Associations Between Hospital Mergers and Hospital Level Nursing Factors, Nurse Well-Being, and Nurse-Sensitive Patient Safety and Quality-of-care Outcomes: A Scoping Review

Abstract

Background:

Hospital mergers have proliferated across the U.S., yet a comprehensive understanding of how mergers affect nurses and patients is lacking.

Objective:

Determine the known associations between U.S. hospital mergers and hospital-level factors that influence nursing, nurse well-being, and nurse-sensitive patient safety and quality-of-care outcomes.

Research Design:

A scoping review of systematically searching 10 databases comprised of business and healthcare literature up to January 2025.

Results:

We found 1,775 articles; 10 met our inclusion criteria and were included in the analysis: 5 quantitative, 3 qualitative, 2 multi-methods. Only 3 studies analyzed data from 2003 or later. Although data were sparse and older, we found that hospital mergers introduced organizational changes in nursing—nurse staffing, leadership, and operations. Whether nurse-sensitive patient safety and quality-of-care outcomes improved post-merger was equivocal. Qualitatively, nurses described poor communication, a perceived lack of trust in leadership, a loss of identity and unity, decreased morale, increased fear or uncertainty, and issues with equal and/or respectful treatment. Employed study methods and designs, as well as a dearth of recent studies, influenced the ability to draw strong causal and/or detailed conclusions, especially about newly emerging issues in today’s healthcare system.

Conclusion:

Our findings suggest that hospital mergers may impact nurses and the nursing workforce. As hospital mergers continue to increase, future research with recent data and rigorous methods are needed to develop timely and applicable policy to mitigate any potential harms and leverage potential benefits of hospital mergers for nurses and patients.

Introduction

Hospital mergers have proliferated across the United States (U.S.) since the 1980s¹ and are projected to continue apace.² Policy changes such as the revocation of the 2021 executive order Promoting Competition in the American Economy³ and the Federal Trade Commission (FTC) increasing the transaction thresholds (i.e., purchase price) necessary for pre-merger notification filings,⁴ make it easier for hospitals to merge. However, the implications of mergers for quality-of-care in general and nursing quality in particular remain difficult to anticipate.

On the one hand, standards-setting organizations and payers like the National Quality Forum,⁵ the Centers for Medicare and Medicaid Services,⁶ and the Joint Commission⁷ now track patient safety and quality-of-care metrics that are strongly impacted by nursing,⁸ tying accreditation and financial incentives to hospital performance. But other healthcare system shocks, like the COVID pandemic, have moved long-standing concerns for nurse well-being to the forefront or policy discourse^9,10 as the nursing workforce crisis grows.¹¹

What is clear are the gaps in our current knowledge about the impact of mergers. The FTC and the U.S. Department of Justice and U.S. Department of Health and Human Services announced a Request For Information in 2023, for empirical evidence on the impact of hospital mergers on market competition, employees, and patient care to inform regulatory decisions.^12,13 Identifying what is currently known about hospital mergers for nursing staff and nursing-related quality is essential for evidence-based policy making.

Hospital mergers often occur for financial reasons,^14,15 and can cause direct changes in hospital leadership, policies, procedures, and healthcare system priorities.¹⁶ Such changes can have considerable impact, positive or negative, on the well-being of nurses who work in these hospitals and nurses’ ability to provide safe, high-quality care. A merger may provide additional investments that were not previously available or result in a hospital being stripped of resources (e.g., decrease in staffing, fewer resources, increased focus on profit). Changes in nurse staffing, or team support, can impact nurses’ ability to provide care, fostering an infrastructure that supports improved patient safety and quality-of-care or alternatively, disrupts caregiving practices in ways that harm quality or safety, ^8,17,18 exacerbating mortality for hospitalized patients.¹⁹ But it is currently unknown how hospital mergers effect nurses and patients in the U.S. Therefore, we examined what is known about U.S. hospital mergers and hospital-level factors that influence nursing, nurse well-being, and nurse-sensitive patient safety and quality-of-care outcomes to guide future research to mitigate any harm and leverage potential benefits of mergers.

Methods

Search strategy

The research team [KR, AH, MS, DKC] consulted with an expert medical librarian [JB] to design the search strategy. The following databases were searched on February 23, 2024, for relevant studies: Ovid MEDLINE(R) ALL <1946 to February 22, 2024>; OVID Embase <1974 to 2024 February 22>; Web of Science; Cochrane CENTRAL; CINAHL; SCOPUS; and ProQuest Health Administration Database. On February 29, 2024, three additional databases were searched: EBSCO ABI Inform Collection database; and EBSCO BusinessSource Complete. Searching these databases, we used both controlled vocabulary and synonymous free text words to capture the concepts: hospital mergers and hospital nurses. Search strategies were adjusted for the syntax appropriate for each database. We applied no language or date limitations during the search. The search was updated on January 17, 2025. Results were uploaded to EndNote (version21– Thompson Reuters) and deduplicated, with the final set uploaded into Covidence systematic review software (Veritas Health Information). Additional studies were identified through citation searching. Search Histories in Supplementary 1.

Study selection

To be eligible for the review, studies must have met the following inclusion criteria: (1) U.S.-based sample, (2) specify a hospital merger and one nursing-related criteria (3) use empirical data, (4) be peer-reviewed, and (5) written in English. Conference abstracts, protocols, interventions, non-empirical studies (e.g., case studies), theses or dissertations, quality improvement, and systematic review articles were excluded. Abstracts and full text were independently reviewed against the inclusion criteria by two authors [KR, AH]. Disagreements at each stage were resolved through discussion and/or with additional reviewers. For each study that met inclusion criteria, the authors [KR, AH] independently completed data extraction to capture variables of interest.

Data extraction methods

A preliminary scan of the literature indicated a high likelihood that our variables of interest—hospital level factors that influence nursing, nurse well-being, and nurse-sensitive patient safety and quality-of-care outcomes—may have various measurements. Therefore, during data extraction we allowed for “other” measures or descriptions of measures that fit within our topic areas of interest to be extracted, in addition to the pre-specified categories (Supplementary 2).

