Journal 2---2 pages APA Format---No Plagiarism
Nurs Admin Q Vol. 43, No. 3, pp. 230–245 Copyright �c 2019 Wolters Kluwer Health, Inc. All rights reserved.
Reexamining Nurse Manager Span of Control With a 21st-Century Lens
Anna Omery, DNSc, RN, NEA-BC; Cecelia L. Crawford, DNP, RN; Ann Dechairo-Marino, PhD, RN, NEA-BC; Beverly S. Quaye, EdD, RN, NEA-BC, FACHE; Jim Finkelstein, MBA, BA
The primary aim of this literature review was to examine the quantity, quality, and consistency of evidence regarding the span of control (SOC) specific to nurse managers. A secondary aim was to meaningfully translate the evidence and offer guidance to 21st-century nurse leaders. The review results were categorized using Donabedian’s (2003) Structure-Process-Outcomes model. The Structure-Process-Outcomes approach was used to review the literature and consider SOC recommendations for today’s health care environment. Structures outlined the conditions for current SOC, which included material resources, human resources, and organizational character- istics. Processes were defined as activities or actions stemming from identified structures that led to outcomes. Examples included management/administrative activities, as well as frontline staff participation in these tasks. Outcomes were performance measures of human resources, financial, and quality metrics. The review revealed that an SOC model built on a simplistic full-time employ- ment ratio is outdated. Yet, nurse managers remain in their role in the face of these simplistic models despite feelings of inadequacy, exhaustion, and failure because they passionately care about patients and staff. New attitudes and integration of advanced technologies, pioneering tools including SOC assessment tools, and ongoing competency developments will result in different needs of SOC as health care moves deeper into the modern era. This evidence is offered to inform and drive conversations focused on providing optimal nurse manager SOC for maximum effective- ness within unique and ever-evolving care environments. Key words: manager span of control, nurse managers, span of attention, span of authority
Author Affiliations: Clinical Practice (Dr Omery) and Evidence-Based Nursing Practice (Dr Crawford), Kaiser Permanente Southern California, Regional Patient Care Services, Pasadena; Providence Holy Cross Medical Center, Mission Hills, California (Dr Dechairo-Marino); California State University, Fullerton, School of Nursing, College of Health and Human Development, Fullerton (Dr Quaye); and FutureSense, LLC, San Rafael, California (Mr Finkelstein).
The authors declare they have no conflicts of interest, including financial, consultant, institutional, and other relationships that might lead to bias or a conflict of interest
Correspondence: Cecelia L. Crawford, DNP, RN, Evidence-Based Nursing Practice, Kaiser Perma-
B EFORE the restructuring of health care in the 1990s, novice nurses worked closely with nurse leaders in an “appren- ticeship system” that fostered professional development.1,2 This vital mentoring process facilitated the growth of nursing profession- als. However, nurse managers’ (NMs’) span of control (SOC) widened during the turbu- lent 1990s, with staff nurses spending less
nente Southern California, Patient Care Services, 393 E Walnut St, Pasadena, CA 91188 (Cecelia.L. Crawford@kp.org).
DOI: 10.1097/NAQ.0000000000000351
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
230
Reexamining Nurse Manager Span of Control 231
time with their nurse leaders. The negative effects of increased SOC continued into the 21st century, with dramatic influences on staff development, job satisfaction, and struc- tural empowerment.1,3-5 Nurse managers have seen their relationship management/ staff empowerment diminish and job satis- faction decrease.2,5-7 Ensuring that NMs have reasonable SOCs not only assists in their per- sonal, leadership, and clinical development but also allows them to empower frontline nurses in practicing to the full scope of their professional role.2,8,9 Patient outcomes are enhanced by strong competent nurses at the bedside and in the boardroom.
This narrative review of the literature will present the integration of research, commen- tary, opportunities, and potential solutions, with the focus on NMs’ SOC. The impacts of outcomes and correlates, such as the scope of complexity and leadership style, are also presented. We offer evidence-based recom- mendations for nurse executives and other nurse leaders to consider regarding appropri- ate SOC and administrative decisions for their organizations.
THE REVIEW
Review aim and design
The primary aim of the review was to ex- amine the quantity, quality, and consistency of evidence regarding the SOC phenomenon specific to NMs. A secondary aim was to mean- ingfully translate the evidence and offer guid- ance to 21st-century executive leaders and NMs.
Methodology, appraisal, and evidence abstraction
Review phases included creation of clini- cal and searchable questions and terms; data retrieval; evidence appraisal; data interpreta- tion and synthesis; and a narrative summary. The review question was crafted by the Nurs- ing Leadership Council of the Hospital Asso- ciation of Southern California.10 A systematic database search structured the review’s sec-
ond phase. The review started in January 2014 and the search was updated until October 2016. The search yielded 61 relevant articles. Several rounds of review, elimination, and other article identification resulted in 28 final citations. Evidence evaluation took place dur- ing the third phase, with article ranking and grading. Review articles were examined for more than 4 months during the fourth phase of data abstraction (Table 1). The strength of the evidence was graded as moderate to high quality (Table 2). We urge nurse leaders to view low to moderate quality evidence as a springboard for dialogue, innovation, and in- vestigation, rather than an automatic stop.31
Evidence synthesis and limitations
Data analysis and interpretation took place during the final phase to establish common categories used in the narrative overview, evidence summary, and recommendations. Result limitations included self-report sur- veys, mixed response rates, and variations in participants’ demographics. Ten articles were published by Nursing Management and may represent article homogeneity. Some articles may not be generalizable to the United States, as many authors were based in Canada. Finally, the evidence spans decades, with 1 article from 1988, 5 articles from the 1990s, 15 citations during the 2000s, and 7 articles published between 2012 and 2013.
