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1. Reexamining Nurse Manager Span of Control Assignment
Reexamining Nurse Manager Span of Control AssignmentReexamining Nurse Manager Span
of Control AssignmentNurs Admin Q Vol. 43, No. 3, pp. 230–245 c 2019 Wolters Kluwer
Health, Inc. All rights reserved. Copyright 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) speci?c 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 de?ned as
activities or actions stemming from identi?ed 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, ?nancial, 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employment ratio is outdated.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 Af?liations: 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 con?icts of
interest, including ?nancial, consultant, institutional, and other relationships that might lead
to bias or a con?ict of interest Correspondence: Cecelia L. Reexamining Nurse Manager Span

2. of Control AssignmentORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE
PAPERSCrawford, 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 “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. Crawford@kp.org). DOI: 10.1097/NAQ.0000000000000351
230 Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this
article is prohibited. Reexamining Nurse Manager Span of Control time with their nurse
leaders. The negative effects of increased SOC continued into the 21st century, with
dramatic in?uences 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 Reexamining Nurse Manager Span of Control
AssignmentThe primary aim of the review was to examine the quantity, quality, and
consistency of evidence regarding the SOC phenomenon speci?c to NMs. A secondary aim
was to 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 sec- 231 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
identi?cation resulted in 28 ?nal 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 ?nal 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.

3. 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 de?ned as activities or actions stemming
from identi?ed structures that led to outcomes. Examples Copyright © 2019 Wolters Kluwer
Health, Inc. Unauthorized reproduction of this article is prohibited. Case Study Alidina and
Funke-Furber (1988)12 Altaffer (1998)13 Nonexperimental Reexamining Nurse Manager
Span of Control AssignmentDesign Systematic Review Grounded Theory Study Armstrong-
Stassen and Cameron (2003)3 Brown et al (2013)14 Carney (2004)15 Explore factors
known to in?uence NM retention and intention to stay How organizational structure
aligns/impacts with strategic management of NM role Examine relationship of nurses’
personal, job, and organizational dimensions Examine organizational and staf?ng on nurse
job dissatisfaction, burnout, and quality of care Discussion of SOC concept, structures,
implications, and in?uencing factors Examine FL NM vs non-NM scope, SOC, and perception
of effectiveness Multisite Cross-sectional Survey Aiken et al (2002)11 Descriptive Survey
Design Purpose Evidence Source Reference Table 1. Literature Review References Common
concerns were dissatisfaction, burnout, and quality of care Managerial /adequate staf?ng
plays key roles for quality of care, job dissatisfaction, burnout, and nurse retention Optimal
SOC is necessary for NM role and responsibilities Understanding certain in?uencing 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 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 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)
Conclusions 232 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019
Copyright © 2019 Wolters Kluwer Health, Inc. Reexamining Nurse Manager Span of Control
AssignmentUnauthorized reproduction of this article is prohibited. 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 Performance Improvement Project Descriptive
Correlation Survey Design Descriptive Survey Design Literature Review Descriptive Survey
Design Comparative Descriptive Survey Study 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

4. Examine differences in self-related health between FL NM and RNs on various psychosocial
factors Examine NM personality traits and staff perceptions of NM leadership Outlines
characteristics of NM leadership style that enhances nurse retention Purpose Evidence
Source Reference Table 1. Literature Review References (Continued) 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 in?uence 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 allows all nurses to
function in stressful work environments (continues) 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 Conclusions Reexamining Nurse Manager Span of Control 233 Copyright
© 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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 Nonexperimental Predictive Design
Nonexperimental Predictive Design Systematic Review Expert Opinion Laschinger and
Finegan (2005)5 Laschinger et al (1999)6 Lee and Cummings (2008)20 Lewis21
Nonexperimental Predictive Design Determine how nursing leadership can improve NM
turnover and vacancy rates Performance Improvement Project Jones et al (2012)19 Lucas
et al (2008)2 Purpose Evidence Source Reference Table 1. Literature Review References
(Continued) (continues) Do more, faster: Reduced SOC increases responsiveness, willing to
lead projects, and connecting with ive personnel Staff empowerment a dramatic impact on
NM SOC NMs may not be able to empower their staff if SOC is large,Reexamining Nurse
Manager Span of Control Assignment