Results

A total of 1,775 records were retrieved. After removing duplicates 1,07 remained. Of the 89 full text studies reviewed for eligibility, we included 10 articles in the final analysis. The results of the search and study selection are reported in the PRISMA Diagram (Supplementary 3).

Study characteristics

Ten studies met criteria. Most data were collected nearly 25 years ago (Figure 1).^20–26 The most recent data were eight years old.²⁷ Study hospitals included teaching and non-teaching, rural and urban/metropolitan, community, for-profit and not-for-profit, and small and large hospitals across the U.S. The largest number of merged hospitals in a study was 92 (Table 1).²² Five studies (40%) involved one to three hospitals.^25–28 Seven (70%) studies surveyed or interviewed participants: chief nursing officers,²⁹ registered nurses (RNs),^24–26,28 licensed practical nurses (LPNs),²⁵ and/or other participants.²⁰ The number of nurse participants in each study varied, from 11 to 350.

Figure 1. Timeline of Published Studies and Key Legislation and Executive Agency Actions Relevant to Hospital Mergers.

Note: The length of the lines under the dates of data collection shows the span of time the study data represents. The year in parentheses is the year of publication. A dashed line with diamonds represents qualitative data and a solid line represents quantitative data. Studies that have both a dashed line with diamonds and straight lines are studies with both qualitative and quantitative data.

*Data were part of a 4-year panel study with data collected between time points 1 and 2 (over 6 months). We estimate data were collected around 1994 at the latest. **Data were published in June 2018 but were collected by interviews with nurses who had experienced a merger in the last 5-years. We estimate that nurse interview data could reflect mergers that occurred in 2012.

EO: Promoting Competition = Executive Order Promoting Competition in the American Economy (July 2021). MFFMA = Merger Filing Fee Modernization Act (December 2022). RFPC = Joint Federal Trade Commission, U.S. Department of Justice, and U.S. Department of Health and Human Services request for public comment on hospital mergers (December 2023). RFFS = Federal Trade Commission and U.S. Department of Justice revised filing fee schedule for the Hart-Scott-Rodino (HSR) Antitrust Improvements Act (January 2025). OBBBA = One Big Beautiful Bill Act (July 2025). REO = Trump Administration Revokes Executive Order Promoting Competition in the American Economy (August 2025).

Table 1.

Summary of Study Designs and Methods

Study	Data Dates/Age of Data	Number of Merged Hospitals	Number of Nurses/Participants from an Acquired Hospital	Study Design/Methods				Outcomes
				Pre/Post (Data prospectively collected both before and after merger)	Comparison Hospitals	Longitudinal	Quantitative, Qualitative, or Both	Nursing Factors	Nurse Well-being	Patient Outcomes
Alexander et al. (1996)	1982– 1989 1980 – 1990	92	–	√	√	√	Quantitative	√	–	–
George et al. (1997)	1995	2	66	–	–	–	Both	√	–	√
Geddes et al. (1999)	unknown*	53	53	unknown*	–	√	Qualitative	√	√	–
Clark et al. (2001)	1998	unknown+	293	–	√ +	–	Quantitative	√	–	–
Bazzoli et al. (2002)	1983–1988 1989–1996	60∞ 75∞	–	–	–	–	Quantitative	√	–	–
Jones (2003)	1999 – 2000	3	98	–	–	–	Both	√	–	–
Romano & Balan (2011)	1998 – 2003	2	–	√	√	√	Quantitative	–	–	√
Robinson & Knight (2018)	unknown**	16	16	–	–	–	Qualitative	–	√	–
Russo et al. (2018)	2016	3	350	–	–	–	Quantitative	–	√	–
Easler (2021)	2017	1	11	–	–	–	Qualitative	√	√	–

Note: Nursing factors included nurse staffing, climate for patient care, nursing governance preferences, professional nursing practice autonomy, organizational culture, organizational commitment, branding, resource allocation, changes in benefits, and changes in leadership. Nurse well-being included nurse resilience and coping. Patient outcomes included decubitus ulcers, post-operative hip fractures, and infections due to medical care.

^∞Authors describe it as 60 and 75 mergers of two hospitals between 1983–1988 and 1989–1996, respectively.

^*Data were part of a 4-year panel study with data collected between time points 1 and 2 (over 6 months). We estimate data were collected around 1994 at the latest.

^**Data were published in June 2018 but were collected by interviews with nurses who had experienced a merger in the last 5-years. We estimate that nurse interview data could reflect mergers that occurred in 2012.

⁺293 nurses were surveyed, but it is unknown if they represented any of the same hospitals and it is not clear if they were exclusively identified as only experiencing a merger versus another type of restructuring.

Five studies were quantitative,^21–24,28 three were qualitative,^20,27,29 and two were multi-methods.^25,30 There was minimal overlap in topic areas between the qualitative and quantitative studies. Three studies^21–23 were longitudinal and only two^21,22 incorporated control hospitals to more precisely estimate the marginal effect of the merger causally. Data collection for the remaining studies occurred during or after completion of the merger employing cross-sectional designs. A distinct evaluation of outcomes relative to each merger stage—pre, during, post, or long-term—and comparisons among the different stages of mergers was absent. See Table 1 for a brief overview of study designs and methods, Table 2 for additional details on qualitative studies, and Table 3 for additional details on quantitative studies. Table 4 provides illustrative quotes from participants about hospital mergers.

Table 2.