REVIEW RESULTS
We categorized review results using Don- abedian’s (2003) Structure-Process-Outcomes model.32 We took the model’s concept and adapted it for NM SOC. The Structure-Process- Outcomes approach was used to review the literature and consider SOC recommenda- tions for today’s health care environment. Structures outlined the conditions for cur- rent SOC, which included material resources, human resources (HR), and organizational characteristics. Processes were defined as ac- tivities or actions stemming from identified structures that led to outcomes. Examples
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
T a b
le 1
. L it
e ra
tu re
R e v ie
w R
e fe
re n
c e s
R e fe
re n
c e
E
v id
e n
c e
S o
u rc
e
P u
rp o
se
C o
n c lu
si o
n s
A ik
e n
e t
al
(2 0
0 2
)1 1
A li d
in a
an d
F u
n k e -F
u rb
e r
(1 9
8 8
)1 2
A lt
af fe
r (1
9 9
8 )1
3
A rm
st ro
n g -S
ta ss
e n
an d
C am
e ro
n
(2 0
0 3
)3
B ro
w n
e t
al
(2 0
1 3
)1 4
C ar
n e y
(2 0
0 4
)1 5
M u
lt is
it e C
ro ss
-s e c ti
o n
al
Su rv
e y
C as
e S
tu d
y
D e sc
ri p
ti v e S
u rv
e y
D e si
g n
N o
n e x
p e ri
m e n
ta l D
e si
g n
Sy st
e m
at ic
R e v ie
w
G ro
u n
d e d
T h
e o
ry S
tu d
y
E x
am in
e o
rg an
iz at
io n
al
su p
p o
rt a
n d
s ta
ffi n
g o
n
n u
rs e j o
b d
is sa
ti sf
ac ti
o n
, b
u rn
o u
t, a
n d
q u
al it
y o
f c ar
e D
is c u
ss io
n o
f SO
C c
o n
c e p
t,
st ru
c tu
re s,
i m
p li c at
io n
s, a
n d
in
fl u
e n
c in
g f
ac to
rs
E x
am in
e F
L N
M v
s n
o n
-N M
sc o
p e , SO
C , an
d p
e rc
e p
ti o
n
o f
e ff
e c ti
v e n
e ss
E x
am in
e r
e la
ti o
n sh
ip o
f n
u rs
e s’
p e rs
o n
al ,
jo b
, an
d
o rg
an iz
at io
n al
d im
e n
si o
n s
E x
p lo
re f
ac to
rs k
n o
w n
t o
in
fl u
e n
c e N
M r
e te
n ti
o n
a n
d
in te
n ti
o n
t o
s ta
y H
o w
o rg
an iz
at io
n al
s tr
u c tu
re
al ig
n s/
im p
ac ts
w it
h s
tr at
e g ic
m
an ag
e m
e n
t o
f N
M r
o le
C o
m m
o n
c o
n c e rn
s w
e re
d is
sa ti
sf ac
ti o
n , b
u rn
o u
t, a
n d
q u
al it
y o
f c ar
e M
an ag
e ri
al s
u p
p o
rt /a
d e q
u at
e s
ta ffi
n g
p la
ys k
e y
ro le
s fo
r q
u al
it y
o f
c ar
e ,
jo b
d is
sa ti
sf ac
ti o
n , b
u rn
o u
t, a
n d
n u
rs e r
e te
n ti
o n
O p
ti m
al S
O C
i s
n e c e ss
ar y
fo r
N M
r o
le a
n d
r e sp
o n
si b
il it
ie s
U n
d e rs
ta n
d in
g c
e rt
ai n
i n
fl u
e n
c in
g f
ac to
rs c
an o
p ti
m iz
e N
M
SO C
N M
s sc
o re
d g
re at
e r
e ff
e c ti
v e n
e ss
t h
an n
o n
-N M
s, e
v e n
t h
o u
g h
th
e y
su p
e rv
is e m
o re
s ta
ff ,
h av
e f
e w
e r
as si
st iv
e p
e rs
o n
n e l,
an
d p
ai d
l e ss
R
e sp
o n
d e n
ts d
id n
o t
ra n
k t
h e m
se lv
e s
as h
ig h
ly e
ff e c ti
v e i n
a n
y d
im e n
si o
n ;
su g g e st
s th
at u
n st
ab le
c ar
e e
n v ir
o n
m e n
t c o
n tr
ib u
te s
to n
e g at
iv e p
e rc
e p
ti o
n o
f e ff
e c ti
v e n
e ss
O
rg an
iz at
io n
al c
o n
tr o
l p
re d
ic te
d c
h an
g e s
in s
u p
p o
rt a
n d
t ru
st .
A lt
h o
u g h
n u
rs e s
re p
o rt
e d
l o
w o
rg an
iz at
io n
al c
o n
tr o
l, m
o re
th
an 1
d im
e n
si o
n o
f c o
n tr
o l is
i n
v o
lv e d
i n
s e n
se o
f p
o w
e rl
e ss
n e ss
N M
r e te
n ti
o n
a n
d i n
te n
ti o
n t
o s
ta y
ar e m
u lt
if ac
to ri
al E x
e c u
ti v e l e ad
e rs
h ip
i s
re sp
o n
si b
le f
o r
th e s
u p
p o
rt o
f N
M i n
re
la ti
o n
t o
S O
C , w
o rk
lo ad
, an
d w
o rk
/l if
e b
al an
c e i ss
u e s
H ie
ra rc
h y
an d
m an
ag e m
e n
t la
ye rs
c o
n tr
ib u
te t
o N
M s
e n
se o
f e x
c lu
si o
n i n
s tr
at e g y
d e v e lo
p m
e n
t N
M m
u st
e n
ab le
t ru
st a
n d
d e m
o n
st ra
te l e ad
e rs
h ip
b y
w il li n
g n
e ss
t o
w o
rk i n
m u
lt id
is c ip
li n
ar y
c ar
e m
o d
e ls
(c o n
ti n
u es
)
232 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
T a b
le 1
. L it
e ra
tu re
R e v ie
w R
e fe
re n
c e s
(C o n
ti n
u ed
)
R e fe
re n
c e
E
v id
e n
c e
S o
u rc
e
P u
rp o
se
C o
n c lu
si o
n s
C at
h c ar
t e t
al
(2 0
0 4
)1
D o
ra n
e t
al
(2 0
0 4
)8
E l-J
ar d
al i e t
al
(2 0
0 9
)1 6
F o
rc e (
2 0
0 5
)4
H an
se n
e t
al
(1 9
9 5
)1 7
Jo h
an ss
o n
e t
al
(2 0
1 3
)1 8
P e rf
o rm
an c e
Im p
ro v e m
e n
t P
ro je
c t
D e sc
ri p
ti v e C
o rr
e la
ti o
n
Su rv
e y
D e si
g n
D e sc
ri p
ti v e S
u rv
e y
D e si
g n
L it
e ra
tu re
R e v ie
w
D e sc
ri p
ti v e S
u rv
e y
D e si
g n
C o
m p
ar at
iv e D
e sc
ri p
ti v e
Su rv
e y
St u
d y
E x
p lo
re r
e la
ti o
n sh
ip s
b e tw
e e n
SO
C a
n d
s ta
ff e
n g ag
e m
e n
t re
la ti
o n
sh ip
s E x
am in
e r
e la
ti o
n sh
ip s
b e tw
e e n
N M
l e ad
e rs
h ip
st
yl e s,
S O
C , an
d p
at ie
n t
an d
n
u rs
e o
u tc
o m
e s
A ss
e ss
n u
rs e r
e te
n ti
o n
c h
al le
n g e s
an d
s tr
at e g ie
s, a
s p
e rc
e iv
e d
b y
L e b
an e se
N M
O u
tl in
e s
c h
ar ac
te ri
st ic
s o
f N
M
le ad
e rs
h ip
s ty
le t
h at
e n
h an
c e s
n u
rs e r
e te
n ti
o n
E x
am in
e N
M p
e rs
o n
al it
y tr
ai ts
an
d s
ta ff
p e rc
e p
ti o
n s
o f
N M
le
ad e rs
h ip
E x
am in
e d
if fe
re n
c e s
in
se lf
-r e la
te d
h e al
th b
e tw
e e n
F L N
M a
n d
R N
s o
n v
ar io
u s
p sy
c h
o so
c ia
l fa
c to
rs
St ro
n g
r e la
ti o
n sh
ip b
e tw
e e n
S O
C a
n d
e m
p lo
ye e e
n g ag
e m
e n
t R
o u
ti n
e r
e v ie
w o
f N
M S
O C
m ay
a d
d re
ss n
e g at
iv e i m
p ac
t o
f la
rg e S
O C
o n
e m
p lo
ye e e
n g ag
e m
e n
t N
o l e ad
e rs
h ip
s ty
le c
an o
v e rc
o m
e a
w id
e s
p an
o f
c o
n tr
o l
E x
e c u
ti v e l e ad
e rs
h ip
m u
st d
e v e lo
p g
u id
e li n
e s
re g ar
d in
g
n u
m b
e r
o f
st af
f N
M c
an e
ff e c ti
v e ly
l e ad
a n
d s
u p
e rv
