span of control (final)

Leading Practices for Addressing Clinical Manager Span of Control in Ontario February 2011

iOntario Hospital Association Leading Practices for Addressing Clinical Manager Span of Control

Foreword

The Ontario Hospital Association (OHA) Provincial Health Human Resources Strategic Plan 2008-2011, developed through OHA member and stakeholder consultations, identified the need to provide resources and support to members on Manager Span of Control.

Following a scan of existing studies on the topic, the OHA decided to best meet members’ needs with a practical study approach that identifies leading practices health care organizations have introduced to assist in alleviating the negative impacts of large spans of control.

This study was conducted by the Hay Group and guided by OHA staff and the OHA Strategic Human Resources Provincial Leadership Council. This Council includes Chief Executive Officers, human resources, nursing, and patient care leaders in hospitals as well as representatives from the educational, long-term care, and community care sectors.

The following report is written by the Hay Group and proposes a number of recommendations from their perspective.

Today, health care organizations consist of flatter organizational structures and larger managerial spans of control as a result of restructuring over the past twenty years. Clinical Managers often have responsibility for large numbers of direct reports. The 2010 OHA-PricewaterhouseCoopers HR Benchmarking survey reveals that the median Nurse Manager Span of Control (SOC) ratio was one manager for every 56.9 employees, with many managers overseeing over 100 workers. This often leaves little time for staff mentorship, coaching, or performance evaluation. Other studies have documented the impacts of wide spans of control on staff and patient satisfaction, staff turnover, and other metrics. The focus of this study is practices or strategies that health care organizations have introduced to address and alleviate some of these impacts.

iiOntario Hospital Association Leading Practices for Addressing Clinical Manager Span of Control

Table of Contents

1.0 Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . 1

2.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 3.0 Overview of Literature Findings . . . . . . . . . . . . 7 3.1 Span of Control Defined . . . . . . . . . . . . . . . . . . . . 7 3.2 Tools to Assess Manager Span of Control . . . . . . . 8 3.3 Span of Control and Impact on Managers, Staff and Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

4.0 Span of Control Survey . . . . . . . . . . . . . . . . . . . . . 13 4.1 Response Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 4.2 Organizational Culture . . . . . . . . . . . . . . . . . . . . . 15 4.3 Manager Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 4.4 Staff Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 4.5 Span of Control Impact on Specific Dimensions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 4.6 Summary of Survey Findings . . . . . . . . . . . . . . . . 31

5.0 Key Informant Interviews . . . . . . . . . . . . . . . . . 33 5.1 Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 5.2 Strategies/Initiatives to Support Manager Span of Control. . . . . . . . . . . . . . . . . . . . . . . . . . . 35 5.3 Change in Model of Care . . . . . . . . . . . . . . . . . . . 37 5.4 Tools to Support Leading Practices. . . . . . . . . . . 38 5.5 Enablers to Support Manager Span of Control . . . . . . . . . . . . . . . . . . . . . . . . . . 38 5.6 Barriers to Mitigating Effects of Span of Control . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 5.7 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 5.8 Summary of Interview Findings. . . . . . . . . . . . . . 42 6.0 Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . 43 6.1 Defining Span of Control . . . . . . . . . . . . . . . . . . . 43 6.2 Leading Practices to Address Span of Control . . 43 6.3 Measuring the Impact of Span of Control . . . . . 47 6.4 Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Appendix A: Recommendations . . . . . . . . . . . . . . . . . . 51 Appendix B: Literature Review: Definition, Key Concepts and Emerging Themes . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Span of Control Defined . . . . . . . . . . . 52 Additional Considerations for Span of Control . . . . . . . . . . . . . . . . . . 54 Span of Control and Impact on Managers, Staff and Patients . . . . . . . . 55 Impact on Managers . . . . . . . . . . . . . . 56 Impact on Staff Performance . . . . . . . . 57 Impact on Patients. . . . . . . . . . . . . . . . . 58 Tools to Assess Manager Span of Control . . . . . . . . . . . . . . . . . . . . . . . . 89 Strategies to Mitigate the Negative Impacts of Large Spans of Control . . . 59

Appendix C: Additional Survey Tables . . . . . . . . . . . 66 Appendix D: Key Informant Interview Participants . . . . . . . . . . . . . . . . . . . . . . . 80 Appendix E: Sample Documents . . . . . . . . . . . . . . . . . 81

Appendix F: References . . . . . . . . . . . . . . . . . . . . . . . 104

1Ontario Hospital Association Leading Practices for Addressing Clinical Manager Span of Control

The Ontario Hospital Association (OHA) sought the assistance of the Hay Group to conduct a study to identify key and practical leading practices, strategies or tools for employers to alleviate the negative impacts of large clinical manager span of control on the workforce and patients. The study included health care organizations in Ontario from across the three health sectors; hospitals, community care, and long-term care.

The objectives of the study were to:

• Summarize key findings from the existing literature related to span of control in health care;

• Identify the most critical leading practices/strategies that are feasible and affordable and provide guidance on the implementation of those practices for employers to reduce the negative impact of large spans of control on unit and patient outcomes through surveys and key informant interviews; and

• Provide recommendations on how the OHA and health care organizations can use existing metrics on span of control and unit outcomes to measure the impacts of span of control province-wide and within individual organizations.

Over the past two decades, healthcare in Canada has experienced significant downsizing and reform. Many hospitals were required to make difficult decisions in order to manage their fiscal restraints while balancing patient care needs. One common cost reduction strategy has been to flatten the organization structure and reduce the number of managerial positions.

Manager span of control has increased, with many managers often responsible for more than one unit, which significantly reduces the time available for staff mentorship, motivation, coaching and evaluation. One Ontario study that evaluated the impact of span of control on leadership

1.0 Executive Summary

and performance and included seven hospitals found that manager span of control ranged from 36-151 workers, with a median of 67 workers10.

There have been a handful of Canadian studies related to span of control in the health care context. A scan of the literature reveals that definitions for span of control can be grouped into two broad categories: total number of “workers” being supervised by a manager and total number of full-time equivalent (FTE) positions being supervised by a manager. For the purposes of the study, the OHA has defined span of control as the total number of “workers” reporting to a manager.

The literature further suggests that span of control is a more complex phenomenon and additional factors such as the overall authority that falls within a manager’s responsibility should be considered.

There are no studies which identify what constitutes an appropriate span of control for a clinical manager. Generally, the literature suggests that three components be considered when identifying the appropriate span on control in an organization:

• frequency and intensity of the relationship between the manager and staff,

• complexity of the work, capabilities of the manager, and

• complexity of the work and capabilities of the staff.

There is some evidence which identifies methods to assess span of control and the impact of the relationship between the clinical manager’s span of control and staff, unit, and patient outcomes.


The Ottawa Hospital Span of Control Assessment Tool (See Appendix B, Table 1) recognizes the complexities in evaluating manager span of control and is currently being validated by the University of Western Ontario/Children’s Hospital of Eastern Ontario study.

In order to obtain a comprehensive understanding of span of control trends, challenges and leading practices of healthcare organizations in Ontario, stakeholder input was solicited through an online survey and via key stakeholder interview. A list of stakeholders can be found in Appendix D.

Based on the findings from the literature, the online survey was structured to capture the impact of span on the following nine dimensions:

1. Impact on effectiveness and/or frequency of communication

2. Impact on manager accessibility to staff

3. Impact on staff retention

4. Impact on staff attendance (levels of absenteeism)

5. Impact on staff injury rates

6. Impact on staff engagement

7. Impact on staff satisfaction

8. Impact on client/patient/resident safety

9. Impact on client/patient/resident satisfaction

Managers were asked to provide information on initiatives that had been implemented to alleviate the impact that span of control. The following initiatives were most frequently reported as strategies that were used across the nine dimensions:

• Manager access and visibility

• Performance appraisals

• Manager/administrative walkabouts

• Staff involvement in decision making/unit activities

• Appreciation and recognition

• Manager flexibility

• Staff forums/town halls

• Use of Email/Other IT tools for communication and accessibility

Managers also indicated whether they had narrow or wide span of control based on their own perceptions. Managers of long-term care homes were most likely to report a wide span of control (90%), followed by hospital managers at 73% and CCAC managers at 65%. Managers who reported a wide span of control were more likely to have:

• Greater than 80 staff members reporting to them

• Responsibility for three or more units

• Budgetary responsibility

• Budgets exceeding $7 million

Structured interviews were conducted with a small sample of Senior Nurse Leaders from the three health sectors (hospital, long-term-care and community care). The purpose of the interviews was to provide further insight into the practices, strategies, and tools that organizations have implemented to minimize or alleviate the potentially negative impacts of large manager span of control on their workforce and patients.


Organizations identified a number of strategies that are being implemented that may assist in alleviating the negative impact of a wide manager’s span of control. However, many of the strategies reported were not isolated to addressing the impact of large span of control and the impetus for implementing the strategies were a result of a number of factors.

The most frequently reported strategy was the redesign of the patient/client services organization structure (67%). This strategy was inherent in both the long-term-care and hospital sector. The next most frequently reported strategy was changing the model of care (33%) which was isolated to the hospital sector. The redesign of the manager role (25%) was reported in both the community and long-term-care sectors. Full scope of practice (17%) was identified in only the hospital sector. Some sample documents can be found in Appendix E.

Enablers and barriers were identified to support the strategies, with leadership education being cited by all three sectors as the most significant enabler. Other enablers included communication, staff education, technology, manager role clarity and a professional practice structure.

Only a few barriers were identified and included staff accountability, recruitment and manager supports.

Based on findings of the literature, survey and interviews the Hay Group has identified key recommendations they suggest/recommend organizations implement. These recommendations are grouped in the following categories:

• Defining span of control

• Leading practices to address span of control

• Measuring the impact of span of control

Defining Span of Control

A consistent definition of span of control is required for monitoring and measuring span of control. The OHA currently utilizes the definition of span of control as identified in the OHA-PricewaterhouseCoopers (PwC) Human Resources Benchmarking Survey. The Hay Group recommends that the OHA membership use this definition and that OHA take the lead in gaining consensus for a consistent definition of span of control that can be used across all three sectors.

Leading Practices to Address Span of Control

The three leading practices that are most important for organizations to address the negative impact associated with manager span of control include:

• Assessing manager span of control

• Clarifying the manager role(s)

• Assessing manager supports

Measuring the impact of Span of Control

The Hay Group recommends the following categories of metrics be used to monitor and measure the impact of manager span of control:

• Safety Metrics

• Satisfaction Metrics

• Human Resource Metrics

Further details of each of the leading practices and metrics can be found in section 6.0 of the report.

Specific recommendations were provided to further guide the OHA Strategic Human Resources Provincial Leadership Council and the OHA in next steps and are as follows:


RECOMMEnDAtiOnS:

It is recommended that:

(1) The OHA and its’ members use their current definition of span of control as identified in the OHA-PwC Human Resources Benchmarking Survey for the purposes of consistency of reporting.

(2) The OHA work collaboratively with leaders from the long- term-care and community care sectors to adopt the current OHA-PwC Human Resources Benchmarking Survey definition and/or develop a consensus definition of span of control that would allow for consistency of reporting across all three sectors.

(3) The OHA together with its members and using the results of the University of Western Ontario/Children’s Hospital of Eastern Ontario led span of control project determine criteria and a tool for assessing manager span of control.

(4) OHA members organizations define and clarify the role of the manager within their organization to minimally include:

• identifying leadership competencies,

• determining responsibilities and deliverables,

• ensuring managers have adequate authority to act, and

• describing how the manager role relates to other professional staff in delivering care.

(5) Organizations within the three health sectors, through existing data collection tools such as incident reporting system and the OHA-PwC Saratoga HR Benchmarking Survey, collect the following metrics to monitor and measure the impact of span of control:

• Safety Metrics

o Patient falls rate

o Medication error rate

o Infection control rate (from one of the commonly reported hospital acquired infection rates)


o Overall staff satisfaction rate

o Overall patient satisfaction rate


o Voluntary turnover rate

o Staff absenteeism rate

(6) The OHA communicate the results of the UWO/ CHEO span of control project to its’ members with regard to the relationship between clinical manager span of control and manager and unit work outcomes in Ontario academic hospitals as well as the reliability of The Ottawa Hospital span of control assessment tool.


2.0 Introduction

Over the past two decades, healthcare in Canada has experienced significant downsizing and reform. Many hospitals were required to make difficult decisions in order to manage their fiscal restraints while balancing patient care needs. Many organizations chose to flatten their organization structure and reduce managerial positions in order to retain the maximum number of caregivers possible43. As a result, there has been a reduction of 6,849 (29%)5, 20 nursing leadership positions in Canada since the 1990s.

This reduction in the number of managers has resulted, in many instances, in an increase in the remaining clinical managers’ span of control (SOC). One Ontario study that evaluated the impact of span of control on leadership and performance and included seven hospitals found that manager span of control ranged from 36-151 workers, with a median of 67 workers10.

In addition, the work environment of clinical managers is more complex with the implementation of new technologies, electronic documentation, “research, increased complexity of patient care, recruitment and retention of multidisciplinary healthcare staff and redesign of professional practice37.”

Over the past decade there have been a handful of Canadian studies related to span of control in the health care context (see Appendix B for the literature review). Some of these studies have identified elements to include in a definition of span of control; however there are no studies which identify what constitutes an appropriate span of control for a clinical manager.

There is some evidence which identifies methods to assess span of control and the impact of the relationship between the clinical manager’s span of control and staff, unit, and patient outcomes.

The 2002 final report of the Canadian Nursing Advisory Committee20 encouraged employers to examine and assess characteristics of reasonable and manageable span of control for clinical managers that allows them to complete assigned functions and be present to meet nurses’ and patients’ needs.

The membership of the Ontario Hospital Association (OHA), through the Strategic Human Resources Provincial Leadership Councili, has suggested there is a need for a practical summary of leading practices, successful strategies and tools to alleviate the impact of a clinical manager’s large span of control.

The Strategic Human Resources Provincial Leadership Council and the OHA have identified “researching span of control tools, guidelines and impacts for front-line managers” as one of its strategies in the OHA Provincial Health Human Resources Strategic Plan 2008-2011ii.

The OHA sought the assistance of Hay Group to conduct a study to identify key and practical leading practices, strategies or tools for employers to alleviate the negative impacts of large clinical manager span of control on the workforce and patients. The study includes health care organizations in Ontario from across the three health sectors; hospitals, community care, and long-term care.

i The OHA Strategic HR Provincial Leadership Council is one of seven leadership councils that report to the OHA Chief Executive Officer. Membership is made up of 12 hospital leaders (Chief Executive Officers, Chief Human Resource Officers, Chief Nursing Executives as well as a Community Care Access Centres, Local Health Integration Networks, Long-Term care, community college and university representative. ii For more information on the OHA’s Provincial Health HR Strategic Plan, go to www.oha.com under Services/Health Human Resources.


The objectives of the study were to:

• Summarize key findings from the existing literature related to span of control in health care;

• Identify the most critical leading practices/strategies that are feasible and affordable and provide guidance on the implementation of those practices for employers to reduce the negative impact of large spans of control on unit and patient outcomes through surveys and key informant interviews; and

• Provide recommendations on how the OHA and health care organizations can use existing metrics on span of control and unit outcomes to measure the impacts of span of control province-wide and within individual organizations.


With growing pressure on fiscal resources, many hospitals and health care organizations have undergone restructuring and have undertaken aggressive cost cutting initiatives and sought ways to decrease costs. One common cost reduction strategy has been the reduction of management positions across organizations.

This has resulted in decision making being decentralized with increasing demands being placed on management. The responsibility of unit managers has generally expanded to include the management of finances, operations, and human resources often across multiple clinical areas in a program management structure. Manager spans of control have increased, with many managers often responsible for more than one unit and significantly reduced time for staff mentorship, motivation, coaching and evaluation.

In this chapter, an overview of findings from the literature is presentediii. A more detailed account of findings is included in Appendix B.

3.1 Span of Control DefinedA scan of the literature reveals that definitions for span of control can be grouped into two broad categories:

total number of “workers” being supervised by a manager

Most typically, span of control has been defined as the number of people supervised by the manager i.e. the number of people assigned to a manager, not the number of full time equivalents (FTEs)38.

iii The following key words were used for an online search in Ovid Medline and a more general Google search: span of control, span of management, supervisory ration, and work group size. Key publications and seminal works were included.

total number of “FtEs” being supervised by a manager

The alternative definition proposes that span of control is measured by the number of FTEs under the jurisdiction of a manager14. Similarly, in Altaffer’s study2 of two complex health care organizations, the following definition was provided; “number of people supervised by a manager as measured by the total number of FTEs.”

OHA’s Working Definition of Span of Control

The OHA’s working definition of span of control is the “total number of workers reporting to a manager.” This definition is based on the Saratoga US Hospital metrics definitions which the OHA uses in its’ HR Benchmarking survey (see Appendix B – span of control defined).

3.1.1 Additional Considerations for Span of Control

Although in its simplest form, span of control refers to the number of employees or FTEs being supervised by a manager, the literature suggests that span of control is a more complex phenomenon. Generally, the literature suggests that three components be considered when identifying the appropriate span on control in an organization2,17,31,36,43:

• Frequency and intensity of the relationship between the manager and staff. This would require considerations of the number of interactions that a manager is required to have with staff to support the day to day performance of staff and functioning of the unit. This would also include consideration of the depth and quality of interaction i.e.: requirement for clinical teaching, mentorship etc.

3.0 Overview of Literature Findings


• Complexity of the work, capabilities of the manager: Complexity of work would require consideration of whether the work of the manager is routine, has a calm and predictable workflow, the level of automated processes etc.; capabilities of the manager would require consideration of experience, skill level, ability to delegate, leadership style, alignment with organization etc.

• Complexity of the work and capabilities of the staff. Complexity of work of staff would include routine versus complex work, degree of decision making in day to day job, level of independence etc., capabilities of staff would require consideration of level of experience, skill level, qualifications, morale, alignment with manager goals, familiarity with the organization etc.

Additional factors for consideration include:

• The combination of people, skills and variety of tasks that they perform

• Scopeofresponsibilityofthemanager(rangeofduties, size and number of units, number of sites etc.)

