Nursing Assignment on Week 2 Journal NUR4945

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 characteristics. 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 The review revealed that an SOC model built on a simplistic full-time employment ratio is outdated.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 effectiveness 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 PermaBEFORE the restructuring of health care
in the 1990s, novice nurses worked
closely with nurse leaders in an “apprenticeship system” that fostered professional
development.1,2 This vital mentoring process
facilitated the growth of nursing professionals. However, nurse managers’ (NMs’) span
of control (SOC) widened during the turbulent 1990s, with staff nurses spending less
nente Southern California, Patient Care Services,
393 E Walnut St, Pasadena, CA 91188 (Cecelia.L.
[email protected]).
DOI: 10.1097/NAQ.0000000000000351
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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 structural empowerment.1,3-5 Nurse managers
have seen their relationship management/
staff empowerment diminish and job satisfaction decrease.2,5-7 Ensuring that NMs have
reasonable SOCs not only assists in their personal, 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, commentary, 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 recommendations for nurse executives and other
nurse leaders to consider regarding appropriate SOC and administrative decisions for their
organizations.
THE REVIEW
Review aim and design
The primary aim of the review was to examine the quantity, quality, and consistency
of evidence regarding the SOC phenomenon
specific to NMs. A secondary aim wasto meaningfully translate the evidence and offer guidance to 21st-century executive leaders and
NMs.
Methodology, appraisal, and evidence
abstraction
Review phases included creation of clinical and searchable questions and terms; data
retrieval; evidence appraisal; data interpretation and synthesis; and a narrative summary.
The review question was crafted by the Nursing Leadership Council of the Hospital Association of Southern California.10 A systematic
database search structured the review’s second 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 during 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 investigation, 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 surveys, 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 Donabedian’s (2003) Structure-Process-Outcomes
model.32 We took the model’s concept and
adapted it for NM SOC. The Structure-ProcessOutcomes 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 (HR), and organizational
characteristics. Processes were defined as activities or actions stemming from identified
structures that led to outcomes. Examples
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Table 1. Literature Review References Reference Evidence Source Purpose Conclusions Aiken et al (2002)11 Alidina and Funke-Furber (1988)12 Altaffer (1998)13 Armstrong-Stassen and Cameron (2003)3 Brown et al (2013)14 Carney (2004)15 Multisite Cross-sectional Survey Case Study Descriptive Survey Design Nonexperimental Design Systematic Review Grounded Theory Study Examine organizational support and staffing on nurse job dissatisfaction, burnout, and quality of care Discussion of SOC concept, structures, implications, and influencing factors Examine FL NM vs non-NM scope, SOC, and perception of effectiveness Examine relationship of nurses’ personal, job, and organizational dimensions Explore factors known to influence NM retention and intention to stay How organizational structure aligns/impacts with strategic management of NM role Common concerns were dissatisfaction, burnout, and quality of care Managerial support/adequate staffing plays key roles for quality of care, job dissatisfaction, burnout, and nurse retention Optimal SOC is necessary for NM role and responsibilities Understanding certain influencing factors can optimize NM SOC NMs scored greater effectiveness than non-NMs, even though they supervise more staff, have fewer assistive personnel, and paid less Respondents did not rank themselves as highly effective in any dimension; suggests that unstable care environment contributes to negative perception of effectiveness Organizational control predicted changes in support and trust. Although nurses reported low organizational control, more than 1 dimension of control is involved in sense of powerlessness NM retention and intention to stay are multifactorial Executive leadership is responsible for the support of NM in relation to SOC, workload, and work/life balance issues Hierarchy and management layers contribute to NM sense of exclusion in strategy development NM must enable trust and demonstrate leadership by willingness to work in multidisciplinary care models
(continues)
232 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019
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Table 1. Literature Review References (Continued)
Reference Evidence Source Purpose Conclusions
Cathcart et al
(2004)1
Doran et al
(2004)8
El-Jardali et al
(2009)16
Force (2005)4
Hansen et al
(1995)17
Johansson et al
(2013)18
Performance
Improvement Project
Descriptive Correlation
Survey Design
Descriptive Survey
Design
Literature Review
Descriptive Survey
Design
Comparative Descriptive
Survey Study
Explore relationships between
SOC and staff engagement
relationships
Examine relationships
between NM leadership
styles, SOC, and patient and
nurse outcomes
Assess nurse retention