is e
R e te
n ti
o n
c h
al le
n g e s
in c lu
d e s
al ar
y, s
h if
ts , w
o rk
in g
h o
u rs
, an
d
b e tt
e r
in te
rn al
a n
d /o
r e x
te rn
al c
ar e e r
o p
p o
rt u
n it
ie s
C h
al le
n g e s
w il l c o
n ti
n u
e i f
af o
re m
e n
ti o
n e d
i ss
u e s
ar e n
o t
ad d
re ss
e d
M o
re i n
fo rm
at io
n i s
n e e d
e d
o n
N M
S O
C a
n d
l e ad
e rs
h ip
/ m
an ag
e m
e n
t c ap
ac it
ie s
5 t
h e m
e s:
t ra
n sf
o rm
at io
n al
l e ad
e rs
h ip
; tr
an sf
o rm
at io
n al
le
ad e rs
h ip
; e x
tr o
v e rt
e d
p e rs
o n
al it
y; M
ag n
e t
h o
sp it
al
st ru
c tu
re s;
t e n
u re
; g ra
d u
at e e
d u
c at
io n
T
h e m
e s
d e m
o n
st ra
te t
h at
l e ad
e rs
h ip
t ra
it s
le ad
t o
n u
rs e j o
b
sa ti
sf ac
ti o
n a
n d
r e te
n ti
o n
N
u rs
e s
fa v o
ra b
ly r
at e d
N M
o n
l e ad
e rs
h ip
s ty
le ,
p o
w e r,
a n
d
in fl
u e n
c e
N M
p e rs
o n
al it
y m
o d
e st
ly l in
k e d
m o
ti v at
io n
t o
m an
ag e a
n d
se
le c t
le ad
e rs
h ip
a sp
e c ts
F ir
st -li
n e N
M s
c an
c o
p e w
it h
h ig
h -d
e m
an d
s it
u at
io n
s if
t h
e y
h av
e h
ig h
c o
n tr
o l o
v e r
th e ir
w o
rk
H ig
h d
e g re
e o
f jo
b c
o n
tr o
l an
d m
an ag
e ri
al s
u p
p o
rt a
ll o
w s
al l
n u
rs e s
to f
u n
c ti
o n
i n
s tr
e ss
fu l w
o rk
e n
v ir
o n
m e n
ts
(c o n
ti n
u es
)
Reexamining Nurse Manager Span of Control 233
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
T a b
le 1
. L it
e ra
tu re
R e v ie
w R
e fe
re n
c e s
(C o n
ti n
u ed
)
R e fe
re n
c e
E
v id
e n
c e
S o
u rc
e
P u
rp o
se
C o
n c lu
si o
n s
Jo n
e s
e t
al
(2 0
1 2
)1 9
L as
c h
in g e r
an d
F in
e g an
( 2
0 0
5 )5
L as
c h
in g e r
e t
al (
1 9 9 9 )6
L e e a
n d
C
u m
m in
g s
(2 0
0 8
)2 0
L e w
is 2
1
L u
c as
e t
al (
2 0
0 8
)2
P e rf
o rm
an c e
Im p
ro v e m
e n
t P
ro je
c t
N o
n e x
p e ri
m e n
ta l
P re
d ic
ti v e D
e si
g n
N o
n e x
p e ri
m e n
ta l
P re
d ic
ti v e D
e si
g n
Sy st
e m
at ic
R e v ie
w
E x
p e rt
O p
in io
n
N o
n e x
p e ri
m e n
ta l
P re
d ic
ti v e D
e si
g n
D e te
rm in
e h
o w
n u
rs in
g
le ad
e rs
h ip
c an
i m
p ro
v e N
M
tu rn
o v e r
an d
v ac
an c y
ra te
s
E x
am in
e e
ff e c ts
o f
e m
p o
w e rm
e n
t o
n s
ta ff
p e rc
e p
ti o
n s
o f
ju st
ic e ,
re sp
e c t,
a n
d t
ru st
i n
m
an ag
e m
e n
t E x
am in
e N
M l e ad
e r
e m
p o
w e ri
n g
b e h
av io
r to
st
af f
p e rc
e p
ti o
n s
o f
e m
p o
w e rm
e n
t, j o
b s
tr e ss
, an
d w
o rk
e ff
e c ti
v e n
e ss
E x
am in
e d
e te
rm in
an ts
o f
F L
N M
j o
b s
at is
fa c ti
o n
C as
e s
tu d
ie s
d e sc
ri b
in g
t h
e
re la
ti o
n sh
ip b
e tw
e e n
e m
p o
w e rm
e n
t an
d C
Q I
v ia
c o
n c e p
t o
f SO
C
M o
d e l li n
k in
g n
u rs
e p
e rc
e p
ti o
n s
o f
N M
e m
o ti
o n
al i n
te ll ig
e n
c e
le ad
e rs
h ip
s ty
le ,
st ru
c tu
ra l
e m
p o
w e rm
e n
t, a
n d
i m
p ac
t o
f N
M S
O C
R e d
is tr
ib u
ti o
n o
f o
p e ra
ti o
n al
a n
d a
d m
in is
tr at
iv e r
e so
u rc
e s
p o
si ti
v e ly
i m
p ac
te d
t u
rn o
v e r
ra te
s, i n
te rn
al t
ra n
sf e rs
, in
te rn
al p
ro m
o ti
o n
s, v
ac an
c y
ra te
s/ d
ay s
o p
e n
, N
M M
SN
E v al
u at
io n
o f
sc o
p e /S
O C
c an
d e te
rm in
e o
p e ra
ti o
n al
a n
d
ad m
in is
tr at
iv e s
u p
p o
rt t
ie rs
n e e d
e d
f o
r N
M s
u c c e ss
St
ru c tu
ra l e m
p o
w e rm
e n
t h
as d
ir e c t
e ff
e c t
o n
i n
te ra
c ti
o n
al ju
st ic
e ,
re sp
e c t,
a n
d o
rg an
iz at
io n
al t
ru st
N
M s
h av
e p
iv o
ta l ro
le i n
c re
at in
g /m
ai n
ta in
in g
s ta
ff t
ru st
H ig
h li g h
ts i
m p
o rt
an c e o
f N
M l e ad
e rs
h ip
t ra
it s
w it
h in
c h
an g in
g
h e al
th c
ar e s
e tt
in g s
N M
b e h
av io
rs i m
p ac
te d
p e rc
e p
ti o
n s
o f
fo rm
al /i
n fo
rm al
p o
w e r
an d
a c c e ss
t o
e m
p o
w e rm
e n
t st
ru c tu
re s
H ig
h e r
p e rc
e iv
e d
a c c e ss
l in
k e d
t o
l o
w e r
jo b
t e n
si o
n s
an d
in
c re
as e d
w o
rk e
ff e c ti
v e n
e ss
A
d d
re ss
in g
S O
C , w
o rk
lo ad
, in
c re
as e d
s u
p e rv
is o
r su
p p
o rt
, an
d
e m
p o
w e rm
e n
t m
ay i n
fl u
e n
c e F
L N
M j o
b s
at is
fa c ti
o n
D o
m o
re , fa
st e r:
R e d
u c e d
S O
C i n
c re
as e s
re sp
o n
si v e n
e ss
, w
il li n
g t
o l e ad
p ro
je c ts
, an
d c
o n
n e c ti
n g
w it
h s
u p
p o
rt iv
e
p e rs
o n
n e l
St af
f e m
p o
w e rm
e n
t a
d ra
m at
ic i m
p ac
t o
n N
M S
O C
N
M s
m ay
n o
t b
e a
b le
t o
e m
p o
w e r
th e ir
s ta
ff i f
SO C
i s
la rg
e ,
e v e n
i f
th e y
h av
e s
tr o
n g
e m
o ti
o n
al i n
te ll ig
e n
c e
Se n
io r
m an
ag e m
e n
t m
u st
e n
su re
t h
at N
M s
h av
e r
e as
o n
ab le
SO
C t
o e
m p
o w
e r
st af
f to
f u
ll s
c o
p e o
f n
u rs
in g
p ra
c ti
c e a
n d
ro
le
(c o n
ti n
u es
)
234 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
T a b
le 1
. L it
e ra
tu re
R e v ie
w R
e fe
re n
c e s
(C o n
ti n
u ed
)
R e fe
re n
c e
E
v id
e n
c e
S o
u rc
e
P u
rp o
se
C o
n c lu
si o
n s
M c C
u tc
h e o
n e
t al
(2
0 0
9 )7
M c H
u g h
e t
al
(2 0
1 3
)2 2
M c N
e e se
- Sm
it h
( 1
9 9
9 )9
M o
ra sh
e t
al
(2 0
0 5
)2 3
P at
ri c k
a n
d
L as
c h
in g e r
(2 0
0 6
)2 4
N o
n e x
p e ri
m e n
ta l
P re
d ic
ti v e D
e si
g n
M ix
e d
M e th
o d
s (R
e tr
o sp
e c ti
v e
A n
al ys
is ;
Su rv
e y
D e si
g n
)
D e sc
ri p
ti v e C
o rr
e la
ti o
n al
Su
rv e y
D e si
g n
M ix
e d
-M e th
o d
s St
u d
y
D e sc
ri p
ti v e C
o rr
e la
ti o
n al
Su
rv e y
D e si
g n
E x
am in
e r
e la
ti o
n sh
ip s
b e tw
e e n
l e ad
e rs
h ip
s ty
le ,
jo b
s at
is fa
c ti
o n
, p
at ie
n t
sa ti
sf ac
ti o
n , an
d S
O C
, m
o d
