Journal of Emerging Trends in Healthcare Administration
Volume 1 Issue 1 (2015)
Merging Nursing Teams? Key Points to Implement
Ana Figueroa-Altmann, Cynthia J. Davies, Renee' Roberts-Turner, Logan Maclean
Corresponding Author: Ana Figueroa-Altmann
15 Curtmantle Road, Mickleton, N. J., 08056
[email protected], (856)304.3278
ABSTRACT
Retention of nurses is essential to manage turnover costs and nursing shortages. An area that has remained
relatively unstudied is the impact and success of inpatient nursing mergers. A single site qualitative descriptive
triangulated case study research design was developed to explore the overarching strategy in an intra-hospital
merger of clinical units that included leadership tactics and strategies and the structure of the merger process that
affected the success of merging the two units. One-on-one interviews were held with management, leadership, and
staff nurses. Pattern matching was performed for each interview question to triangulate similarities and find
connections among the interviewed groups. Seven themes resulted from the analysis and eleven initial
recommendations resulted from triangulating the three groups’ responses which led to the final nine
recommendations regarding intra-hospital unit mergers. Findings include new information for nurse managers to
utilize during intra-hospital unit mergers to decrease complications during the process and increase the overall
success of the merger.
Keywords: merger, nursing, combine, leadership, strategies
INTRODUCTION
Retention through inclusiveness of nurses is essential when planning for inpatient clinical unit mergers to
achieve minimal turnover. As nurse managers implement new changes when merging nursing staff, careful
attention to retention of the nursing staff must be considered to reduce the cost of turnover and the risk of a nursing
shortage. Turnover costs for nurses associated with turnover has been estimated anywhere from $10,098 to $88,000
per registered nurse and the ratio of nurse turnover costs relative to nurses’ salary ranged from 0.31 to 1.3 (Li &
Jones, 2013). The other factor is the nation’s present nursing shortage which was adversely impacted by the
economic crisis in 2008 through 2010 (Lewis, Kay, Keslo, & Larson, 2010). It is predicted that by 2020 the nation
will be short 300,000 to 1 million RN jobs (Juraschek, Zhang, Ranganathan, & Lin, 2012). One change that could
impact nurse retention is clinical unit mergers (Lowery, 2007).
Recent literature shows that most mergers are financial failures and produce undesirable consequences for
both the employees and company. Approximately 83% of all deals fail to deliver shareholder value and 53%
actually destroy value (Cartwright & Cooper, 2013; Marks & Mirvis, 2012). Although the success rate of inpatient
nursing mergers is not discussed in the literature, nurse managers can anticipate that the success of nursing mergers
may parallel the statistics in the business industry. As the risks of turnover and staff disengagement are high,
managing the change of an inpatient nursing staff and clinical unit merger needs to be well thought out. A single
site qualitative descriptive triangulated case study research design was developed to explore the clinical nurses’ view
of leadership styles, use of psychological contracts, and strategies when merging two inpatient clinical units. The
study involved interviewing members of nursing management and comparing any identified leadership strategy or
style patterns to a second group of leadership nurses (clinical nurse specialists, clinical educators and charge nurses).
The information gathered from these two groups was then triangulated with the interview responses of staff nurses.
BACKGROUND: MERGER STRATEGY
A gap of knowledge remains in merging of nursing units in the healthcare industry. There is a shortage of
nurses accompanied by high turnover rates. This nursing crisis is concerning as leaders plan to accelerate the amount
of change, which may translate into staff turnover with a merger of nursing units. Closing the gap on the knowledge
of leadership styles and strategies used during a nursing unit merger will allow nurse leaders to retain staff by using
effective nursing merger strategies. An examination of the overarching strategy in an intra-hospital inpatient clinical
unit merger specifically observing psychological contracts, leadership tactics and strategies, and the structure of the
merger process that contributed to a successful merge between the two clinical units and respective nursing staffs are
outlined in this paper.