• Planningorganizational,budgetaryandleadership responsibilities

• Presenceofmanagerialsupportarecriticalfactors to be considered when evaluating a manager’s span of control

3.1.2 Ideal Span of Control

Span of control is a multidimensional concept that, as noted above, is influenced by many factors. An evaluation of the optimum number of staff that should report to managers requires a multifaceted evaluation of the work, worker, manager and the organization.

Although the literature does not provide a “formula” to calculate the number of direct reports in an optimal span of control, it should be noted, however, that span of control

theory34 proposes that there is a certain size at which span of control reaches its maximum capacity to be effective, and increasing beyond that capacity may in fact be harmful.

While classic organizational theory13 proposed that every 5-6 workers needed a first line supervisor, Del Bueno and Pabst suggest current management opinion is that a supervisor could manage between 100 and 200 individuals9,43. Indeed, the studies reviewed as part of the literature review and that provided information on span of control included managers with a broad range in the number of employees under their supervision.

3.2 Tools to Assess Manager Span of ControlAlthough a review of the literature confirms that span of control is a complex phenomenon, requiring consideration of many factors beyond the number of staff reporting to the manager, there is little information on how to assess manager span of control.

The development of the Michigan Leadership Model (2005)8 included an assessment matrix designed to assess the span of control or scope of work. Information gathered from this matrix was used to determine the level of clinical and administrative staff required to support the work of a manager. This matrix recognizes the complex role of nurse managers and includes factors in addition to the number of staff reporting to a manager. Key items included in the matrix are:

• Experience of the nurse manager

• Strength and stability of staff (including staff nurse years of experience)

• Morale/turnover and independence

• Current level of manager support


• Cooperation of ancillary departments

• Physician support

• Support from senior leadership

The Ottawa Hospital has developed span of control assessment tools for various leadership positions in the hospital. The Management Span on Control Assessment Tool, presented at the OHA’s Skill Mix: Work and Redesign Conference (December 2009) includes assessment in three broad categories which are further broken down into specific areas of focus (See Appendix B, Table 1). To determine the impact on manager span of control, each area of focus is rated as low, medium and high. Listed below are each of the three categories and areas of focus:

• Unit Focused:

o Complexity

o Material management

• Staff Focused:

o Volume of staff

o Skill level/autonomy of staff

o Staffing stability

o Diversity of staff

• Program Focused:

o Diversity

o Budget/Statistical

The Ottawa Hospital span of control assessment tool is currently being tested for reliability. The project is funded through the Ontario Ministry of Health and Long term Care Nursing Research Fund and sponsored by the Council of Academic Hospitals of Ontario. The OHA will communicate the results of the study upon project completed anticipated in late 2012.

3.3 Span of Control and Impact on Managers, Staff and PatientsA handful of health care specific studies have examined the impact of span of control on various managerial, staff and patient dimensions. Factors that are considered to be influenced by manager span of control include communication, employee morale, staff fulfillment, staff satisfaction and turnover rates as well as patient/staff safety and satisfaction. Although direct evidence of the impact of span of control on each of these dimensions is limited, there is a degree of consistency in the findings.

The research study being led by the University of Western Ontario and the Children’s Hospital of Eastern Ontario will examine the relationship between clinical manager span of control and manager/unit outcomes in 15 Ontario Academic Hospitals including:

• Staff absenteeism

• Staff turnover

• Overtime hours

• Work injury rates

• Patient satisfaction

3.3.1 Impact on Managers

Over the last several years, there have been increasing demands on individuals in management positions, with the role of unit managers expanding to include the management of finances, operations, human resources often across multiple clinical areas in a program management structure. Many managers spend a large amount of their day coordinating staffing issues, patient flow and working on committees8,32,37. As a result, not only do they feel increasingly overwhelmed48, but they consequently have little time left for staff development and quality improvement activities37,41 (see impact on staff and patients below). Doran et al.’s hallmark study10 of the impact of span of control and leadership and performance


concluded that it was “not humanly possible to consistently provide positive leadership to a very large number of staff while at the same time ensuring the effective and efficient operation of a large unit on a daily basis.”

3.3.1.1 Stress Levels and Burnout

With front line managers taking on increasing responsibility, more work and more employees, there are growing reports of managers being overwhelmed and experiencing high levels of stress and burn out. In a qualitative study of nurse managers, complexity, conflict and ambiguity were often identified as sources of stress. Large SOC was seen as adding complexity to nurse manager roles47,48. The findings are re-enforced in stress and coping literature related to the nurse manager role in the “post re-engineering” period46.

3.3.1.2 Communication between Managers and Workers

There is mixed evidence of the impact of large spans of control on communication. However, a review of the literature produces greater evidence of the negative impact of large span of control on communication. Larger spans of control impact communication patterns and inevitably impact the number of interactions that a manager must undertake43.

3.3.1.3 Management and Decision Making

Altaffer’s study2 that compared span of control of first line nurse managers (large spans of control) with first line non-nurse managers (smaller spans of control) found that in all dimensions except one measuring effectiveness, nurse managers were less likely to report that they were highly effective in fiscal management, negotiation and conflict management as well as change management.

In fact, studies have shown that even when managers possess the desired leadership style, their ability to influence positive outcomes may be impacted by their span of control10. Even highly emotionally intelligent managers may not be able to have an impact on staff

nurse empowerment due to large spans of control which invariably results in limited opportunities to engage with staff7,38.

Feldman’s study15 also supports the notion that clinical supervision is more effective when frontline supervisors have a narrower span of control) i.e. a smaller, more easily identifiable group of nurses whose care delivery must be monitored on a regular basis.

Organizations with large spans of control that effectively delegate responsibility to employees are often associated with managers feeling more fulfilled and rewarded17. On the other hand, multi-layered organizations, typically identified with smaller spans of control, are seen to have a significant (negative) impact on decision making. It is argued that when there are multiple levels in a chain of command, the likelihood that decisions and problems will be forced to a higher level is increased. As the number of layers increase, responsibility is “diluted and diffused” and ultimately, decisions are made in a vacuum, absent of context and at a distance from where they originated31.

3.3.1.4 Mentorship, Access and Visibility

Increasing demands and changing responsibilities of frontline managers has meant that mentorship and guidance traditionally provided to staff nurses is no longer available6. How much time a manager spends interacting with employees is dependent on other competing demands and the overall distribution of managerial resources36. Managers who are over extended and have overly wide spans may limit access to staff and the mentorship that managers wish to offer1.

Growing spans of control limit the attention, support, clinical supervision and feedback the manager can provide to an employee often with detrimental impacts.


3.3.2 Impact on Staff Performance

A study in the airline industry supports the notion that narrow spans of control improve performance through positive effects on group processes.

3.3.2.1 Staff Engagement & Empowerment

Several studies address the impact of large spans of control on employee engagement. Cathcart’s study7 found a fairly consistent decline in employee engagement scores as work group size increased. At two points in particular, employee engagement dropped considerably – when work group sizes grew larger than 15, and then again when work group sizes grew larger than 40.

Large spans of control are also thought to influence employee perceptions of empowerment7,29,38. As demonstrated in Lucas’ study29 of two Ontario community hospitals, while emotionally intelligent nurse managers were able to promote empowering work environment, span of control was a significant moderator of the relationship between nurses’ perceptions of their emotionally intelligent behaviors and feelings of workplace empowerment.

3.3.2.2 Staff Satisfaction & Retention

Smaller spans of control have consistently been linked to higher levels of staff satisfaction and higher rates of employee retention. While Doran’s study10 of seven Canadian teaching and community hospitals (51 units), did not find span of control to be a predictor of nurses’ job satisfaction, it did find that span of control decreases the positive effect of transactional and transformational leadership styles on nurses job satisfaction. The study also found empirical evidence that the wider the span of control, the higher unit turnover rate. The study reported a 1.6% increase in turnover for every increase of 10 in span of control.

3.3.2.3 Staff Safety

Hechanova’s study22 of span of control and safety performance in teams revealed that large spans of control resulted in less monitoring of safety by supervisors. The study concluded that span of control was positively correlated to unsafe behaviors and safety accidents.

3.3.3 Impact on Patients

3.3.3.1 Patient Satisfaction

Doran et. al’s study10 of Canadian hospitals, found that managers who had a large number of staff reporting to them had lower levels of patient satisfaction. Further, the researchers found that having a large span of control reduced the positive effect of positive leadership styles on patient satisfaction.

3.3.3.2 Patient Safety

Griffiths’ review16 of infection control literature concluded that excessive spans of control among clinical leaders were a risk for increased infection and infection control problems in hospitals. This finding is consistent with findings in other professions. Nurses who reported that reduced access to the support and resources from nurse managers limited their ability to provide high quality care19.

3.3.3.3 Strategies to Mitigate the Negative Impacts of Large Spans of Control

A review of the literature provides very few case examples of organizations that recognized the negative impacts of large spans of control, identified and implemented solutions and monitored outcomes.


• The development of a Management Infrastructure (Michigan Leadership Model) at the University of Michigan Health System (UMHS) was prompted by an analysis of organizational metrics and indicators that revealed that downsizing strategies (resulting in larger spans of controls) in the 1990s had negatively impacted employee satisfaction and the quality of nursing care. After a comprehensive review of current nurse manager responsibilities, members of the re-design team identified key elements of an ideal nurse manager role (ensuring quality of care, providing leadership, coaching and mentorship to staff, and managing operations). The team also identified the need for clinical infrastructure support and administrative/operations infrastructure support for responsibilities that were not identified as key elements and that could be easily delegated8. For detailed information on the outcome see Appendix B.

• Another strategy, implemented by Huntsville Hospital System in Alabama in response to a changing health care environment and larger spans of control was the implementation of a unit-based shared governance model on a Mother/Baby-GYN. By allowing staff nurses to have an active role in the decision-making process, the Hospital sought to increase staff participation, improved communication and increased job satisfaction. For more information on the outcome see Appendix B.

• At Fairview Health Services in Minneapolis, the organization responded to managers concerns about large spans of control. After studying the issue within their health care system, Fairview found a strong relationship between manager span of control and employee engagement. They subsequently added four nurse managers to observe the effects of smaller spans of control and realized positive improvement in employee engagement in all four areas7.

• There recent work by The Ottawa Hospital relative to span of control at is referenced only in the Morash article37. High level details regarding the Span of Control Assessment tool were presented at the OHA’s Skill Mix: Work and Redesign Conference in December 2009. For more information of the Span of Control Assessment Tool see Appendix B, Table 1. Specific strategies to mitigate the negative impact of large spans of control were not cited in either of these references.


In order to obtain a comprehensive understanding of Span of Control trends, challenges and leading practices of healthcare organizations in Ontario, stakeholder input was solicited through an online survey and via key stakeholder interviews. The process of survey development and distribution as well as overall findings from the survey is described below. Detailed tables of survey findings can be found in Appendix C and an analysis of stakeholder interview findings is presented in Section 5.0.

The Span of Control Survey was developed based on findings from the initial literature review. The survey was sent to:

• Chief Nursing Executives (CNEs) of Ontario Hospitals, with a request to forward the survey to front line managers;

• Executive Directors (EDs) of all 14 Community Care Access Centres with a request to forward the survey link to the Senior Director of Client Care who in turn would forward the survey link to the front line managers; and

• Directors of Care (DOCs) in Long-Term Care (LTC) Homes with a request to forward the survey link to front line managers. A representative sample of 51 LTC (large, small, for profit, not-for-profit, municipal etc.) distributed across the five OHA regions were utilized as the sample for long-term-care.

For the purposes of the survey distribution, managers were defined as: “those having Registered Nurses (RNs) or Registered Practical Nurses (RPNs) actively engaged in the practice of providing patient care reporting directly to them, and may as well have direct reports who are not RNs or RPNs.”

As noted earlier, the literature revealed two broad definitions of span of control: 1) the total number of “workers” being supervised by a manager and 2) the total number of “FTEs” being supervised by a manager.

For the purposes of the survey, span of control was defined as “the number of people supervised by a manager.”

As noted in the earlier chapter, the literature review revealed that span of control is a complex phenomenon that requires, among other things, consideration of the:

• Number of people reporting to a manager

• Combination of people, skills and variety of tasks that they perform

• Scope of responsibility (including duties, size and number of units, number of sites)

• Frequency of interaction with staff

• Planning and budgetary responsibilities

• Managerial supports

The first few sections of the survey including the manager’s demographic profile and staff profile were developed to gain an understanding of the current state analysis of the various factors contributing to Ontario manager’s span of control. Given the complexity of factors that influence span of control, the survey did not define “wide” and “narrow” span of control; instead, managers were asked to identify the scope of their span of control based on their own impressions. Characteristics of managers who reported a “wide” span of control are described in section 4.3.

The literature review also revealed a handful of studies that have examined the impact of span of control on various managerial, staff and patient safety. Factors that are considered to be influenced by manager span of control include communication, employee morale, staff fulfillment, staff turnover rates as well as patient and staff safety and satisfaction.

Based on the findings from the literature, the online survey was structured to capture the impact of span on the following nine dimensions:

4.0 Span of Control Survey






5. Impact on staff injury rates





In the sections that follow, findings from the survey, including the overall response rates, organizational and manager profile and a profile of the staff being supervised are described. The impact of the span of control on each of the nine dimensions identified above, as well as strategies that have been implemented by organizations and their relative impact are described in detail in the sections below.

All findings are presented on a sector specific level to provide meaningful opportunity for analysis and to ensure that the responses from the hospital sector (that accounted for the most individual responses) did not artificially skew findings. Findings for the manager and staff profile as well as span of control impact on nine dimensions are presented for managers who reported “narrow” and “wide” span of control. An explanatory note precedes the exhibits presented in each of the sections.

Note of caution: The results for the LTC homes that are presented as “narrow” versus “wide” span of control should be interpreted with caution given the small number of LTC managers who reported that they had a narrow span of control (n=3).

4.1 Response RatesGiven that initial communication regarding participation in the OHA’s Span of control surveys was sent to CNOs, EDs and DOCs, with a request to forward the survey link to appropriate managers, the total number of managers that the survey was ultimately sent to is not known. As such, it is not possible to determine the manager response rate. Based on survey results, however, it was possible to determine the response rate by sector. The highest response rate was for CCACs with 79% of CCACs who received this survey submitting at least one response to the survey, followed by 75% of hospitals submitting at least one response. The lowest participation rate was from the LTC sector. It should be noted that during the survey period, the LTC sector was highly involved with other activities such as implementation of new requirements of the Long-Term Care Act.

Although the CCAC sector had the highest response rate, given the large number of hospitals to which the survey was sent, and the total number of individuals responding to the survey, hospital managers accounted for the largest number of responses to the survey (86%).

It should be noted that although 733 respondents started the survey, not all individuals completed the survey. For each of the tables presented in the survey, the percentage calculation is based on the actual number of individuals responding to the survey question (shown as “Total n” in each table) and not on the number of individuals who started the survey.

Exhibit 1: Survey Response Rates

Responses by Sector

Sector total “n”

Sector

Response

Rate

% of Survey

Respondents

Community Care Access

Centre73 79% 10%

Hospital (including

Complex Continuing

Care and Rehab)

627 75% 86%

Long term Care Home 33 37% 5%


Managers in the hospital sector were also asked to provide information on the types of unit(s)/service(s) that they were responsible for. As demonstrated in Exhibit 2, the top 3 services that hospital managers responding to the survey had accountability for were: Ambulatory units (22%), medicine units (17%) and emergency departments (16%). 21% of respondents were responsible for hospital units/services not presented in the options below.

Exhibit 2: Units/Areas Supervised by Hospital Managers

Hospital Managers - Areas Supervised

Areas Supervised total “n”% of

Respondents

Ambulatory 128 22%

Cancer Care 54 9%

Complex Continuing Care 87 15%

Critical Care 81 14%

Emergency Department 94 16%

Medicine 101 17%

Medicine/Surgery 55 9%

Mental Health 78 13%

Peri-operative Services (all OR

related services including day surgery)72 12%

Rehabilitation/therapies 73 12%

Surgery 75 13%

Women’s and Children’s 59 10%

Other Hospital Unit 121 21%

total Managers Responding to

Question585 nA*

*note: this question allowed respondents to select multiple responses. As such the total “n”s and percentages is greater than the number of unique individuals responding to the survey questions. Percentage calculations for this question were made accordingly.

4.2 Organizational CultureSurvey respondents were asked to describe their organization’s culture based on four culture types identified in Duxbury, Higgins and Lyons recent article12. Respondents from Long-Term Care Homes were most likely to agree or strongly agree that their organizations supported each of the cultures identified in the study:

• Cohesive culture: Experienced leaders who have a clear sense of direction and vision for the future and who are accessible to employees. There is a culture of respect in the organization and a sense of trust between managers and staff. There is high morale in the organization.

• Culture of appreciation and respect: The organization fosters a positive attitude and celebrates successes; mistakes are seen as an opportunity to learn. The workplace is safe and secure and there is sufficient time for training and development. People are appreciated.

• Culture of teamwork: People work as a team and work is fairly distributed. There is good and ongoing communication in the team.

• Balanced work life culture: There is recognition that employees have personal commitments outside of work and employees who leave on time or do not take extra shifts are not made to feel guilty.

48% of LTC respondents reported that their organization espoused the characteristics of all four cultures above, compared to 38% of hospital respondents and 29% of CCAC respondents. A breakdown of responses for each culture type is provided in Appendix C, exhibits 22-25.

Exhibit 3: Percentage of Respondents Reporting all Four Cultures in their Organization

Cohesive Culture, Culture of Appreciation and Respect, teamwork and

Balanced Worklife by Sector

Sector total “n”% Agree or

Strongly Agree

Community Care Access Centre 66 29%

Hospital (including Complex

Continuing Care and Rehab)563 38%

Long term Care Home 29 48%

Authors of this study were interested in whether these findings varied by span of control reported by managers. Responses from the hospital sector were consistent for managers who reported narrow or wide span of control. For LTC homes, managers who reported wide span of control


were less likely to report agreement in all four culture dimensions, whereas for the CCAC sector, the opposite was true. As mentioned in the introductory notes, given the small “n”, caution should be used when interpreting findings for LTC narrow versus wide span of control.