e ra
ti n
g e
ff e c t
o f
SO C
a s
ab o
v e
D e te
rm in
e w
h e th
e r
M ag
n e t
h o
sp it
al s
h av
e l o
w e r
m o
rt al
it y/
fa il u
re -t
o -r
e sc
u e
th an
n o
n -M
ag n
e t
h o
sp it
al s
E x
am in
e r
e la
ti o
n sh
ip o
f N
M
m o
ti v at
io n
t o
l e ad
e rs
h ip
b
e h
av io
rs , st
af f
jo b
sa
ti sf
ac ti
o n
, p
ro d
u c ti
v it
y,
o rg
an iz
at io
n al
c o
m m
it m
e n
t,
an d
p at
ie n
t sa
ti sf
ac ti
o n
D
e si
g n
/i m
p le
m e n
t SO
C t
o o
l u
si n
g e
v id
e n
c e ,
su rv
e ys
, fo
c u
s g ro
u p
s, a
n d
fi el
d
te st
in g
( O
tt aw
a H
o sp
it al
C
li n
ic al
M an
ag e m
e n
t SO
C
D e c is
io n
-M ak
in g
I n
d ic
at o
rs
T O
H t
o o
l)
E x
am in
e r
e la
ti o
n sh
ip b
e tw
e e n
st
ru c tu
ra l e m
p o
w e rm
e n
t an
d o
rg an
iz at
io n
al s
u p
p o
rt
an d
e ff
e c t
o n
N M
r o
le
sa ti
sf ac
ti o
n
H ig
h e r
SO C
d e c re
as e d
p o
si ti
v e e
ff e c ts
o f
tr an
sf o
rm at
io n
al /
tr an
sa c ti
o n
al l e ad
e rs
h ip
o n
o u
tc o
m e s
M an
ag e m
e n
t b
y e x
c e p
ti o
n a
n d
l ai
ss e z-
fa ir
e l e ad
e rs
h ip
s ty
le s
in c re
as e d
n e g at
iv e i
m p
ac ts
o n
j o
b s
at is
fa c ti
o n
M ag
n e t
h o
sp it
al s
h ad
l o
w e r
m o
rt al
it y/
fa il u
re -t
o -r
e sc
u e o
d d
s B
e tt
e r
w o
rk e
n v ir
o n
m e n
t is
a d
is ti
n g u
is h
in g
f ac
to r
b e tw
e e n
M
ag n
e t/
n o
n -M
ag n
e t
h o
sp it
al s
an d
k e y
to b
e tt
e r
o u
tc o
m e s
B e tt
e r
o u
tc o
m e s
p ar
tl y
at tr
ib u
te d
t o
i n
v e st
m e n
ts i n
q u
al ifi
e d
e d
u c at
e d
n u
rs e s
an d
e n
v ir
o n
m e n
ts s
u p
p o
rt iv
e o
f q
u al
it y
c ar
e “A
tt e n
ti o
n o
f n
u rs
e s
to y
o u
r c o
n d
it io
n ”
p o
si ti
v e ly
c o
rr e la
te d
w
it h
p ro
d u
c ti
v it
y, j o
b s
at is
fa c ti
o n
, o
rg an
iz at
io n
al
c o
m m
it m
e n
t, a
n d
a ll
5 l e ad
e rs
h ip
p ra
c ti
c e s
N M
m o
ti v at
io n
p o
si ti
v e ly
c o
rr e la
te d
w it
h a
c h
ie v e m
e n
t,
m o
ti v at
io n
, an
d 5
l e ad
e rs
h ip
p ra
c ti
c e s
T o
o l in
c lu
d e s
3 d
e c is
io n
-m ak
in g
c at
e g o
ri e s
(u n
it , st
af f,
p
ro g ra
m -f o
c u
se d
) to
c la
ss if
y 8
i n
d ic
at o
rs (
u n
it c
o m
p le
x it
y;
m at
e ri
al m
an ag
e m
e n
t; s
ta ff
v o
lu m
e ;
sk il l/
au to
n o
m y;
st
ab il it
y; d
iv e rs
it y;
b u
d g e ta
ry ;
an d
s ta
ti st
ic al
r e sp
o n
si b
il it
ie s)
N
e e d
f o
r st
an d
ar d
iz at
io n
, E B
P c
h an
g e s,
a n
d a
ss e ss
m e n
t o
f ro
le s/
re sp
o n
si b
il it
ie s
o f
e n
ti re
n u
rs in
g g
ro u
p
C o
m b
in at
io n
o f
o rg
an iz
at io
n al
s u
p p
o rt
a n
d e
m p
o w
e rm
e n
t is
a
si g n
ifi c an
t p
re d
ic to
r N
M r
o le
s at
is fa
c ti
o n
P
e rc
e p
ti o
n s
o f
o rg
an iz
at io
n al
s u
p p
o rt
m ay
p la
y an
i m
p o
rt an
t ro
le i n
r e ta
in in
g N
M a
n d
a tt
ra c ti
n g
f u
tu re
n u
rs e l e ad
e rs
Reexamining Nurse Manager Span of Control 235
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
(c o n
ti n
u es
)
T a b
le 1
. L it
e ra
tu re
R e v ie
w R
e fe
re n
c e s
(C o n
ti n
u ed
)
R e fe
re n
c e
E
v id
e n
c e
S o
u rc
e
P u
rp o
se
C o
n c lu
si o
n s
R it
c h
e y
an d
C
o m
m e n
ta ry
D
e te
rm in
e o
p ti
m al
n u
m b
e r
o f
R e d
u c e l ar
g e r
u n
it s
to s
u b
u n
it s/
c lu
st e rs
r an
g in
g 6
-1 2
r o
o m
s St
ic h
le r
p at
ie n
t ro
o m
s in
a c u
te c
ar e
N e w
c lu
st e rs
i n
c re
as e d
n u
rs in
g e
n g ag
e m
e n
t w
h e n
N M
S O
C
(2 0
0 8
)2 5
se
tt in
g s
av e ra
g e d
5 0
o r
le ss
d ir
e c t
re p
o rt
s Sh
ir e y
an d
F is
h e r
Se c o
n d
ar y
A n
al ys
is o
f a
T h
e m
at ic
e x
am in
at io
n o
f 2
0 0
4
4 t
h e m
e s:
l e ad
e rs
h ip
, p
ra c ti
c e e
n v ir
o n
m e n
t, s
ta ffi
n g , an
d
(2 0
0 8
)2 6
D
e sc
ri p
ti v e S
u rv
e y
N at
io n
al C
ri ti
c al
C ar
e S
u rv
e y
p ro
fe ss
io n
al a
d v an
c e m
e n
t an
d r
e c o
g n
it io
n
St u
d y
F in
d in
g s
R e p
o rt
t o
L e ad
e rs
h ip
i s
ab o
u t
p e o
p le
a n
d r
e la
ti o
n sh
ip s
an d
i s
d e te
rm in
e i m
p li c at
io n
s fo
r tr
an sf
o rm
at io
n al
n u
rs in
g a
d m
in is
tr at
o rs
A
ss e ss
N M
S O
C a
n d
m ak
e a
p p
ro p
ri at
e c
h an
g e s
in s
tr u
c tu
re s
M o
n it
o r
th e i m
p ac
t o
f c h
an g e s
in S
O C
o n
u n
it -b
as e d
a n
d
o rg
an iz
at io
n al
o u
tc o
m e s
Sh ir
e y
(2 0
1 3
)2 7
E d
it o
ri al
R
e v ie
w o
f a
re se
ar c h
s tu
d y
A u
th o
rs a
ll u
d e t
o 2
a re
as f
o r
n e e d
e d
i n
te rv
e n
ti o
n : SO
C a
n d
in
v e st
ig at
in g
N M
s tr
e ss
o rs
th
e ra
p e u
ti c d
ia lo
g u
e
an d
c o
p in
g e
x p
e ri
e n
c e s
N M
S O
C v
ar ia
b il it
y is
a m
aj o
r th
re at
t o
N M
a b
il it
y to
a c h
ie v e
w o
rk s
at is
fa c ti
o n
, e n
g ag
e s
ta ff
, an
d a
ff e c t
o rg
an iz
at io
n al
c o
m m
it m
e n
t W
o n
g e
t al
N
o n
e x
p e ri
m e n
ta l
V al
id at
e T
O H
t o
o l an
d e
x am
in e
M an
ag e ab
le S
O C
e ss
e n
ti al
f o
r q
u al
it y
jo b
/u n
it o
u tc
o m
e s
(2 0
1 2
)2 8
P
re d
ic ti
v e S
u rv
e y
re la
ti o
n sh
ip s
b e tw
e e n
F L
O n
ly S
O C
p re
d ic
te d
a d
v e rs
e u
n it
o u
tc o
m e s
St u
d y
N M
S O
C a
n d
m an
ag e r
w o
rk
C o
m b
in at
io n
o f
SO C
a n
d s
e lf
-e v al
u at
io n
p re
d ic
te d
j o
b
o u
tc o
m e s
sa ti
sf ac
ti o
n , w
o rk
c o
n tr
o l,
a n
d r
o le
o v e rl
o ad
N
e it
h e r
se lf
-e v al
u at
io n
n o
r SO
C p
re d
ic te
d u
n it
t u
rn o
v e r
W o
n g
e t
al
M ix
e d
M e th
o d
s (F
o c u
s E x
am in
e c
o m
b in
at io
n o
f F L
N M
s re
p o
rt h
ig h
r o
le o
v e rl
o ad
/j o
b d
e m
an d
s, l im
it e d
j o
b w
o rk
, (2
0 1
3 )2
9
G ro
u p
