- Email: [email protected]
Merger Destiny: Synthesizing Organizational and Executive Leadership Change
Merger Destiny: Synthesizing Organizational and Executive Leadership Change Kathleen Brodbeck, MS, RN, NEA-BC
T
hroughout the past decade, hospital mergers and consolidations have been a consistent
and accelerating trend occurring across the nation. Although the trend is expected to continue as a key industry response to the economic climate and healthcare reform, the results of mergers often fall short of desired outcomes.1,2 The literature reflects a plethora
of evidence of failed mergers, including tactical suggestions to overcome the barriers; however, the evidence of theory to ground a successful merger is mainly anecdotal and episodic.
F
undamental to any merger development is a staged change process that has been well described in the literature.The phases of premerger, merger, and postmerger are illustrative of the structural changes that accompany this change effort.3 Although this sequential description provides a solid framework for merger progression, it does not encompass the interplay of other variables that contribute to the complex evolution change inherit in a merger process.The reality is that mergers evolve in highly variable patterns that are influenced by leadership behavior, environmental conditions, and organizational culture.4 Appreciating this complexity and noting the historical evidence framing the issues faced by nurse executives dealing with a merger process, the challenges can be overwhelming. Therefore, it is imperative that the nurse leader develop and execute an integrated strategic approach to avoid the negative consequences experienced by many merged systems. The transformational nurse executive must draw from many different evidence-based management theories, including change management, complexity theory, and strategy deployment. This article provides an overview of the processes, leadership attributes, and cultural aspects of change that a nurse executive must synthesize to lead a successful merger endeavor.
CONSTRUCTION OF A MERGER: PREMERGER ESSENTIAL BUILDING BLOCKS During the preparation phase for a merger, a comprehensive due diligence process encompasses more than a financial risk www.nurseleader.com
assessment. Key assessments in this stage also include: a complete clinical and risk assessment, stakeholder analysis, and cultural assessment. All of these assessments should be well vetted in the initial phases of a planned merger to alleviate postmerger problems This premerger analysis is an important leadership function that the chief nursing officer (CNO) is well positioned to lead during premerger negotiations. A comprehensive clinical risk assessment provides a wide scope of analysis beyond the financial metrics. Key elements include quality, risk, and utilization components.5,6 The nurse executive must be fully aware of the quality performance of each organization, develop a risk/benefit analysis, and execute proactive strategies to mitigate postmerger problems. A stakeholder analysis provides insights into key relationships that must be managed within a new network. Internal and
Nurse Leader
29
external stakeholders can often present competing interests and can greatly influence the success or failure of a merger.7 Reengineered governance structures of the new entity should be designed to leverage these varying stakeholder needs and to support the increased demands and complexity associated with healthcare governance.8 It is vital that the CNO is well aware of all constituents and is facile in leading and developing new and existing relationships. Positive working relationships between the CNO, the board, the executive suite, and staff are essential for the formation of a healthy work environment.The subsequent design of the nursing leadership governance structures need to be developed in alignment with these factors.9 A cultural assessment provides insights into the merging entities’ compatibility and provides a yardstick by which to anticipate the degree of required change necessary for the success of the merger. Being sensitized to the cultural norms of the organizations and executing responsive leadership techniques is the role of the nurse leader. Failure to assimilate the cultures leads to lowered commitment and greatly impacts the overall merger process.10
MERGER PHASING: BALANCING ON THE TIGHTROPE OF CHANGE AND SECURITY Once the premerger due diligence has been completed, it is essential to then describe the mission, vision, and strategy of the new organization. Failing to clearly articulate the benefits and goals of the new organization can have a negative impact on the execution phase of the merger. During the merging process, it is essential that the nurse leader balance the organizational need to establish a sense of urgency for change while simultaneously creating an environment that maintains the security of the strengths identified in the premerger analysis. The vulnerable staff needs to sense that there is calm among the chaos of change. As the metaphor goes, the leader must stretch the rubber band as far as possible without it snapping. An important tactic to balance the merger disequilibrium is to create an environment where small tests of change can be successful. These initiatives keep the staff engaged in ways that they can see and measure progress. This will sustain and motivate people until the long-term outcomes can be measured over time. This approach begins to develop the system unit while supporting business-unit autonomy and innovation. While supporting small-scale change, utilizing a broad and consistent framework for realignment of clinical services is an important step in executing the new vision of the merged entity. This assessment should include multiple parameters including growth, quality, clinical capabilities, financial opportunity, brand identity, and physician alignment.3,11 The nurse leader with advanced knowledge of healthcare systems and strategic planning expertise can lead the clinical care redesign efforts, engage staff in the process, and drive overall system performance.