It should be noted that not all individuals who responded to the culture question (earlier in the survey) responded to the span of control question, so the total “n”s for the question when categorized by narrow and wide span of control do not total the numbers in the earlier exhibits.

Exhibit 4: Percentage of Respondents Reporting all Four Cultures by “narrow” Span of Control

Cohesive Culture, Culture of Appreciation and Respect, teamwork

and Balanced Worklife for Managers Reporting a “narrow” Span of

Control by Sector


Strongly Agree





Exhibit 5: Percentage of Respondents Reporting all Four Cultures by “Wide” Span of Control

Cohesive Culture, Culture of Appreciation and Respect, teamwork

and Balanced Worklife for Managers Reporting a “Wide” Span of

Control by Sector


Strongly Agree





Responses for hospital managers reporting “wide” span of control were further analyzed to determine if responses varied by the number of staff reporting to managers with wide spans of control. No material differences were noted in the following cultural dimensions: culture of teamwork, culture of appreciation and respect and cohesive culture. In the cultural aspect related to balanced work life, managers with wide spans of control who had greater than 100 employees were less likely to report a culture of balanced work life.

Similar analysis for CCAC and LTC managers reporting a wide span of control was not undertaken, given the small “n”s when categorized at this level.

4.3 Manager ProfileManagers were asked to identify whether they had narrow or wide span of control. As stated earlier, narrow and wide span of control were not defined in the survey; managers responded to this question based on their own perceptions of their span of control. Managers of LTC homes were most likely to report a wide span of control (90%), followed by hospital managers at 73% and CCAC managers at 65%.

Exhibit 6: Percentage of Respondents Reporting narrow and Wide Spans of Control

Reported Span of Control by Sector

Sector total “n”narrow Span of

Control

Wide Span

of Control


Centre63 35% 65%

Hospital (including

Complex Continuing Care

and Rehab)

524 27% 73%

Long term Care Home 29 10% 90%

As seen on the next page, the number of staff supervised by managers varied greatly by sector; Exhibits 26 & 27 in Appendix C provides the breakdown of this information by managers reporting narrow and wide spans of control.


4.3.1 Characteristics of Managers with Wide Span of Control

As stated previously, while many factors are considered to influence a manager’s span of control, a review of the literature did not provide a set definition of what constituted narrow and wide spans of control. Based on the responses provided by managers, those who reported a wide span of control were more likely to have:

• Greater than 80 staff members reporting to them (39% compared to 15% for managers reporting a narrow span of control)

• Responsibility for three or more units (62% compared to 29% for managers reporting a narrow span of control)

• Budgetary responsibility (94% compared to 79% for managers reporting a narrow span of control)

• Budgets exceeding $7 million (41% compared to 15% for managers reporting a narrow span of control)

Detailed survey results on number of staff reporting to managers, number of units/service per manager, budgetary size and responsibility can be found in Appendix C, exhibits 26-31.

4.3.2 Manager Background and Education

There was no material difference in the respondent background for managers who reported narrow and wide span of control. Over 80% of CCAC and hospital respondents had a nursing background; and 100% of LTC managers had a nursing background (See Appendix C, exhibit 32).

In addition, managers who reported a wide span of control had a higher percentage of Master’s/PhD completion for all three sectors (34% of compared to 26% of managers who reported a narrow span of control.) See Appendix C, exhibit 33.

Managers were also asked if they had received any leadership education (e.g. facilitation, negotiation, coaching, mentoring, emotional intelligence etc.) and/or management/operations education (e.g. finance/budgeting, human resources etc.). Although over 85% of CCAC managers had received leadership education, managers who reported a wide span of control were more likely to have received both leadership and management/operations education. No real differences were noted in hospital respondents.

Exhibit 7: number of Staff Reporting to Managers

number of Staff Reporting to Managers

Sector total “n” Less than 40 40 - 60 61 - 80 81 - 100 101 - 125 126-150 Greater than 150

Community Care Access Centre 59 83% 15% 2% 0% 0% 0% 0%

Hospital (including Complex Continuing

Care and Rehab)509 24% 22% 19% 15% 11% 6% 4%

Long term Care Home 28 25% 7% 25% 7% 4% 21% 11%

Grand total 596 30% 20% 17% 13% 9% 6% 4%


4.3.3 Years in Management

For all three sectors, managers who reported a wide span of control were more likely to have over five years in management experience compared to colleagues who reported a narrow span of control; 71% compared to 36% in CCACs, 65% compared to 17% in hospitals and 46% compared to 0% in LTC homes (See Appendix C, exhibit 34).

4.3.4 Multi-site Responsibility

CCAC managers who reported a wide span of control were more likely to report multisite responsibility compared to those that reported narrow span of control (90% compared to 68%). There were no real differences in multi-site responsibility for hospital respondents.

Note: High percentage for LTC managers with narrow span of control is not as material given the small number of respondents in this category (n=3).

Exhibit 9: Percentage of Respondents Reporting Multi-site Responsibility

Multi-Site Responsibilty by Sector

Sectornarrow Span of Control Wide Span of Control

total “n” % “yes” total “n” % “yes”

Community Care

Access Centre

22 68% 41 90%

Hospital (including

Complex

Continuing Care

and Rehab)

143 21% 381 28%

Long term Care

Home

3 67% 26 23%

Exhibit 8: Leadership and Management Education of Managers

Leadership/Management Education in the Last two Years by Sector

Sector

narrow Span of Control Wide Span of Control

total “n”Leadership

Education

Management/

Operations

Education

BOtH

Leadership and

Management/

Operations

Education

total “n”Leadership

Education

Management/

Operations

Education

BOtH

Leadership and

Management/

Operations

Education


Centre

22 86% 50% 50% 41 88% 71% 68%

Hospital (including

Complex Continuing

Care and Rehab)

143 76% 57% 50% 381 79% 59% 52%

Long term Care Home 3 67% 67% 67% 26 62% 46% 31%


4.3.5 Manager Supports

The survey findings did not reveal any material differences in the manager supports present for managers who reported a narrow or wide span of control. The only exception to this category in CCACs and hospitals was the presence of educators (See Appendix c, exhibits 35-36).

Managers were also asked “what supports would you find most helpful to manage your span of control?” Responses received were grouped into three broad categories: administrative, clinical and other.

By far, the most frequently reported desired support was that of administrative/clerical/secretarial support with 52% of hospital managers, 40% of LTC managers and 37% of CCAC managers reporting this as the most helpful support to manage their span of control. Managers also requested support in the more operational tasks of budgeting, the use of data to support decision making and HR support for attendance management etc.

From a clinical perspective, managers expressed a desire for increased advanced practice nurse roles as well as clinical leader roles to support them in their day-to-day activities. Many managers specifically noted the need for clinical leader positions to be filled by “non-union” staff.

Managers also noted other supports such as management and operations training, mentorship and coaching, support in policy and procedure/best practice reviews and improved technologies to support their work.

Listed in exhibit 10 is a more comprehensive list of supports that were identified by managers:

Exhibit 10: Supports Most Useful to Managers to Manage Span of Control

types of Supports Most Useful to

Manage Span of Control

CCAC Hospital LtC

n= 30 n= 335 n= 15

Administrative

Secretarial/Clerical/Administrative

Supports37% 52% 40%

Data Manager/Decision Support/

Quality Management13% 1% 0%

Scheduling Support 0% 2% 0%

HR Support 7% 4% 13%

Occupational Health Support 0% 1% 0%

Financial/Business Analyst Support 13% 4% 0%

Material Management Coordinators 0% 1% 0%

Senior Management Support

(Directors, Regional Managers etc.)7% 2% 0%

Assistant Managers, Supervisors,

Additional Managers17% 5% 13%

Clinical

APn Roles 10% 26% 40%

Advanced Practice nurse 3% 5% 13%

Clinical nurse Specialist 0% 1% 0%

nurse Practitioner 0% 0% 0%

nurse Educator 7% 20% 27%

Care Leaders 17% 16% 73%

team Leader 10% 2% 0%

Clinical Care Coordinator 7% 14% 73%

Patient Flow/Patient Care Facilitator 0% 1% 0%

Consistent Charge nurse 0% 13% 13%

Professional Practice Leaders 3% 5% 0%

increase Allied Staff Support 0% 1% 0%

increase Front Line Staff 0% 0% 0%

Other

technology Enablers 0% 3% 0%

Management/Operations training 7% 1% 0%

Mentorship and Coaching 3% 0% 0%

Regular Policy and Procedure Review/

Best Practice Review3% 1% 0%


4.4 Staff Profile4.4.1 Number of Staff in a Single Workday/Shift and Frequency of Contact with Staff

Managers who reported wide span of control were three times more likely to have responsibility for more than 41 staff in a single workday/shift (21% compared to 7% for managers who reported a narrow span of control.) This trend was particularly apparent in the CCAC and hospital sector (See Appendix C, exhibits 37-38).

As would be expected, CCAC and LTC managers reporting wide span of control were less likely to have multiple contacts with their staff in a single workday; interestingly no difference was reported by managers in the hospital sector (See Appendix C, exhibits 39-40).

These results are consistent with the literature review that found that the amount of time a manager spends interacting with employees is dependent on other competing demands and the overall distribution of managerial resources36. Managers who are over extended and have overly wide spans may limit access to staff and the mentorship that managers wish to offer1.

4.4.2 Skill/Autonomy and Union Status of Staff

CCAC and LTC home managers who reported a wide span of control had higher percentages of highly skilled/specialized and autonomous staff compared to colleagues who reported a narrow span of control; no real differences were noted for managers in the hospital sector. CCAC managers reporting wide span of control also had a much smaller percentage of unionized staff compared to CCAC managers who reported a narrow span of control (See Appendix C, exhibits 41-42).

4.4.3 Types of Staff

While the percentages of regulated, registered nursing staff were similar for managers reporting narrow and wide spans of control across all three sectors, managers in the hospital sector reporting a wide span of control reported higher percentages of unregulated care providers, allied health professions and administrative/facility staff reporting to them as well.

These results are consistent with the literature review that found wide spans of control are more commonly found in flat structures and associated with managers supervising units in which the employees perform routine tasks with little variation27, or when managers are supervising highly skilled or specialized staff who have extensive knowledge of the work and require less supervision35 (See Appendix C, exhibits 43-44).

There was slight variation in managers with narrow/wide span of control reporting that their professional staff worked to full scope of practice (See Appendix C, exhibit 45).

4.5 Span of Control Impact on Specific DimensionsA handful of healthcare specific studies have examined the impact of span of control on various managerial, staff and patient dimensions. Factors that are considered to be influenced by manager span of control include communication, employee morale, staff fulfillment, staff satisfaction and turnover rates, in addition to patient/staff safety and satisfaction. Although direct evidence of the impact of span of control on each of these dimensions is limited, there is a degree of consistency in the findings.


The online survey to Ontario managers explored the experience of Ontario managers in each of these categories. Managers were asked to provide feedback on the following:

• The impact of their span of control on each dimension

• Whether or not they had implemented specific initiatives to alleviate the impact that their span of control had on each of these dimensions

• The length of time the initiatives had been in place (if applicable)

• The impact that the initiative had had on each dimension

• A list of the initiatives that had been implemented

In the sections that follow, information is provided on the perceived impact of a manager’s span of control on each dimension, whether or not initiatives had been implemented, the relative time that an initiative had been in place and the perceived impact that the initiative had on each dimension. For each sector, the time period during which the greatest positive impact of these initiatives was felt and a corresponding “menu” of initiatives provided by managers was determined. The percentage of managers citing each initiative has been provided. Given that these were free text comments, it is possible that managers may not have thought of a particular initiative at the time of survey completion and as such, the percentages under represent the number of managers who have implemented these initiatives; a pre-set multiple choice listing may have avoided this issue.

While many of the initiatives directly relate to the manager’s span of control and impact on a specific dimension, some of the initiatives provided by the managers appear to be more general in nature. These initiatives are also included

in the lists provided. Additionally, it should be noted that while a list of initiatives is provided in table form, the Hay Group has identified initiatives that they believe are the most relevant to span of control.

A summary of the overall findings of the impact of these dimensions on span of control and initiatives that have been implemented to mitigate their impact is presented below. It should be noted that the total “n” within each dimension may vary; not all respondents completed all questions within each dimension.

Exhibit 11: Managers Reporting negative or Very negative impact of Span Of Control on nine Dimensions

Percentage of Managers Reporting Span of Control has a negative or

Very negative impact on Specific Dimensions

Dimension/Sector

Community

Care Access

Centre

Hospital

(including

Complex

Continuing

Care and

Rehab)

Long term

Care

Home

Grand

total

Effectiveness and/

or Frequency of

Communication

18% 31% 12% 29%

Manager

Accessibility to

Staff

24% 35% 29% 33%

Staff Retention 13% 10% 4% 10%

Staff Attendance

(Levels of

Absenteeism)

11% 19% 17% 18%

Staff injury Rates 4% 3% 13% 4%

Staff Engagement 15% 23% 5% 21%

Staff Satisfaction 16% 21% 5% 19%

Client/Patient/

Resident Safety2% 8% 9% 8%

Client/Patient/

Resident

Satisfaction

5% 7% 9% 7%


Exhibit 12: Percentage of Managers who have implemented Strategies to Alleviate Span of Control impact on nine Dimensions

Percentage of Managers who have implemented Strategies to Alleviate

SOC impact on Specific Dimensions

Dimension/Sector

Community

Care Access

Centre

Hospital

(including

Complex

Continuing

Care and

Rehab)

Long term

Care

Home

Grand

total

Effectiveness and/

or Frequency of

Communication

77% 75% 88% 76%

Manager

Accessibility to

Staff

52% 43% 67% 45%

Staff Retention 40% 55% 67% 54%

Staff Attendance

(Levels of

Absenteeism)

66% 78% 78% 77%

Staff injury Rates 61% 78% 87% 77%

Staff Engagement 72% 66% 77% 67%

Staff Satisfaction 50% 60% 73% 59%

Client/Patient/

Resident Safety69% 86% 91% 85%

Client/Patient/

Resident

Satisfaction

85% 68% 86% 70%

4.5.1 Impact on Communication

Managers in hospitals and LTC homes reporting a wide span of control were more likely to report a negative or very negative impact of their span of control on communication. This was especially true for managers in the hospital sector (40% compared to 9% of managers reporting a narrow span of control.) See Appendix C, exhibit 46.

There is mixed evidence of the impact of large spans of control on communication. However, a review of the literature produces greater evidence of the negative impact of large span of control on communication. The findings from the survey add to literature findings that demonstrate a negative impact of wide span of control on communication.

The majority of respondents to this question reported that they had implemented initiatives to alleviate the impact that their span of control had on communication. Over 85% of respondents who stated that they had implemented initiatives reported a positive or very positive impact. The greatest positive response to these initiatives was when the initiative had been in place for greater than two years in hospitals and LTC homes and between one and two years in CCACs. (See Appendix C, exhibits 47-48).

Initiatives implemented by managers and/or their organizations are provided in exhibit 12 below. While some of these initiatives to improve communication may be directly related to span of control, other initiatives appear to be broader in nature and may have been developed for other specific purposes. A summary of leading practices is provided in section 6.2.


Exhibit 13: initiatives Related to Enhancing the Effectiveness and Frequency of Communication

Span of Control impact on Communication

Menu of initiativesCCAC Hospital LtC

n= 11 n= 127 n= 12

Regular staff meetings 55% 61% 42%

Email updates 0% 37% 17%

Administrative walkabouts/rounding 18% 25% 0%

Communication binders, bulletin

boards, posters0% 22% 33%

Manager Visibility/Access (incl. open

door policy)0% 17% 42%

Online communication (WebPages/

shared drives)45% 13% 0%

newsletters 9% 13% 0%

team Huddles/Bullet Rounds 0% 12% 17%

interprofessional/professional practice/

nursing council meetings0% 12% 8%

Staff forums/town halls 9% 9% 25%

Phone/Blackberries, tele/Video

conferencing9% 8% 8%

Ad-hoc Staff/individual meetings 0% 7% 8%

involvement in committees/goal setting 0% 7% 0%

Admission, transfer, shift reports 0% 5% 8%

Staff educational opportunities 0% 5% 0%

Charge nurse meeting/consistent

charge nurse0% 5% 0%

Performance Appraisals 9% 4% 0%

Appreciation/recognition/team building

days & events0% 3% 0%

Organizational/program action plan

updates0% 2% 8%

Management/union meetings 0% 2% 17%

Consistent charge/resource nurse 0% 0% 0% Length of time initiative has been in place - largest positive response: CCAC: 1 -2 years Hospitals: 2 + years LtC: 2 + years

It can be assumed that a manager’s ability to successfully implement the following initiatives would be directly impacted by their span of control:

• Regular staff meetings

• Manager walkabouts/rounding



• Ad-hoc staff/individual meetings

• Staff involvement in committees/goal setting

• Performance Appraisals

• Management/union meetings

4.5.2 Impact on Access to Manager by Staff

Managers in CCACs and hospitals reporting a wide span of control were more likely to report a negative or very negative impact of their span of control on the manager’s ability to be accessible to staff. CCAC managers with large spans of control were twice as likely and hospital managers were four times more likely to report a negative impact than those that reported a narrow span of control (See Appendix C, exhibit 49).

As documented in the literature, many managers spend a large amount of their day coordinating staffing issues, patient flow and working on committees etc. and as such, managers who are over extended or have overly wide spans may only provide limited access and mentorship to staff. Growing spans of control limit the attention, support, clinical supervision and feedback that a manager can provide to an employee often with detrimental impacts.


Approximately half of respondents to this question reported that they had implemented initiatives to alleviate the impact that their span of control had on the manager’s ability to be accessible to staff. Over 75% of respondents who stated that they had implemented initiatives reported a positive or very positive impact of the initiative. Across all sectors, the greatest positive response to these initiatives was when the initiative had been in place for greater than two years. (See Appendix C, exhibits 50-51).