; Su
rv e y)
N
M c
h ar
ac te
ri st
ic s
an d
S O
C
an d
m o
d e ra
te S
O C
s at
is fa
c ti
o n
o
f jo
b a
n d
u n
it o
u tc
o m
e s
In c re
as in
g s
ys te
m d
e m
an d
s c o
n tr
ib u
te t
o e
x p
an d
e d
w o
rk
re sp
o n
si b
il it
ie s/
ro le
o v e rl
o ad
T
O H
s c o
re s
ig n
ifi c an
t in
d ic
at o
r o
f N
M j o
b s
at is
fa c ti
o n
, jo
b
d e m
an d
s, w
o rk
c o
n tr
o l,
a n
d S
O C
s at
is fa
c ti
o n
236 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
A b
b re
v ia
ti o
n s:
C O
I, c
o n
ti n
u o
u s
q u
al it
y im
p ro
v e m
e n
t; E
B P
, e v id
e n
c e -b
as e d
p ra
c ti
c e ; F L , fr
o n
tl in
e ;
N M
, n
u rs
e m
an ag
e r;
S O
C ,
sp an
o f
c o
n tr
o l;
T O
H , T
h e O
tt o
w a
H o
sp it
al .
Reexamining Nurse Manager Span of Control 237
Table 2. Evidence Appraisal: Ranking and Gradinga,b,c
Academy of Evidence-Based Practice Evidence Leveling System
Relevant Article Level Description Articles Reference
A Meta-analysis of multiple large sample or small sample 2 14,20 randomized controlled studies, or meta-synthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment
B Well-designed controlled studies, both randomized and 6 2,3,5-7,28 nonrandomized, prospective or retrospective studies, and integrative reviews with results that consistently support a specific action, intervention, or treatment
C Qualitative studies, descriptive, or correlational studies, 13 8,9,11,13, integrative reviews, systematic reviews, or 15-18,22-24,26,29 randomized controlled trials with inconsistent results
D Peer-reviewed professional organizational standards, with clinical studies to support recommendations
E Theory-based evidence from expert opinion or multiple 7 1,4,12,19,21,25,27 case reports, case studies, consensus of experts, and literature reviews
MA Manufacturer’s recommendation; anecdotes LR Laws and regulations (local, state, federal; licensing
boards; accreditation bodies, etc) Total 28
aCopyright Kaiser Permanente Southern California, Regional Nursing Research Program. Used with permission. bAdapted with permission from Canadian Medical Association & Centre for Evidence-Based Medicine, Levels of the Evidence, 2001, and AACN Evidence Leveling System, 2009. cJohns Hopkins Evidence-Based Practice Research/Nonresearch Appraisal Grading High quality: 12 articles2,5-8,14,17,22,25,28,29
Consistent, generalizable results; sufficient sample size for study design; adequate control; definitive conclusions; consistent recommendations based on comprehensive literature review that includes thorough reference to scientific evidence or expertise is clearly evident; draws definitive conclusions; provides scientific rationale; thought leader in the field. Moderate quality: 13 articles1,3,4,9,12,13,15,16,18,20,21,23,24
Reasonably consistent results; sufficient sample size for study design; some control and fairly definitive conclusions; reasonably consistent recommendations based on fairly comprehensive literature review that includes some reference to scientific evidence or expertise appears to be credible; draws fairly definitive conclusions; provides logical argument for opinions. Low quality: 3 articles19,26,27
Little evidence with inconsistent results; insufficient sample size for study design; conclusions cannot be drawn or expertise is not discernable or is dubious; conclusions cannot be drawn. Final summary of the body of evidence = Moderate to high quality.
included management/administrative activi- ties, as well as frontline staff participation in these tasks. Outcomes were performance measures of HR, financial, and quality metrics.32 Taken in totality, we used the Structure-Process-Outcomes model to capture a comprehensive description of the SOC phenomenon (Table 3).
NURSE MANAGER SPAN OF CONTROL IN THE 21st CENTURY
Not everything that counts can be counted, and not everything that can be counted counts.
William Bruce Cameron, Sociologist (often attributed to Albert Einstein)
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
238 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019
The basic principles of SOC were first out- lined by a military general in 1927. The sol- dierly metaphors and descriptions lingered through the 1950s and formed the basis for various business interpretations.1,27 Synony- mous terms were span of authority and span of attention. These non–health care models ensured that managers could have sufficient time with their employees.30 One sentence neatly captures the heart of these early dis- cussions: “No superior can supervise directly the work of more than five or, at the most, six subordinates whose work interlocks.”33(p41)
Simple operations permitted an SOC of up to 20 to 30 people. After 1960, companies used flatter SOC models to increase produc- tivity and empower staff, with direct reports increasing to 15 to 25 people.1,30
The 1990s saw an explosion in SOC re- search studies.15 Three variables were iden- tified as being essential to health care–related SOC, which were (1) manager-staff relation- ship frequency and intensity, (2) work com- plexity, and (3) manager-staff capabilities.1
The literature outlined the basic SOC tenets of 20th-century health care: if manager-staff relationships were less intense and less fre- quent, if work was less complex, and if both managers and staff were capable, a large SOC could be accommodated.1,21 These beliefs have been carried into the 21st century, with mixed results for specific SOC outcomes as- sociated with organizational structures and processes.