challenges and strategies, as
perceived by Lebanese NM
Outlines characteristics of NM
leadership style that
enhances nurse retention
Examine NM personality traits
and staff perceptions of NM
leadership
Examine differences in
self-related health between
FL NM and RNs on various
psychosocial factors
Strong relationship between SOC and employee engagement
Routine review of NM SOC may address negative impact of
large SOC on employee engagement
No leadership style can overcome a wide span of control
Executive leadership must develop guidelines regarding
number of staff NM can effectively lead and supervise
Retention challenges include salary, shifts, working hours, and
better internal and/or external career opportunities
Challenges will continue if aforementioned issues are not
addressed
More information is needed on NM SOC and leadership/
management capacities
5 themes: transformational leadership; transformational
leadership; extroverted personality; Magnet hospital
structures; tenure; graduate education
Themes demonstrate that leadership traits lead to nurse job
satisfaction and retention
Nurses favorably rated NM on leadership style, power, and
influence
NM personality modestly linked motivation to manage and
select leadership aspects
First-line NMs can cope with high-demand situations if they
have high control over their work
High degree of job control and managerial support allows all
nurses to function in stressful work environments
(continues)
Reexamining Nurse Manager Span of Control 233
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Table 1. Literature Review References (Continued)
Reference Evidence Source Purpose Conclusions
Jones et al
(2012)19
Laschinger and
Finegan (2005)5
Laschinger
et al (1999)6
Lee and
Cummings
(2008)20
Lewis21
Lucas et al (2008)2
Performance
Improvement Project
Nonexperimental
Predictive Design
Nonexperimental
Predictive Design
Systematic Review
Expert Opinion
Nonexperimental
Predictive Design
Determine how nursing
leadership can improve NM
turnover and vacancy rates
Examine effects of
empowerment on staff
perceptions of justice,
respect, and trust in
management
Examine NM leader
empowering behavior to
staff perceptions of
empowerment, job stress,
and work effectiveness
Examine determinants of FL
NM job satisfaction
Case studies describing the
relationship between
empowerment and CQI via
concept of SOC
Model linking nurse
perceptions of NM
emotional intelligence
leadership style, structural
empowerment, and impact
of NM SOC
Redistribution of operational and administrative resources
positively impacted turnover rates, internal transfers,
internal promotions, vacancy rates/days open, NM MSN
Evaluation of scope/SOC can determine operational and
administrative support tiers needed for NM success
Structural empowerment has a direct effect on interactional
justice, respect, and organizational trust
NMs have a pivotal role in creating/maintaining staff trust
Highlights importance of NM leadership traits within changing
health care settings
NM behaviors impacted perceptions of formal/informal power
and access to empowerment structures
Higher perceived access is linked to lower job tensions and
increased work effectiveness
Addressing SOC, workload, increased supervisor support, and
empowerment may influence FL NM job satisfaction
Do more, faster: Reduced SOC increases responsiveness,
willing to lead projects, and connecting with supportive
personnel
Staff empowerment a dramatic impact on NM SOC
NMs may not be able to empower their staff if SOC is large,
even if they have strong emotional intelligence
Senior management must ensure that NMs have reasonable
SOC to empower staff to full scope of nursing practice and
role
(continues)
234 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019
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Table 1. Literature Review References (Continued)
Reference Evidence Source Purpose Conclusions
McCutcheon et al
(2009)7
McHugh et al
(2013)22
McNeeseSmith (1999)9
Morash et al
(2005)23
Patrick and
Laschinger
(2006)24
Nonexperimental
Predictive Design
Mixed Methods
(Retrospective
Analysis; Survey
Design)
Descriptive Correlational
Survey Design
Mixed-Methods Study
Descriptive Correlational
Survey Design
Examine relationships
between leadership style,
job satisfaction, patient
satisfaction, and SOC,
the moderating effect of SOC as
above
Determine whether Magnet
hospitals have lower
mortality/failure-to-rescue
than non-magnet hospitals
Examine the relationship of NM
motivation to leadership
behaviors, staff job
satisfaction, productivity,
organizational commitment,
and patient satisfaction
Design/implement SOC tool
using evidence, surveys,
focus groups, and field
testing (Ottawa Hospital
Clinical Management SOC
Decision-Making Indicators
TOH tool)
Examine relationship between
structural empowerment
and organizational support
and effect on NM role
satisfaction
Higher SOC decreased positive effects of transformational/
transactional leadership on outcomes
Management by exception and laissez-faire leadership styles
increased negative impacts on job satisfaction
Magnet hospitals had lower mortality/failure-to-rescue odds
Better work environment is a distinguishing factor between
Magnet/non-Magnet hospitals and key to better outcomes
Better outcomes partly attributed to investments in qualified
educated nurses and environments supportive of quality
care
“Attention of nurses to your condition” positively correlated
with productivity, job satisfaction, organizational
commitment, and all 5 leadership practices