Exhibit 14: initiatives Related to Enhancing Manager Access to Staff

Span of Control impact on Access

Menu of initiatives CCAC Hospital LtC

n= 7 n= 72 n= 9

Use of email, other it (blackberry,

phone etc.)86% 49% 89%

Manager access and availability

(including open door policy, office

proximity, daily interaction, work

hours)

43% 44% 89%

Manager rounds 0% 29% 22%

Staff meetings, town halls 0% 26% 0%

Decrease manager span of control

(number of units, people, reduce

multisite responsibility)

0% 11% 0%

Performance appraisal, individuals

meetings0% 6% 0%

Revaluate manager involvement in

non-unit meetings and workload0% 4% 0%

Managerial supports (secretarial,

charge nurse etc.)0% 3% 0%

Length of time initiative has been in place - largest positive response: CCAC: 2 + years Hospitals: 2 + years LtC: 2 + years

4.5.3 Impact on Staff Retention

Interestingly, only hospital managers reporting a wide span of control were more likely to report a negative or very negative impact of their span of control on staff retention (See Appendix C, exhibit 52).

Smaller spans of control have consistently been linked to higher rates of employee retention, with at least one Canadian study10 providing empirical evidence that the wider the span of control, the higher unit turnover rate. The study reported a 1.6% increase in turnover for every increase of 10 in span of control.

A smaller sample of respondents to this question reported that they had implemented initiatives to alleviate the impact that their span of control had on staff retention (40% of CCAC managers, 55% of hospital managers and 67% of LTC home managers). However, for those that had implemented initiatives, over 80% reported that they had had a positive or very positive impact (94% for LTC respondents). The greatest positive response to these initiatives was when the initiative had been in place for greater than two years in hospitals and LTC homes and between one and two years in CCACs (See Appendix C, exhibits 52-53).

Initiatives implemented by managers and/or their organizations are provided in exhibit 15 on the next page.


Exhibit 15: initiatives Related to Enhancing Staff Retention

Span of Control impact on Staff Retention


n= 9 n= 108 n= 12

Educational opportunities 0% 42% 8%

Manager flexibility (scheduling, work

hours etc.)11% 21% 33%

Work life balance, wellness activities,

EAP, OD initiatives0% 20% 8%

Staff appreciation/recognition 44% 19% 33%

new grad/late career initiatives 0% 15% 0%

Culture of safety, respect, code of

conduct0% 11% 0%

Staff involvement in decision making, unit

councils etc.33% 11% 0%

Positive feedback, staff empowerment,

leadership opportunities0% 9% 8%

Orientation, preceptorship, education 11% 9% 0%

Staff surveys and feedback 0% 6% 0%

Manager approachability, accessibility,

communication (including open door

policy)

11% 5% 42%

team building activities 0% 4% 0%

Encourage staff movement within

organization0% 3% 0%

Manageable span of control 0% 2% 0%

Safe working environment, standards of

care0% 2% 0%

implementing changes suggested

through surveys etc.0% 2% 0%

Performance/Attendance management 22% 2% 0%

Student placements 0% 2% 0% Length of time initiative has been in place - largest positive response: CCAC: 1 - 2 years Hospitals: 2 + years LtC: 2 + years

It is likely that a manager’s ability to successfully implement the following initiatives may be directly impacted by their span of control:

• Manager flexibility (scheduling, work hours etc.)

• Staff involvement in decision making/unit councils etc.

• Manager approachability, access, communication

• Implementing changes suggested through surveys

• Performance/attendance management

4.5.4 Impact on Staff Attendance/Absenteeism

Managers in hospitals and LTC homes reporting a wide span of control were more likely to report a negative or very negative impact of their span of control on staff attendance/absenteeism (See Appendix C, exhibit 55).

Over two thirds of respondents to this question reported that they had implemented initiatives to alleviate the impact that their span of control had on staff absenteeism. This percentage was higher in hospitals and LTC homes (78%). There was great variation in the success of these initiatives reported by respondents with a low of 54% in the hospital sector reporting a positive or very positive impact to a high of 83% in the LTC sector reporting a positive or very positive impact. The greatest positive response to these initiatives was when the initiative had been in place for greater than two years in Hospitals and LTC homes and between one and two years in CCACs (See Appendix C, exhibits 56-57).

Initiatives implemented by managers and/or their organizations are provided on the next page.


Exhibit 16: initiatives Related to Enhancing Staff Attendance/Reducing Absenteeism

Span of Control impact on Staff Absenteeism


n= 13 n= 113 n= 8

Attendance management policies and

awareness programs92% 84% 75%

Work life balance, wellness initiatives,

EAP, Return to work support0% 12% 0%

Support from HR, occupational health 0% 11% 0%

incentives and recognition 0% 7% 38%

Sharing of data 15% 4% 0%

third party adjudication/review 0% 3% 0%

Manager flexibility and open

communication0% 3% 0%

Span of Control impacts ability to

follow up with attendance mangement0% 2% 0%

Performance management 0% 2% 0%

Length of time initiative has been in place - largest positive response: CCAC: 1-2 years Hospitals: 2 + years LtC: 2 + years It is likely that a manager’s ability to successfully implement the following initiatives may be directly impacted by their span of control:

• Sharing of data

• Manager flexibility and open communication

• Performance management

• Ability to follow up on staff attendance issues

4.5.5 Impact on Staff Injury Rates

Interestingly, there was no material difference in staff injury rates reported by managers. This finding differs from studies that have found that span of control was positively correlated to unsafe behaviors and safety accidents22 (See Appendix C, exhibit 58).

Two thirds of respondents to this question reported that they had implemented initiatives to alleviate the impact that their span of control had on staff injury rates although this percentage was higher in hospitals (78%) and LTC homes (87%). 80% of respondents who stated that they had implemented initiatives reported a positive or very positive impact. Across all sectors, the greatest positive response to these initiatives was when the initiative had been in place for greater than two years (See Appendix C, exhibits 59-60).

Initiatives implemented by managers and/or their organizations are provided below.

Exhibit 17: initiatives Related to Reducing Staff injury

Span of Control impact on Staff injury


n= 10 n= 171 n= 12

Supportive safety equipment,

ergonomic assessments and training30% 36% 17%

Health/Safety education and training 30% 36% 83%

Staff engagement in problem solving,

safety groups, taskforces0% 15% 0%

Environmental evaluations and

inspections30% 14% 25%

incident reporting process and follow up 20% 12% 8%

Process for follow-up and ownership 0% 8% 8%

Leadership walkarounds 0% 8% 0%

Occupational health support 10% 7% 8%

Safety culture/programs 0% 5% 0%

Physio and Ot involvement with staff 0% 4% 0%

Return to work programs, work

modification0% 2% 0%

Appropriate staffing 0% 1% 0%

Health and safety committee/reps,

meetings60% 0% 33%

Length of time initiative has been in place - largest positive response: CCAC: 2+ years Hospitals: 2 + years LtC: 2 + years



• Supportive equipment

• Incident follow up

• Leadership/manager walkabouts

• Staff engagement in problem solving etc.

4.5.6 Impact on Staff Engagement

Across all sectors, managers who reported a wide span of control were more likely to report a negative or very negative impact of their span of control on staff engagement. This was especially true for managers in the hospital sector (29% compared to 7% of managers reporting a narrow span of control.) See Appendix C, exhibit 61.

These results are consistent with findings from the literature7, that have found a fairly consistent decline in employee engagement scores as work group size increase. Closely linked is the impact of employee perceptions of empowerment, which are inversely related to span of control. Several of the initiatives reported by managers in the survey support the notion that employee engagement and empowerment through various activities can have a positive impact.

Over two thirds of respondents to this question reported that they had implemented initiatives to alleviate the impact that their span of control had on staff engagement. Over 80% of respondents who stated that they had implemented initiatives reported a positive or very positive impact with higher success noted by CCAC and LTC managers. The greatest positive response to these initiatives was when the initiative had been in place for greater than two years in hospitals and LTC homes and for both one and two years and greater than two years in CCACs (See Appendix C, exhibits 62-63).


Exhibit 18: initiatives Related to Enhancing Staff Engagement

Span of Control impact on Staff Engagement


n= 24 n= 124 n= 10

interprofessional committees and

projects, partnership councils17% 40% 20%

Opportunity for staff input, staff

involvement46% 27% 70%

Staff surveys 8% 16% 20%

Education and training opportunities 0% 14% 20%

Regular meetings and town halls 33% 13% 50%

Staff recognition/appreciation;

celebration of successes4% 13% 0%

Communication and contact with

manager0% 10% 20%

increased use of it/communication

tools25% 8% 0%

Patient safety rounds, safety triads 0% 7% 0%

Staff involvement in lean/process

improvement activities0% 7% 0%

Planning days, team building activities 0% 6% 0%

Engagement opportunities with senior

leadership0% 5% 0%

informal leadership opportunities/staff

champions0% 4% 10%

Social activities 8% 4% 0%

Manager access (including open door

policy)0% 3% 20%

Performance appraisals 0% 1% 0%

Length of time initiative has been in place - largest positive response: CCAC: 1-2 years, 2+ years Hospitals: 2 + years LtC: 2 + years



• Opportunity for staff input and involvement in lean processes

• Education and training opportunities

• Regular staff meetings/town halls

• Staff recognition/appreciation; celebration of successes

• Communication and contact with manager

• Manager access


4.5.7 Impact of Staff Satisfaction

Managers in hospitals and LTC homes reporting a wide span of control were more likely to report a negative or very negative impact of their span of control on staff satisfaction (See Appendix C, exhibit 64).

These results validate literature that smaller spans of control are consistently linked to higher levels of staff satisfaction. In addition, large spans have been noted to decreases the positive effect of transactional and transformational leadership styles on nurse’s job satisfaction10.

Fewer respondents to this question reported that they had implemented initiatives to alleviate the impact that their span of control had on staff satisfaction. There was broad variation in responses ranging from 50% in CCACs to 73% in LTC homes. However, for those that stated initiatives had been implemented, over 80% of respondents stated that they had a positive or very positive impact. Across all sectors, the greatest positive response to these initiatives was when the initiative had been in place for greater than two years (See Appendix C, exhibits 65-66).

Initiatives implemented by managers and/or their organizations are provided in exhibit 19 below.

Exhibit 19: initiatives Related to improving Staff Satisfaction

Span of Control impact on Staff Satisfaction


n= 13 n= 118 n= 6

Staff satisfaction survey 38% 34% 67%

Recognition/appreciation awards and

events23% 32% 17%

Staff empowerment, input in decision

making8% 21% 17%

Manager access and timely response

(including open door policy. Visibility,

flexible hours etc.)

8% 14% 17%

Open communication forums, staff

meetings38% 14% 33%

implementing changes from survey

suggestions8% 10% 0%

Education support, professional

development opportunities0% 9% 0%

Social activities 8% 9% 17%

Wellness and work life improvement

initiatives0% 8% 0%

Manager flexibility (scheduling etc.) 0% 8% 0%

Performance appraisals, opportunity to

connect with managers0% 5% 0%

Appropriate staffing/workload 0% 3% 0%

Manager-union meetings 8% 0% 0%

Length of time initiative has been in place - largest positive response: CCAC: 1-2 years, 2+ years Hospitals: 2 + years LtC: 2 + years



• Staff empowerment, input into decision making

• Manager access and timely response

• Communication forums/staff meetings

• Manager flexibility (including scheduling etc.)


• Manager-union meetings

4.5.8 Impact on Client/Resident/Patient Safety

Only hospital managers who reported a wide span of control were more likely to report a negative or very negative impact of their span of control on client/resident/patient safety (See Appendix C, exhibit 67).

These results are different from what would have been expected based on literature findings that suggest clinical supervision is more effective when supervisors have a narrow span of control and that reduced access to support from managers negatively impacts staffs’ ability to provide high quality care.

The majority of respondents to this question reported that they had implemented initiatives to alleviate the impact that their span of control had on client/resident/patient safety. There was, however, broad variation in responses ranging from 69% in CCACs to 91% in LTC homes. Perceived impact of these initiatives also varied greatly by sector with 68% of CCAC respondents, 87% of hospital respondents and 95% of LTC respondents reporting a positive or very positive impact. Across all sectors, the greatest positive response to these initiatives was when the initiative had been in place for greater than two years (See Appendix C, exhibits 68-69).


Exhibit 20: initiatives Related to Enhancing Client/Resident/ Patient Safety

Span of Control impact on Patient Safety


n= 16 n= 180 n= 11

Safety programs/policies (including

many of Accreditation Canada’s

Required Organizational Practices

13% 35% 27%

Patient safety huddles, triads, discussion

at team meetings

19% 29% 73%

incident reporting, review and follow up 19% 28% 0%

Health/safety/quality teams or councils

or dedicated resources

19% 18% 9%

Safety rounds 0% 18% 0%

Culture of safety/openness 0% 10% 0%

Patient/client/resident education and

involvement in patient safety

6% 7% 9%

improved equipment 0% 7% 0%

Regular inspections, audits and

monitoring

0% 7% 27%

Client surveys 6% 5% 0%

improved communication 0% 5% 0%

Safety plans, root cause analysis 0% 4% 0%

Large Span of Control makes follow up

difficult

0% 2% 0%

Appropriate staffing 0% 2% 0%

Public reporting 0% 2% 0%

Manager access (including open door

policy)

13% 1% 9%

Adherence to practice guidelines 19% 0% 9%

Risk assessment and documentation 31% 0% 9% Length of time initiative has been in place - largest positive response: CCAC: 1-2 years, 2+ years Hospitals: 2 + years LtC: 2 + years


It is likely that a manager’s ability to successfully implement the following initiatives would be directly impacted by their span of control:

• Safety rounds

• Timely follow up of concerns

• Manager access

4.5.9 Impact on Client/Resident/Patient Satisfaction

CCAC and hospital managers who reported a wide span of control were more likely to report a negative or very negative impact of their span of control on client/resident/patient satisfaction (See Appendix C, exhibits 70).

These percentages, although small, are consistent with findings from Doran’s study10 that found that managers who had a large number of staff reporting to them had lower levels of patient satisfaction. Further, they noted that having a large span of control reduced the positive effect of positive leadership styles on patient satisfaction.

The majority of respondents to this question reported that they had implemented initiatives to alleviate the impact that their span of control had on client/resident/patient satisfaction. Responses and impact of these initiatives varied by sector however, with just over two thirds of hospital managers reporting implementation of initiatives (83% positive/very positive impact) compared to 85% of CCAC managers reporting implementation of initiatives (66% positive/very positive impact) and 86% of LTC managers reporting implementation of initiatives (95% positive/very positive impact). Across all sectors, the greatest positive response to these initiatives was when the initiative had been in place for greater than two years. (See Appendix C, exhibits 71-72).

Initiatives implemented by managers and/or their organizations are provided in exhibit 21.

Exhibit 21: initiatives Related to improving Client/Resident/ Patient Satisfaction

Span of Control impact on Patient Satisfaction


n= 14 n= 135 n= 13

Patient satisfaction surveys 64% 52% 46%

Program planning and changes based on

patient/client feedback7% 21% 15%

involving patients/families in care and

planning (including patient centred care)14% 19% 46%

Manager rounds/accessibility 0% 13% 8%

Patient feedback process 21% 11% 23%

Patient interviews around time of

discharge0% 9% 0%

Patient/family education and

communication0% 9% 8%

timely follow up of concerns 7% 8% 0%

Patient advocate/patient relations 0% 7% 0%

Reporting and sharing of metrics/

performance0% 7% 8%

Wait time strategies/processes 0% 4% 0%

Appropriate staffing; Employee skills &

attitudes0% 4% 0%

Culture of respect 7% 4% 8%

Staff education and communication 0% 2% 8%

incident monitoring 14% 2% 0%

Patient/family friendly environment 0% 1% 0% Length of time initiative has been in place - largest positive response: CCAC: 1-2 years, 2+ years Hospitals: 2 + years LtC: 2 + years


• Manager rounds/accessibility

• Timely follow up of concerns

• Incident monitoring and follow up


4.6 Summary of Survey FindingsAt present, healthcare related literature on span of control does not clearly define what is meant by narrow and wide span of control, nor does it provide guidance on what would be considered an “ideal” number of staff to report to a manager. Generally, the literature suggests that three components be considered when identifying the appropriate span on control in an organization:

• frequency and intensity of the relationship between the manager and staff,

• complexity of the work, capabilities of the manager, and

• complexity of the work and capabilities of the staff.

Based on the responses received from the survey, managers who reported a wide span of control were more likely to report:

• A higher likelihood that they had completed a Master’s/PhD. CCAC and hospital managers were also more likely to have received leadership education

• Greater than five years in management

• Responsibility for three or more units

• Budgetary responsibility

• Budgets exceeding $7 million

• Greater than 80 staff members reporting to them

• Greater number of staff reporting to them in a single workday. CCAC and LTC managers were also likely to report reduced frequency of contact with staff in a single workday.

• CCAC and LTC managers were also more likely to report a higher percentage of highly skilled/specialized and autonomous staff reporting to them.

A review of the literature also revealed that factors that are considered to be influenced by manager span of control include communication, employee morale, staff fulfillment, staff satisfaction and turnover rates as well as patient/staff safety and satisfaction. Although direct evidence of the impact of span of control on each of these dimensions is limited, there is a degree of consistency in the findings. The feedback received from the survey support findings in eight of nine dimensions explored:









Managers were asked to provide information on any initiatives that had been implemented to alleviate the impact that span of control had on each of the nine dimensions. Managers provided brief, point form listings of their initiatives. The following initiatives were most frequently reported as strategies that were used across the nine dimensions:

Manager access and visibility

Managers provided examples of using an open door policy to encourage staff interaction, where possible ensuring that their office was physically located on the unit to support easier access, having a visible presence on the unit through walkabouts and/or rounding, varying work hours and working outside of regular business hours to ensure access and interaction with staff on other shifts and finally, maximizing the use of technology such as email, blackberry etc. to be available and accessible to staff beyond the regular work days or on days when they are not on site.


Performance management

Managers provided examples of various performance management techniques that included not just the use of traditional annual performance appraisals, but also ad-hoc one-on-one meetings as required to address issues as they arose or to simply provide the opportunity for an informal “check-in”. Managers also noted the importance of providing positive or constructive feedback on a real time basis.