Summary of Qualitative Studies

Author (Publication Year) Journal Title	Purpose	Study Characteristics	Variables Examined Measurement	Results
Easler (2021) Nurse Leader Nurses’ aesthetic responses and emotional judgments to senior leaders’ use of language, action, and behavior	“...to examine nurses’ emotional responses and experiences with senior leaders’ use of language, action, and behavior during a time of intense organizational change”	Sample size Hospitals- 1 Nurses- 11	Nurses’ feelings and emotions regarding their experiences of senior leaders’ use of language, action, and behavior during a time of intense organizational change	Branding Some nurses saw changes in branding as the “hallmark of change” and described their experiences as “hard to identify with”, “a breakup”, “totally off from what it had been”, and “taking our identity”. Resource allocation Nurses anticipated that the merger would increase their access to supplies but instead found that new bureaucracy was a hindrance in accessing supplies and providing patient care and felt angry, confused, and uneasiness/fear. Nurse staffing was a resource that was affected. Although there was an increase in salary, nurses were asked to work more hours with fewer nurses each shift. One nurse said, “...it’s like with our staffing being crunched, that I am here more than I am at Home...” Restructuring maneuvers Nurses’ emotional or aesthetic judgments in response to restructuring included words like “pain, painful, horrible, scary, and anxiety.” Nurses relayed a lack of clear or authentic communication and felt that values and expectations were at odds. Leadership connection Lack of in-person and personal connections with new leadership produced concerns by nurses.
		Geographic location Unknown
		Hospital characteristics Teaching, not-for-profit
		Data Qualitative interview primary data collection (2017)
		Study design/Type of Analysis Qualitative descriptive, with thematic analysis
		Period of time when the merger was studied During the merger
Geddes et al. ± (1999) The Journal of Nursing Administration Nursing in the nineties: Managing the uncertainty	“...examine the effect of nursing unit organizational structure (at both hospital level and nursing unit level) on delivery of care at the nursing unit level, patient outcomes, and nursing administrative outcomes”	Sample size Hospitals- 53 Participants- 53 study site coordinators (unclear whether they are nurses or not)	Critical incident Implications	Nurses felt a loss of workplace identity when experiencing a merger as well as stress from uncertainty and diminished trust in leadership due to rumors. “Topics for the rumor mill focused primarily on personnel cuts, mergers, and leadership changes. “The merger has created feelings of job insecurity, low morale, and anger.”
		Geographic location 11 southeastern states, Washington, D.C., and Texas
		Hospital characteristics Hospital bed sizes ranged between 91 and 902. The average case mix index was 1.3, indicating a complex mix of patients and 21 hospitals were teaching.
		Data Open-ended narrative journal entries using topic headers critical incident and implications (6 months of data [between time point 1 and 2 of data collection]; n.d.β)
		Study design/Type of analysis Qualitative prospective with thematic and content analysis
		Period of time when the merger was studied Unknown
George et al.*† (1997) The Journal of Nursing Administration Research-based planning for change: Assessing nurses’ attitudes towards governance and professional practice autonomy after hospital acquisition	“This article describes one medical center’s experience in using research to plan for nursing staff integration after hospital acquisition.”	Sample size Hospitals- 2 Nurses- 100 at acquiring hospital (type of nurse unknown) 66 at acquired hospital (RNs and LPNs)	Attitudes towards transition	Things considered both potential advantages and concerns of a merger included: job security, changes in pay/benefits, and changes in quality of care. The advantages perceived were expanded resources, opportunities for growth and change, improved educational opportunities. The perceived concerns were unequal treatment and lack of being informed or involved. Suggestions for a successful transition include keeping staff informed, increasing involvement and collaboration in governance, treating staff with honesty and respect, and being patient and taking things slowly.
		Geographic location Milwaukee, Wisconsin
		Hospital characteristics Urban/metropolitan
		Data Open-ended survey administered by authors (1995) 3 questions: 1) the most important advantages of becoming part of St. Luke’s, 2) list the three most serious concerns you have about becoming a part of St. Luke’s Medical Center, 3) give two ideas to make the transition successful
		Study design/Type of Analysis Qualitative cross-sectional with thematic analysis
		Period of time when the merger was studied During (2 weeks into merger)
Jones* (2003) The Journal of Nursing Administration Dual or dueling culture and commitment: The impact of a tri-hospital merger	“...addresses differences in RNs’ commitment to their employing hospital versus the umbrella corporate organization, and the role of organizational culture during a tri-hospital merger.”	Sample size Hospitals- 3 (1 acquirer, 2 targets/acquirees) Nurses- 98 medical-surgical RNs surveyed 9 of the 98 medical-surgical RNs were interviewed	Changes in organizational culture  Organizational identity  Trust in leadership	A cohesive sense of system identity was missing. The acquiring hospital had clear branding with signage and banners, while the two acquired hospitals had minimal visualization of system identifiers and no personal hospital identification. CEOs had a significant influence on organizational culture. There was a lack of trust in administration after the merger. Nurses shared the desire to feel a sense of belonging and camaraderie after the merger but found it sometimes missing. Being part of the process of change was important.
		Geographic location New York
		Hospital characteristics Teaching, community, not-for-profit, urban/metropolitan
		Data Primary data collection, Semi-structured interviews, participant observations, analysis of company documents by authors (Nov 1999-Jan 2000)
		Study design/Type of Analysis Cross-sectional, descriptive, exploratory
		Period of time when the merger was studied 3.5 years post-merger
Robinson & Knight (2018) Nursing Management Hospital acquisitions: The chief nurse executive perspective	“This article presents the results of a qualitative study of current and former hospital CNEs from rural facilities to major academic medical centers across the country who experienced an acquisition.”	Sample size Hospitals- 16 (11 targets/acquirees, 5 acquirers) Nurses- 16 CNEs	Overall experiences with hospital mergers	Although communication was identified as important it was often nonexistent, disorganized, and/or conflicting. However, some CNEs in acquiring hospitals felt communication was good during the merger. Respect was an issue. Nurses in the acquired hospital frequently used the phrase “stepchildren” do describe how they felt during the acquisition and that they were treated as if they were stupid. CNEs in acquiring hospitals also commented on the importance of respect, while seemingly to speak un-respectfully about or towards those in the acquired hospital. Sudden impacts were seen on staff turnover, whether by choice or force, and decreases in morale were seen by an increase in fear and uncertainty for the future. Forty-five percent of CNEs were let go during acquisition. Failure to launch was demonstrated by many CNEs sharing that frequently there was no plan for transition during the acquisition leading to issues related to cohesiveness in values, vision, business operations (e.g., nurses not properly on payrolls), and day-to-day procedures. Advice from CNEs in acquiring hospitals included spending time on the frontend to establish relationships, integration plans, and making the transition a “celebration”. CNEs from acquired hospitals discussed clear, transparent, and regular communication with staff regarding changes and the merger were helpful. They also spoke about having critical support from CEOs throughout the process.
		Geographic location Across the US
		Hospital characteristics Teaching, rural, urban/metropolitan
		Data Qualitative interviews using an interview created by the authors (n.d. specified for collection)††
		Study design/Type of Analysis Qualitative using phenomenology
		Period of time when the merger was studied Post-merger, within 5 years prior to the study