POSTMERGER: ADVANCING COMMUNITY HEALTH AND NURSING IMAGE Whereas the nurse executive time spent on the first two stages of the merger are primarily focused on the internal stakeholders, the postmerger process denotes a transition for
30
Nurse Leader
the nurse leader to additionally focus on the broader community. A successful merger has the potential to have a greater impact on community health. The alteration of care delivery and the resulting outcomes of care need to be transparent to the community. The nurse executive should lead the public promotion of community impact and promote nursing’s image. These tactics include education, advocacy, and partnerships with community groups.
CULTURAL ADAPTATION: THE REAL GAME CHANGER Blending cultures in merged entities and defining a path for the desired cultural assimilation is the most daunting objective in any merger. Cultures are inherently impervious to change and require continual leadership intervention to foster a culture that will facilitate a healthy work environment necessary for the newly changed organization to survive and thrive. Failure to effectively address cultural conflicts is the most often cited reason for mergers to fail.10,12 The failure to address cultural issues results in disassociated employees. This is a result of management’s tendency toward isolation, undercommunication with staff, and centralization of decision making. Most organizations during mergers resist the need to engage teams in decision making at a time when it is most needed.13 The execution of a well-developed cultural assimilation plan based on the initial premerger cultural assessment is a key role for the nurse executive. Effective models for cultural cohesion and employee involvement can improve quality, staff retention, and job satisfaction.14,15 The nurse executive expert in leading within a shared governance framework has the skill mastery to avoid merger syndrome and to facilitate the cultural assimilation process. The principles of engagement can facilitate staff ownership and create healthy work environments that are necessary to meet the new organizational challenges. These positive group dynamics, coupled with strong transformational leadership, can generate the stamina to endure the stresses associated with significant organizational change. Table 1 summarizes the merger phases and identifies essential integrating mechanisms to be considered during the merger process.
NURSE LEADER COMPETENCY ASSESSMENT AND DEVELOPMENT: YOU DON’T KNOW WHAT YOU DON’T KNOW When transitioning from a role as a CNO in a single entity to one leading an integrated system, one must pause to reflect on the skill sets required to lead a newly merged system. Although differences in CNO roles exist from organization to organization, the literature cites larger differences in the system CNO corporate role.7 Acknowledging this role difference is the first step in acclimating to the role change. This adaptive leadership approach is particularly relevant theory applied to systems that are undergoing major transition. Applying an evidence-based framework within a new context helps the CNO to be open minded, to be continuously adapting to change, and reduces the vulnerabilities associated with past biases.
June 2012
Table 1. Nurse Executive Merger Process Map Domain
Premerger
Active Merging Phasing
State of Integration/ Consolidation
Exploratory
Planned service integration/ consolidation
Loosely affiliated service integration
Service delivery integration
Unified entities and established new culture
Nurse Executive Aim
Create vision
Create purpose
Create trust
Create balance
Create a new order
Key Nursing Leadership Tactics
Active participant in due diligence processes including: Legal/regulatory requirements Financial assessment Clinical and risk assessment Cultural assessment Stakeholder analysis
Define and communicate merger goals with measurable outcomes
Define nursing organization with defined leaders. Support transitions of nursing leaders
Build staff engagement Drive to a new steady state
Celebrate successes
Complete a currentstate assessment of each organization Determine a desired future state (decentralized or centralized)
Postmerger
Establish integrating processes and structures for staff decision making
Develop public image: Community ambassador Market nursing contributions Partner with affiliated groups to advance community health
Determine services that will be eliminated or expanded
Integrating Mechanisms
Cultural integration groups Stakeholder forums
Change management teams: Clinical integration groups Professional practice groups
Clinical operating groups Active professional assimilation groups
Community boards
Outcomes
Go/no go decision
Interim measures: define short-term measurable, teambased outcomes
Interim measures: monitor and communicate shortterm team based outcomes
System-based measures: Operating performance Clinical performance Cultural assimilation
System- and community-based outcomes: System measures Impact on community health Sum of the community image
Warning Signs
Weak business case for merger Nonaligned leadership and culture
High degree of resistance to change
Disenfranchised staff and leadership
Deteriorating financial and clinical performance
Deteriorating customer loyalty
Overpromising: Overstating deliverables will undermine trust if not achieved
Too narrow focus: Relying on past practices and assumptions will thwart innovation and change efforts.