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Literature Review
Leadership Strategies
Transformational leadership is traditionally guided by four principles: motivation, consideration, charisma,
and stimulating employees. Fundamentally, a transformational leader strives to empower employees to high levels
of motivation and accomplishes this by partnering with employees to assure they understand their job and how to
accomplish it (Ahmad, Abbas, Latif, & Rasheed, 2014; Bass, 1985). The situational leadership style is founded on
the ability of the leader to be aware of employee engagement and level of competence prior to mentoring employees.
The level of competence and employee engagement must be evaluated by a leader who then chooses to mentor by
directing, coaching, supporting, or delegating (Blanchard, Zigarmi, & Zigarmi, 1999; Hersey, Blanchard, &
Johnson, 2006). Transactional leadership promotes the reward of an employee upon the completion of a task. By
proactively preventing problems, the transactional leader develops high levels of trust between the employee and
him/herself (Strom, Sears, & Kelly, 2014). Theory X and Theory Y leadership style are founded on the assumption
that employees most of the time are self-fulfilling (McGregor, 1966). Theory X is a pessimistic management style,
which anticipates their employees are not hard workers, cannot problem solve, worried about themselves, and tend
to be rigid (Kopelman, Prottas, & Falk, 2012). This management theory also finds that employees must be directed
and are not autonomous (Kopelman, Prottas, & Davis, 2008; Kopelman et al., 2012). Theory Y is the opposite of
Theory X and has a more optimistic style founded on employees are self-motivated, able to direct themselves to
achieve high outcomes, can be innovative and able to control their behaviors and work produced (Akindele, 2013).
Psychological Contracts
In a working environment, psychological contracts occur between the employee and leader. This
agreement involves the employee’s personal assumptions, beliefs, and perceptions when entering a relationship with
a leader and is voluntary (McDermott, Conway, Rousseau, & Flood, 2013; Rousseau, 1995). This agreement leads
to the trust that an employee has with his or her supervisor and organization. The use of psychological contracts can
impact the success of inpatient nursing unit mergers (Cortvriend, 2004).
Merger Process
The process of merging has a full cycle and is viewed as a deal between two or more groups of individuals
or companies (Cartwright & Cooper, 2013). The merger cycle completes four phases. The first phase is due
diligence (Galpin & Herndon, 2008), where confidentiality can be used to control rumors as well as to develop risk
management and integration plans post-merger. The second phase is pre-merger planning, which allows for the
construction and analysis of new innovative ideas (Harwood & Ashleigh, 2005), development of key partnerships,
and assessment of best practices and failures prior to merging (Lowrey, 2007), gives leaders the information that can
be used to develop strategic integration plans. A de-merger plan should be developed to allow leaders to develop a
clear path in the event a merger is not successful (Sinkin & Putney, 2007). The third phase, merger execution, will
happen as the two companies or groups are integrated. In the final phase, post-merger integration, employees will
be analyzing the merger at not only a personal level but by being part of a new team or organization (Honore &
Maheia, 2003).
Methods
Design
A one-on-one interview with each nurse participant was held at an urban academic hospital that merged
nursing units within one year of beginning the proposed study. Prior to the study the research was approved by the
nursing research advisory committee and institutional review board. Members of nursing management were
interviewed and the information from the interviews was then compared with identified leadership strategy or style
patterns to a second group of leadership nurses (clinical nurse specialists, clinical educators and charge nurses). Ten
interview questions were asked of each group to allow participants to share their lived experience before and after
the merger. The information gathered from these two groups was then triangulated with the responses of staff
nurses.
The answers to the first nine questions resulted in the development of seven themes. The answer to the
final question, an open-ended question regarding what could have been performed better during the merger, resulted
in initial recommendations. Both the seven themes and initial recommendations were then synthesized into nine
final recommendations.
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Volume 1 Issue 1 (2015)
Sample
Eligible participants were full time nurses and nurse leaders on two inpatient units that merged to become a
single large nursing unit in an urban academic hospital in the North East United States. The topic was explored by
interviewing the nursing management, nursing leaders, and the staff nurses. The final study involved interviewing
six leaders in nursing management and comparing any identified leadership strategy or style patterns to a second
group of leadership nurses. The leadership strategy or style patterns were then compared with reports from nine
staff nurses. All participants were employed on one of the two units that were involved in the nursing unit merger.