Manager/administrative walkabouts

Related to the notion of increased access and visibility, managers stated that they had implemented regular unit walkabouts to connect with both staff, and patients; they also made an effort to be present when there was an opportunity to interact or be available to all staff such as at shift change or report times.

Staff involvement in decision making/unit activities

Many managers stated that they had struck inter-professional committees at their individual unit level to encourage participation from all disciplines. In addition, managers noted the importance of encouraging staff to participate in corporate committees such as health and safety committees, quality committees, LEAN initiatives etc. to gain broader exposure in the hospital and to increase their sense of empowerment.

Appreciation and recognition

Managers noted the importance of appreciating and recognizing staff through formal events such as annual staff BBQs and long-term service awards. However, many also noted the importance of appreciation and recognition at the local unit levels by scheduling team building days/activities, and providing unit specific staff recognition opportunities.

Manager flexibility

Several managers noted the importance of flexibility when interacting with staff. This included flexibility in employee scheduling and work hours as well as specific back to work accommodation initiatives etc. Managers also stressed the importance of being generally open to staff ideas and incorporating staff feedback in unit functioning.

Staff forums/town halls

Managers cited the increased use of staff forums and town halls at both the individual unit level as well as at the organizational level as important forums for communication. Such venues not only provided managers or hospital administrators to share information and provide updates, but provided staff an opportunity to share their thoughts and feedback directly with managers or senior hospital administrators.

Use of email/other information technology

Maximizing the use of email and other information technology (intranet, blackberry access etc.) was seen as instrumental in supporting and managing wide spans of control. The opportunity to “connect” with staff virtually was important to support communication and accessibility to a large group of staff who worked different shifts.


Structured interviews were conducted with a small sample of Senior Nurse Leaders from three health sectors: community care (Senior Director of Client Services), long-term care (Directors of Care/Clinical Services) and hospital (Vice President and Chief Nursing Executives).

The purpose of the interviews were to provide further insight into the practices, strategies, and tools that organizations have implemented to minimize or alleviate the potentially negative impacts of large manager span of control on their workforce and patients.

For the purposes of the interviews the same definition of a manager and span of control was used as described earlier in this report.

A total of twelve telephone interviews were completed. The respondents represented the three health sectors as follows:

• Community Care (2)

• Long-Term Care (2)

• Hospital (8)

The eight respondents from the hospital sector were divided as follows:

• Academic Health Sciences Centres (3)

• Large Community Hospitals (3)

• Small Community Hospital (1)

• Specialty Hospital (1)

The respondents represented each of the OHA regions and were distributed as follows:

• Region One (2)

• Region Two (2)

• Region Three (4)

• Region Four (3)

• Region Five (1)

The interview encompassed patient/client services portfolio demographics, practices, strategies and tools implemented to alleviate the negative impact of manager span of control, enablers, and barriers, and finally evaluation.

In the sections that follow, findings from the interviews are described.

5.1 DemographicsThe demographic information was elicited to provide context to the patient/client services portfolio.

The majority of the participant organizations were multi-site/multi-facility.

The majority of the senior nurse leaders/chief nursing executives had responsibility for operations/patient services. The other senior nurse leaders/chief nursing executives who did not have responsibility for operations/patient services had primary responsibility for interprofessional and nursing practice.

The senior nurse leaders were asked to identify the approximate budget size of their current portfolio. The budgets ranged in size from < 5 million dollars to upwards of 200 million dollars. The smallest budget portfolios of < 5 million included two LTC homes and a community hospital, while the two largest budget portfolios were comprised of a large community hospital (180 million dollars) and an academic health sciences centre (200 million dollars).

5.0 Key Informant Interview Process


Interviewees were asked to describe their organization structure to provide context to their portfolio composition. The organization structure identified by participants differed by health care sector. Community care was structured geographically, long-term care was structured by site or service, and hospitals were structured by clinical programs.

In all health care sectors there was a director role and a manager role, although the manager role had many different titles. The titles of the manager role included manager, patient care manager, patient care facilitator, coordinator, supervisor, and assistant director.

A small number of hospitals reported changing their manager structure to include multiple levels of managers and in one hospital the director and manager role was combined.

Management supports included clerical, financial, human resources, decision support, clinical educators, leadership education professional practice leaders, advanced practice nurses, professional practice councils, patient flow/ navigation, RAI coordinator, after hours on site support and schedulers.

Community care primarily had finance, human resources and clerical support along with leadership education.

The long-term care homes primary supports were clerical and leadership education.

Hospitals had more supports than both community and long-term-care. In particular, hospitals had more resources to support patient navigation and flow, schedulers to assist with scheduling and staff replacement; and after hours on site support to address immediate patient care issues.

Additionally, hospitals have a more developed professional practice infrastructure with professional practice leaders, professional practice councils and advanced practice nurses.

Each senior nurse leader was asked to provide their perspective on the breath of the span of control of their managers.

In the community sector one senior nurse leader defined the manager’s span of control as narrow with 20 direct reports while another senior leader identified the span of control as wide with 16 direct reports. In the long-term sector both senior nurse leaders identified their manager’s as having a wide span of control with 50 and 100 direct reports. The hospital sector identified a combination of narrow and wide manager span of control. The three hospitals which identified a narrow manager span of control were hospitals where the manager had a range of 40-70 direct reports. The remaining hospitals that reported a wide manager span of control had between 80 -85 direct reports.

Although there were differing perspectives of wide and narrow span of control, the senior nurse leaders consistently commented on the complexity of span of control and that simply measuring the number of staff reporting to the manager was not sufficient to evaluate span of control.The senior nurse leaders identified that span of control was complex and required broader evaluation of further variables such as complexity of the unit/service, budget, and manager /staff experience.

The type of staff in the three health sectors included Registered Nurses (RNs), Registered Practical Nurses (RPNs), health disciplines, clerical and some unregulated health workers. More specifically the community care sector staffing included RNs, clerical and contracted health disciplines as required. Both the nurses and clerical were unionized.

The long-term care sector staff included RNs, RPNs, and health disciplines. All staff were members of a union.

The hospitals staffing included Registered Nurses, Registered Practical Nurses, and health disciplines. All nurses at the hospitals were unionized with a mix of union and nonunion for health disciplines.


Unregulated health workers were reported in all three sectors. The unregulated health workers performed personal care in the LTC homes and activities of daily living in two large hospitals. In one academic health science centre, unregulated health workers assisted patients out of bed, transferred patients and made beds. In another academic health science centre, the unregulated health workers were utilized for observational care only.

Geography/location in the province and recruitment challenges may play a part in the utilization of unregulated health workers.

5.2 Strategies/Initiatives to Support Manager Span of ControlOrganizations identified a number of strategies that are being implemented that may assist in alleviating the negative impact of a wide manager’s span of control. However, many of the strategies reported were not isolated to addressing the impact of large span of control and the impetus for implementing the strategies were a result of a number of factors.

A thematic analysis was conducted of the strategies and tools reported by each senior nursing leader and only the strategies that have a frequency of three or greater are presented in detail in this report.

The key informant interviews were conducted with senior nursing leaders/executives. These nursing leaders provided a different perspective on the type of strategies to manage span of control than those provided by managers in the survey. Their perspective provides a broader scope focused on organizational strategies and included:

• Redesign of the patient/client services organization structure

• Changes to the model of care

• Redesign of the manager role

• Move to full scope of practice

The strategies are further described below by health sector and by hospital type where applicable.

As well sample documents from organizations can be found in Appendix E and include the following:

• Role Profile, Patient Care Manager, Sunnybrook Health Sciences Centre

• Model of Care - Coordinated Care Team, Toronto East General Hospital

• Model of Care – Coordinated Care Team evaluation results, Toronto East General Hospital

• Model of Care – Potential Core Team Compositions, Toronto East General Hospital

• Role Description, Manager, Windsor Regional Hospital

• Organization Chart, Vice President Acute Care & Chief Nursing Executive portfolio, Windsor Regional Hospital

5.2.1 Structure Redesign

The most frequent strategy implemented was the redesign of the patient/client services portfolio structure. This strategy was inherent in both the long-term care and hospital sectors and again their strategy was implemented as a result of a number of factors within organizations with span of control being cited as one of the factors.

Six hospitals, four community hospitals and two academic health science centres reported a change in structure in the patient/client services portfolio to include the addition of new manager roles. These new roles were either a result of the addition of a new manager position where a position did not originally exist or additional manager roles where organizations have added different levels to their current manager role.

Three hospitals, two community hospitals and one academic health science centre have also introduced additional manager levels to their current manager role.


For example at the Windsor Regional Hospital, structure was redesigned to include three different leadership roles with in each clinical program; director, operational manager and clinical practice leader. The operational manager(s) and the clinical practice leader(s) are peers and report to the director and have specific and distinct responsibilities and accountabilities. The operational manager is responsible for the overall management of the programs and the patient care services provided within their unit(s). Key responsibilities include budgeting, program planning, performance management, quality of care and safety. The clinical practice leader acts as a resource to staff and assists staff with learning plans. As well, the clinical practice leader plays a key role in patient safety and infection control initiatives. A sample manager role description, organization chart and a depiction of the structure has been made available by Windsor Regional Hospital and can be found in Appendix E.

Another community hospital introduced a new manager role (supervisor, patient care manager) which has primary responsibility for the day-to-day operations of the clinical unit, as well as patient flow, staff support and service recovery. These roles may or may not have responsibility for fiscal or performance management and these roles generally report to a manager however may report to a director level.

Sunnybrook Health Sciences Centre has developed three levels for their patient care manager role (PCM I, II, II). The responsibilities for PCM I, II and III are similar, however the breadth of the role varies for example in the number of direct staff reports and/or the size of the budget. PCM experience will facilitate a higher level of functioning of PCM. Like the community hospitals, these roles may report to a manager of a different level or to the director level.

The PCMs are responsible and accountable for the patient care provided on their unit and provide leadership in the management of human and financial resources. As well, the PCMs are responsible for unit planning, implementing

their unit’s quality improvement plan and supporting coordinated interprofessional practice within the context of a competent care delivery model. For further details see the sample PCM role profile from Sunnybrook Health Sciences Centre located in Appendix E.

A LTC home introduced a new manager role to provide leadership to resident care, by redistributing the workload of resident care in a multi-site organization to a more manageable size. Two new manager positions were created and implemented. Each manager is responsible for resident care on their respective site and report to the director of resident care. The role is non union, and oversees clinical issues, family concerns, supports the direct care coordinator (RN), leads patient care projects e.g. falls, restraints. The managers do not have budget or performance appraisal responsibility, however, contribute to both.

A community hospital introduced a new supervisor role in one particular clinical area which required additional leadership support.

The news roles and additional manager levels have assisted with decreasing manager span of control and enabling the majority of the managers to have responsibility for a single patient/client care unit in hospitals and long-term care.

It was noted that clarifying the different manager roles and levels is essential to ensure the roles are distinct with minimal overlap/duplication and are aligned with the portfolio.

The redesign of structure was also cited in the literature as a strategy for addressing span of control. In particular, Fairview Health Services in Minneapolis studied the span of control and identified a strong relationship between manager span of control and employee engagement. As a result, they added four additional nurse managers to their structure.


5.3 Change in Model of Care The next most frequent strategy reported was changing the model of care which was reported only in the hospital sector. This strategy was implemented for various organization specific reasons and also to support manager span of control.

Three community hospitals and one academic health sciences centre have implemented or are implementing in the near future, changes in their model of care.

A community hospital implemented a change in the model of care to a collaborative inter-professional recovery model. Each team member has full accountability for their assigned patients.

The Toronto East General Hospital has designed and implemented an interprofessional model of care through their coordinated care team project. A sample of the model can be found in Appendix E.

Point of care staff were involved in the design of the model and a consultation process was undertaken to determine the principles, concepts, values and structures of the new model.

Interprofessional staff received six days of education which included a range of topics including an overview of the model of care, roles and team development. The new model was implemented on three pilot clinical units prior to being expanded to the other units.

Care is delivered by core care teams which have a Registered Nurse Team Leader and includes RN(s), RPN(s), and a Patient Care Associate (PCA) who work together to provide care to a group of patients. The responsibilities and accountabilities were defined for each role to ensure clarity and optimal use of knowledge and skills. Staff practice to full scope in a coordinated and collaborative manner.

A third community hospital is in the process of moving to a collaborative inter-professional care model.

An academic health sciences centre has developed professional models for both nursing and interprofessional practice. These models are collaborative patient centred and support the organizations strategic directions. In particular, the nursing model supports full scope of practice and accountability for individual practice and recognizes competencies and expertise.

There is scant literature in relation to changes in model of care and changes in skill mix as a strategy to support managers with a large span of control. Pabst notes three factors that may have an impact on the span of control of managers and include skill mix and the experience of the staff and the functions of the charge nurse. As well, Pabst speaks to the fact that nurses who have the ability to make sound decisions at the point of care require less supervision. Pabst further poses the question of whether the nursing model of care could explain differences in manager span of control. Though she does not elaborate on this point, it is potentially a future area of research.

5.3.1 Manager Role Redesign

The redesign of the manager role was reported in both the community and long-term care sectors. The role redesign was a result of a need to support manager span of control and other organization specific issues.

The community care access centres have expanded the scope of the manager role from client review and approvals to more of a supervisory role, which now includes functional responsibilities such as budgeting and performance appraisals. As well, the role is now more visible and supportive of the case managers and is involved in staff development.

A long-term home is in the process of reviewing a vacant manager role prior to posting the position to determine if a change in scope of the role is required.

Sample manager role descriptions from Sunnybrook Health Sciences Centre and Windsor Regional Hospital can be found in Appendix E.


5.3.2 Full Scope of Practice

Full scope of practice as a strategy was identified in only the hospital sector and was implemented for a number of organization reasons, one of them being to support manager span of control.

The literature did not note moving to full scope of practice as a strategy to support manager span of control.

Full scope of practice of nurses varied between health sectors. In the community care sector one community care access centre reported the RNs were working to full scope of practice while another community care access centre reported case managers (RNs) not working to full scope of practice. This was in part due to a planned review and expansion of the scope of the case manager role. In the long-term-care sector both RNs and RPNs are working to full scope of practice. In the hospital sector the majority of nurses are working in varying degrees of full scope of practice ranging between 75-100%.

Two hospitals who have implemented a change in model of care incorporated the move to full scope of practice for both nursing and allied health discipline staff as a component of the model of care transition.

5.3.3 Other Identified Practices

Other strategies to support manager span of control that were identified by respondents included:

• Implementation of staffing office/clerks/central scheduling to assist the managers with scheduling and replacement of staff

• Development of patient population specific patient satisfaction surveys to identify opportunities for change

• Senior management walk-about or rounding to assist in bringing to light issues and concerns at the senior level.

Again these strategies were noted as strategies to support manager span of control however span of control was not cited as the primary reason for implementing these initiatives.

5.4 Tools to Support Leading PracticesThe review of the literature did not identify specific tools that had been developed to support managers’ span of control.

However, interview respondents did identify tools used to assist the manager in supporting span of control and include the following:

• Human resource tools included a web based performance appraisal tool (CCAC) and sick call algorithm (large community hospital).

• One academic health science centre developed a number of guides to assist with decisions related to staff mix, tools to assess educator span of coverage and manager span of control.

The literature did note that an assessment matrix to assess manager span of control was a component of the Michigan Leadership Model. As well The Ottawa Hospital has developed an assessment tool to measure the span of control of different leadership positions within their organization.

5.5 Enablers to Support Manager Span of ControlEnablers were identified by respondents as key strategies that organizations could undertake to help support manager span of control.

5.5.1 Leadership Education

Community, long-term care and hospitals alike were providing leadership education for their managers. In community care, one CCAC reported providing a leadership development program for a period of six weeks which incorporated leadership competencies. Another CCAC reported leadership education which highlighted leadership styles.


In long-term care, one facility provided mandatory leadership education on-site while another facility provided financial assistance for managers to attend leadership education sessions.

All hospitals supported leadership education for their managers by either providing on-site education or providing financial support to attend off-site education. One community hospital provides a structured six week core leadership course which requires the participant to complete a project related to enhancing patient satisfaction within a six week period. This education is then augmented with individualized learning plans. Another community hospital provides an on-site leadership day with an emphasis on emotional intelligence and transformational leadership.

All three academic health science centres have formal leadership education programs for their managers. One centre’s program is delivered by Rotman and another centre has a partnership with a local university to provide a health care leadership program.

As well, all hospitals reported bursary dollars available for the manager to access for support of further leadership development.

5.5.2 Communication

Communication was specified as a key enabler to implementing a change in organization structure and role redesign in the community and hospital sectors.

Seeking feedback often and early in the process with key stakeholders was expressed as a “must have” to gain support and build trust.

Communication strategies and tools for ongoing sharing of information and open dialogue with staff and managers included:

• communication forums,

• leadership forums,

• communication boards,

• use of the intranet, and

• coffee with the vice president and chief nursing executive.

5.5.3 Staff Education

Educating those impacted by change was paramount for successful implementation of new initiatives in all three health sectors. Different forms of education were provided based on the type of the initiative. Education ranged from formal education such as structured courses to mentoring and coaching and informal education on the unit or department. General education and communication were provided to all staff regarding the new initiative at ongoing intervals.

All three sectors were committed to providing the required knowledge, skill and support to the managers and staff to ensure a successful implementation of the new initiative as able.

One large community hospital is working with an academic institution to provide guidance regarding the development of the nursing leadership curriculum in their nursing program.

Two hospitals noted the importance of the Nursing Graduate Guarantee (NGG) in supporting their nursing workforce and were successful in hiring all of the new graduates completing the initiative. The NGG is an initiative through the Ministry of Health and Long Term Care which provides a guaranteed 7.5-month employment opportunity in a supernumerary (above staffing) position to support new graduates’ transition into full-time permanent positions, as they become available40. One hospital has worked to provide a nurse residency program specific to their patient population and have been successful in attracting new graduates.