Mistakes to Avoid
Unclear merger goals
It is also critical to remember not to rely on history for the practices that worked in the past. In times of uncertainty, it is natural to revert to one’s comfort zone to try to replicate prior successes. Embracing ambiguity might be the best leadership tactic that a CNO can generate in an organizational merger. www.nurseleader.com
Avoiding conflict: Innovation and culture will suffer if creative tension and diversity is oppressed
Abandoning change efforts prematurely: remember that things appear to get worse before they get better
The whole is less than the previous individual entities Being invisible to the community: Failure to market the value of nursing to community health diminishes the image of nursing
Utilizing the American Organization of Nurse Executives leadership competencies16 and the American Association of Critical-Care Nurses leadership competencies17, a nurse leader can frame her self assessment and seek the learning opportunities appropriate to the role transition. Although all
Nurse Leader
31
Table 2. Nurse Executive Merger Self-Assessment Competency Guide Domain
Premerger
Active Merging Phasing
Postmerger
AONE Nurse Competencies16
Knowledge of healthcare environment
Communication and relationship building
Professionalism
Business skills
Leadership skills
AACN Standards for Establishing and Sustaining Healthy Work Environments17
Effective decision making
Authentic leadership Skilled communication
Appropriate staffing
True collaboration
Meaningful recognition
Developmental Tactics
Assess skill sets
Assess power shifting leadership dynamics
Assess transformational/a daptive leadership skills
Measure professional growth from premerger period: Rebase skill development needs
Image
Develop action plan for identified weaknesses Seek out mentors Assess relationships with key constituents
Assess fit with new organization Assess fit with peers Identify effective stress-reducing strategies
of these skills require proficiency at any stage during a merger, certain skills can be more acutely emphasized along the merger continuum of change (Table 2).
SUMMARY The CNO who is in a position to lead during a turbulent time of transition is afforded a great opportunity to dramatically shape the new order of a transformed organization. Deciphering the proper balance with ingenuity and evidence-based practices best summarizes the challenges faced during a merger. In the healthcare world, where old hierarchies no longer work, where rules are obsolete, and business models are outdated, the opportunity to lead a merger can be an exhilarating opportunity to transform what is broken in healthcare. NL
Assess stakeholder confidence in CNO leadership
Political skill assessment Public speaking ability
Secure required supports Assess selfperformance and satisfaction with progress
delivery systems/networks: a stakeholder approach. Health Care Manage Rev. 1997;22(1):7-20. 9. Porter-O’Grady T, Bradley C, Crow G, Henrich A. After a merger: the dilemma of the best leadership approach for nursing. Nurs Adm Q. 1997;21(2):8-19. 10. Jones J. Dual or dueling culture and commitment: the impact of a trihospital merger. J Nurs Adm. 2003;33:235-242. 11. McCarthy K, Zuckerman A. Realizing the full financial benefits of true integration Healthc Financ Manage. 2010;64(11):78-82, 84, 86. 12. Appelbaum S, Gandell J, Yotis H, Proper S, Jobin F. Anatomy of a merger: behavior of organizational factors and processes throughout the pre- duringpost-stages (part 2). Manage Decision. 2000;38:674-684. 13. Marks ML. A framework for facilitating adaptation to organizational transition. J Organiz Change Manage. 2007;20:721-739. 14. Nash M, Everett L. Cultural cohesion versus collision: a model for facilitating organizational mergers. J Nurs Adm. 1996;26(7/8):11-18. 15. Kullen A, Resengren K, Hallberg L. Balancing involvement: employees’ experiences of merging hospitals in Sweden. J Adv Nurs. 2002;38:11-18. 16. American Organization of Nurse Executives. AONE Nurse Executive Competencies. Nurse Leader. 2005;3(2):15-21. 17. American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments. Aliso Viejo, CA: AACN; 2005.