Structures associated with increased SOC
We isolated 6 structural elements associ- ated with increased SOC (Table 3). There was no “gold standard” for the number of units an NM should be supervising. Instead, work environments determined the number of units as a function of several weighted fac- tors that focused on unit, staff, and program.28
These factors had a direct influence on SOC via reporting structures, closeness of contact, and quality of NM-staff relationships.4,7,8,19
The evidence aligned SOC with increased supervisor satisfaction, improved work en-
vironment quality, and positive safety climates.7,20,22,26
Increased SOC decreased the positive ef- fects of transformational and transactional leadership styles, causing an inverse rela- tionship between the 2 styles.4,7,18 Alter- natively, access to organizational resources, data, and other information; system and tech- nical support; collaboration with HR, peers, and staff; participation in strategy planning; and recognition programs all had positive im- pacts on NM retention.14,24,25 Nurse man- agers who felt empowered by organizational supports were more likely to stay in their role, remain committed to goals, and act as role models for future nurse leaders. The evidence supports significant positive rela- tionships between SOC, system supports, empowerment, and job satisfaction of front- line NM.3,9,20,29
Work control and emotional intelligence (EI) of NMs had significant interplay with SOC.2 Work control was defined as the extent NMs perceived having control over various job aspects.3,18 The combination of SOC and NMs’ core appraisal of personal effectiveness and capacity significantly pre- dicted role overload, work control, and job satisfaction.13 Only SOC predicted unit ad- verse outcomes and the manager’s effect on staff self-report of empowerment.28
Hierarchical and decentralized structures had substantial influences on NM SOC. A narrow hierarchical span of management re- sulted in tall structures and disruption in communication.12,13,15 The more organiza- tional levels, the more communication “filter- ing” occurred as information moved up and down these pathways.15,25 In contrast, decen- tralized structures combined with HR prac- tices correlated with positive organizational commitment, enhanced professional practice climate, higher job satisfaction, and reduced intent to leave.14,15,20 A broad NM SOC with more direct reports increased efforts in co- ordinating institutional goals and activities across multiple units.7,8 The evidence artic- ulated the need to develop structures unique to each setting, work unit, and culture.15,17,20
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Reexamining Nurse Manager Span of Control 239
Table 3. Impacts of Organizational Structures, Processes, and Outcomes on Increased Nurse Manager Span of Control
Structures Processes Outcomes Comments
Number of units Unit complexity Managers Patient complexity, work and patient acuity Job satisfaction environment, and support
Intent to leave systems have mediating effects Administrative on number of units
support Narrow SOC may result in Time in position underutilized NM and staff
feeling micromanaged; can mediate impacts on unit complexity
Decreased time in position has a mediating impact on decreased NM job satisfaction
Reporting Functional Staff Deceased staff satisfaction with structures architecture Workplace NM within reporting structures
empowerment Suggested number of rooms 6-12 Retention for 50 staff; can offset negative
effects of unit design Turnover can increase 1.6% for
every 10-added staff, with a negative effect on staff retention
Staff perceptions of positive effects of NM emotional intelligence can mediate negative impacts on staff workplace empowerment
Input into Changes in Patient organizational manager’s scope Patient satisfaction decision making and role Nurse-sensitive
indicators Leadership style Magnet status Inverse relationships can exist
Transactional between the 2 leadership styles Transformational
Work control Organizational Positive NM work control can factors mediate adverse unit outcomes
NM education/training opportunities have a mediating impact on poor organizational processes
Senior leadership Mediated by CNE reporting structure
Centralized versus Decentralized structures can decentralized strengthen communication
pathways and lessen adverse unit outcomes
Abbreviations: CNE, Chief Nurse Executive; NM, nurse manager; SOC, span of control.
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240 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019
Processes associated with increased SOC
We used the evidence to articulate 5 specific processes that should be considered when determining an NM SOC (Table 3). These processes flowed directly from the SOC structural components. Unit complexity and patient acuity consistently influenced SOC processes. Research suggests that patient characteristics (age, illness level, acuity, and duration of care needs) effected perceived NM SOC.12,23,28 Patient acuity in the emergency department was a particular concern. Nurse managers in the emergency department may require a smaller SOC due to increased patient acuity, greater decision immediacy, increased coordination demands, and higher patient turnover.12 However, a narrow SOC may result in underutilized managers and micromanaged staff.21
We were not surprised that the physi- cal layout of patient care units was an es- sential component of functional architec- ture, physical proximity, and optimal nursing workflows.12,25 Research revealed that acute care environments supported a reduced scale of larger units, with subunit design or clusters ranging from 6 to 12 rooms. These unit re- ductions were associated with increased staff engagement when NM SOC averaged 50 or less direct reports.25
Managers who experience increased or decreased scope, role, or number of supervised staff change had lower work satisfaction than managers not experiencing any change.20 Large spans can empower and support nurses in their practice and may have a positive impact on staff retention if adequate infrastructure and supportive resources are present.16,18,23,24 Magnet hos- pital status directly correlated to improved patient outcomes as well as NM leadership practices.4,11,22 A key characteristic of a Magnet hospital was the density of the nursing management structure relative to nursing personnel. Greater density enhanced management’s accessibility, visibility, and responsiveness to staff. These factors have been positively associated with nurse em-
powerment and job satisfaction in Magnet versus nonmagnet hospitals.4,22
We identified several processes related to organizational factors. Managers were more satisfied when they had opportuni- ties for educational development and job training.2,4,14,20 High levels of training and communication embedded into organically developed structures positively impacted NM job satisfaction.8,20 If organizations wish to re- tain dynamic and passionate NMs, they must assume the mantle of responsibility as they address and support NM workloads and SOC, as well as understanding work/life balance issues.3,14,18,23,24,26,27
Outcomes associated with increased SOC
We categorized the associated NM SOC out- comes into 3 groups: manager, staff, and pa- tient (Table 3). Manager outcomes included the multiple and complex demands NMs ex- perience daily. We discovered that these de- mands often generate considerable stress and can result in work/life imbalance, negative health consequences, and burnout.26 Span of control was a critical element in NM work- load, job satisfaction, and intent to leave.14,20
The literature demonstrated that (1) NM job satisfaction was multifactorial and (2) SOC positively influenced job satisfaction for some NMs. Managers who were in their positions a shorter time had greater job satisfaction.14 In- creased SOC also has implications for staff out- comes such as turnover rates. One research study demonstrated a 1.6% increase in unit staff turnover rate for every additional 10 in- dividuals in an NM SOC. Therefore, a span of 100 staff members predicted a 16% turnover rate.8
Ultimately, manager and staff outcomes resulting from a large SOC negatively im- pacted patient outcomes. Research revealed that patient satisfaction was lower on units where NMs had large numbers of report- ing staff.7,8 Span of control predicted other adverse outcomes such as NM perception of medication error frequencies, nosocomial infections, patient/family complaints, patient
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Reexamining Nurse Manager Span of Control 241
falls with injuries, work-related injuries, and verbal abuse.29 Decreased NMs’ SOC and bet- ter nurse staffing were positively associated with better quality of care,11,16 while a short- age of nurses increased the risk of infection.16
A study of surgical patients in Magnet hos- pitals found that these facilities had signifi- cantly better work environments, higher num- bers of RNs with BSN degrees, and specialty certification. A supportive work environment and higher proportion of degrees greatly con- tributed to the 14% lower odds of mortality (P = .02) and 12% lower odds of failure to rescue (P = .07).22
Finally, EI was identified as being vitally im- portant in health care environments, as it fa- cilitates structural empowerment to achieve patient and organizational outcomes.2 Span of control was a significant moderator of staff nurses’ perceptions of their NM EI behavior and feelings of workplace empowerment.2
Having a large number of staff reduced the effect of positive leadership styles on staff satisfaction and increased its negative effect.1,8
There are implied costs associated with a large SOC, but actual organizational costs from negative SOC outcomes are still un- known. Each health care institution must de- termine the risks it is willing to bear with in- creased NM SOC. These risks include
� decreased leadership pipeline due to higher staff and manager turnover8,14,16,19,29;
� adverse clinical outcomes such as decreased patient safety, length of stay, communication flow, and nurse workflow8,15,25,28; and
� decreased NM, staff, and patient satisfaction.7,8,19,20,25,27
Review results highlighted the significant influences SOC structures and processes have on specific organizational, NM, staff, and pa- tient outcomes. We discovered that the liter- ature emphasized that no single metric drives efficacious SOC for any organization. Rather, appropriate, effective, and efficient SOC is dependent on understanding how organiza- tions measure against the performance met-
rics associated with specific structures and 12,18,23,24,28 We must then beg the processes.
