
Cloutier, E., 2006
Debesay, J., 2014
Hertting, A., 2004
Ingersoll, G., 2001
Kristiansen, L., 2010
Country of study
Participants
Method
Types of structural changes
England
4 RNs employed in day hospital
Qualitative method: semistructured interviews, observations
Closing hospital units, restructuring hospital units
Canada
Canada
Canada
Norway
Sweden
New York, USA
Sweden
51 RNs employed in a hospital 59 RNs employed in a hospital
24 registered nurses (RNs) are group interviewed, 11 RNs are observed
19 RNs employed in home care services
14 RNs employed in a hospital
48 RNs employed in two different hospitals
13 RNs employed in home
Qualitative method: observations and telephone interviews Qualitative method: focus group interviews, interviews
Mixed methods: interviews, focus group interviews, observations, document analysis, questionnaire
The structural changes were implemented because of cost reductions Reforms, cutbacks The structural changes were implemented because of cost reductions Personal reductions, closing hospital units, restructuring hospital units The structural changes were implemented because of cost reductions Reforms, closing hospitals, shift to ambulatory care, removal of care from hospitals to home
Qualitative method: semistructured interviews
The structural changes were implemented because of cost reductions Reforms, demographic changes, lack of resources, standardization of work tasks
Qualitative method: semistructured interviews
The structural changes were implemented because of cost reductions Personnel reductions, new treatment methods
Qualitative method: focus group interviews
The structural changes were implemented because of cost reductions Reforms, changes in management structure, personal reductions
Qualitative method: focus
The structural changes were implemented because of cost reductions Reforms, removal of hospital units to
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care services (psychiatry)
Montour, A., 2009
Shindul-Rothschild, J., 1994 Venturato, L., 2007
Wynne, R., 2004
Canada
Massachusetts, USA Australia
Australia
21 RNs employed in hospitals
29 RNs employed in different hospitals 14 RNs employed in home care services
10 RNs employed in a hospital
group interviews
Qualitative method: semistructured interviews, telephone interviews, e-mail interviews Qualitative method: focus group interviews, telephone interviews Qualitative method: interviews
Qualitative method: semistructured interviews, document analysis, policy analysis, author’s experiences
home care services The structural changes were implemented because of a wish to improve the quality of life for psychiatric patients, but the nurses experienced the structural changes as an excuse for cost reductions. Reforms, changes in management structure The structural changes were implemented because of cost reductions Reforms, personal reductions, cutbacks The structural changes were implemented because of cost reductions Reforms, changes in the hospital hierarchy, improving the quality in care, accreditation The structural changes were implemented because of cost reductions Reforms, changes in the hospital hierarchy, relocating hospitals, personnel reductions, closing hospitals, cutbacks The structural changes were implemented because of cost reductions
Table 1. The schematic comparative appraisal, showing the characteristics of every study.
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Table 1 summarizes the characteristics of the 12 included articles by explicating similarities and differences. The review represents 317 participants from six different countries. Furthermore, the majority of the articles describe the structural changes as the result of cost reductions, but one (Kristiansen et al., 2010) claimed that the structural changes were implemented to improve the quality of life for the patients, though the nurses believed that the changes were an excuse for reducing costs. Notably, the 12 articles are distinct from each other. In other words, we have not included articles based on the same study.
Classifying the findings in the included studies Study findings have to be interpreted to some extent if they are to be considered real findings. In order to understand what the researchers actually did in their analyses and gain knowledge about the interpretations the findings went through, we classified the findings from the included studies into one or two of the following classifications: thematic surveys, conceptual/thematic descriptions, or interpretive explanations.
Conducting a metasummary A metasummary was conducted to achieve quantitative aggregation of the qualitative findings. The metasummary illuminated which findings were the most frequent across the studies and which study contributed the most to the analysis. All findings from every study were extracted, edited, grouped, and abstracted.
Development of a metasynthesis by synthesizing the research findings There are many different ways to synthesize research findings. We used the constant targeted comparison because the purpose of this type of analysis is to identify similarities and
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differences in the included studies (Sandelowski and Barroso, 2007). This identification can contribute to increasing our understanding of nurses’ experiences working in organizations undergoing structural changes.
Findings The findings of the review are reported in a metasummary and a metasynthesis.
Metasummary The metasummary is shown in Table 2; the results are quantitative aggregations describing the frequency of each finding. The subcategory increased workload was the most frequent finding in every study (100%), whereas compromising ideal nursing was present in 83.33% of the included studies. Therefore, these two findings are the top findings in the metasummary. The metasummary also clarified which studies we used the most. The study conducted by Venturato et al. (2007) was used in 81.25% of all subcategories, which means that the findings of this review are strongly influenced by the findings in that study.