Note:

^*= both quantitative and qualitative (multi methods) study.

^†= study results are mixed between mergers and restructuring at large; only clearly merger-specific results are presented.

^β= Data were part of a 4-year panel study with data collected between time points 1 and 2 (over 6 months). We estimate data were collected around 1994 at the latest.

^††= Data were published in June of 2018 but were collected by interviews from nurses who had experienced a merger in the last 5-years. We estimate that nurse interview data could reflect mergers that occurred between 2013 and 2018.

CEO= chief executive officer. CNE= chief nursing executive. n.d.= no date.

Table 3.

Summary of Quantitative Studies

Author (Publication Year) Journal Title	Purpose	Study Characteristics	Variables Examined Measurement			Results
			Hospital-level Factors that Influence Nursing	Nurse Well-being	Patient Outcomes
Alexander et al. (1996) Health Services Research The short-term effects of merger on hospital operations	To examine the short-term effect of hospital mergers on three areas of hospital operations: scale of operation, efficiency, and staffing practices	Sample size Hospitals- 276 control hospitals, 194 hospitals engaged in a merger, 92 merged hospitals (two-hospital mergers)	Nurse staffing  Nurses per average daily census   *Levels of nursing personnel were calculated as the sum of FTE RNs, LPNs, and ancillary nursing personnel with part-time staff equaling 0.5 FTE   *Nurses per average daily census were calculated as sums of the mean staffing levels divided by summed mean average daily census values	–	–	The rate of increase in mean staffing ratios post-merger increased at a slower pace compared with pre-merger rates for staffing ratio increases. Authors note that this was most likely not due to mergers because when comparing differences in rates of changes between merger groups and groups that did not have mergers there was not a significant difference in the change of staffing ratios.
		Geographic location Unknown
		Hospital characteristics Government not-for-profit, private not-for-profit, for-profit, varying sizes of hospitals (6–500+ beds)
		Data AHA (1982– 1989) AHA (1980 – 1990)
		Study design Longitudinal (6 years)-multiple time-series
		Period of time when the merger was studied 3 years Pre-merger & 3 years post-merger
Bazzoli et al. (2002) Health Care Management Review Hospital reorganization and restructuring achieved through merger	“Our purpose is twofold. First, we assess the rationale, and reorganization actions of merging hospitals in this more recent period. Second, we contrast merging hospitals in this more recent period with the original study to examine how hospital rationale for merger and their restructuring efforts changed.”	Sample size: Hospitals- 60 and 75 mergers of two hospitals between 1983–1988 and 1989–1996, respectively	Nurse staffing (by RN & LPN)  Changes in # of FTEs)  Use of # of RNs vs LPNs)	–	–	The top 3 reasons identified for mergers: strengthening financial position, achieving operating efficiencies, and consolidating services. Later mergers (1989–1996) more often had higher reductions in nursing FTEs (57.7% vs 27.3%). Earlier mergers (1983–1988) had a higher increase in the use of part-time nursing staff compared to hospitals that merged later (60% vs 28.6%). In the earlier group (1983–1988), nursing FTEs increased almost identically across all hospitals, however, merging hospitals had a greater decrease in LPN FTEs (29.3% vs
		Geographic location: National sample (28% northeast, 20% south, 26.7% north central, 25.3% west)
		Hospital characteristics: Urban, non-profit, acute care general
		Data AHA (1983–1988) AHA (1989–1996) Survey by Bogue et al (1991) Survey by Bogue et al (for hospitals that merged 1989–1996) collected (1998)
		Study design Cross-sectional
		Period of time when the merger was studied: Data collected post-merger representing pre-and postmerger data
Clark et al.† (2001) Industrial and Labor Relations Review Healthcare reform and the workplace experience of nurses: implications for patient care and union organizing	“This paper reports the results of a survey of the workplace experiences of hospital- based registered nurses under healthcare reform.”	Sample size Nurses- 519 RNs (205 did not experience a merger and 293 experienced a merger in the last 5 years).	Climate for patient care  Nurses’ perceptions of the level of the following 5 items in their workplace using a Likert scale with possible answers ranging from 1 (strongly disagree) to 5 (strongly agree) of nurses’ perception of:   1. voice, nurses have in the hospital   2. staffing   3. administrative support   4. paperwork   5. bureaucracy	–	–	Of the 5 items, only the perception that staffing levels were inadequate was statistically significantly more likely among RNs who had experienced mergers than among those who had not. While all 5 dimensions of climate for patient care were significantly associated with restructuring, only staffing was significantly associated with mergers.
		Geographic location Penn State University School of Nursing (current & past students); may be working outside of PA
		Hospital characteristics Unknown
		Data Primary data collection using an original survey developed and validated using CFA by authors (1998): questions addressing nurses’ perceptions of the climate for patient care, their experience with healthcare reform, and their attitudes toward unions.
		Study design Cross-sectional
		Period of time when the merger was studied Post-merger time frame (merger must have occurred within the last 5 years).