NM motivation positively correlated with achievement,
motivation, and 5 leadership practices
Tool includes 3 decision-making categories (unit, staff,
program-focused) to classify 8 indicators (unit complexity;
material management; staff volume; skill/autonomy;
stability; diversity; budgetary; and statistical responsibilities)
Need for standardization, EBP changes, and assessment of
roles/responsibilities of entire nursing group
Combination of organizational support and empowerment is a
significant predictor NM role satisfaction
Perceptions of organizational support may play an important
role in retaining NM and attracting future nurse leaders
Reexamining Nurse Manager Span of Control 235
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(continues)

Table 1. Literature Review References (Continued)
Reference Evidence Source Purpose Conclusions
Ritchey and Commentary Determine optimal number of Reduce larger units to subunits/clusters ranging 6-12 rooms
Stichler patient rooms in acute care New clusters increased nursing engagement when NM SOC
(2008)25 settings averaged 50 or less direct reports
Shirey and Fisher Secondary Analysis of a Thematic examination of 2004 4 themes: leadership, practice environment, staffing, and
(2008)26 Descriptive Survey National Critical Care Survey professional advancement and recognition
Study Findings Report to Leadership is about people and relationships and is
determine implications for transformational
nursing administrators Assess NM SOC and make appropriate changes in structures
Monitor the impact of changes in SOC on unit-based and
organizational outcomes
Shirey (2013)27 Editorial Review of a research study Authors allude to 2 areas for needed intervention: SOC and
investigating NM stressors therapeutic dialogue
and coping experiences NM SOC variability is a major threat to NM ability to achieve
work satisfaction, engage staff, and affect organizational
commitment
Wong et al Nonexperimental Validate TOH tool and examine Manageable SOC essential for quality job/unit outcomes
(2012)28 Predictive Survey relationships between FL Only SOC predicted adverse unit outcomes
Study NM SOC and manager work Combination of SOC and self-evaluation predicted job
outcomes satisfaction, work control, and role overload
Neither self-evaluation nor SOC predicted unit turnover
Wong et al Mixed Methods (Focus Examine combination of FL NMs report high role overload/job demands, limited job work,
(2013)29 Group; Survey) NM characteristics and SOC and moderate SOC satisfaction
of job and unit outcomes Increasing system demands contribute to expanded work
responsibilities/role overload
TOH score significant indicator of NM job satisfaction, job
demands, work control, and SOC satisfaction
236 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Abbreviations: COI, continuous quality improvement; EBP, evidence-based practice; FL, frontline; NM, nurse manager; SOC, span of control; TOH, The Ottowa Hospital.

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 activities, 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)
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238 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019
The basic principles of SOC were first outlined by a military general in 1927. The soldierly metaphors and descriptions lingered
through the 1950s and formed the basis for
various business interpretations.1,27 Synonymous 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 discussions: “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 productivity and empower staff, with direct reports
increasing to 15 to 25 people.1,30
The 1990s saw an explosion in SOC research studies.15 Three variables were identified as being essential to health care–related
SOC, which were (1) manager-staff relationship frequency and intensity, (2) work complexity, 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 frequent, 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 associated with organizational structures and
processes.
Structures associated with increased
SOC
We isolated 6 structural elements associated 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 factorsthat 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 environment quality, and positive safety
climates.7,20,22,26
Increased SOC decreased the positive effects of transformational and transactional
leadership styles, causing an inverse relationship between the 2 styles.4,7,18 Alternatively, access to organizational resources,
data, and other information; system and technical support; collaboration with HR, peers,
and staff; participation in strategy planning;
and recognition programs all had positive impacts on NM retention.14,24,25 Nurse managers 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 relationships between SOC, system supports,
empowerment, and job satisfaction of frontline 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 predicted role overload, work control, and job
satisfaction.13 Only SOC predicted unit adverse 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 resulted in tall structures and disruption in
communication.12,13,15 The more organizational levels, the more communication “filtering” occurred as information moved up and
down these pathways.15,25 In contrast, decentralized structures combined with HR practices 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 coordinating institutional goals and activities
across multiple units.7,8 The evidence articulated 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 adversely
unit outcomes
Abbreviations: CN