question: What is the optimal SOC for NM in the current century?1,7,16
SOC MATTERS
Count what is countable, measure what is mea- surable, and what is not measurable, make measurable.
Galileo Galilei, 1610
No leadership type can overcome large numbers of reporting staff.7,8 Because NMs passionately care about patients and staff, they often remain in their role despite feelings of inadequacy, exhaustion, and failure.18,27 As SOC increases, the impact of NM EI decreases. Even managers with strong EI may not em- power staff if their SOC is large.2 Managers are less able to develop satisfying relation- ships, which in turn increases staff turnover, even with 10 additional individuals.2,7,8,16
Nonetheless, leaders with higher knowledge levels, experience, and self-assessed higher personality characteristics can manage larger SOC.2,18,21,29
The evidence established a high correla- tion between SOC and support resources, work role and function distribution, and job retention.1,7,8,14,19,20 Nurse managers cannot have both a large SOC and decreased cleri- cal or clinical support such as educators and charge nurses. The absence of these critical staff members at the point of care results in NM not supporting the processes needed to develop staff while also managing daily pa-
and flow issues.8,16,18,23,24 tient care How- ever, NMs can tolerate a larger SOC if they are given the appropriate type and level of technology and tools.15,24 Using The Ottawa Hospital SOC tool to assess institutional re- sources is a first step in identifying appropri- ate support resources and technology needed to mitigate adverse outcomes.23,29
Organizational systems often do not moni- tor the number of direct reports for NMs, even though individuals at the microlevel know ex- actly who reports to whom.19,23 Staff direct
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242 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019
Table 4. Recommendations for Constructing Health Care Systems of the Future
Recommendations Comments
Develop a model that drives the positive impacts of NM SOC.2 , 7 , 8 , 16
Use The Ottawa Hospital SOC tool as part of an organizational assessment to gain a better understanding of required NM SOC.23 , 28 , 29
Develop guidelines and/or tools to support the optimum number of staff reporting to NM.6-8 , 12
Determine how SOC will impact the NM ability to drive and support interprofessional
6 , 7 , 29care. Ensure adequate and increasing clerical and
clinical support if a large NM SOC is unavoidable.30
Reconsider the concept of “empowerment.”2 , 5 , 20 , 24
Link assessment and monitoring of nurse-driven data to NM outcomes and incentives7 , 8 , 9 such as value-based purchasing.
Escalate NM SOC to higher priority levels within executive leadership.23
Crosswalk SOC with organizational performance assessment, career development, policy, and recommendations from reports such as the Future of Nursing Report20 , 23 , 28 , 36
Abbreviations: NM, nurse manager; SOC, span of control.
reports may not have access to their mentor- ing leaders because of increased SOC.1,2,15,20
Nurse managers can often be found in their offices contending with the demands of au- diting, operational tasks, and follow-up.19,20
Managers attempting to connect with increas- ing numbers of staff experience higher levels of stress, which drives decreased staff/patient satisfaction and work engagement.2,18,27 Con- nection with staff is necessary to establish and sustain reciprocal NM-frontline staff relation- ships with its impact on SOC, empowerment,
1,2,4,7-9 and job satisfaction for both groups.
Model should include assessments of (1) frequency and intensity of NM-staff relationships, (2) NM-staff capability, and (3) complexity of the NM unit(s).
Assessment should include unit complexity; material management; staff volume; skill/ autonomy, stability, and diversity; and budgetary and statistical responsibilities.
Supports include hands-on instruction for new/evolving technology, promoting clinical advancement, and sustaining coaching and consultation skills (El-Jardali et al16; Johansson et al18; Morash et al23; and Patrick and Laschinger24).
Determine how the concept of empowerment is used in the modern NM role, responsibilities, and practices.
Do not assume that SOC will remain a low priority and that NMs can handle their current SOC because they do not complain.
The roles of the chief executive officer and se- nior nursing leadership as a mediator of NMs’ SOC cannot be overemphasized, as they co- ordinate shared governance and other lead- ership activities outside of direct SOC, repre- senting the organizational system.21
RECOMMENDATIONS
Nurse managers have the largest variation in SOC in the United States.34 Executive lead- ership must recognize that SOC is no longer a separate HR issue or nursing issue—it is
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Reexamining Nurse Manager Span of Control 243
an organizational systems issue. Nursing has the largest SOC within health care, result- ing in the largest impact on patient clinical outcomes.7,8,28,29,34 The last decade has seen SOC linked to important strategic and busi- ness implications requiring ongoing assess- ment and monitoring of nurse-sensitive indi- cators and outcomes data.19,23,28,29
The review revealed that an SOC model built on a simplistic full-time employ- ment ratio is outdated. The model and its basic assumptions cannot and do not work in today’s complex health care environment.4,11,15,17,20,23,35 We offer the fol- lowing evidence-based recommendations in Table 4 for nurse executives, chief execu- tive officers, and other leaders to consider as they construct health care systems of the future.
EVOLVING HEALTH CARE MODELS AND SOC: A CALL TO ACTION
If we don’t get the science first, there ain’t gonna be no art.
William DeMille, 20th-century silent film screenwriter and filmmaker
Evolving health care environments are becoming larger and more complex.7,15,23,28
Future leaders may be able to tolerate
broader SOC because they will use tech- nology differently from current generations. The present century has been defined as the digital revolution, which is reflected in the rapid introduction of new technology and requisite skills.23,24,37 New attitudes toward these advanced technologies, tools, and competencies will result in different needs of SOC as health care moves deeper into the
10,35 modern era. Robust research studies and other sources
of evidence are needed to generate new knowledge regarding the expanding role of the NM.8,16,23 Support and interest from sci- entists and academic faculty are needed to conduct rigorous research studies that are specific to the US health care system. These data will then inform and drive conversations focused on providing optimal NM SOC for maximum effectiveness within unique care environments.38
Future leaders will not willingly take on the burdens of previous generations and they will not lead the way this generation leads.10,36,39
Current nurse leaders must invest in deter- mining how health care business is run now, put on their 21st-century glasses, and envision how it should be run in the future. Leaders cannot ignore this conversation—we must get this dialogue right or the consequences will be exponential.
REFERENCES
1. Cathcart D, Jeska S, Karnas J, Miller SE, Pechacek J, Rheault L. Span of control matters. J Nurs Ad. 2004; 34(9):395-399.
2. Lucas V, Laschinger HK, Wong CA. The impact of emotional intelligent leadership on staff nurse em- powerment: the moderating effect of span of control. J Nurs Manag. 2008;16(8):964-973. doi:10.1111/j .1365-2834.2008.00856.x.
3. Armstrong-Stassen M, Cameron SJ. Dimensions of control and nurses’ reactions to hospital amalgama- tion. Int J Soc Soc Policy. 2003;23:104-128.