References 1. Appelbaum S, Gandell J, Yotis H, Proper S, Jobin F. Anatomy of a merger: behavior of organizational factors and processes throughout the pre- duringpost-stages (part 1). Manage Decision. 2000;38:649-661. 2. Kramer M, Schmalenberg C. Magnet hospital nurses describe control over nursing practice. West J Nurs Res. 2003;25:434-452 3. Kamrad-Marrone S, Stabile MA, Smeltzer CH. Understanding and championing the merger process: key leadership roles for successful outcomes. Nurs Adm Q. 1999;23(4):47-57. 4. Freed D. Hospital turnarounds agents, approaches, alchemy. Health Care Manag. 2005;24(2):96-118. 5. Blouin AS, Brent N. Strategic partnering: clinical and risk management concerns. J Nurs Adm. 1997;27(6):10-13. 6. Zuckerman A. Healthcare mergers and acquisitions: strategies for consolidation. Front Health Serv Manage. 2011;27(4):3-12. 7. Baker C, Ogden, S, Prapaipanich W, Keith CK, Beattie L, Nickleson L. Hospital consolidation: applying stakeholder analysis to merger life-cycle. J Nurs Adm. 1999;29(3):11-20. 8. Savage G, Taylor R, Rotarius T, Buesseler J. Governance of integrated
32
Nurse Leader
Kathleen Brodbeck, MS, RN, NEA-BC, is the executive vice president and chief nursing officer for St. Peter’s Health Partners in Albany, New York, and can be reached at [email protected]. 1541-4612/2012/ $ See front matter Copyright 2012 by Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl/2012.03.004
June 2012
T
hroughout the past decade, hospital mergers and consolidations have been a consistent
and accelerating trend occurring across the nation. Although the trend is expected to continue as a key industry response to the economic climate and healthcare reform, the results of mergers often fall short of desired outcomes.1,2 The literature reflects a plethora
of evidence of failed mergers, including tactical suggestions to overcome the barriers; however, the evidence of theory to ground a successful merger is mainly anecdotal and episodic.
F
undamental to any merger development is a staged change process that has been well described in the literature.The phases of premerger, merger, and postmerger are illustrative of the structural changes that accompany this change effort.3 Although this sequential description provides a solid framework for merger progression, it does not encompass the interplay of other variables that contribute to the complex evolution change inherit in a merger process.The reality is that mergers evolve in highly variable patterns that are influenced by leadership behavior, environmental conditions, and organizational culture.4 Appreciating this complexity and noting the historical evidence framing the issues faced by nurse executives dealing with a merger process, the challenges can be overwhelming. Therefore, it is imperative that the nurse leader develop and execute an integrated strategic approach to avoid the negative consequences experienced by many merged systems. The transformational nurse executive must draw from many different evidence-based management theories, including change management, complexity theory, and strategy deployment. This article provides an overview of the processes, leadership attributes, and cultural aspects of change that a nurse executive must synthesize to lead a successful merger endeavor.
