The nurse manager role remains one of the most challenging in hospitals. Now a new report suggests that it may be time for executives to look more closely at how they can support these leaders to optimize their effectiveness.
Nurse managers represent the highest leverage point in a hospital to impact outcomes and should factor highly into decisions and investments driven by return on investment, notes the analysis “Quantifying Nurse Manager Impact.” It was co-developed by the AHA’s American Organization for Nursing Leadership (AONL) and Laudio, a data analysis platform used by health leaders to create large-scale change through human actions.
Specifically, leaders are urged to examine closely the responsibilities and number of direct reports assigned to nurse managers — commonly known as span of control — and how this affects their ability to deliver strong outcomes and maintain purposeful interactions. In addition, optimizing nurse managers’ span of control and making strategic investments to support them can yield benefits like increased RN retention, reduced incremental overtime/overall overtime, decreased role overload/burnout, and improved patient outcomes and experience.
Benchmarking Spans of Control
The report details the complexities of nurse managers’ work today and recommends right-sizing spans of control and to support managers with targeted investments and resources. The report is based on Laudio’s data set which includes more than 50 acute care hospitals and hundreds of ambulatory and clinical facilities nationally, and the statistical analyses are based on the 34,301 RNs in the data set.
Among the findings:
- The median span of control for nurse managers is a 46 head count, which includes full-time, part-time and per diem employees. One in four inpatient managers have spans of control of 78 or higher.
- Emergency departments (EDs) have the highest median span of control at 83, followed by intensive care units at 80; medical-surgical units, 62; and operating rooms, 36.
- 56% of nurse managers have the support of at least one assistant nurse manager, but only 18% of these assistants have direct reports.
The High Cost of Expanded Spans of Control
The broad span of control of nurse managers can compromise their ability to connect with subordinate nurses, the report explains. Those managing a greater number of employees often will experience additional financial challenges due to higher turnover and overtime costs.
Departments in the highest quartile of span of control may experience higher turnover because of the stresses placed on the managers’ ability to support and coach each team member. In the ED, for example, head counts of fewer than 70 showed a 14% turnover rate while those with more than 115 staff members experienced 23% turnover.
Nurse managers with higher spans of control also take relatively more corrective actions, the report states. Prior AONL research and focus groups have documented that as spans of control increase, nurse managers have to “cast aside transformational and relational leadership styles regardless of their leadership ability.” This can lead to difficulty and more time spent in maintaining staff accountability when managers are overwhelmed. Illustrating this point, the data showed that the relative mix of corrective actions was 3.5 times higher for managers of the largest teams.
4 Takeaways for Executives
1 | Reduce the highest spans of control, if possible.
Consider dividing departments into smaller ones. For example, an organization can reduce the size of a large ED by segmenting off a specialty such as cardiovascular, behavioral health or pediatrics.
2 | Consider adding a nurse manager.
With the national average of each RN turnover estimated to be $52,358, the added cost for another nurse manager could be financially positive if turnover is reduced by two or three RNs a year. Similarly, if such a change reduced incremental overtime by 30% to 40%, it also could provide financial justification. These changes can be challenging, however, and may require physical layout changes and coordination from many other teams that would be affected by the change, including finance and environmental services.
3 | Add an assistant nurse manager where they will have the greatest positive financial impact.
Having one or two assistant nurse managers vs. none was found to result in an average 3-point reduction in turnover, the report noted. For a team with 50 RN full-time equivalents, this equates to a difference of 1.5 RNs per year, a savings of $78,500. Promoting a team member to assistant nurse manager with a goal of reducing team turnover is another option that could net financial benefits.
4 | Help nurse managers to maintain consistent, purposeful interactions.
These interactions with team members go beyond routine daily conversations that occur in hallways, team meetings and break rooms. These interactions are documented by the manager in local working files and relate to the work or behavior of individual employees in areas like celebration and recognition, check-ins and corrective actions.
Adding tools, training and support systems can help nurse managers maintain consistent, purposeful interactions with their direct reports. Data in the report show that one purposeful interaction per month per RN is associated with a 68% increase in odds of employee retention. Executives also can partner with human resource and information technology leaders to identify solutions that support and reduce administrative burden.