4. Force MV. The relationship between effective nurse managers and nursing retention. J Nurs Adm. 2005;35(7-8):336-341.
5. Laschinger HK, Finegan J. Using empowerment to build trust and respect in the workplace: a strat- egy for addressing the nursing shortage. Nurs Econ. 2005;23(1):6-13, 3.
6. Laschinger HK, Wong C, McMahon L, Kaufmann C. Leader behavior impact on staff nurse empower- ment, job tension, and work effectiveness. J Nurs Adm. 1999;29(5):28-39.
7. McCutcheon AS, Doran D, Evans M, Hall LM, Pringle D. Effects of leadership and span of control on nurses’ job satisfaction and patient satisfaction. Nurs Lead- ersh (Tor Ont). 2009;22(3):48-67.
8. Doran D, McCutcheon A, Evans MG, et al. Impact of the manager’s span of control on leadership and performance. Can Health Serv Res Found. 2004:1-7. https://www.cfhi-fcass.ca/SearchResultsNews/04-09 -01/b3cabd8a-3277-40b8-bd29-b56c67773de4.aspx. Accessed April 20, 2019.
9. McNeese-Smith DK. The relationship between man- agerial motivation, leadership, nurse outcomes and patient satisfaction. J Organ Behav. 1999;20(2):243- 259.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
244 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019
10. Hospital Association of Southern California (HASC). Span of control: clinical impact and business solu- tions. http://www.hasc.org/association-news/hasc- releases-span-control-white-paper. Accessed April 20, 2019.
11. Aiken LH, Clarke SP, Sloane DM. Hospital staffing, organization, and quality of care: cross-national find- ings. Nurs Outlook. 2002;50(5):187-194.
12. Alidina S, Funke-Furber J. First line nurse managers: optimizing the span of control. J Nurs Adm. 1988; 18(5):34-39.
13. Altaffer A. First-line managers: measuring their span of control. Nurs Manage. 1998;29(7);36-39; quiz 40.
14. Brown P, Fraser K, Wong CA, Muise M, Cummings G. Factors influencing intentions to stay and retention of nurse managers: a systematic review. J Nurs Manag. 2013;21(3):459-472. doi:10.1111/j.1365-2834.2012. 01352.x.
15. Carney M. Middle manager involvement in strat- egy development in not-for profit organizations: the director of nursing perspective—how organiza- tional structure impacts on the role. J Nurs Manag. 2004;24(1):13-21.
16. El-Jardali F, Merhi M, Jamal D, Dumit N, Mouro G. Assessment of nurse retention challenges and strate- gies in Lebanese hospitals: the perspective of nurs- ing directors. J Nurs Manag. 2009;17(4):453-462. doi:10.1111/j.1365-2834.2009.00972.x.
17. Hansen HE, Woods CQ, Boyle DK, Bott MJ, Taunton RL. Nurse manager personal traits and leadership characteristics. Nurs Adm Q. 1995;19(4):23-35.
18. Johansson G, Sandahl C, Hasson D. Role stress among first-line nurse managers and registered nurses—a comparative study. J Nurs Manag. 2013;21(3):449- 458. doi:10.1111/j.1365-2834.2011.01311.x.
19. Jones D, Gebbens C, McLaughlin M, Brock L. Nurse manager scope and span of control: an objective busi- ness and measurement model. Paper presented at: the American Organization of Nurse Executives An- nual Conference; 2012; Denver, CO.
20. Lee H, Cummings GG. Factors influencing job sat- isfaction of front line nurse managers: a systematic review. J Nurs Manag. 2008;16(7):768-783. doi:10. 1111/j.1365-2834.2008.00879.x.
21. Lewis A. Too many managers: major threat to CQI in hospitals. QRB Qual Rev Bull. 1993;19(3):95-101.
22. McHugh MD, Kelly LA, Smith HL, Wu ES, Vanak JM, Aiken LH. Lower mortality in magnet hospitals. Med Care. 2013;51(5):382-388. doi:10.1097/MLR .0b013e3182726cc5.
23. Morash R, Brintnell J, Rodger GL. A span of control tool for clinical managers. Nurs Leadersh (Tor Ont). 2005;18(3):83-93.
24. Patrick A, Laschinger HK. The effect of structural empowerment and perceived organizational support on middle level nurse managers’ role satisfaction. J Nurs Manag. 2006;14(1):13-22. doi:10.1111/j.1365- 2934.2005.00600.x.
25. Ritchey T, Stichler JF. Determining the optimal num- ber of patients’ rooms for an acute care unit. J Nurs Adm. 2008;38(6):262-266.
26. Shirey MR, Fisher ML. Leadership agenda for change: toward healthy work environments in acute and crit- ical care. Crit Care Nurse. 2008;28(5):66-79.
27. Shirey M.: “Walking a tight rope”: an investigation of nurse managers’ work stressors and coping expe- riences. J Res Nurs. 2013;18(1):80-81. doi:10.1177/ 1744987112438650.
28. Wong C, Elliott-Miller P, Laschinger HK, et al. Ex- amining the Relationships Between Clinical Man- ager Span of Control and Manager and Unit Work Outcomes in Ontario Academic Hospitals: Final Re- port for The Ontario Ministry of Health and Long- Term Care Nursing Research Fund Project #06511. London, Ontario, Arthur Labatt Family School of Nursing, The University of Western Ontario; 2012.
29. Wong CA, Elliott-Miller P, Laschinger H, et al. Ex- amining the relationships between span of control and manager job and unit performance outcomes. J Nurs Manag. 2013;23(2):156-68. doi:10.1111/jonm .12107.
30. Jones D, McLaughlin M, Gebbens C, Terhorst L. Uti- lizing a scope and span of control tool to measure workload and determine supporting resources for nurse managers. J Nurs Adm. 2015;45(5):243-249. doi:10.1097/nna.0000000000000193.
31. Crawford CL, Omery AK, Spicer J. An integrative re- view of 21st century roles, responsibilities, character- istics, and competencies of chief nurse executives: a blueprint for the next generation. Nurs Adm Q. 2017;41(4):297-309.
32. Donabedian A. An Introduction to Quality Assur- ance in Health Care. Oxford, England: Oxford Uni- versity Press; 2003.
33. Urwick L. The manager’s span of control. Harvard Bus Rev. 1956;34(3):39-47.
34. HR Advancement Center. Seven Insights From Hos- pital Span of Control Benchmarks. Washington, DC: The Advisory Board; 2014. https://www.advisory. com/research/hr-advancement-center/resources/ 2015/seven-insights-from-hospital-span-of-control- benchmarks. Accessed April 20, 2019.
35. Havaei F, Dahinten VS, MacPhee M. The ef- fects of perceived organisational support and span of control on the organisational commitment of novice leaders. J Nurs Manag. 2015;23(3):307-314. doi:10.1111/jonm.12131.
36. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. The Future of Nursing: Leading Change, Advancing Health. Insti- tute of Medicine of the National Academies. Wash- ington, DC: The National Academies Press; 2011. https://www.nap.edu/catalog/12956/the-future-of- nursing-leading-change-advancing-health. Accessed April 20, 2019.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Reexamining Nurse Manager Span of Control 245
37. Wikipedia. 21st century. https://en.wikipedia.org/ wiki/21st century. Published 2018. Accessed April 20, 2019.
38. Witt Kieffer. Emerging millennial healthcare leader- ship: views and reflections from the new generation. Witt/Kieffer Study. 2017:1-16. http://www.wittki effer.com/thought-leadership-research-reports/
emerging-millennialhealthcare-leaders-survey-report. Accessed April 20, 2019.
39. Simpson BB, Dearmon V, Graves R. Mitigating the impact of nurse manager large spans of control. Nurs Adm Q. 2017;41(2):178-186. doi:10.1097/NAQ .0000000000000214.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.