George et al.* (1997) The Journal of Nursing Administration Research-based planning for Change: Assessing nurses’ attitudes toward governance and professional practice autonomy after hospital acquisition	“This article describes one medical center’s experience in using research to plan for nursing staff integration after hospital acquisition.”	Sample size Hospitals- 2 hospitals Nurses- 100 nurses at acquiring hospital (type of nurse unknown) 66 nurses at acquired hospital (RNs and LPNs)	Nursing governance preferences  Professional Nursing Governance scale developed by Hess Professional nursing practice autonomy Schutzenhofer’s Nursing Activity Scale	–	–	Shared governance: Nurses at the acquired hospital reported that nursing should be significantly more involved in hospital decision making than they perceived they were at the time of acquisition. Autonomy: Nurses at both the acquired and acquiring hospitals reported negligible differences in how they measured their level of autonomy (192 vs 194) indicating that they felt they were highly autonomous.
		Geographic location Milwaukee, Wisconsin
		Hospital characteristics Urban/metropolitan, 200 and 700 beds
		Data Primary survey data collection by authors (1995)
		Study design Cross-sectional, descriptive
		Period of time when the merger was studied During merger (2 weeks into merger)
Jones* (2003) The Journal of Nursing Administration Dual or dueling culture and commitment: The impact of a tri-hospital merger	“...addresses differences in RNs’ commitment to their employing hospital versus the umbrella corporate organization, and the role of organizational culture during a tri-hospital merger.”	Sample size Hospitals- 3 (1 acquirer, 2 targets/acquirees) Nurses- 98 medical-surgical RNs surveyed 9 of the 98 medical-surgical RNs were interviewed	Organizational commitment  (Mowday’s, Steers’, and Porter’s Organizational Commitment Questionnaire [OCQ])	–	–	Overall, nurses did not demonstrate a strong commitment to their individual hospitals or the system. Commitment to a corporate system was, on average, greater for the acquiring hospital than the acquired hospitals. RN commitment to the individual hospital itself was generally higher than their commitment to the corporate system. There were no statistical correlations between nurses’ demographics and commitment to either the hospital or system.
		Geographic location New York, US
		Hospital characteristics Teaching, community, not-for-profit, urban/metropolitan, acute care, 190–741 beds
		Data Primary survey data collection by authors (Nov 1999-Jan 2000)
		Study design Cross-sectional, descriptive, exploratory
		Period of time when the merger was studied 3.5 years post-merger
Romano & Balan (2011) International Journal of the Economics of Business A retrospective analysis of the clinical quality effects of the acquisition of Highland Park Hospital by Evanston Northwestern Healthcare	“Respondent’s Counsel claimed that the merger caused clinical quality at Highland Park Hospital to improve in several important ways. The main purpose of this paper is to describe the analyses that we performed in response to those claims.”	Sample size Hospitals- 2 (1 acquirer, 1 acquiree) and unknown number of controls	–	–	Nursing-sensitive quality indicators [risk adjusted]  1. Decubitus ulcers  2. Post-operative hip fractures  3. Infections due to medical care	Rates of fractures slightly worsened and there were small improvements in rates of pressure ulcers and hospital-acquired infections. Although changes in hospital-acquired infections were statistically insignificant.
		Geographic location Illinois, US
		Hospital characteristics Teaching, 70% metropolitan, 80% not-for-profit, for-profit, non-federal acute care
		Data Illinois Department of Public Health (IDPH) Universal Dataset (1998–2003)
		Study design Longitudinal difference-in-differences
		Period of time when the merger was studied 3 years post-merger
Russo et al. (2018) Clinical Nurse Specialist Resilience and coping after hospital mergers	“...to examine the concepts of resilience and coping in frontline nurses who have recently undergone a hospital merger.”	Sample size Hospitals- 3 (merged into 1 health system) Nurses- 350 (72% RNs, 28% role unspecified), representing 14% of nurses across all 3 campuses.	–	Resilience  (Connor-Davidson Resilience Scale [CD-RISC]- how you felt in the last 30-days) Coping  (Coping Orientation to Problems Experienced [COPE] Inventory-comprised of 15 sub-scales)		Positive correlations were found between coping subscales and overall resilience. Resilience scores from each of the 3 hospitals were either just at or above the mean score for the general population in the US. The hospital with the least number of resources and the smallest staff had the greatest overall resilience score (83.66) and the largest hospital with the greatest number of resources had the lowest reported resilience score (80.8).
		Geographic location Northeast region of the US
		Hospital characteristics Teaching, not-for-profit, community, urban/metropolitan, Magnet, non-Magnet, level-1 trauma, non-trauma center, varying bed size (non-specific)
		Data Survey primary data collection by authors (2016)
		Study design Cross-sectional, descriptive
		Period of time when the merger was studied 2 years post-merger

Note:

^*= both quantitative and qualitative (multi methods) study.

^†= study results are mixed between mergers and restructuring at large; only clearly merger-specific results are presented.

CNO= Chief Nursing Officer. RN= registered nurse. LPN= licensed practical nurse. AHA= American Hospital Association. FTE= full-time equivalent. CFA= confirmatory factor analysis.

Table 4.