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Figure 2. Metasummary showing the intensity of every study used and the frequency of every subcategory.
Metasynthesis The metasynthesis contributes to the review by using a more qualitative approach to the categories and subcategories. The metasynthesis shows how findings from the different studies relate to each other in the same subcategory and how they contribute to illuminating nurses’ experiences working in organizations undergoing structural changes. The overall findings are four categories: nursing management, emotional responses, nursing work, and colleagues. The subcategories are 16 different types of experiences.
Nursing management
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This category consists of four types of experiences describing how structural changes influence nurses’ relationships with the nursing management. The need for visible nursing management, the relationship between nurses and managers, the feeling of being torn between conflicting demands, and the feeling of being imposed upon by top-down decisions are experiences that contribute to illuminating how nurses experience nursing management when working in organizations undergoing structural changes. The nurses describe a serious lack of communication from management when restructuring (Kristiansen et al., 2010; Montour et al., 2009; Wynne, 2004). Some nurses see management as representatives of the changes and distance themselves from managers and leaders (Ardern, 1999). For some nurses, the feeling of being torn between conflicting demands is due to a rigid organizational system that limits the nurses in their daily work. On the other hand, there is an expectation of high-quality care in which the nurses should be flexible and independent (Venturato et al., 2007). Top-down decision making is perceived by nurses as a way of excluding them from decisions, thereby taking away their co-determination (Blythe et al., 2001; Cloutier et al., 2008; Debesay et al., 2014; Ingersoll et al., 2001; Venturato et al., 2007; Wynne, 2004).
Emotional responses This category consists of six types of experiences describing how structural changes impact nurses emotionally. Generally, the feelings associated with structural changes are negative, despite the feelings described in the subcategory the joy associated with nursing work. Nurses in half of the included studies indicated that, despite all negative outcomes from structural changes, some nurses enjoy their job and caring for patients (Bakker et al., 2006; Hertting et al., 2004; Kristiansen et al., 2010; Montour et al., 2009; Shindul-Rothschild, 1994; Venturato et al., 2007). The joy associated with nursing work should not be seen as a result of structural
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changes, but as some nurses managing to maintain the joy despite the negative consequences of the structural changes. Nevertheless, many nurses also feel frustrated, without influence, and “emotionally drained” (Shindul-Rothschild, 1994, p. 551) because of the restructuring. In one of the studies the nurses experienced a need for “mentally turning work off (when going home) in order to safeguard their own health” (Hertting et al., 2004, p. 150), which can be perceived as a disturbance in the balance between the nurses’ working lives and their private lives. It can also be understood as a way of “surviving” the restructuring (Bakker et al., 2006, p. 84) or that the desire to be a nurse was more important.
Nursing work This category consists of four types of experiences describing how nursing work is affected by structural changes. All of the included studies are represented in this category. Nursing work comprises the daily work tasks that nurses perform when they are on the job, including patient care, drug administration, documentation, patient guidance and education, monitoring patients, and screening tasks. The nurses experience that an increase in nursing tasks has consequences on the quality of the basic nursing work (Ardern, 1999; Bakker et al., 2006; Blythe et al., 2001; Cloutier et al., 2008; Debesay et al., 2014; Hertting et al., 2004; Ingersoll et al., 2001; Kristiansen et al., 2010; Montour et al., 2009; Shindul-Rothschild, 1994; Venturato et al., 2007; Wynne, 2004). During reorganization, nurses experience an increased amount of administrative work, which makes the nurses feel that they have to take on extra work tasks (Montour et al., 2009; Shindul-Rothschild, 1994). However, some nurses also see the administrative work as “a chance to unwind and relax, as the constant empathy required of them in their job could be emotionally draining” (Hertting et al., 2004, p. 149).
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Colleagues This category consists of two types of experiences describing how structural changes significantly influence nurses’ collegial relationships in both a negative and positive way. Most structural changes imply redundancies and, therefore, an increased workload for the remaining nurses. The redundancies also result in hiring “unlicensed personnel” (ShindulRothschild, 1994, p. 500), which compromises the quality of the nursing care and creates frustrations among the nurses. However, it also fosters a feeling of team spirit and a desire to help one’s colleagues (Ardern, 1999; Bakker et al., 2006; Blythe et al., 2001; Ingersoll et al., 2001; Kristiansen et al., 2010; Montour et al., 2009; Shindul-Rothschild, 1994; Venturato et al., 2007).
Interpretive integration We also found that the 16 different types of experiences are linked to each other in a way that goes beyond the four categories, which is the interpretive integration of this study (Figure 3). While systematizing the findings in the metasynthesis, we were surprised to find increased workload and the joy associated with nursing work because they represent a paradox in the nurses’ descriptions of their experiences working in organizations undergoing structural changes. Therefore, these findings are placed as the outset for the interpretive integration (Figure 3). To conduct the interpretive integration of this study, we used a meta-ethnographic method in order to integrate the findings from the reports. This method implied an inductive approach, where the findings from the reports were integrated with each other in order to produce a new interpretated wholeness and not just a summary of the findings.