Participants worked on one of two medical units, One North and Two North (1N and 2N) and all were female. Of
the participants, 50% worked on the One N unit and 50% worked on the Two N unit.
Data Collection
A total of 23 nurses volunteered to participate by responding to email letters and a snowball recruitment
and referral technique (Groenewald, 2004). However, only 20 actually took part in the interview process. The
following groups were developed:
Group 1: Nursing Management (sample size of 6)
Vice President of Nursing (1), Director of Nursing (1), Clinical Supervisors (4)
Group 2: Nursing Leadership (sample size of 5)
Shift Coordinators (charge Nurses who are not in patient care) (2), Professional Practice Specialists
(Masters prepared Clinical Nurse Specialists) (1), and Clinical Instructors (Clinical IV nurse) (1)
Group 3: Staff Nurses (sample size of 9)
Nurses in direct patient care
IRB approval was received at the hospital prior to meeting with the nurses. Interviews were conducted by
appointment, away from the clinical unit in a private location after consent was obtained. Interviews were audio
recorded and personal notes were made by the interviewer.
Analysis
For this specific study the data were analyzed by creating displays (flow charts), counting the repetition of
data and placing the data in chronological order. After this was completed, a strategy for case study analysis was
done. Pattern matching was completed for each interview question for each group. As this is a triangulated case
study design, after initial pattern matching was completed as described above, the research then sought to find any
patterns that overlapped between the two or all three groups. Last, the existence of any opposing patterns in the
responses between one or two groups were sought.
Results
Theme 1: Pre and Post-Merger Planning Strategies are Needed When Merging Nursing Units
A lack of a formal merger plan was recognized within the management and leadership group. Staff did not
recognize that a formal merger plan was or was not done. Participants also shared that those who were involved in
the pre-planning process were mainly management and leaders. One staff member did voice adding input into the
merger but that her thoughts were neither considered nor reflected in the merger design.
Theme 2: Communication Tactics Need to be Open During a Nursing Unit Merger
Lack of communication was raised as a concern by members of all three groups: management, leadership
and staff. All three groups shared that they were not clearly informed about the merger process or how it was going
to transpire. The lack of clear communication resulted in a few members of each group sharing that anxiety was
present in the work environment after the merger.
Theme 3: Educational Plans Need to be Identified When Merging All or Some of the Nurses to a New Patient
Population
The majority of management, leadership, and staff found that the educational plans that were implemented
were effective. A few leadership and staff nurses felt that the education training day took too long to complete and
inhibited the ability to cross train staff sooner. One staff nurse also mentioned that the resources on night shift were
not as vast as those that were made on day shift. Patterns also emerged regarding the other educational resources
and support provided for the staff. Management, leadership, and staff recalled that the use of in-service (short
educational sessions lasting less than one hour) posters and support leadership in the working environment were
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Volume 1 Issue 1 (2015)
beneficial. The use of booklets and online material were only recalled as being used and beneficial by two groups:
the leadership and staff. The management group did not report the use of booklets or online material.
Theme 4: Theory X and Theory Y Management Theory Used During a Nursing Unit Merger
A few participants shared styles that paralleled Theory Y management style, which assumes that the
employees are ambitious and self-motivated, while more participants shared Theory X management style emerged
which assumes employees are inherently lazy and must be closely supervised. The management group and staff
revealed a pattern of not having the opportunity to challenge management in an upward manner. Yet, this was not
found among the leadership group. A detailed management approach was disclosed only by the management group
and a few members of the leadership group. Triangulation of this revealed that one participant from each group
disclosed a Theory Y management style while parts of Theory X management style repeatedly emerged in all three
groups.
Theme 5: Integration Strategies are Needed to Merge Staff Effectively Before and After The Merger
Few participants from the management and leadership team recalled socials prior to the merger.