CONSTRUCTION OF A MERGER: PREMERGER ESSENTIAL BUILDING BLOCKS During the preparation phase for a merger, a comprehensive due diligence process encompasses more than a financial risk www.nurseleader.com
assessment. Key assessments in this stage also include: a complete clinical and risk assessment, stakeholder analysis, and cultural assessment. All of these assessments should be well vetted in the initial phases of a planned merger to alleviate postmerger problems This premerger analysis is an important leadership function that the chief nursing officer (CNO) is well positioned to lead during premerger negotiations. A comprehensive clinical risk assessment provides a wide scope of analysis beyond the financial metrics. Key elements include quality, risk, and utilization components.5,6 The nurse executive must be fully aware of the quality performance of each organization, develop a risk/benefit analysis, and execute proactive strategies to mitigate postmerger problems. A stakeholder analysis provides insights into key relationships that must be managed within a new network. Internal and
Nurse Leader
29
external stakeholders can often present competing interests and can greatly influence the success or failure of a merger.7 Reengineered governance structures of the new entity should be designed to leverage these varying stakeholder needs and to support the increased demands and complexity associated with healthcare governance.8 It is vital that the CNO is well aware of all constituents and is facile in leading and developing new and existing relationships. Positive working relationships between the CNO, the board, the executive suite, and staff are essential for the formation of a healthy work environment.The subsequent design of the nursing leadership governance structures need to be developed in alignment with these factors.9 A cultural assessment provides insights into the merging entities’ compatibility and provides a yardstick by which to anticipate the degree of required change necessary for the success of the merger. Being sensitized to the cultural norms of the organizations and executing responsive leadership techniques is the role of the nurse leader. Failure to assimilate the cultures leads to lowered commitment and greatly impacts the overall merger process.10
MERGER PHASING: BALANCING ON THE TIGHTROPE OF CHANGE AND SECURITY Once the premerger due diligence has been completed, it is essential to then describe the mission, vision, and strategy of the new organization. Failing to clearly articulate the benefits and goals of the new organization can have a negative impact on the execution phase of the merger. During the merging process, it is essential that the nurse leader balance the organizational need to establish a sense of urgency for change while simultaneously creating an environment that maintains the security of the strengths identified in the premerger analysis. The vulnerable staff needs to sense that there is calm among the chaos of change. As the metaphor goes, the leader must stretch the rubber band as far as possible without it snapping. An important tactic to balance the merger disequilibrium is to create an environment where small tests of change can be successful. These initiatives keep the staff engaged in ways that they can see and measure progress. This will sustain and motivate people until the long-term outcomes can be measured over time. This approach begins to develop the system unit while supporting business-unit autonomy and innovation. While supporting small-scale change, utilizing a broad and consistent framework for realignment of clinical services is an important step in executing the new vision of the merged entity. This assessment should include multiple parameters including growth, quality, clinical capabilities, financial opportunity, brand identity, and physician alignment.3,11 The nurse leader with advanced knowledge of healthcare systems and strategic planning expertise can lead the clinical care redesign efforts, engage staff in the process, and drive overall system performance.
POSTMERGER: ADVANCING COMMUNITY HEALTH AND NURSING IMAGE Whereas the nurse executive time spent on the first two stages of the merger are primarily focused on the internal stakeholders, the postmerger process denotes a transition for
30
Nurse Leader
the nurse leader to additionally focus on the broader community. A successful merger has the potential to have a greater impact on community health. The alteration of care delivery and the resulting outcomes of care need to be transparent to the community. The nurse executive should lead the public promotion of community impact and promote nursing’s image. These tactics include education, advocacy, and partnerships with community groups.
CULTURAL ADAPTATION: THE REAL GAME CHANGER Blending cultures in merged entities and defining a path for the desired cultural assimilation is the most daunting objective in any merger. Cultures are inherently impervious to change and require continual leadership intervention to foster a culture that will facilitate a healthy work environment necessary for the newly changed organization to survive and thrive. Failure to effectively address cultural conflicts is the most often cited reason for mergers to fail.10,12 The failure to address cultural issues results in disassociated employees. This is a result of management’s tendency toward isolation, undercommunication with staff, and centralization of decision making. Most organizations during mergers resist the need to engage teams in decision making at a time when it is most needed.13 The execution of a well-developed cultural assimilation plan based on the initial premerger cultural assessment is a key role for the nurse executive. Effective models for cultural cohesion and employee involvement can improve quality, staff retention, and job satisfaction.14,15 The nurse executive expert in leading within a shared governance framework has the skill mastery to avoid merger syndrome and to facilitate the cultural assimilation process. The principles of engagement can facilitate staff ownership and create healthy work environments that are necessary to meet the new organizational challenges. These positive group dynamics, coupled with strong transformational leadership, can generate the stamina to endure the stresses associated with significant organizational change. Table 1 summarizes the merger phases and identifies essential integrating mechanisms to be considered during the merger process.