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Figure 3. Metasynthesis, the interpretive integration, showing the relations between the study’s findings.
The main finding increased workload is the ultimate result of structural reorganization. Nurses also experience a connection between increased workload and lack of nurses, which causes the remaining nurses to experience a neglect of professional development due to a lack of resources. In addition, nurses feel that the lack of nurses generates a significant change in the collegial relationship and a need for role clarification among the remaining nurses. As seen in Figure 3, the increased workload also contributes to nurses feeling torn between conflicting demands. On one hand, they should cope with new economic demands coming from the reorganization, but on the other hand they should give the best nursing care to
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patients. According to the nurses, this results in compromising the ideal nursing, as the system defined by the reorganization does not allow them to perform the care they hoped for professionally and for which they were educated. Therefore, some nurses apply survival strategies in order to endure in jobs in which their job satisfaction is challenged by structural reorganization. The feeling of being torn between conflicting demands also results in some nurses having a problematic relationship with their managers, as the nurses see them as representatives of the structural changes and, therefore, as threats. Consequently, there is a need for visible nursing management. The nurses’ experiences with imposed top-down decisions also challenge the relationship with their managers, as the nurses do not feel that they have opportunities to ask questions or debate the structural reorganization. Some nurses see this as a control form exercised by managers, and some nurses describe physical and emotional responses as a consequence of imposed top-down decisions because they feel frustrated and unable to adequately stand up for their nursing ideals. The result of this is that some nurses experience negative development in their professional status, as they do not feel that they are seen as competent coworkers in the implementation of the structural reorganization. The physical and emotional responses also contribute to the threat to the normal balance between working and private lives because the nurses feel so affected by the structural reorganization, even when they are at home. The additional finding, the joy associated with nursing work, is notable because it is not associated with the main findings of this metasynthesis. This presentation was chosen to show that, despite the other rather negative findings, some of the nurses describe a joy associated with being a nurse. We found that some nurses describe being so satisfied by
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working with patients that it compensates for the negative consequences of the structural reorganization.
Discussion This metasynthesis based on interpreted findings from 12 qualitative studies offers a thorough understanding of how nurses experience being employed in organizations undergoing structural changes. 16 different types of experiences were found, organized into four categories. Figure 3 shows the interrelations between the experiences, including the paradox in the main findings.
Increased workload and joy The findings increased workload and the joy associated with nursing work contradicted nurses’ experiences working in organizations undergoing structural changes. The findings show, that while all the nurses in the included studies experience the reorganizations as frustrating and challenging, some nurses also experience a joy. As a heavy workload usually reduce employee job satisfaction (Billeter-Koponen and Fredén, 2005; Grønkjær, 2013; Kristensen, 2012), it is paradoxical that some nurses experience this joy associated with nursing work. Thus, some nurses from the included studies accepted the negative consequences of structural changes because working with patients is considered more valuable. Furthermore, some nurses experienced a joy associated with nursing work despite the fact that an increased workload reduces job satisfaction (Billeter-Koponen and Fredén, 2005; Grønkjær, 2013; Kristensen, 2012). During the appraisal it became clear that when the structural change occurred relative to when the study was carried out was different from study to study. Studies were performed in
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the middle of the change, a few months after the change, or years after the change. Therefore, it is not possible to determine whether nurses are able to put their needs aside for shorter or longer periods of time. However, when in the process of structural change nurses are asked about their experiences seems to be important. In a 3-year follow-up study, Hertting et al. (2004) found that nurses felt reverted to a resigned approach due to recurrent demands. The nurses felt trapped because they realized that the structural changes were a basic condition. Consequently, nurses can be sceptical of structural changes argued to improve the quality of care. Kristiansen et al. (2010) found that nurses see the structural changes as an excuse for reducing costs despite the policy makers’ statement about improving the quality of care. Another finding in the metasynthesis is the need for visible nursing management. This need is supported by an international research team working with the PSYRES-project that recommended management be visible and in dialog with employees when a company is going through structural changes (Pahkin et al., 2012). Therefore, visible nursing management can contribute to increasing job satisfaction among nurses working in organizations undergoing structural changes. The significance of paying attention to structural changes in an organization was also described by Leavitt (1974), who developed a theory concerning changes in an organization. Through his research, Leavitt concluded that managers have to include every part of an organization when implementing structural changes (Bakka and Nielsen, 1990; Danielsen and Lange, 2013; Leavitt, 1974). The parts that comprise an organization are tasks, structure, people, and technology. In addition, society will also influence an organization’s structure. Recognizing the interactions between every part is essential when understanding the dynamic of an organization undergoing structural changes (Leavitt, 1974). Society can be seen as health care reforms, which affect the structures (i.e., structural changes), which again affect
