Editor’s Note: This content has been excerpted from “Understanding the Impact of Span of Control on Nurse Managers and Hospital Outcomes,” Journal of Healthcare Management, vol. 39, no. 2, by Asiah Ruffin, RN; Maria R. Shirey, PhD, RN, FACHE; Tracey Dick, PhD, RN, CNE; Pariya L. Fazeli, PhD; Patricia A. Patrician, PhD, RN, FAAN. It has been edited down for length.
Emerging evidence suggests that the psychosocial impact of the COVID-19 pandemic has perpetuated burnout among healthcare workers. During the height of the pandemic, nurses reported insomnia and feelings of posttraumatic stress, while their managers faced diminished staff well-being and excessive workloads.
American Organization for Nursing Leadership research priorities include healthy work environments, workplace safety, nurse well-being and leader development. Each of these priorities has implications for nurse managers, as they are the closest leaders to front-line staff. Therefore, understanding the organizational practices related to nurse managers is essential to inform better, evidence-based job designs in today's complex healthcare system.
Researchers have identified registered nurses' negative experiences with management as a top cause of preventable intention to leave their job. These experiences may be related to the increasing complexity of the role of nurse managers and their capacity to support the registered nurses they supervise in acute care settings. Managerial expectations for nurses have broadened over the past few decades, particularly in the number of direct reports and units that one manager is expected to supervise—that is, the manager's span of control. For every 10 employees added to a nurse manager's span of control, the unit turnover rate increases by 1.6%.
Span of control emerged as a business concept in the 1930s to describe the number of subordinates reporting to a supervisor. There is a suggestion that one manager can effectively supervise up to six people with interlocking work. Interest in span of control became popular in business literature during the 1980s and 1990s, coinciding with corporate downsizing that created the massive nursing and management shortages that persist today. Healthcare reform widened spans of control for nurse managers, limiting their capacity to build relationships. During this time, their role shifted from that of a coach or mentor to an administrator with added financial management, human resource tasks and staff supervision duties.
Reviews examine the nurse manager's span of control in acute care settings. However, the pandemic has introduced new challenges in the healthcare workforce. This concept analysis is among the first to evaluate the span of control since the pandemic's arrival.
Span of control can be measured by direct head count, full-time equivalents (FTEs), or the Ottawa Hospital span of control decision-making indicator tool. Direct head count is the total number of individuals under a manager's supervision. An FTE is defined as “a unit of measure based on the total number of hours worked that shows how many full-time equivalent employees a certain company employs within a fiscal year.” To calculate FTEs, the number of hours worked is divided by full-time hours (usually 40 per week). The proposed multidimensional instrument calculates a span of control score based on various unit characteristics (e.g., complexity and unit size).
Heavy workloads and job pressures have become the norm since the pandemic's arrival. The current span of control practices limits the effectiveness of nurse managers and hinders quality outcomes. The deteriorating environments diminish nurses' ability to safely provide quality care. Today's nursing workforce requires strong and adaptable leadership. Unfortunately, nurse managers' effectiveness as leaders is restricted as they handle many direct reports and constantly shift among various roles. Nurse managers need more support as healthcare evolves, and improving the knowledge of span of control will help researchers and hospital leaders establish evidence-based strategies to provide that support.
Learn more from the authors about how an awareness of span of control can promote sustainable nursing practices.