Date of Award

May 2014

Degree Type


Degree Name

Doctor of Philosophy



First Advisor

Rachel Schiffman

Committee Members

Patricia Stevens, Edward Levitas, JoAnn Appleyard, Kerry Kosmoski-Geopfert


Adaptation, Environmental Turbulence, Nurse Executives, Strategic Flexibility, Strategic Planning, Strategy





Donna F. M. Jamieson

Despite multiple industry cycles of rapid and complex changes in the last three decades, the body of research in health care services strategy has not addressed the idea of strategic flexibility, that is, when and how should strategy evolve under conditions of environmental turbulence. Strategic flexibility has been defined in the literature as the ability to adapt to rapidly changing conditions by leveraging internal resources and competencies to effectively compete. With increasing scope of responsibility in both nursing and non-nursing functional areas, nurse executives have not only participated as members of the executive team in setting strategic direction for hospitals but also developed specific strategic agendas for how nursing contributes to the overall value of a hospital's services. With few studies available to guide practice development, a paucity of information exists on how nurse executives should conduct strategic planning and what particularly leads to effective adaptation. A multi-case study research approach explored how acute care hospitals manifested strategic flexibility in response to changing conditions and how nurse executives played a role in developing and using those flexibilities. Seventeen nurse executives from seven acute care hospitals in a midwestern

metropolitan area participated in the study. Using interview data, document analysis and field observations, a combination of operational, tactical and strategic level types of strategic flexibility were noted at all seven hospitals. Strategic flexibility was associated with external environmental conditions related to policy changes, market dynamics and consumer perspectives. External conditions were associated with three internal conditions related to human resources, facility renovations and hospital culture. Nurse executives demonstrated various examples of tactical and strategic flexibilities, playing a major role in developing strategic flexibility. An unexpected finding was the discovery of five subcategories of tactical flexibilities. Results from the study provide a beginning description of strategic flexibility in hospitals. Examples of strategic flexibility identified in this study can be used to operationally define and, thus, measure strategic flexibility. The possibility of measuring strategic flexibility allows for other empiric studies of how strategic flexibility influences hospital performance such as patient care outcomes and quality of care.