Management found socials prior to the merger effective yet leadership did not. A mixture of responses among the
staff group were identified. A few of the participants of the staff group could not recall or attend the socials prior to
the merger. One staff shared that a social prior to the merger would have been beneficial. The analyzed data
revealed a pattern of a culture clash occurring. All three groups discussed clashes in the cultures that were
experienced by them. Management and Leadership did recall the use of human resources to foster teambuilding and
develop behavioral expectations. The analyzed data did not reveal a similar pattern among the staff and they did not
discuss this theme. Socialization strategies were recalled by participants of the management and staff groups. Both
found them beneficial after the merger yet the leadership group did not recall them.
Theme 6: The Development of Trust and Relationships are Needed When Conducting a Nursing Unit Merger
Staff reported that clear expectations were set forth when the merger occurred while a few of the members
of leadership did as well. Members of the management group, a few staff, and most of leadership did not report the
establishment of clear expectations. Most members of the management group and leadership identified and
disclosed different tactics they used to develop trust and relationships with the staff.
Theme 7: Breach of Psychological Contracts Can Harm Team Development in a Nursing Unit Merger
The development of psychological contracts seemed to not occur prior, during, or after the merger occurred
between management and employees nor management and the organization. This pattern was similar among all
participants. Analyzed triangulated data revealed that staff participants felt the lack of visibility from their manager
the most. A few participants of the management and leadership group felt it as well. Lack of organizational support
was also experienced by a few staff. However, management and leadership shared this experience more. Analyzed
triangulated data found that two groups, management and staff, expressed poor development of relationships during
the merger. Staff expressed this concern more frequently than management. Analyzed triangulation revealed that
the leadership group did not find management as trusting. The leadership group and staff did reveal that the nurse
manager was not trusting in nature. Most participants of the management group and a participant of the leadership
group disclosed that management did not create a trusting environment. Only a very few reported a breach in
confidentiality. A few participants of the management group experienced a breach in confidentiality while most
participants of the leadership group shared this experience as well. The behaviors of colleagues and lived
experience by the participants impacted the level of trust by all groups. Trust either was initially low or decreased
with the experience of the merger.
Initial Recommendations
Participants provided recommendations for the future based on the last question in the survey instrument.
The data was quantified to calculate the amount of times a recommendation was repeated . These initial
recommendations were also triangulated between each group. The most frequently discussed recommendations by
the participants are designated by an asterisk and were then merged with the seven themes to develop the final nine
recommendations.
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Findings
The top eleven initial recommendations based on total times the recommendation was discussed by
participants were revealed. The initial recommendations by the participants were then integrated with the seven
themes to develop the nine recommendations.
Recommendation 1: Formalized Planning Strategies May Benefit Inpatient Nursing Unit Mergers
The development of Recommendation One was based on the combination of Theme one: pre and postmerger planning strategies are needed when merging nursing units, Initial Recommendation four: formalize the
planning process of an inpatient nursing unit merger, Initial Recommendation six: identify leadership structure
before merger, and Initial Recommendation nine: match competencies and like patient populations of merged units.
Hurtado (2008) and Mintzberg (1973) both share that strategies can be made based on the present needs for an
organization.
Recommendation 2: Open Communication With A Seamless Message From Leadership May Benefit Inpatient
Nursing Unit Mergers
The development of Recommendation Two was based on the combination of Theme two and Initial
Recommendation five and seven. Theme two discussed communication tactics need to be open during a nursing
unit merger. Initial Recommendation five recommended for leadership to be on the same page. Initial
Recommendation seven recommended nursing management should develop communication plans to reach all
nursing staff on all shifts and days. Open communication methods during a nursing merger are supported by
Angwin, Mellahi, Gomes, & Peter (2014), Cheng & Seeger (2012), and Piper & Schneider (2015).