NURSE LEADER COMPETENCY ASSESSMENT AND DEVELOPMENT: YOU DON’T KNOW WHAT YOU DON’T KNOW When transitioning from a role as a CNO in a single entity to one leading an integrated system, one must pause to reflect on the skill sets required to lead a newly merged system. Although differences in CNO roles exist from organization to organization, the literature cites larger differences in the system CNO corporate role.7 Acknowledging this role difference is the first step in acclimating to the role change. This adaptive leadership approach is particularly relevant theory applied to systems that are undergoing major transition. Applying an evidence-based framework within a new context helps the CNO to be open minded, to be continuously adapting to change, and reduces the vulnerabilities associated with past biases.
June 2012
Table 1. Nurse Executive Merger Process Map Domain
Premerger
Active Merging Phasing
State of Integration/ Consolidation
Exploratory
Planned service integration/ consolidation
Loosely affiliated service integration
Service delivery integration
Unified entities and established new culture
Nurse Executive Aim
Create vision
Create purpose
Create trust
Create balance
Create a new order
Key Nursing Leadership Tactics
Active participant in due diligence processes including: Legal/regulatory requirements Financial assessment Clinical and risk assessment Cultural assessment Stakeholder analysis
Define and communicate merger goals with measurable outcomes
Define nursing organization with defined leaders. Support transitions of nursing leaders
Build staff engagement Drive to a new steady state
Celebrate successes
Complete a currentstate assessment of each organization Determine a desired future state (decentralized or centralized)
Postmerger
Establish integrating processes and structures for staff decision making
Develop public image: Community ambassador Market nursing contributions Partner with affiliated groups to advance community health
Determine services that will be eliminated or expanded
Integrating Mechanisms
Cultural integration groups Stakeholder forums
Change management teams: Clinical integration groups Professional practice groups
Clinical operating groups Active professional assimilation groups
Community boards
Outcomes
Go/no go decision
Interim measures: define short-term measurable, teambased outcomes
Interim measures: monitor and communicate shortterm team based outcomes
System-based measures: Operating performance Clinical performance Cultural assimilation
System- and community-based outcomes: System measures Impact on community health Sum of the community image
Warning Signs
Weak business case for merger Nonaligned leadership and culture
High degree of resistance to change
Disenfranchised staff and leadership
Deteriorating financial and clinical performance
Deteriorating customer loyalty
Overpromising: Overstating deliverables will undermine trust if not achieved
Too narrow focus: Relying on past practices and assumptions will thwart innovation and change efforts.
Mistakes to Avoid
Unclear merger goals
It is also critical to remember not to rely on history for the practices that worked in the past. In times of uncertainty, it is natural to revert to one’s comfort zone to try to replicate prior successes. Embracing ambiguity might be the best leadership tactic that a CNO can generate in an organizational merger. www.nurseleader.com
Avoiding conflict: Innovation and culture will suffer if creative tension and diversity is oppressed
Abandoning change efforts prematurely: remember that things appear to get worse before they get better
The whole is less than the previous individual entities Being invisible to the community: Failure to market the value of nursing to community health diminishes the image of nursing
Utilizing the American Organization of Nurse Executives leadership competencies16 and the American Association of Critical-Care Nurses leadership competencies17, a nurse leader can frame her self assessment and seek the learning opportunities appropriate to the role transition. Although all
Nurse Leader
31
Table 2. Nurse Executive Merger Self-Assessment Competency Guide Domain
Premerger
Active Merging Phasing
Postmerger
AONE Nurse Competencies16
Knowledge of healthcare environment
Communication and relationship building
Professionalism
Business skills
Leadership skills
AACN Standards for Establishing and Sustaining Healthy Work Environments17
Effective decision making
Authentic leadership Skilled communication
Appropriate staffing
True collaboration
Meaningful recognition
Developmental Tactics
Assess skill sets
Assess power shifting leadership dynamics
Assess transformational/a daptive leadership skills
Measure professional growth from premerger period: Rebase skill development needs
Image
Develop action plan for identified weaknesses Seek out mentors Assess relationships with key constituents
Assess fit with new organization Assess fit with peers Identify effective stress-reducing strategies
of these skills require proficiency at any stage during a merger, certain skills can be more acutely emphasized along the merger continuum of change (Table 2).