Cross-cutting Qualitative Themes and Illustrative Participant Quotes

Communication quality	“My hospital was told that we were getting a new president. Actually, we had heard through the grapevine that it would occur by the end of the week. On Monday, we heard the rumors; on Tuesday it was confirmed. By Friday, the new president was in place. No warning, no interviews, nothing.” (Robinson & Knight, 2018) “The corporation that purchased us ignored us for 6 months and we didn’t have any interaction at all.” (Robinson & Knight 2018) “There is speculation concerning the sale of our hospital, which is denied by administration; however staff read about it in the local newspaper.” (Geddes et al., 1999)
Loss of identity and unity	“[The acquiring hospital] wanted to do things their way and they didn’t care what we were doing, even in areas in which we were clearly better in terms of outcomes.” (Robinson & Knight, 2018) “We don’t seem to be walking down the same path ...I think we’re all running separate. I really do.” (Jones, 2003) “Hospital B’s downfall was the merger. It seems the corporate system is trying to transform us into Hospital A and we’re losing our identity.” (Jones, 2003)
Equal and respectful treatment	“What I did hear from the nurses is that they felt like stepchildren. They felt as if they were being treated as stupid and were being slighted regarding resources as well.” (Robinson & Knight, 2018) “[staff] totally resented the way they were talked to and the implication that they were a bunch of idiots who didn’t know what they were doing. They were efficient and felt that they were being discounted. It made for a lot of bad feelings and the turnover was significant.” (Robinson & Knight, 2018) “You must include people from both campuses to assist in the transition. These need to include staff nurses. This will provide some credibility and validity to what’s being said and done. Obviously, it should be somewhat gradual, starting with aspects that are not that different from what’s being done already so that the first changes can be positive, hopefully decreasing fatalistic feelings and increasing positive feelings about the transition.” (George et al., 1997) “What we do, what we say, what we feel doesn’t matter...” (Easier, 2021)
Decreased morale and increased fear or uncertainty	“There was a lot of angst as [staff] saw their friends let go and, of course, the fear factor comes in. Is this going to happen to me? And you can message all you want, but the rumor mill kicks in because they can see it and you can’t message that away.” (Robinson & Knight, 2018) “But it’s very hard to be positive and upbeat and move things forward when you’re standing in quick-sand.” (Robinson & Knight, 2018) “When the whole merger happened, it was supposed to be great for everybody. But it wasn’t so great for some people because they don’t work here anymore.” (Easier, 2021) “...staff were very unhappy and people are feeling very vulnerable.” (Geddes et al., 1999) “What does this mean for me? What does this mean for the organization? (Easier, 2021)
Organizational changes	“We’ll have a wider patient and doctor pool due to the size of the institution and number of HMOs, etc. Hopefully, the increased patient census will help to keep the hospital open and I’ll be able to keep my job.” (George et al., 1997) “With mergers and acquisitions, things might be really wonderful at the top when they shake hands and seal the deal, but there’s a lot of work to be done at the point of care and not everybody is just thrilled about it. There’s a lot of role shuffling and a lot of competition for resources and attention.” (Robinson & Knight, 2018) “It’s interesting because this system had acquired so many hospitals that I thought there would be an ‘integration for dummies book’, but there was nothing. There wasn’t even an organizational table at the highest system level.” (Robinson & Knight, 2018)
Trust and leadership	Regarding a senior leader: “...it is the feeling they give when they come by. It is like they are too stressed to talk to you right now. And it is like they really don’t want you to stop them because they may not be able to tell you the whole truth. They can’t even look you in the eye.” (Easler, 2021) “Be truthful with staff” and “Don’t beat around the bush” (George et al., 1997) “The staff felt very unsure of themselves. They didn’t know who was going to be leading them and what their expectations were going to be.” (Robinson & Knight, 2018)

Qualitative results

Qualitative studies examined nurses’ feelings and attitude towards, and experiences with, hospital mergers.^{20,25–27,29} (Table 2). Data were collected through interviews, open-ended narrative journal entries, and free-text survey responses. Recurring topics included: 1) communication quality,^20,25,27,29 2) loss of identity and unity,^20,26,27 3) issues with equal and respectful treatment between nurses at the acquiring versus acquired hospitals,^25,29 4) decreased morale and increased fear or uncertainty,^20,25,27,29 5) organizational changes,^25,27,29 and 6) the importance of trust and leadership.^{20,25–27,29} These were discussed by bedside nurses and nurse leaders alike. It was unclear whether nurses’ experiences were related to the mechanics of change during a merger or long-term consequences of the merger. As such, there was insufficient evidence to distinguish between the short and long-term perceptions of a hospital merger due to a small sample of studies.

Communication Quality

Nurses valued honest, transparent, and frequent communication before, during, and after the merger,^20,25,27,29 but the communication that they experienced was described as nonexistent, disorganized, and/or conflicting. Nurses felt that they were blindsided when things changed because of the merger. A chief nursing executive remembered, “On Monday, we heard the rumors; on Tuesday it was confirmed. By Friday, the new president was in place. No warning, no interviews, nothing.” ²⁹

Loss of identity and unity

Nurses shared their feelings of loss of identity and unity^20,27,29,30 and felt their values, vision, and expectations were at odds with the rebranding or restructuring caused by a merger.^27,29 Nurses used phrases such as “hard to identify with,” “a breakup,” “totally off from what it had been,” and “taking our identity” to describe their experiences. It is unclear if these feelings remained over time, were only present during the time of transition/implementation, and/or unique to hospital mergers versus organizational restructuring broadly.

Equal and respectful treatment

There were issues with unequal and disrespectful treatment between nurses at the acquired hospitals compared with the acquiring hospital; this was reported by both executives and staff nurses. Some nurses felt they no longer mattered after the merger: “No one from the new company questioned me about anything. We were invisible and we didn’t matter anymore.”²⁹

Decreased morale and increased fear or uncertainty

Four^20,25,27,29 of the five studies with qualitative data reported nurses’ experiencing a decrease in morale and an increase in fear or uncertainty which were often linked to changes in staffing, poor or unclear communication, loss of autonomy, and/or a general uncertainty.

Nurses reflected on their feelings regarding the merger as mostly negative. In Easler’s²⁷ work, participants used the terms “ugliness,” “confusion,” “anger,” “scary,” “anxiety,” and “sadness” when describing their experiences during the hospital merger. Nurses in other studies echoed these sentiments in anticipation of the merger. In George et al.’s study, 50% of nurses had fears about loss of autonomy—“we will have no voice.” But there was little detail included about what could have been done during the merger to ameliorate these feelings or whether these were short-lived during the merger process or longer-lasting sentiments after the merger was completed.