One large multisite community hospital added more clinical educators to support the increasing number of new graduates requiring orientation and ongoing guidance on the clinical units.

Two hospitals have partnered with local universities to provide on-site post graduate education (BSCN) for their staff.

One large community hospital is partnering with researchers to conduct formal research.

5.5.4 Technology

Technology was identified as an enabler to the implementation of the changes in practice within all three health sectors. Computerized scheduling and payroll were identified by an academic health sciences centre to reduce the amount of time the manager spends on payroll and scheduling.

One community care access centre has implemented a web based performance appraisal tool to assist with the completion of annual performance reviews and manage some of the geographic barriers inherent in the nature of community care.

One large community hospital has 95% of their clinical record in electronic format. One community care access centre is planning to move to an electronic record system in the future to assist with data collection and documentation.

Although some organizations have implemented the technology, most organizations are looking at future implementations.

5.5.5 Role Clarity

All three health sectors recognized the importance of clarifying and defining the role and the accountabilities of the manager in their current, and for some, their redesigned structure.

5.5.6 Professional Practice Structure

Moving to full scope of practice was identified as being essential to support a change to an inter-professional collaborative model of care.

A collaborative inter-professional model of care requires all health professions function to the fullest extent of their training and capability.

As well, a professional practice committee structure was identified by the hospital sector as an enabler to support shared communication and decision making. The majority of hospitals either had in place, or, were in the process of implementing professional and nursing practice councils. One large multisite community hospital and one academic health science centre have implemented unit councils to support shared governance.

5.6 Barriers to Mitigating Effects of Span of ControlOnly a few barriers were mentioned by respondents. The literature was limited in citing barriers.

5.6.1 Staff Accountability

Staff accountability was reported to be a barrier in the community and hospital sector.

Some respondents reported reluctance on the part of the managers to embrace the increased accountability with the change in roles. This was identified as being the result of the significant and rapid changes while implementing the leading practices and particularly in those organizations that implemented changes to the organization structure and redesigned the role of the manager.

As well it was reported that one community care access centre identified the need for managers to take a more proactive role in their own professional and leadership development.


5.6.2 Recruitment

Challenges in recruitment of experienced managers were reported by the long-term care and hospital sectors. Geographical location was cited by these two sectors as the primary cause of the decreased availability of experienced managers.

As well, the senior nursing leaders consistently noted the importance of manager characteristics and having the right person in the right manager position. Further elaboration regarding recruitment practices was not provided.

5.6.3 Supports

Although all three sectors reported varying types of support for their managers, clerical support was identified as not sufficient in all three health sectors. This finding was also supported in the survey findings as noted under section 4.3.5. As well, it was noted that if additional dollars were available, further initiatives would be implemented to support the work of the managers.

Dawson et al, noted the University of Michigan Health System redesign team identified the need for clinical infrastructure support and administrative supports that could provide assistance to the manager.

5.7 EvaluationHalf of the organizations interviewed had evaluated in some form the impact of the strategies implemented. The remaining organizations had not yet embarked on an evaluation, as the strategies were recently implemented and it was too premature to effectively evaluate the impact of the change.

Of those evaluated, only two organizations had conducted a formal evaluation with data being reported, while other organizations reported only anecdotal observations.

Based on the responses to the Span of Control survey, it would appear that strategies may need up to two years to see results. Data is presented either qualitatively or quantitatively as provided by the respondents.

One community care access centre reported a decrease in absenteeism and turnover rate after the implementation of a change in organization structure and the redesign of the manager role to include more functional responsibilities. As well, this same organization reported decreased staff satisfaction with the accessibility of the manager with the expansion of the manager role.

One long-term care home reported improved accessibility of management with the addition of two new managers which was reflected in their staff survey. As well, staff absenteeism and the number of falls were reduced.

One large community hospital anecdotally reported improved relationships with managers, as managers were more accessible to staff with the move to one manager per unit.

Toronto East General Hospital implemented a change in their model of care, with professional staff working to full scope of practice, the implementation of unregulated care providers as part of the care team and hourly patient rounding. The hospital reported the following results at one year; 28% decrease of patient-to-patient transmission of infection, 31% decrease in patient falls, 33% decrease in medication incidents, 43% decrease in patient mortality, and 32% decrease of pressure ulcers in patients > 70 yrs. As well patient satisfaction improved by 14% for availability of nurses, 57% improvement for getting patients to the bathroom and 19% improvement in call bell response. As well patient complaints have decreased by 23%. Staff/physician identified the benefits of the model as improved role clarity, collaboration and teamwork. The hospital also reported an increase in direct care by 66 minutes per patient per day.

Another large hospital (multi-site) identified an increase in compliance with hand washing, a decrease in staff turnover to 4.2 %, minimal nursing vacancies and increased overall patient satisfaction rating of 94% with the introduction of the additional manager role and each manager generally responsible for one unit.


One academic health science centre evaluated the impact of a decrease in the manager’s portfolio’s size by changing to three levels for their manager role and each manager being responsible for one unit. This organization reported overall increased manager satisfaction, increased performance management, and a reduction of nurse agency use from 20% to 0%.

Another academic health science centre which has been proactively implementing strategies since 2002 completed a longitudinal study from 2003-2006 to measure the impact of the implementation of two models of nursing clinical practice and inter-professional patient care. The following results were reported; a decrease in the vacancy rate of 13.9% to 2%; a decrease in the turnover rate from 12% to 5.7%; improvements in nurse satisfaction, recruitment and engagement; improvements in continuity of patient care; enhanced documentation; valuing of staff expertise; recognition of nursing contribution; and a safety net for novice staff.

5.8 Summary of Interview FindingsDemographically, the structures of the patient/client services portfolio differed by health sector. However, all health sectors reported having a director and manager role with the exception of one hospital which had a combined director and manager role.

There were different perceptions of wide and narrow manager span of control by the senior nurse leaders. The senior nurse leaders consistently reported that using the number of staff or the number of FTEs was insufficient to adequately describe the complexity of span of control.

Manager supports were similar across health sectors; however, hospitals had more resources than both community and long-term care. Hospitals also had a more developed professional practice infrastructure.

Organizations reported implementing strategies that may assist in alleviating the impact of a wide span of control;

however, many of these initiatives were implemented as a result of a number of factors.

The most frequent strategy reported was the redesign of the patient/client services organization structure (67%). This strategy was inherent in both the long-term care and hospital sector. The next most frequent strategy reported was changing the model of care (33%) which was isolated to the hospital sector. The redesign of the manager role (25%) was reported in both the community and long-term care sectors. Full scope of practice (17%) was identified in only the hospital sector.

Many of these initiatives were recently implemented with only a few being evaluated. Of those evaluated only two organizations had conducted a formal evaluation with specific metrics while others reported anecdotal observations.

Enablers and barriers were identified, with leadership education being cited by all three sectors as a key enabler.

Organization strategies, tools and enablers were consistent with eight (89%) of the nine dimensions cited in the literature.

• Impact on effectiveness and/or frequency of communication

• Impact on manager accessibility to staff

• Impact on staff retention

• Impact on staff attendance (levels of absenteeism)

• Impact on staff engagement

• Impact on staff satisfaction

• Impact on client/patient/resident safety

• Impact on client/patient/resident satisfaction


6.1 Defining Span of ControlThe scan of the literature reveals two broad category definitions of span of control. One related to the total number of FTEs and the other related to the total number of individuals reporting to a manager. For the purposes of this review the latter definition was utilized. It should be noted that a consistent definition of span of control is required to enable clarity when monitoring and measuring span of control among organizations and health sectors.

Span of control is however a complex phenomenon particularly in healthcare requiring further in depth analysis of the work, worker, manager and the organization to determine the appropriate span of control.

The OHA has identified a definition of span of control in their Human Resources Benchmarking Survey that may be prudent to use this definition across the three sectors for consistency in reporting.

RECOMMEnDAtiOnS:


(1) The OHA and its members use their current definition of span of control as identified in the OHA-PwC Human Resources Benchmarking Survey for the purposes of consistency of reporting.


6.2 Leading Practices to Address Span of ControlEven though there are only a few studies that have studied the impact of span of control in healthcare, researchers were able to extrapolate from the literature nine key dimensions that impact span of control. The literature also provides few examples of practices and tools implemented and evaluated that effectively minimize/ alleviative the negative impact of span of control.

As such, the nine dimensions were utilized to guide the survey and interviews to assess practices and tools implemented to minimize/alleviate the negative impact of manager span of control in three health sectors.

The practices and tools reported by organizations did in fact align with eight of the nine dimensions. The practices and tools reported by the senior nursing leaders tended to be more corporate in nature than those reported by the managers. However, both sets of practices and tools were helpful in addressing the impact of span of control as reported by respondents.

Based on findings of the literature, survey and interviews, the three key leading practices the Hay Group recommends organizations consider implementing are categorized as follows:

1. Assessing manager span of control

2. Clarifying the manager role(s)

3. Assessing manager supports

A note of caution that the strategies identified by the interview respondents were implemented as a result of a number of factors, manager span of control being only one of them.

6.0 Recommendations


These practices are broader in nature and correspond more closely to the initiatives identified by the senior nursing leaders.

The Hay Group also believes implementing the three leading practices in concert with the initiatives noted below from the surveys, will assist organizations to address issues related to span of control:



• Manager/administrative walkabouts

• Staff involvement in decision making/unit activities

• Appreciation and recognition

• Manager flexibility


• Use of Email/Other IT for communication and accessibility

6.2.1 Assessing Manager Span of Control

The first leading practice is assessing manager span of control. There was modest information gleaned from the literature, surveys and interviews regarding tools to assess span of control. As a result, and as noted above, the Hay Group is recommending the development of criteria and a tool to assess manager span of control.

The development of criteria and an assessment tool to assess span of control will assist organizations in understanding the span of control of the managers in their respective organizations.

The Hay Group believes assessing manger span of control is an essential step organizations should undertake in understanding span of control and necessary to complete prior to moving forward with manager role redesign, span of control adjustment and changing manager supports.

Tools to support the assessment of span of control are needed to ensure all aspects of span of control are considered prior to organizations determining an appropriate span of control for managers.

The work of the University of Western Ontario/Children’s Hospital of Eastern Ontario led span of control project may be of assistance in estimating the appropriate span of control and developing a tool to assess manager span of control.

RECOMMEnDAtiOn:


(3) The OHA together with its members and using the results of the University of Western Ontario/ Children’s Hospital of Eastern Ontario led span of control project determine criteria and a tool for assessing manager span of control.

6.2.2 Clarifying the Manager Role(s)

The second leading practice is clarifying and aligning the manager role with the organization.

Clarifying the Manager Role

As noted in the literature, the role of the manager is critical in healthcare and yet over the past two decades many organizations have flattened their organizational structure, reduced the number of managers and increased their span of control.

It is now know from recent studies that a wide manager span of control can negatively impact patient and staff.

Some organizations have implemented additional manger roles and created multiple layers of managers within the organization structure to address large span of control.

Clarifying the role(s) of managers is essential to prevent role confusion, and becomes especially critical if there are layers of managers in the organization structure to ensure the roles are distinct and minimize duplication and overlap.


Clarifying the manager role includes identifying the key competencies, responsibilities and manager authority.

The ability to recruit managers can be challenging as result of many factors. As noted in the interviews, challenge in recruiting managers was noted as a result of geographical location. However, even if geographical distance is not a factor, organizations have still struggled to recruit managers with the right characteristics.

There was scant literature to identify the key characteristics of managers who had superior performance in managing a wider span of control. However, leadership literature has shown that the manager staff relationship is fundamental to staff retention. In one study45, 84% of nurses were leaving or considering leaving their jobs as a result of their relationship with their manager.

Research conducted by the Hay Group18 in the National Health Service (NHS) has demonstrated the link between leadership style and the impact on team performance and ultimately the patient experience.

High performing managers consistently used a wider variety of leadership styles which resulted in a 36% lower staff turnover, 57% reduction in absenteeism and 40% fewer number of medication errors.

Further Hay Group research19 identifies leadership competencies which are underlying personal characteristics and behaviours of an individual that are important contributors to predicting superior performance.

Responsibilities and authority to act also need to be determined for managers to work autonomously in their role.

It is recommended that organizations determine competencies for their managers to assist with recruiting the individual with the right characteristics and to ensure the individuals in the manager role have the appropriate knowledge and skills to be successful in their role.

This can be accomplished by the Vice President Patient Services in collaboration with human resources developing/redefining the manager role description, corresponding accountabilities and competencies.

One resource that may be of assistance to organizations is the Leadership Development Institute (LDI) of the OHA. The LDI utilizes competency models as a basis of their talent management framework. Competencies have been developed for various management positions along with an implementation guide and questionnaires to assess strengths and areas for development in respect to identified behavioural competencies of managers.

The dissemination of the role to the staff and physicians is imperative to ensure there is a clear understanding of the manager role(s) within the context of the organization.

RECOMMEnDAtiOn:







6.2.3 Assessing Manager Supports

The third key leading practice is assessing manager supports. Key internal manager supports to minimize/alleviate the impact of span of control identified in the interviews included identifying leadership education opportunities, developing an inter-professional infrastructure, assessing clinical, clerical and technological supports.


identifying Leadership Education Opportunities

Leadership education has been identified as a key initiative to support the manager’s development and sustain the longevity of a manager in their role. Managers are often left to develop their leadership skills on their own. That being said, more and more organizations are recognizing the need to provide education for their managers. This notion was supported in the findings with leadership education being reported in the interviews as a key support for managers in all three sectors. The leadership education varied in delivery and content with more formal structured leadership education programs being delivered in academic health science centres.

Few programs specific to nursing leadership development currently exist. However, three health care leadership programs of note include the Dorothy M. Wylie Nursing Leadership/Health Leaders Institutes, the Executive Training for Research Application (EXTRA) program and the OHA Leadership Development Institute.

The Hay Group suggests organizations review their leadership education and perhaps explore opportunities to partner with other organizations, and/or academic institutions to deliver leadership education programs where feasible and support manager attendance at external leadership programs.

Developing an inter-professional Practice infrastructure

The inter-professional practice infrastructure was identified as a combination of collaborative model of care, full scope of practice and professional practice councils. These initiatives were primarily isolated to hospitals, however, are applicable to all three health sectors.

Inter-professional collaborative care is the provision of comprehensive health services to a patient/client by multiple health care professionals who work collaboratively to deliver the best quality of care in every health care setting. It encompasses partnerships, collaboration, and a

multidisciplinary approach to enhancing care outcomes21. Collaboration supports interdependent professionals reaching decisions together and sharing responsibility for these decisions.

Organizations reported moving to an inter-professional collaborative model of care to strengthen collaboration amongst disciplines in planning and providing care to patients/clients, enhancing autonomy of decisions at the point of care for all disciplines and accountability for these decisions.

Full scope of practice is required to support an interprofessional collaborative model of care. Full scope of practice is when a regulated health discipline is functioning to the fullest extent of their training and capability. As noted in the interviews, the majority of the organizations were at, or moving toward, full scope of practice.

A professional practice decision-making structure such as nursing, interprofessional and unit councils where identified as supporting the practice of disciplines, their specific discipline development needs, and communication and decision making of point of care providers. This enabled increased autonomy of each profession in addressing their professional issues and developmental needs as well as enhancing engagement of staff in decisions related to practice.

There is minimal documentation in the literature that point to interprofessional practice and changes to the model of care as strategies to support manager span of control however it was the second most frequently reported strategy by hospitals respondents and therefore warrants consideration.

It is suggested that organizations investigate interprofessional collaborative practice models, move towards full scope of practice of all professions and implement interprofessional forums.


Assessing Clinical and Clerical Resources

Many organizations across the three health sectors and in particular long-term care and hospitals are hiring more novice staff. Novice staff require additional orientation and ongoing support as they transition into their new role. Providing this support to the novice staff is needed, however, it is unrealistic to expect this support to be delivered by the manager.

Clinical supports such as clinical educators and professional practice leaders were identified in the interviews as being essential to supporting not only the novice staff, but the experienced staff in meeting their clinical and professional developmental needs while recognizing the accountability of staff to partner in their own professional development.

Further supports for the manager included clerical staff that provided clerical support, staffing and scheduling. Again, clerical functions, staffing and scheduling can consume a significant amount of the manager’s time leaving little time for managers to be visible and building relationships with their team.

The Hay Group suggests organizations review the clinical and clerical resources available to support managers within their organizations.

There was not sufficient information from the literature, surveys and interviews to suggest an average number or type of support per manager.

Assessing technology Supports

The use of technology was identified as an enabler to streamlining and enhancing key processes which take up a significant amount of time of the managers’ such as scheduling, and payroll.

Electronic documentation was noted by a number of organizations across the three sectors as being an important enabler to support interprofessional collaborative practice.

It is suggested organizations review the technology available to support the managers within their organization.

6.3 Measuring the Impact of Span of Control Although the literature is not conclusive in identifying specific metrics to measure the impact of manager’s span of control on staff and patients, the literature does identify factors that impact various staff and patients dimensions that are considered to be influenced by manager span of control.

The following nine dimensions were identified throughout the literature:

• Impact on effectiveness and/or frequency of communication

• Impact on manager accessibility to staff

• Impact on staff retention

• Impact on staff attendance (levels of absenteeism)

• Impact on staff injury rates

• Impact on staff engagement

• Impact on staff satisfaction

• Impact on client/patient/resident safety

• Impact on client/patient/resident satisfaction

In particular the survey and interview findings yielded a high degree of support with both supporting eight of the nine dimensions. The one dimension the survey and interview findings did not support was impact on staff injury rates.

Metrics to measure the impact of span of control of these dimensions were not specifically identified in the survey; however, the interview respondents did identify metrics their organizations used to evaluate the strategies implemented.


Although the strategies were implemented for a variety of reasons, the metrics measured patient safety, patient outcomes, staff retention, and patient and staff satisfaction which are consistent with four of the nine dimensions. As well, the impact of the initiatives observed related to two additional dimensions (staff absenteeism, and accessibility).

A deliverable of this review is to specify metrics organizations can use to measure the impact of span of control.