Recommendation 3: Development of an Educational Plan Inclusive of Cross-Training for New Patient
Populations May Benefit Inpatient Nursing Unit Mergers
The development of Recommendation three was based on the combination of Theme three: educational
plans need to be identified when merging all or some of the nurses to a new patient population, Initial
Recommendation one: Educate nurses to new patient populations, and Initial Recommendation three: Cross-train
staff before the inpatient nursing unit merger. As the way education is delivered to healthcare providers can greatly
affect the knowledge acquired and experience gained by the learner (Brooks & Barr, 2004), nursing leaders must
develop an educational plan for inpatient nursing unit mergers.
Recommendation 4: Identification of Management With a Blend of Transactional and Transformational
Leadership Style May Benefit an Inpatient Nursing Unit Merger
The development of Recommendation four was based on Themes four and seven. Theme four4
represented the use of Theory X and Theory Y management theory used during a nursing unit merger. Theme seven
represented how a breach of psychological contracts can harm team development in a nursing unit merger is
discussed. As Theme four and seven impacted the nursing unit merger in this study a review of literature was
visited for comparison to finalize Recommendation four. Transformational and transactional leadership styles are
needed to implement change (Ahmad et al., 2014; Bass, 1985; Johnson, 2009; Strom et al., 2014). Transformational
and transactional leadership styles also allow for the development of trust with employees, which is essential in
developing psychological contracts (McDermott et al., 2013). The study supported the recommendation of a
purposeful blend of transactional and transformational leadership style and develop psychological contracts along
with the minimal use of Theory X management theory and more Theory Y management theory. As participants
disclosed that this broke trust between them and management, the final conclusion of recommendation four was
developed.
Recommendation 5: Engagement of Staff During the Merger Planning Process May Benefit an Inpatient
Nursing Unit Merger
The development of Recommendation five was based on the repetitive theme requesting staff engagement
during the analysis of participant recommendations. Initial Recommendation two advised for the involvement of
staff in the merger planning process. Szdylowski and Smith (2009) and Brodbeck (2012) found that engaging staff
during a change process was beneficial. Nursing leaders should consider staff engagement when planning for an
inpatient nursing unit merger.
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Recommendation 6: Development of a Cultural Integration Plan May Benefit an Inpatient Nursing Unit Merger
Integration of cultures emerged as a recommendation yet not enough to be included in the top ten initial
recommendations. Participants did recommend for staff to be integrated, or meet one another, prior to the merger
within Initial Recommendation ten. Recommendation six was developed by the review of literature which strongly
supports the need for a cultural integration plan (Frantz & Carley, 2013; Gerbler, 2009; Lieb & Butner, 2007;
Walker & Price, 2008; Yamanoi & Sayama, 2013) and Initial Recommendation ten.
Recommendation 7: Nursing Management May Seek to Disclose Their Leadership Style and Develop Trust to
Initiate and Maintain Psychological Contracts During an Inpatient Nursing Unit Merger
The triangulated analyzed data allowed for two themes to be considered when developing Recommendation
seven. Theme six discussed the development of trust and relationships is needed when conducting a nursing unit
merger while Theme seven detailed how breaches of psychological contracts can harm team development in a
nursing unit merger. In summary, findings from the review of literature (McDermott et al., 2013), Initial
Recommendation eleven, and participant data discussed in Theme six and seven resulted in the development of
Recommendation seven.
Recommendation 8: Development of Psychological Supportive Systems for Nursing Staff May Benefit an
Inpatient Nursing Unit Merger
The recommendation detailed by various participants allowed for the development of Initial
Recommendation eight: Allow for nursing staff to talk about their feelings before and during the merger.
McDermott et al. (2013) and Cortvriend (2004) shared the need to enact a psychological supportive system for
nurses involved in a merger. This is also supported by Bridges (1991) transition of the ending phase where
employees reflect upon the past while they navigate through a change process. In summary, the development of
Recommendation eight was founded on participants’ recommendations in Initial Recommendation eight which is
supported by McDermott et al. (2013), Bridges (1991), and Cortvriend (2004).
Recommendation 9: Merging of Like Patient Populations May Benefit an Inpatient Nurse Merger
Merging like patient populations emerged as a repeated recommendation among participants. This allowed
for the development of Initial Recommendation nine, merge like patient populations. The review of literature did
not find this as a recommendation or theme. Yet, the increased frequency among participants allowed for the
development of Recommendation nine.