SUMMARY The CNO who is in a position to lead during a turbulent time of transition is afforded a great opportunity to dramatically shape the new order of a transformed organization. Deciphering the proper balance with ingenuity and evidence-based practices best summarizes the challenges faced during a merger. In the healthcare world, where old hierarchies no longer work, where rules are obsolete, and business models are outdated, the opportunity to lead a merger can be an exhilarating opportunity to transform what is broken in healthcare. NL
Assess stakeholder confidence in CNO leadership
Political skill assessment Public speaking ability
Secure required supports Assess selfperformance and satisfaction with progress
delivery systems/networks: a stakeholder approach. Health Care Manage Rev. 1997;22(1):7-20. 9. Porter-O’Grady T, Bradley C, Crow G, Henrich A. After a merger: the dilemma of the best leadership approach for nursing. Nurs Adm Q. 1997;21(2):8-19. 10. Jones J. Dual or dueling culture and commitment: the impact of a trihospital merger. J Nurs Adm. 2003;33:235-242. 11. McCarthy K, Zuckerman A. Realizing the full financial benefits of true integration Healthc Financ Manage. 2010;64(11):78-82, 84, 86. 12. Appelbaum S, Gandell J, Yotis H, Proper S, Jobin F. Anatomy of a merger: behavior of organizational factors and processes throughout the pre- duringpost-stages (part 2). Manage Decision. 2000;38:674-684. 13. Marks ML. A framework for facilitating adaptation to organizational transition. J Organiz Change Manage. 2007;20:721-739. 14. Nash M, Everett L. Cultural cohesion versus collision: a model for facilitating organizational mergers. J Nurs Adm. 1996;26(7/8):11-18. 15. Kullen A, Resengren K, Hallberg L. Balancing involvement: employees’ experiences of merging hospitals in Sweden. J Adv Nurs. 2002;38:11-18. 16. American Organization of Nurse Executives. AONE Nurse Executive Competencies. Nurse Leader. 2005;3(2):15-21. 17. American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments. Aliso Viejo, CA: AACN; 2005.
References 1. Appelbaum S, Gandell J, Yotis H, Proper S, Jobin F. Anatomy of a merger: behavior of organizational factors and processes throughout the pre- duringpost-stages (part 1). Manage Decision. 2000;38:649-661. 2. Kramer M, Schmalenberg C. Magnet hospital nurses describe control over nursing practice. West J Nurs Res. 2003;25:434-452 3. Kamrad-Marrone S, Stabile MA, Smeltzer CH. Understanding and championing the merger process: key leadership roles for successful outcomes. Nurs Adm Q. 1999;23(4):47-57. 4. Freed D. Hospital turnarounds agents, approaches, alchemy. Health Care Manag. 2005;24(2):96-118. 5. Blouin AS, Brent N. Strategic partnering: clinical and risk management concerns. J Nurs Adm. 1997;27(6):10-13. 6. Zuckerman A. Healthcare mergers and acquisitions: strategies for consolidation. Front Health Serv Manage. 2011;27(4):3-12. 7. Baker C, Ogden, S, Prapaipanich W, Keith CK, Beattie L, Nickleson L. Hospital consolidation: applying stakeholder analysis to merger life-cycle. J Nurs Adm. 1999;29(3):11-20. 8. Savage G, Taylor R, Rotarius T, Buesseler J. Governance of integrated
32
Nurse Leader
Kathleen Brodbeck, MS, RN, NEA-BC, is the executive vice president and chief nursing officer for St. Peter’s Health Partners in Albany, New York, and can be reached at [email protected]. 1541-4612/2012/ $ See front matter Copyright 2012 by Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl/2012.03.004
June 2012