Based on the literature, survey, and interview findings, it is recommended the following metrics be used to monitor and measure the impact of manager span of control:

• Safety Metrics



o Infection control rate







It is our hope that organizations will view these metrics in a different light and strengthen the connection of these metrics and the impact of manager span of control.

It is anticipated that many, if not all of the above metrics, are currently being collected by organizations across the three health sectors. For example, voluntary turnover rate and staff absenteeism rate are currently collected by hospitals through the OHA-PwC HR Benchmarking Survey. As well, overall patient satisfaction rate is being collected via patient/client satisfaction surveys such as NRC Picker.

RECOMMEnDAtiOn:



• Safety Metrics











6.4 Future ResearchAlthough a thorough review of the literature was conducted, there was a gap in the literature regarding the relationship between organizational culture and span of control. The authors of this study believe there is a potential opportunity to conduct research investigating the relationship between the type of culture and span of control.

As well, although the Hay Group has suggested specific metrics to monitor and measure the impact of manager span of control, more structured research is required to study the empirical relationship of the metric in measuring the impact of manager span of control.

It is further suggested that the findings from studies conducted by The Ottawa Hospital, Cambridge Memorial Hospital and University of Western Ontario/Children’s Hospital of Eastern Ontario span of control project (funded by the Ministry of Health and Long Term Care and sponsored by the Council of Academic Hospitals) regarding manager span of control may be a further source of information to inform/complement future work of the OHA related to span of control. The results of this study will be available in late 2012.

RECOMMEnDAtiOn:


(5) The OHA communicate the results of the University of Western Ontario/Children’s Hospital of Eastern Ontario span of control project to its’ members with regard to the relationship between clinical manager span of control and manager and unit work outcomes in Ontario academic hospitals as well as the reliability of the Ottawa Hospital span of control assessment tool.


Laura Pavilonis (Chair) Director, Corporate Services St. Thomas Elgin General Hospital

Nancy Cooper Director of Policy & Professional Development Ontario Long Term Care Association

Dennis Fong Senior Director, Human Resources & Organizational Development Toronto Central Community Care Access Centre

Anne-Marie Malek President & CEO West Park Healthcare Centre

Karim Mamdani Chief Operating Officer Ontario Shores Centre for Mental Health Sciences

Lori Marshall Vice President, Patient Care Thunder Bay Regional Health Sciences Centre

Patricia Maxwell Senior Planner, Integration Central Local Health Integration Network

Lynda Parks Sahadat Vice President, Human Resources Sudbury Regional Hospital

Acknowledgements

Marilyn Reddick Vice President, Human Resources Sunnybrook Health Sciences Centre

Monica Reilly Senior Research & Policy Advisor Colleges Ontario

Jan Richardson VP Human Resources, Medical Affairs & Support Quinte Healthcare Corporation

Donnalene Tuer-Hodes Chief Nursing Executive, Program Director – Surgery Huron Perth Healthcare Alliance

Karima Velji Vice President, Clinical and Residential Programs & Chief Nursing Executive Baycrest

Lois Kozak Chief Executive Officer Englehart & District Hospital

Thank you to the Hay Group who was engaged by the OHA to conduct the study and write the report.

The OHA would like to thank all of the Nursing, Patient, and Resident Care Leaders, listed in Appendix D, who took the time to participate and share their practices and strategies in the survey and interviews. The OHA would also like to thank the members of the OHA Strategic Human Resources Provincial Leadership Council for providing guidance and support throughout this study.

OHA Strategic Human Resources Provincial Leadership Council


The following is a summary of the recommendations. Further details of each recommendation are provided in section 6.0 of the report along with additional suggestions for strategies to assist with mitigating the negative effects of a wide span of control.

RECOMMEnDAtiOnS:


(1) The Ontario Hospital Association (OHA) and its’ members use their current definition of span of control as identified in the OHA-PwC Human Resources Benchmarking Survey for the purposes of consistency of reporting.


(3) The OHA together with its members and using the results of the University of Western Ontario/Children’s Hospital of Eastern Ontario led span of control project determine criteria and a tool for assessing manager span of control.







• Safety Metrics










(6) The OHA communicate the results of the University of Western Ontario/Children’s Hospital of Eastern Ontario span of control project to its’ members with regard to the relationship between clinical manager span of control and manager and unit work outcomes in Ontario academic hospitals as well as the reliability of the Ottawa Hospital span of control assessment tool.

Appendix A: Recommendations


Appendix B: Literature Review: Definition, Key Concepts and Emerging Themes IntroductionWith growing pressure on fiscal resources, many hospitals and health care organizations have undergone restructuring and have undertaken aggressive cost cutting initiatives and sought ways to decrease costs. One common cost reduction strategy has been the reduction of management positions across organizations.

This has resulted in decision making being decentralized with increasing demands being placed on management. The responsibility of unit managers has generally expanded to include the management of finances, operations, human resources often across multiple clinical areas in a program management structure. Manager span of controls have increased, with many managers often responsible for more than one unit leaving significantly reduced time for staff mentorship, motivation, coaching and evaluation.

Span of Control DefinedA scan of the literature reveals that definitions for span of control can be grouped into two broad categories:

total number of “workers” being supervised by a manager

Span of control refers to a supervisory ratio, and is frequently measured as the amount of supervisory positions per unit of total human resources42.

Most typically, span of control has been defined as the number of people supervised by the manager, i.e. the number of people assigned to a manager, not the number of FTEs7, 38.

Variations to this definition include the number of workers that a supervisor can “effectively” manage/oversee27,43 and in the business industry, span of control is broadly defined as “the area of activity, number of functions or subordinates etc. for which an individual or organization is responsible36.

total number of “FtEs” being supervised by a manager

The alternative definition proposes that span of control is measured by the number of FTEs under the jurisdiction of a manager14. Similarly, in Altaffer’s study2 of two complex health care organizations, the following definition was provided “number of people supervised by a manager as measured by the total number of FTEs.

OHA’s Working Definition

The OHA supports the definition of total number of “workers” reporting to a manager. Based on the Saratoga US Hospital Metric definitions, the OHA is using the following definitions in the OHA-PwC HR Benchmarking Survey.

Management Span of Control

Headcount / Management Headcount

nurse Manager Span of Control

nurse Headcount / nurse Manager Headcount

Management Headcount: The average number of management core employees.

1. Add the total number of management core employees as of the beginning and as of the end of the survey period (for non-health care organizations, this is the beginning of January and the end of December; for healthcare organizations, this is the beginning of April and the end of March). 2. Management headcount is defined as executives (i.e., the top three (3) tiers of your organization’s Canadian operations (i.e., the CEO, and the next two (2) levels


of reports), plus managers (i.e., all employees classified as Supervisor, Manager, Director, Executive Director, etc.). Therefore, management headcount should equal the sum of executive headcount (1.10) and manager headcount (1.11). Exclude project managers. 3. Divide by two (2) for an annual average headcount. For health care organizations: 1. this is a core data element. Saratoga uses management headcount to calculate the following metrics: management span of control, percent of management with no direct reports.

Nurse Manager Direct Reports Headcount: The total number of core employees, regardless of title or role, who report to Nurse Managers. These employees may be RNs or RPNs actively engaged in the practice of providing patient care, as well as employees who are not registered nurses or Registered Practical Nurses but serve in other roles including physiotherapists, occupational therapists, unit clerks, respiratory therapists, unit aides, rehabilitation assistants, patient service workers, social workers, etc. Core Employees:

Defined as all workers who are paid by the organization (i.e., receive a T4 from the organization). This includes full-time, part-time and casual staff. Casual Staff: Defined as an employee working less than normal full-time hours (as defined by your organization) who does not commit to a regular schedule.

1. Add the total number of core employees (regardless of title or role) who report directly to Nurse Managers, as of the beginning of April 2009 and as of the end of March 2010. 2. Include full-time, part-time and casual employees. Count contract staff paid through payroll as casual. Exclude contingent workers (e.g., contract, consultant, temporary, seasonal and agency staff). 3. Exclude employees on short-term disability (STD), long-term disability (LTD), and various temporary paid leave of absence (LOA) programs. 4. Do not include vacancies. 5. Divide by two (2) for an annual average headcount. Saratoga uses Nurse Manager direct reports headcount for the following metrics: Nurse Manager span of control.

Nurse Manager Headcount: The average number of core employees classified as Nurse Manager. Nurse Managers are defined as those having RNs or RPNs actively engaged in the practice of providing patient care reporting directly to them, and may have direct reports who are not RNs or RPNs but serve in other roles including physiotherapists, occupational therapists, unit clerks, respiratory therapists, unit aides, rehabilitation assistants, patient service workers, social workers, etc.

Nurse Managers may have titles including Nurse Supervisor, Head Nurse or Nurse Manager. Exclude executives. Core Employees: Defined as all workers who are paid by the organization (i.e., receive a T4 from the organization). This includes full-time, part-time and casual staff. Casual Staff: Defined as an employee working less than normal full-time hours (as defined by your organization) who does not commit to a regular schedule.

1. Add the total number of Nurse Managers as of the beginning of April 2009 and as of the end of March 2010. 2. Include full-time, part-time and casual employees. Count contract staff paid through payroll as casual. Exclude contingent workers (e.g., contract, consultant, temporary, seasonal and agency staff). 3. Include employees on short-term disability (STD) and on various temporary paid leave of absence (LOA) programs. 4. Exclude employees on long-term disability (LTD). 5. Do not include vacancies. 6. Divide by two (2) for an annual average headcount. Saratoga uses Nurse Manager headcount for the following metrics: Nurse Manager span of control.


Additional Considerations for Span of ControlAlthough in its simplest form, span of control refers to the number of employees or FTEs being supervised by a manager, the literature suggests that span of control is a more complex phenomenon. Generally, the literature suggests that three components be considered when identifying the appropriate span on control in an organization2,17,31,36,43:

• Frequency and intensity of the relationship between the manager and staff. This would require considerations of the number of interactions that a manager is required to have with staff to support the day to day performance of staff and functioning of the unit. This would also include consideration of the depth and quality of interaction i.e.: requirement for clinical teaching, mentorship etc.

• Complexity of the work, capabilities of the manager: Complexity of work would require consideration of whether the work of the manager is routine, has a calm and predictable workflow, the level of automated processes etc.; capabilities of the manager would require consideration of experience, skill level, ability to delegate, leadership style, alignment with organization etc.

• Complexity of the work and capabilities of the staff. Complexity of work of staff would include routine versus complex work, degree of decision making in day to day job, level of independence etc., capabilities of staff would require consideration of level of experience, skill level, qualifications, morale, alignment with manager goals, familiarity with the organization etc.

Additional factors for consideration include:

• The combination of people, skills and variety of tasks that they perform

• Scope of responsibility of the manager (range of duties, size and number of units, number of sites etc.)

• Planning organizational, budgetary and leadership responsibilities

• Presence of managerial support are critical factors to be considered when evaluating a manager’s span of control.

Ideal Span of ControlSpan of control is a complicated phenomenon that, as noted above, is influenced by many factors (qualities of the staff, attributes of the manager, organizational characteristics, administrative systems etc.) as well as types of task that the job encompasses, in addition to the nature of the job, characteristics of the job and the demands of the job and the role27. An evaluation of the optimum number of staff that should report to managers requires a multifaceted evaluation of the work, worker, manager and organization.

Although the literature does not provide a “formula” to calculate the number of direct reports in an optimal span of control, it should be noted that span of control theory34 proposes that there is a certain size at which span of control reaches its maximum capacity to be effective, and increasing beyond that capacity may in fact be harmful. Span of control, then, is used to describe the theoretical mix of responsibilities that would be “just right”31.

While classic organizational theory13 proposed that every five-six workers needed a first line supervisor, the ideal number of direct reports to allow for effective management depends, in fact on several characteristics including the types of tasks being performed by the workers, the skill level of the workers and, equally important, the skill level of the supervisor/manager27,44.

Current management opinion suggests that a supervisor could manage between 100 and 200 individuals9,43. Indeed, the studies that were reviewed as part of the literature review and that provided information on span of control included managers with a broad range in the number of employees under their supervision:


• Doran’s study examining the impact of span of control on leadership and performance focused on seven Ontario hospitals. Manager span of control ranged from 36-151 workers, with a median of 67 workers10. The study found that wide span of control decreased patient satisfaction, increased turnover. It also decreased the positive effects transformational and transactional of leadership styles on nurses job satisfaction and increased the negative effects of management-by-exception on nurses job satisfaction.

• Pabst’s study43 examined manager to staff ratios in two tertiary medical centers in the Midwest. There was wide variation in the manager/staff ratio in each of the units examined (from 11.5 – 40.7); there was also wide variation in the % of RN staff in each of the units (from 69% - 100%). The conclusion was that there is a need to explore care delivery models, skill mix etc. when determining ideal spans of control.

• Manion’s research30 on nurturing a culture of nurse retention included nurse managers with SOC ranging from 42 – 170 employees. While 46% of nurse managers in this study had responsibility for one department, 42% were responsible for two departments and 12% had accountability for three of more departments. Critical success factors related to nursing retention included manager accessibility, listening and responding, forging authentic connections, coaching and development, performance management etc. Wide spans of control hinder a manager’s ability to incorporate the practices identified above.

• Shirey et. al’s study48 on nurse manager stress and work omplexity included a sample of 21 nurse managers at three US acute care hospitals with SOC from 21- 251 FTEs; with 66% having responsibility for up to 110 employees. Wide spans of control were identified as contributors to manager stress levels.

• Cathcart’s study7 on span of control and employee engagement included managers that had SOC ranging from five – 100 direct reports. 13% of managers had

more than 40 direct reports; 86% of these were nurse managers of patient care areas. The study noted positive changes in employee engagement when manager spans of control were reduced.

• The American Organization of Nurse Executives’ (AONE) study3 of acute care hospital survey of RN vacancy and turnover rate noted that management load increased as the size of the facility increased. Hospitals with 350+ beds had an average of 54 staff within their span of control, hospitals with 100-349 beds had an average of 44 staff within their span of control, hospitals with 50-99 beds had an average of 30 staff under their span of control and finally, hospital with fewer than 50 beds had an average of 16 staff under their span of control. Wider spans of control and lower turnover rates were noted in larger facilities; however, caution should be used in drawing conclusions with these two findings since the report was not designed to test the relationship between span of control and turnover rates.

Span of Control and Impact on Managers, Staff and PatientsLiterature suggests three components to be considered when identifying the appropriate span on control in an organization: i) frequency and intensity of the relationship between the manager and staff, ii) complexity of the work, capabilities of the manager and iii) complexity of the work, capabilities of the staff1,2,7,28,43,44. Nancy New’s “Span of Control Pyramid”39 sums up the various characteristics in each category of work, manager, workers and organization that would be most suited to a broad or narrow span of control (See Appendix B, Table 2).

Large spans of control are more commonly found in flat structures and are associated with managers supervising a units in which the employees perform routine tasks with little variation27, or when managers are supervising highly skilled or specialized staff who have extensive knowledge of the work and require less supervision35.


Narrow spans of control are more commonly found in tall, hierarchical structures and associated with managers who supervise workers who perform highly unique and complex tasks27.

A handful of healthcare specific studies have examined the impact of span of control on various managerial, staff and patient dimensions. Factors that are considered to be influenced by manager span of control include communication, employee morale, staff fulfillment, staff satisfaction and turnover rates as well as patient/staff safety and satisfaction. Although direct evidence of the impact of span of control on each of these dimensions is limited, there is a degree of consistency in the findings.

The research study being led by the University of Western Ontario and the Children’s Hospital of Eastern Ontario will examine the relationship between clinical manager span of control and manager/unit outcomes in 15 Ontario Academic Hospitals including:

• Staff absenteeism

• Staff turnover

• Overtime hours

• Work injury rates

• Patient satisfaction

Impact on ManagersOver the last several years, there have been increasing demands on individuals in management positions, with the role of unit managers generally expanding to include the management of finances, operations, human resources often across multiple clinical areas in a program management structure. Many managers spend a large amount of their day coordinating staffing issues, patient flow and working on committees8,32,37. As a result, not only

do they feel increasingly overwhelmed48, but they have little time left for staff development and quality improvement activities37,41 (see impact on staff and patients below). Doran et al.’s hallmark study10 of the impact of span of control and leadership and performance concluded that it was “not humanly possible to consistently provide positive leadership to a very large number of staff while at the same time ensuring the effective and efficient operation of a large unit on a daily basis.”

Stress Levels and Burnout

With front line managers taking on increasing responsibility, more work and more employees, there are increasing reports of managers being overwhelmed and experiencing high levels of stress and burn out. In a qualitative study of nurse managers, complexity, conflict and ambiguity were often identified as sources of stress. Large SOC was seen as adding complexity to nurse manager roles47,48. The findings are re-enforced in stress and coping literature related to the nurse manager role in the “post re-engineering” period46.

Communication

There is mixed evidence of the impact of large spans of control on communication. There is some literature that cites a positive impact between large spans of control and communication17, and conversely, a narrow span of control as defined by more levels in the organizational structure results in more meetings and a more significant amount of time spent coordinating these activities31. However, a review of the literature produces greater evidence of the negative impact of large span of control on communication. Larger spans of control impact communication patterns and inevitably impact the number of interactions that a manager must undertake43.


Management and Decision Making

Altaffer’s study2 that compared span of control of first line nurse managers (large spans of control) with first line non-nurse managers (smaller spans of control) found that in all dimensions except one measuring effectiveness, nurse managers were less likely to report that they were highly effective in fiscal management, negotiation and conflict management as well as change management.

In fact, studies have shown that even when managers possess the desired leadership style, their ability to influence positive outcomes may be impacted by their span of control10. Even highly emotionally intelligent managers may not be able to have an impact on staff nurse empowerment due to large spans of control which invariably results in limited opportunities to engage with staff7,38.

Feldman’s study15 also supports the notion that clinical supervision is more effective when frontline supervisors have a narrower span of control) i.e. a smaller, more easily identifiable group of nurses whose care delivery must be monitored on a regular basis.

