Miami Dade College Reexamining Nurse Manager Span of Control Essay Instructions:Read- Journal Article: Reexamining Nurse Manager Span of Control with a 21s

Miami Dade College Reexamining Nurse Manager Span of Control Essay Instructions:Read- Journal Article: Reexamining Nurse Manager Span of Control with a 21st Century LensSubmit – Two-page APA 6th edition reflective response to the article with at least two references. Nurs Admin Q
Vol. 43, No. 3, pp. 230–245
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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) 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 The review revealed that an SOC model built on a simplistic full-time employment ratio is outdated.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 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
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Reexamining Nurse Manager Span of Control
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 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 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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Case Study
Alidina and
Funke-Furber
(1988)12
Altaffer (1998)13
Nonexperimental Design
Systematic Review
Grounded Theory Study
Armstrong-Stassen
and Cameron
(2003)3
Brown et al
(2013)14
Carney (2004)15
Explore factors known to
influence 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
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
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 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)
Conclusions
232
NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019
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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
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
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)
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
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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 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
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 linked to lower job tensions and
increased work effectiveness
Addressing SOC, workload, increased supervisor support, and
empowerment may influence FL NM job satisfaction
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 direct effect on interactional
justice, respect, and organizational trust
NMs have pivotal role in creating/maintaining staff trust
Conclusions
234
NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019
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Nonexperimental
Predictive Design
Mixed Methods
(Retrospective
Analysis; Survey
Design)
Descriptive Correlational
Survey Design
Mixed-Methods Study
Descriptive Correlational
Survey Design
McHugh et al
(2013)22
McNeeseSmith (1999)9
Morash et al
(2005)23
Patrick and
Laschinger
(2006)24
Evidence Source
McCutcheon et al
(2009)7
Reference
Purpose
Examine 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
Examine relationships
between leadership style,
job satisfaction, patient
satisfaction, and SOC,
moderating effect of SOC as
above
Determine whether Magnet
hospitals have lower
mortality/failure-to-rescue
than non-Magnet hospitals
Table 1. Literature Review References (Continued)
(continues)
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
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
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
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
Conclusions
Reexamining Nurse Manager Span of Control
235
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Nonexperimental
Predictive Survey
Study
Mixed Methods (Focus
Group; Survey)
Wong et al
(2012)28
Wong et al
(2013)29
Examine combination of FL
NM characteristics and SOC
of job and unit outcomes
Validate TOH tool and examine
relationships between FL
NM SOC and manager work
outcomes
Review of a research study
investigating NM stressors
and coping experiences
Determine optimal number of
patient rooms in acute care
settings
Thematic examination of 2004
National Critical Care Survey
Findings Report to
determine implications for
nursing administrators
Purpose
Reduce larger units to subunits/clusters ranging 6-12 rooms
New clusters increased nursing engagement when NM SOC
averaged 50 or less direct reports
4 themes: leadership, practice environment, staffing, and
professional advancement and recognition
Leadership is about people and relationships and is
transformational
Assess NM SOC and make appropriate changes in structures
Monitor the impact of changes in SOC on unit-based and
organizational outcomes
Authors allude to 2 areas for needed intervention: SOC and
therapeutic dialogue
NM SOC variability is a major threat to NM ability to achieve
work satisfaction, engage staff, and affect organizational
commitment
Manageable SOC essential for quality job/unit outcomes
Only SOC predicted adverse unit outcomes
Combination of SOC and self-evaluation predicted job
satisfaction, work control, and role overload
Neither self-evaluation nor SOC predicted unit turnover
NMs report high role overload/job demands, limited job work,
and moderate SOC satisfaction
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
Conclusions
Abbreviations: COI, continuous quality improvement; EBP, evidence-based practice; FL, frontline; NM, nurse manager; SOC, span of control; TOH, The Ottowa Hospital.
Editorial
Secondary Analysis of a
Descriptive Survey
Study
Commentary
Evidence Source
Shirey (2013)27
Ritchey and
Stichler
(2008)25
Shirey and Fisher
(2008)26
Reference
Table 1. Literature Review References (Continued)
236
NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019
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Reexamining Nurse Manager Span of Control
237
Table 2. Evidence Appraisal: Ranking and Gradinga,b,c
Academy of Evidence-Based Practice Evidence Leveling System
Level
A
B
C
D
E
MA
LR
Description
Meta-analysis of multiple large sample or small sample
randomized controlled studies, or meta-synthesis of
qualitative studies with results that consistently
support a specific action, intervention, or treatment
Well-designed controlled studies, both randomized and
nonrandomized, prospective or retrospective studies,
and integrative reviews with results that consistently
support a specific action, intervention, or treatment
Qualitative studies, descriptive, or correlational studies,
integrative reviews, systematic reviews, or
randomized controlled trials with inconsistent results
Peer-reviewed professional organizational standards,
with clinical studies to support recommendations
Theory-based evidence from expert opinion or multiple
case repor…
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