1. Piper, Letty Roth EdD, RN
  2. Schneider, Maureen PhD, RN, NEA-BC, CPHQ, FACHE


The recent growth in hospital mergers and the resultant mergers of nursing service departments (NSDs) have produced a need for chief nursing officers (CNOs) to be aware of implications and anticipated dynamic changes. This article addresses the major issues raised by mergers for NSDs and presents an operational step-by-step checklist for CNOs.


Article Content

The merger of healthcare organizations is on the rise. Although the discussion of mergers is initiated at the board level, rumors about possible mergers are common. Senior nursing leaders must be prepared to handle rumors as plans become more public. Nurse leaders report success in dealing with mergers starting with truthful information presented in a timely, reliable, and carefully disseminated process.1 Skilled communication and vision in a merger situation requires committed, visible, and authentic leadership.


Some of the steps in an organizational merger include premerger planning, due diligence, regulatory approval, possible litigation, and postmerger organization redesign. Once a decision is made, implementation may take a year or more before the actual merger is finalized. This interval allows for the development and use of strategies to support the formation of the new organization and employee empowerment, including redesigning of committees, open forum meetings, implementation workgroups, and frequent, consistent communication at all levels.2


Resource Management

Once the nursing leadership structure for the new organizational entity is defined and announced, proper plans concerning reporting relationships and the integration of processes can be developed and shared. Mergers seek economies, effectiveness, and synergies; thus, changes are anticipated. Stakeholders in the merger must contribute to the new system to support engagement and adoption. The combination of resources requires compromise that may not be satisfactory to all parties of previous entities. The new vision articulated by nursing leaders will strongly influence the perception of the nursing staff and middle management. How employees react to a merger and move to achieve stated corporate goals is key to the success of the initiative. Merged organizations can use integration or coordination to achieve their goals. To contrast, coordination is not fusion; it is an "arrangement of roles and tasks into an organized whole."3(p8) Coordination permits a decentralized, collaborative management team to approach goals from the standpoint of the various organizations to achieve a "new normal." The importance to the nursing staff, of the department's unique identity, cannot be ignored. In coordination, dual nursing structures may be possible. Consolidation indicates the merger of systems and often leads to centralization of functions including leadership. In either model, the empowerment and self-actualization of employees at all levels support job satisfaction and retention.2 Presentation of a clear and actionable mission and vision is essential to aligning organizational goals with departmental goals, thus moving to resource consolidation, whether centralized or decentralized. The mission and vision should support how the merger will strengthen each institution and provide improvements in patient and community health. Nurse leaders should focus on how the merging of resources will enhance the professions ability to improve quality of care and the work environment.


The Role Of Middle Management

Middle managers are essential to the development of organizational trust. On the frontlines with employees, their credibility supports the integrity of the organization. Middle managers control informal channels of communication. Informal and formal channels must be congruent to achieve organizational trust.2 The inclusion of middle management input should be a priority as senior nursing leaders are able to communicate anticipated changes and incorporate middle managers into redesign and consolidation. It is important to look for nonverbal resistance such as inaction, delay, and diversion.4 Senior managers need to pay attention to completion of assigned tasks by subordinates, because noncompletion or delay in goal attainment may signal resistance. The loss of a sense of self, an organization's culture, and a professional position in the organization can enhance the resistance factor. It is important for leaders to establish a vision of how the merger benefits the individual employee, the patient, and the organizations. Merged organizations typically anticipate enhanced capital and administrative capabilities, contributing to future anticipated success. This message is one that needs to be clearly stated to middle managers and frontline employees.


Building Trust

Delays experienced in the operational process of the merger may also be considered sabotage and create distrust among the merger partners. Therefore, there remains an acute need to create connections, trust relationships between the cultures, and leadership that visibly supports and enables effective integration.5 The ultimate goal is that values, group norms, and steps are agreed on; that units and employees know what is expected of them; and individuals feel united by these values, norms, and goals.6 This shared mental model of roles and tasks is essential to successfully performing work that requires coordination. Facilitated processes among nursing leaders to address practice models, support structures, resources, and communication are important to demonstrate the transition of nursing to the new expectations. Successful transition must be rooted in consensus and not the dominance of any 1 party. Strategic consensus provides the basis for effective decision making during an integration project and beyond.


Integrated models will identify which services should be consolidated: populations that will benefit from integration, the primary objectives for integration, and the vision of the new future state. New models may involve integration across sites in addition to the larger corporate perspective. Nursing leaders must ensure that parties at all levels of patient care services understand their value and roles in the new models.


Decisions to consider in evaluating levels of integration include to what extent shared governance and employee empowerment models should be standardized, salary model consolidation, the handling of seniority in the new entity, and whether to unify orientation, education departments, and human resource functions. Consideration should be given regarding planning for Magnet(R) designation, those entities on the journey, and whether the new organization will pursue system recognition as a future goal. Nursing leaders should be involved in all levels of these discussions and lead those that affect patient care providers. A checklist of activities and steps for nursing leaders to consider in planning for a merger is included in Table 1. Many of these activities take place more than a year in advance of finalization of merger discussions and should be planned and systematic.

Table 1 - Click to enlarge in new windowTable 1. Steps to Consider Prior to an Organizational Merger

As influential organization-wide leaders, chief nursing officer (CNOs) must be involved and participate in the planning and execution of a merger at all phases. The transition of organizations is not always easy for the CNO and may involve role or job changes that were not anticipated. The challenge for nurse leaders in these new structures cannot be underestimated but can be proactively managed through planning and anticipatory guidance.




1. Urden LD, Rogers S. Tips for successful merger integration. J Nurs Adm. 2000; 30(4): 161-162. [Context Link]


2. Laschinger HK, Finegan J, Shamian J, Casier S. Organizational trust and empowerment in restructured healthcare settings: effects on staff nurse commitment. J Nurs Adm. 2000; 30(9): 413-425. [Context Link]


3. Lillrank P. Integrationa and coordination in healthcare: an operations management view. J Integr Care. 2012; 20(1): 6-12. [Context Link]


4. McLaughlin T. Nonprofit Mergers and Alliances: Strategic Planning Guide. 2nd ed. Hoboken, NJ: John Wiley & Sons; 2010. [Context Link]


5. Galpin T, Herndon M. The Complete Guide to Mergers and Acquisitions: Process Tools to Support Integration at Every Level. San Francisco, CA: Jossey-Bass; 2007. [Context Link]


6. Evans JM, Baker GR. Shared mental models of integrated care: aligning multiple stakeholder perspectives. J Health Organ Manag. 2012; 26(6): 713-736. [Context Link]