Organizational and Operational Changes

Organizational changes encompassed nurse staffing, nurses’ benefits, and new operations. Nurse turnover was discussed most frequently in regards to organizational changes.^20,25,27,29 Although it was not always clear to nurses whether turnover was related to staff layoffs or leaving by choice, the loss of colleagues was a notable source of anxiety. Easler²⁷ found that nurses’ workloads increased after the merger, and although nurses were given higher wages, nurses did not feel it was a positive change. Quality-of-care was briefly discussed once; nurses perceived care quality might be affected by the merger but were unsure if the effect would be positive or negative.²⁵

Some participants in George et al.’s²⁵ study were cautiously optimistic about the merger’s potential for improvements in job security due to increased patient volume, better compensation, and changes in quality-of-care, yet, participants also felt these could be negatively impacted by the merger but did not specify why. Job security and benefits did not improve; 45% of chief nursing executives interviewed from hospitals that were acquired were let go during the acquisition process, and staff nurses lost “premium pay, weekend options, and favored insurance plans.”²⁹

Operational changes consisted of new time-keeping and purchasing systems, electronic health records software, and financial and operational management systems, which were identified as a source of stress during a merger.^20,29 Although nurses anticipated resource allocation would improve, it became more difficult and frustrating. Nurses felt they were being hindered in their ability to provide care due to increased bureaucracy.²⁷ Nurses noted disorganization when implementing changes from the merger, even when acquiring hospitals had previously engaged in mergers.²⁹

Trust and leadership

Leadership played an important role during the merger. Changes in leadership style or personnel often made things more difficult for staff nurses.^26,27,29 Lack of familiarity, in-person contact, and transparent communication with leadership were all identified as sources of distrust, frustration, and emotional angst. A nurse shared, “I don’t trust administration [of the corporate system]. They say they won’t have any more layoffs, but you turn around and someone else is gone.”³⁰

Quantitative results

Hospital-level factors that influence nursing were categorized as hospital structural factors that may potentially influence the work environment or nursing. These factors were nurse staffing (most frequently studied),^22–24 climate for patient care,²⁴ nursing governance preferences and professional nursing practice autonomy,²⁵ and organizational commitment.³⁰ Nurse-sensitive patient safety and quality-of-care outcomes²¹ and nurse well-being²⁸ were each examined once.

Nurse staffing

Three studies^22–24 quantitatively examined nurse staffing associated with hospital mergers (Table 3). Two^22,23 measured the use of full-time equivalent (FTEs) RNs and LPNs leveraging data from the American Hospital Association annual survey from the 1980s and 1990s. Alexander et al. concluded that there were small increases in mean nurse staffing, but no evidence these changes were attributable to mergers. Bazzoli and colleagues compared changes in nurse staffing due to mergers at two different time periods (1983–1988 and 1989–1996) in two different samples and found differences in post-merger changes. Across both time periods, there was a change in the composition of the nursing team (i.e., merged hospitals decreased LPNs (32%) two-fold compared to non-merged hospitals (16.6%)), and potentially an increase in nurse workload (i.e., merged hospitals reduced FTE RNs by 6% on average compared to non-merged hospitals, which increased FTE RNs by 19.6%). Findings were not separated by hospitals that had recently merged versus hospitals that merged years earlier.

Climate for patient care

Climate for patient care is a construct comprised of five dimensions: 1) voice (i.e., how much voice nurses have in hospital decisions), 2) staffing, 3) administrative support, 4) paperwork, and 5) bureaucracy.²⁴ Clark et al.²⁴ found that RNs who experienced a hospital merger evaluated nurse staffing as inadequate significantly more often than nurses who had not experienced a merger. Nurse staffing was the only dimension significantly associated with hospital mergers, with increased nurse staffing associated with higher climate for patient care scores.

Nursing governance preferences and professional nursing practice autonomy

George et al. examined the consequences of a merger of two hospitals in Wisconsin in 1995.²⁵ Two weeks into the merger, 100 nurses at the acquired hospital were surveyed regarding shared governance (i.e., nurses’ input in hospital decision making) prior to acquisition and what nurses believed their shared governance should be at the time of purchase. Nurses at the acquired hospital reported that nursing should be significantly more involved in hospital decision making than they were at acquisition. Nurses at acquired and acquiring hospitals reported negligible differences in their perceived level of autonomy, indicating that they were highly autonomous in their roles immediately before and after the merger.

Organizational commitment

When a New York health system expanded to create a five-facility system in 2003, Jones³⁰ investigated the organizational commitment—the degree to which one identifies with the goals and values of the organization and has a strong desire to maintain their involvement to achieve these goals²⁶—of nurses to both the healthcare system and to their individual hospital. Three of the five hospitals were studied. One hospital was the acquiring hospital, two were acquired hospitals, and 98 RNs were surveyed across the three hospitals. Overall, although nurses did not report a strong commitment to their individual hospital or the system, their commitment to the hospital at which they worked was generally higher than to the corporate system. Nurses’ commitment to a corporate system was, on average, greater for the acquiring hospital than the acquired hospitals.

Nurse-sensitive patient safety and quality-of-care outcomes

In 2004, the FTC launched an investigation into the acquisition of Highland Park Hospital by Evanston Northwestern Healthcare in Illinois due to concern about the impact of the merger on clinical quality. Romano and Balan²¹ empirically evaluated care quality pre- and post-merger. Post-merger at Highland Park Hospital, rates of fractures slightly worsened and there were small improvements in rates of pressure ulcers and hospital-acquired infections, although changes in hospital-acquired infections were statistically insignificant. However, Evanston Northwestern had mixed results post-merger with statistically significant improvements in some nurse-sensitive patient safety and quality-of-care outcomes and deterioration in others (Table 3).

