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complexity theory, discontinuous change, nurses, ownership conversion, participation in decision making, physicians, service coordination, threat-rigidity theory



  1. Anderson, Ruth A.
  2. Allred, Charlene A.
  3. Sloan, Frank A.


This study looks into the "black box" of hospital ownership conversion in a "natural experiment." We posed two competing theories about how conversion might influence management practices. Results support complexity theory and not threat-rigidity theory. As predicted from complexity theory, MDs and RNs had greater levels of participation and influence over final decision choices in converted hospitals than in nonconverted hospitals.


Ownership conversion of hospitals, particularly conversion from nonprofit (NP) to for-profit (FP) status, has captured public attention and aroused emotion-laden debate for clinical professionals, policy makers, and community leaders. In particular, people fear that shifting assets from NP to FP use will lead to loss of a public good.1-4 Research on hospital ownership conversion has used existing, secondary databases and focused almost exclusively on questions of why ownership conversions occur5,6 and the impact of conversion on a community's charitable assets and uncompensated care.7-11


Knowing that ownership conversion may affect outcomes, such as quality or access to care, provides only part of the picture, however. When differences are observed using secondary data sources, the result is often a "black box" phenomenon.12 That is, we may know a change in performance occurred due to ownership conversion, but we do not know how or why the change(s) occurred. Looking into the black box, by identifying and describing differences in organizational processes, is critical to understanding what accounts for differences in outcomes (if they do exist). The goal of this study is not to model the entire conversion-outcomes pathway, but rather to take the first step in that endeavor by exploring whether differences in hospital decision making and service coordination, including feedback and programmed mechanisms, are related to conversion. The overarching research questions were: (1) Do hospitals that convert ownership differ from nonconverted hospitals in participation in decision making by medical doctors (MDs) and registered nurses (RNs) and in their use of feedback and programmed service coordination processes? (2) Do hospitals that convert ownership differ from nonconverted hospitals in the level of influence that MDs and RNs have over final choices made in organizational decision making?