Limitations
Researcher bias could have occurred as the members of the study team have experienced a clinical unit
merger. In order to decrease this bias, the study was not conducted in the setting of this prior experience. Another
limitation was the sample size of the study which resulted from a limited time to collect data.
Opportunities for Further Research
Further research could be to investigate the merger of nursing units that have similar patient populations
and those that are not similar. Merging of like patient populations emerged as a strong recommendation among
participants that resulted in the development of recommendation nine. Yet, the review of literature did not include
the impact of merging like or unlike patient populations. Another opportunity for research may be the incidence of
nurse turnover as a result of a merger or assess the impacts over a long time assessing milestones. The review of
literature on nursing mergers that have been studied did not include concrete nurse turnover data as a result of a
nurse merger. An opportunity for research may seek to study nurses who left after a nursing unit merger and find
why they left and the cost to the organization to further benefit nursing mergers in the future. Lastly, another
opportunity lies in evaluating the impacts of a nursing merger due to bed reduction as in this case the merger
occurred due to a bed expansion.
CONCLUSION
Merging nurses is a challenging process. The development of a strong communication and implementation
plan can aid in the success of a merger. Identification of a leader with key traits; establishment of trust, emotional
support, transactional and transformational leadership styles may also yield positive outcomes when merging nurses.
Integration of these components along with the recommendations listed will assist in a successful nursing merger.
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Journal of Emerging Trends in Healthcare Administration
Volume 1 Issue 1 (2015)
Dr. Ana Figueroa-Altmann is a nursing leader whose career focuses on quality improvement, patient safety and
nursing management. Her professional passions include professional development of nurses, retention strategies and
improving patient safety. She has published with peers on these topics such as “Nearing Zero…Reducing Grade C
Medication Errors,” “Is Your Facility Struggling With Millenial Retention?,” and “Using Four-Phased Unit-Based
Patient Safety Walkrounds to Uncover Correctable System Flaws.” She holds a BSN from Villanova University, a
MSN with a concentration in leadership and management from Drexel University and a Doctoral degree in
management with a concentration in organizational leadership from the University of Phoenix. She is also a board
certified Nurse Executive. She is currently the Lead Nursing Quality and Patient Safety Coordinator at The
Children's Hospital of Philadelphia.
Dr. Cynthia Davies, noted as a transformational Human Resources leader, has successfully built, restructured, and
directed Human Resources practices in high growth businesses. She is experienced in all functional areas of Talent
Management as well as strategic marketing and sales of Human Capital Management software. She is currently an
Adjunct Professor at University of Phoenix online where she mentors doctoral candidates during their dissertation
process and at Rutgers University where she teaches in the School of Business-Management and Global Business.
She holds a BA in Business and Management from DeSales University, a MBA with Marketing and Finance
concentrations from Wilkes University and a Ph.D. in Organizational Development from Temple University. She
has achieved the professional designation of SPHR (Senior Professional in Human Resources) and SHRM-SCP.
Dr. Renee’ Roberts-Turner has been a Registered Nurse for 15 years. She is currently the Director Nursing,
Professional Practice & Magnet® Program Director at Children’s National Health System. Previously she was the
Manager and Nursing Outcomes Coordinator of Nursing. Dr. Roberts-Turner’s received an MSN in Nursing
Education from Marymount University and a Doctorate of Health Administration from the University of Phoenix.
She is a board certified Nurse Executive and Certified Professional in Healthcare Quality. Dr. Roberts-Turner’s
research interests include RN and patient satisfaction.
Logan MacLean is a Pediatric ICU nurse at the Children's Hospital of Philadelphia. He is also currently pursuing a
doctorate in Nurse Anesthesia Practice at the University of Pennsylvania. Logan MacLean received his
undergraduate education in nursing at the University of Pennsylvania School of Nursing. He also holds an
economics degree from the Wharton School of the University of Pennsylvania, with concentrations in finance and
health care management & policy.
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