Nurse well-being

We classified nurse well-being as measures that were related to or may potentially influence nurses’ emotional or mental state. Quantitatively, there was only one study on nurse well-being²⁸ in which 350 nurses were surveyed from three hospitals that merged two years prior regarding their perceived coping skills and resilience. When nurses used positive coping skills, they reported higher resilience. Interestingly, the hospital with the fewest resources and the smallest staff had the greatest overall resilience scores while the largest hospital with the most resources had the lowest reported resilience scores. In this study, however, there were no comparisons made to nurses’ coping skills or resilience in hospitals that did not undergo a merger, no descriptors regarding resilience or coping of nurses prior to or during the mergers, and no direct evaluation of coping skills and/or resilience linked to the merger.

DISCUSSION

We systematically summarized the literature regarding what is known about U.S. hospital mergers and hospital-level factors that affect nursing, nurse well-being, and nurse-sensitive patient safety and quality-of-care outcomes. We found a limited number of studies about U.S. hospital mergers (n=10) using data mostly from the 1990s; these studies had more differences than similarities. Overall, we found that organizational changes did occur after hospital mergers, such as differences in nurse staffing,^22,23,27 leadership,^20,25,27,29 and operations,^20,27,29 but it is unclear if the changes resulted from broader organizational changes or those specific to the merger. We found that nurses described their well-being—stress, anxiety, and morale—as negatively impacted during hospital mergers. But data on the impact of hospital mergers on nurse-sensitive patient safety and quality-of-care outcomes, despite their significance in the U.S. healthcare system, were lacking.^21,25

Despite the sparse, older data that limit generalizability, we identified several takeaways. First, existing evidence supports the hypothesis that nurses and nurse-sensitive patient outcomes may be affected by hospital mergers; additional research is needed to elucidate the direction (negative or positive) and magnitude of these effects. Second, further expanding this line of inquiry has potential to inform policy solutions to address current workforce and safety concerns. Third, future research must expand methodological approaches to generate rigorous, more detailed analyses that can assess the causal effect of hospital mergers.

Although the data are old, our findings suggest possible links between hospital mergers and nursing (e.g., hospital-level factors, well-being) and nurse-sensitive patient safety and quality-of-care. However, the small study sample, ongoing changes in the U.S. healthcare system, and age of the data available makes it difficult to generate evidence-based conclusions about the likely strength and direction of the contemporary associations between hospital mergers and nursing. In addition to the reviewed studies, we also found many recent U.S.-based non-empirical articles (e.g., op-eds, viewpoints) of where nurses’ shared stories about hospital mergers³¹, and persistent understaffing, poor nurse retention, and concern for patient care.³² Our scoping review results and the volume of the non-empirical literature suggest possible links between present-day hospital mergers and nursing but additional research is critical.

While there is limited data on hospital mergers, nursing, and nurse-sensitive patient safety and quality outcomes, more literature exists about the associations among hospital mergers, physician well-being, and physician-sensitive outcomes that are more sensitive to physician care; the most commonly examined are rates of readmissions, acute myocardial infarctions, strokes, and mortality.^33–35 A small, up-to-date body of literature demonstrates that physicians currently report higher rates of burnout and decreases in job satisfaction post-merger.^36,37 And although there are approximately four to five nurses per physician in the U.S.,³⁸ responses to the FTC’s request for public comment were primarily focused on physicians, and not nurses. Comments to the FTC highlighted physicians’ concerns: increased costs, less access to care, lower quality-of-care, and less autonomy.³⁹

Understanding how hospital mergers impact nurses and patients is necessary to develop policies and best practices. These are likely to call for a combination of national standards for policies and practices related to the timing, content, and scope of notification, combined with implementation guidelines implemented at the state or local level. Substantial potential exists to inform policy solutions to address nursing workforce and patient safety concerns with additional research on hospital mergers and nursing. Nurses are experiencing high rates of burnout,^10,11,40 job dissatisfaction,⁴¹ and are leaving the profession.¹¹ Concurrently, patient safety and quality-of-care incidents remain high,¹⁹ and costly.¹⁹ Furthermore, nurse staffing, work environments, and well-being are significantly associated with patient safety and quality,^42–45 which could be further compounded by hospital mergers.

While qualitative and quantitative evidence suggested hospital mergers affect nursing and patient safety, the methods employed did not address or capture the complexity of these relationships. Few studies were pre-post designs limiting the ability to determine causality. Analyzed studies did not adequately distinguish short-term (transitional) effects of mergers from longer-term consequences (perhaps several years later after the transitional problems have been resolved), either in qualitative or quantitative studies. Synergistic mixed and multi-methods research may produce a more nuanced understanding of what happens and more adequately capture mergers’ complexity. For example, future research could consider incorporating organizational behavior to understand how decisions are made and by whom, the variation in how mergers are implemented, and how changes in hospital and/or unit culture could have significant implications for nursing and patient safety and quality-of-care. The use of hospital controls within studies and comparisons between different stages of the merger (pre, during, post, long-term) can provide a comprehensive understanding of what happens during hospital mergers and their long-term implications. Interdisciplinary teams comprised of nurses, health economists, and organizational behavior and healthcare management experts are critical in co-designing studies to address the unique complexities of hospital mergers.

Limitations

We conducted a robust review following PROSPERO guidelines for scoping reviews leveraging an expansive search of multiple databases; however, we had a small number of included studies, we may have missed potentially relevant studies (as in any review), and we did not conduct a risk of bias assessment. While qualitative findings suggest lack of trust and communication as a theoretical underpinning of the relationship between hospital mergers and nursing, the small sample size and limited data prevent a detailed description of why hospital mergers may impact nurses and patients, this warrants further investigation.

CONCLUSION

While we did find some evidence of a link between hospital mergers and nursing in a few studies conducted over 20 years ago, there is a dearth of contemporary high-quality data to inform policy decisions about hospital mergers. Despite the request by the FTC in 2023 for new evidence, no empirical studies have been produced examining the effect of mergers on nursing practice. Up-to-date high-quality research with more rigorous methods is crucial to support evidence-based policy to leverage potential benefits and mitigate the potential harms associated with hospital mergers for nurses and patients as U.S. hospital mergers continue to apace.