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the people (i.e., nurses). Therefore, health care reforms affect the tasks (i.e., nursing care) and the technology (i.e. new treatment methods). This means that health care reforms start an avalanche of interactions between every part of the model. Consequently, a combination of the PSYRES-project and Leavitt can contribute to our understanding of why nurses in this metasynthesis have a need for visible nursing management when the nurses are seen as part of a system. Nurses need someone to guide them when structures are changing. If Leavitt’s theory is used when organizations are restructuring, the challenges may be dealt with in a more systematic and comprehensive manner and contribute to preventing some of the problems nurses described in this metasynthesis. A study investigating the impact of the Productive Ward-Releasing Time to Care program (Van Bogaert et al., 2014) showed that, when restructuring, it is important to ensure that the new strategies are aligned with the daily practices of health care workers so that the employees have the best possibility of doing their jobs and feeling satisfied with it. These findings support the results of the metasynthesis, in which we found that nurses experience an increased workload, including extra administrative work and extra nursing tasks (Ardern, 1999; Bakker et al., 2006; Blythe et al., 2001; Cloutier et al., 2008; Debesay et al., 2014; Hertting et al., 2004; Ingersoll et al., 2001; Kristiansen et al., 2010; Montour et al., 2009; Shindul-Rothschild, 1994; Venturato et al., 2007; Wynne, 2004). This increased workload is something the nurses cannot see the point in because it takes away time from patient care and, therefore, is not aligned with their daily work, causing the nurses to feel that they have to compromise the ideal nursing (Ardern, 1999; Bakker et al., 2006; Blythe et al., 2001; Cloutier et al., 2008; Debesay et al., 2014; Ingersoll et al., 2001; Kristiansen et al., 2010; ShindulRothschild, 1994; Venturato et al., 2007; Wynne, 2004). The experiences described in this
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metasynthesis show that nurses do not feel that management has taken daily practice into account, which may be why the nurses practically see the structural changes as burdens.
Strengths and limitations This study has some limitations. First, we tried to identify every study relevant to this metasynthesis by searching different databases covering the period from 1994 to 2014. However, we cannot be sure to have discovered all published studies in this field, despite consulting a librarian and using a comprehensive search strategy. In April 2015, no further studies were found, so we stopped the search. Another limitation of this metasynthesis is that we did not include studies from non-Western countries. Also, our metasynthesis was based on studies from Sweden, Norway, Australia, Canada, England, and the United States and our findings are not necessarily transferable to nurses in other Western countries. However, the findings from this metasynthesis are deeply rooted in Western nurses’ experiences and, therefore, to some extent, transferable to Western nurses, which strengthens the review. Despite a wish to conduct an extensive metasynthesis, we chose to exclude the one study we found that was conducted in Asia. The study was from Taiwan and excluded because it clearly argued that the working conditions for Taiwanese and Western nurses could not be compared (Su et al., 2009). Supplementing our findings with other methodical studies, such as a qualitative interview study exploring nurses’ experiences working in organizations undergoing structural changes at the present time, would be relevant.
Conclusion
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We demonstrated how nurses experience structural changes and how an interpretive integration of the qualitative findings can increase our understanding of nurses’ experiences being employed in organizations undergoing structural changes. The nurses from the included studies tended to put their own needs aside when an increased workload pressed them physically and emotionally because they experience joy in their daily work with the patients despite the negative consequences of the structural changes. This enlightening of the circumstances is central for hospital management if they wish to secure a good working environment and job satisfaction for nurses in the long-term when restructuring the organization. The implementation of changes is challenging, but research shows that a well-organized approach to implementation increases the success rate (Dulko, 2007). For example, the hospital management could benefit from using some of the components from Leavitt’s theory to ensure that they deal with every aspect of the restructuring and its consequences. In addition, the management could take into account whether the structural changes actually improve the daily work of the nurses and, if not, how they can achieve this. According to the Productive Ward-Releasing Time to Care program, this would increase nurses’ job satisfaction and patient care (Van Bogaert et al., 2014). Future studies should explore the long-term consequences of nurses working in organizations undergoing structural changes, thereby setting their own needs aside, as seen in this metasynthesis. Some nurses burnout because of the pressure (Grønkjær, 2013), but it would be interesting to know how large of a proportion of nurses is affected. According to this review, many nurses exhibit signs of burnout, and if every nurse working in the context of restructuring is at risk of burning out, our hope is that it is taken serious by politicians and managers for the sake of both the nurses and patients.
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