Organizations with large spans of control that effectively delegate responsibility to employees are often associated with managers feeling more fulfilled and rewarded17. However, challenges of reorganization can be compounded if senior management does not permit increased decision making authority and independent functioning to support their larger span of control31. On the other hand, multi-layered organizations, typically identified with smaller spans of control, are seen to have a significant (negative) impact on decision making. It can be argued that when there are multiple levels in a chain of command, the likelihood that decisions and problems will be forced to a higher level is increased. As the number of layers increase, responsibility is “diluted and diffused” and ultimately, decisions are made in a vacuum, absent of context and at a distance from where they originated31.

Mentorship, Access and Visibility

Increasing demands and changing responsibilities of frontline managers has meant that mentorship and guidance traditionally provided to staff nurses is no longer available6. How much time a manager spends interacting with employees is dependent on other competing demands and the overall distribution of managerial resources36. Managers who are over extended and have overly wide spans may limit access to staff and the mentorship that managers wish to offer1.

Growing spans of control limit the attention, support, clinical supervision and feedback that managers can provide to an employee often with detrimental impacts.

Impact on Staff PerformanceA study in the airline industry supports the notion that narrow spans of control improve performance through positive effects on group processes.

Engagement and Empowerment

Several studies address the impact of large spans of control on employee engagement. Cathcart’s study7 found a fairly consistent decline in employee engagement scores as work group size increased. At two points in particular, employee engagement dropped considerably – when work group sizes grew larger than 15, and then again when work group sizes grew larger than 40.

Large spans of control are also thought to influence employee perceptions of empowerment7,29,38. As demonstrated in Lucas’ study29 of two Ontario community hospitals, while emotionally intelligent nurse managers were able to promote an empowering work environment, span of control was a significant moderator of the relationship between nurses’ perceptions of their emotionally intelligent behaviors and feelings of workplace empowerment. Laschinger26 suggests that employee empowerment is determined by access to resources, information, support and opportunity which allow staff to influence working conditions positively.


Satisfaction and Retention

Smaller spans of control have consistently been linked to higher levels of staff satisfaction and higher rates of employee retention. While Doran’s study10 of seven Canadian teaching and community hospitals (51 units), did not find span of control to be a predictor of nurses’ job satisfaction, it did find that span of control decreases the positive effect of transactional and transformational leadership styles on nurses job satisfaction. The study also found empirical evidence that the wider the span of control, the higher unit turnover rate. The study reported a 1.6% increase in turnover for every increase of 10 in span of control.

Manion’s research30 that included 26 managers from a broad array of hospital departments examined critical factors in nurse retention. Factors identified by nurses included amongst others: listening and responding, appreciating and recognizing, supporting, getting to know staff, creating a sense of community, coaching, modeling behavior, visibility and accessibility. Each of these factors is better supported when a manager has a smaller, more manageable span of control. Similarly Meade’s study found that for rural hospitals, where nurse managers had a significantly higher percentage of mentors, there was significantly lower turnover for RNs. The link between nurse retention and the quality and continuity of care had already been established in literature. These findings are reinforced by nurses who reported that reduced access to support from their managers negatively impacted their ability to provide high quality care25.

Staff Safety

Hechanova’s study22 of span of control and safety performance in teams that revealed that large spans of control resulted in less monitoring of safety by supervisors. The study concluded that span of control was positively correlated to unsafe behaviors and workplace safety accidents.

Impact on PatientsSatisfaction

Doran et. al’s study10 of Canadian hospitals, found that managers who had a large number of staff reporting to them had lower levels of patient satisfaction. Further, the researchers found that having a large span of control reduced the positive effect of positive leadership styles on patient satisfaction.

Patient Safety

Griffiths’ review16 of infection control literature concluded that excessive spans of control among clinical leaders were a risk for increased infection and infection control problems in hospitals. This finding is consistent with findings in other professions such as nurses who reported that reduced access to the support and resources from nurse managers limited their ability to provide high quality care25.

Interestingly, a larger study33 that examined nurse manager span of control and effectiveness and included 36 hospitals and 190 units did not find many significant findings based on span of control. The authors did report on findings that may have been significant had the sample sizes been larger, however, findings related to patient safety indicators such as medically unnecessary days, decubitus ulcers, nosocomial infections, administration of beta blockers etc. were mixed with no clear patterns in the three categories of spans of control defined in the study (one-45 staff, 46-71 staff and 72-152 staff).

Tools to Assess Manager Span of ControlAlthough a review of the literature confirms that span of control is a complex phenomenon, requiring consideration of many factors beyond the number of staff reporting to the manager, there is little information on how to assess manager span of control.


The development of the Michigan Leadership Model8 included an assessment matrix designed to assess the span of control or scope of work. Information gathered from this matrix was used to determine the level of clinical and administrative staff required to support the work of a manager. This matrix recognizes the complex role of nurse managers and includes factors in addition to the number of staff reporting to a manager. Key items included in the matrix are:

• Experience of the nurse manager

• Strength and stability of staff including (including staff nurse years of experience)

• Morale/turnover and independence

• Current level of manager support

• Cooperation of ancillary departments

• Physician support

• Support from senior leadership

At The Ottawa Hospital, the Senior Leadership team has developed span of control assessment tools for various leadership positions in the hospital. The Management Span on Control Assessment Tool, presented at OHA’s Skill Mix: Work and Redesign Conference includes assessment in three broad categories which are further broken down into specific areas of focus. To determine the impact on manager span of control, each area of focus is rated as low, medium and high. Listed below are each of the three categories and areas of focus:

• Unit Focused:

o Complexity

o Material management

• Staff Focused:

o Volume of staff

o Skill level/autonomy of staff

o Staffing stability

o Diversity of staff

• Program Focused:

o Diversity

o Budget/Statistical

As mentioned earlier in this report, The Ottawa Hospital span of control tool is currently being tested for reliability as part of the Council of Academic Hospitals’ (led by CHEO and UWO and funded by the MOHLTC) study on span of control.

Strategies to Mitigate the Negative Impacts of Large Spans of ControlA review of the literature provides very few case examples of organizations that recognized the negative impacts of large spans of control, identified and implemented solutions and monitored outcomes.

The development of a Management Infrastructure (Michigan Leadership Model) at the University of Michigan Health System (UMHS) was prompted by an analysis of organizational metrics and indicators that revealed that downsizing strategies (resulting in larger spans of controls) in the 1990s had negatively impacted employee satisfaction and the quality of nursing care. After a comprehensive review of current nurse manager responsibilities, members of the re-design team identified key elements of an ideal nurse manager role (ensuring quality of care, providing leadership, coaching and mentorship to staff and managing operations.) The team also identified the need for clinical infrastructure support and administrative/operations infrastructure support for responsibilities that were not identified as key elements and that could be easily delegated. The team developed a “cafeteria or menu style” of positions that managers could choose from to


support clinical or administrative components. Examples of additional resources were i) Clinical Nurse III/IV roles to function as clinical experts and program coordination of specific populations, ii) Clinical Nurse Supervisor Role and iii) the Administrative Assistant II (AII) role who along with payroll, secretarial and personnel paperwork support carried additional budgetary responsibilities and supervision of non clinical staff such as unit clerks. Two years after the model was implemented, units that received additional infrastructure support demonstrated an improvement in their ability to recruit, hire and retain new staff. Managers who have received the support of clinical nurse supervisor positions also expressed satisfaction with this additional support. At the time of publication, UMHS was in the process of analyzing the impact of these changes on employee and patient satisfaction, clinical indicators and turnover rates8.

Another strategy, implemented by Huntsville Hospital System in Alabama in response to a changing health care environment and larger spans of control was the implementation of a unit-based shared governance model on a Mother/Baby-GYN. By allowing staff nurses to have an active role in the decision-making process, the hospital sought to increase staff participation, improved communication and increased job satisfaction. One year post-implementation, results were mixed: although team members reported a shared vision of the unit, improved team functioning and improvements in the quality and timeliness of communication, there was a surprising decrease in scores for job satisfaction and an increase in scores for the number of staff planning a career change in the near future. The authors suggested that the unexpected findings post implementation of the shared governance model could perhaps be attributed to unit reorganization, leadership transition and budget constraints between pre and post implementation surveys44.

At Fairview Health Services in Minneapolis, the organization responded to managers concerns about large spans of control. After studying the issue within their health care system, Fairview found a strong relationship between manager span of control and employee engagement. They subsequently added four nurse managers to observe the effects of smaller spans of control and realized positive improvement in employee engagement in all four units7.

Other Considerations

Other solutions identified in the literature include obvious strategies such as increasing management positions to reduce the number of direct reports and enhancing clerical support.

Layman27 suggests an overall review of spans of control within organizations to ensure that supervisors in the same hierarchal level of the organization chart should be similar and have the same number of direct reports. Where discrepancies in spans of control exists, Layman suggest that these should be clearly explained vis-à-vis dissimilarities in terms of the types of tasks performed by staff (routine versus trouble shooting etc.), the experience of the supervisor and competence of direct reports. Layman also suggests that when a supervisor oversees multiple groups or units within the departments, there should be similarities between the groups or units.


table 1: the Ottawa Hospital Clinical Management Span of Control Decision Making indicators Source: Morash et. al (2005) A Span of Control tool for Clinical Managers. nursing Leadership Vol. 18(3)


table 2: Span of Control Pyramid (nancy new, 2009)

(Referenced in Appendix B, Span of Control impact on Managers, Staff and Patients)

www.nurseleader.com Nurse Leader 47

There is little in nursing literature to suggest optimal NMspan of control. Available studies are inconclusive or indicatethat NM leadership style is as important an indicator as thenumber of employees supervised.4

FACTORS INFLUENCING SPAN OF CONTROLThere is no magic ratio for NM span of control. A myriad offactors involving the nature of the work, the qualities of thenurse, the attributes of the manager, and organizational char-acteristics must be considered.5

The nature of nursing work is knowledge-based and variesby clinical setting and specialty practice. Variability, turbulence,and complexity are common characteristics of nursing practicein today’s healthcare environment. Nursing work’s interdiscipli-nary nature adds a level of interdependency that complicatespractice. Availability of technology that provides work supportsuch as feedback systems and artificial intelligence has an impacton nursing productivity and span of control.

Nursing staff member qualities such as skills, experience,seniority, qualifications, capabilities, and morale greatly affect theneed for manager involvement. Nurses need and often expectprofessional development and coaching in the workplace.

Manager skills, ability, experience, seniority, qualifications,capabilities, and morale affect the ability to lead successfully.Leadership style has a major impact on the manager’s capacityrelated to span of control.

Key organizational characteristics that influence span ofcontrol are the level of senior leadership support and thestability of the organization. As with nursing work, the diver-sity, turbulence, and complexity of the organization has asignificant bearing. Administrative systems such as clerical,human resources, and ancillary supports can make a differ-ence in the work of the nurse and the NM.

THE SPAN-OF-CONTROL PYRAMIDFigure 1 is a graphic representation of factors influencingspan of control as they relate to nursing work, nursingstaff, the NM, and the organization (N.N., unpublisheddata, 2009). At the top of the pyramid, characteristics thatsupport a narrow span of control are listed. At the bottomof the pyramid, factors that are conducive to a broad spanof control are noted.

The number of characteristics to consider isoverwhelming. In the 1960s, industrial businesses attachednumerical values to work characteristics in an attempt todevelop guidelines for the optimal span of control.6 Thiswork was simplistic and did not result in meaningfulguides. The sheer number of factors indicates just howcomplex the determination of an optimal NM span ofcontrol can be.

A list of frequently asked questions in Table 1 addresses thekey considerations related to NM span of control.

Figure 1. Factors Influencing Span of Control


Appendix C: Additional Survey Tables

The following tables provide detailed information for survey findings described in Chapter 4.0 Span of Control Survey.

Exhibit 22: Percentage of Respondents Reporting a Cohesive Culture

Cohesive Culture by Sector

Sector total “n”Strongly

AgreeAgree

neither

Agree nor

Disagree

DisagreeStrongly

Disagree

% Agree

or Strongly

Agree

Community Care Access Centre 65 9% 45% 37% 9% 0% 54%


Care and Rehab)566 12% 49% 19% 18% 2% 61%

Long term Care Home 29 24% 59% 10% 7% 0% 83%

Exhibit 23: Percentage of Respondents Reporting a Culture of Appreciation and Respect

Culture of Appreciation and Respect by Sector


AgreeAgree

neither

Agree nor

Disagree

DisagreeStrongly

Disagree

% Agree

or Strongly

Agree



Care and Rehab)565 18% 54% 15% 12% 1% 72%


Exhibit 24: Percentage of Respondents Reporting a Culture of teamwork

Culture of teamwork by Sector


AgreeAgree

neither

Agree nor

Disagree

DisagreeStrongly

Disagree

% Agree

or Strongly

Agree



Care and Rehab)567 15% 56% 18% 10% 1% 72%



Exhibit 25: Percentage of Respondents Reporting a Culture of Balanced Work life

Balanced Worklife Culture by Sector


AgreeAgree

neither

Agree nor

Disagree

DisagreeStrongly

Disagree

% Agree

or Strongly

Agree



Care and Rehab)563 13% 44% 22% 17% 4% 57%


Exhibit 26: number of Staff Reporting to Managers Reporting narrow Span of Control

number of Staff Reporting to Managers who Stated that they had a nARROW Span of Control by Sector

Sector total “n” Less than

40

40 - 60 61 - 80 81 - 100 101 - 125 126-150 Greater

than 150



Continuing Care and Rehab)140 39% 26% 19% 9% 5% 2% 1%


Exhibit 27: number of Staff Reporting to Managers Reporting Wide Span of Control

number of Staff Reporting to Managers who Stated that they had WiDE Span of Control by Sector

Sector total “n” Less than

40

40 - 60 61 - 80 81 - 100 101 - 125 126-150 Greater

than 150



Continuing Care and Rehab)369 18% 20% 19% 17% 13% 8% 5%


Exhibit 28: number of Units/Services per Manager

number of Units/Services Manager is Responsible for by Sector

Sector


total “n” One two threeMore than

threetotal “n” One two three

More than

three


Centre22 18% 36% 14% 32% 41 22% 24% 12% 41%


Continuing Care and Rehab)143 43% 29% 10% 17% 381 16% 21% 17% 46%

Long term Care Home 3 33% 67% 0% 0% 26 19% 15% 27% 38%


Exhibit 29: Percentage of Managers Reporting Budgetary Responsibility

Budgetary Responsibility by Sector



Community Care Access Centre 22 41% 41 76%


Continuing Care and Rehab)143 85% 381 96%

Long term Care Home 3 67% 26 81%

Exhibit 30: Budget Size for Managers Reporting narrow Span of Control

Budget Size for Managers with nARROW Span of Control by Sector

Sector total “n”Less than 1

Million Dollars1 - 3 Million 4 - 6 Million 7 - 10 Million

Greater than

10 Million

Community Care Access Centre 3 0% 33% 33% 33% 0%

Hospital (including Complex Continuing Care

and Rehab)74 12% 46% 27% 7% 8%

Long term Care Home 1 0% 0% 100% 0% 0%

Exhibit 31: Budget Size for Managers Reporting a Wide Span of Control

Budget Size for Managers with WiDE Span of Control by Sector

Sector total “n”Less than 1

Million Dollars1 - 3 Million 4 - 6 Million 7 - 10 Million

Greater than

10 Million



and Rehab)258 3% 27% 29% 18% 23%


Exhibit 32: Respondent Background by Sector

Respondent Background by Sector

Sector


total “n” nurse

Other

Healthcare

Discipline

total “n” nurse

Other

Healthcare

Discipline

Community Care Access Centre 22 82% 18% 41 80% 20%


and Rehab)143 86% 14% 381 83% 17%

Long term Care Home 3 100% 0% 26 100% 0%


Exhibit 33: Respondent Education Level of Managers

Respondent Education Level by Sector

Sector


total “n” DiplomaBachelor’s

Degree

Master’s

DegreePhD Other total “n” Diploma

Bachelor’s

Degree

Master’s

DegreePhD Other


Centre22 23% 77% 0% 0% 0% 41 66% 10% 22% 0% 2%

Hospital (including

Complex Continuing

Care and Rehab)

143 28% 38% 30% 1% 3% 381 44% 17% 36% 2% 0%

Long term Care Home 3 33% 67% 0% 0% 0% 26 31% 46% 15% 8% 0%

Exhibit 34: Respondent Management Experience

Years in Management Position by Sector

Sector


total “n”Less than

1 year

1 to < 3

years

3 to 5

years

Greater

than 5

years

total “n”Less than

1 year

1 to < 3

years

3 to 5

years

Greater

than 5

years


Centre

22 32% 5% 27% 36% 41 2% 17% 10% 71%


Continuing Care and Rehab)

143 55% 8% 19% 17% 381 7% 12% 17% 65%


Exhibit 35: Managerial Supports for those Reporting narrow Span of Control

Supports for Managers with nARROW Span of Control by Sector

Sector total “n”Admin

Support

Clinical

Leader Educators

Advanced

Practice

nurse

Consistent

Charge nurse

(Monday –

Friday Days)

Professional

Practice

Leader

i do not

have any

managerial

supports

Other

Supports

Present

Community Care Access Centre 22 91% 5% 9% 0% 0% 0% 9% 9%


Continuing Care and Rehab)143 57% 24% 45% 19% 49% 23% 12% 13%

Long term Care Home 3 100% 33% 33% 0% 0% 0% 0% 0%


Exhibit 36: Managerial Supports for those Reporting a Wide Span of Control

Supports for Managers with WiDE Span of Control by Sector

Sector total “n”Admin

Support

Clinical

Leader Educators

Advanced

Practice

nurse

Consistent

Charge nurse

(Monday –

Friday Days)

Professional

Practice

Leader

i do not

have any

managerial

supports

Other

Supports

Present

Community Care Access Centre 41 95% 10% 27% 5% 0% 0% 2% 15%


Continuing Care and Rehab)381 60% 22% 51% 19% 49% 28% 6% 18%

Long term Care Home 26 81% 23% 12% 8% 31% 8% 12% 15% note: this question allowed respondents to select multiple responses. As such the total “%”s for each sector will not add up to 100%. Percentage calculations for each category were made based on the number of respondents selecting a particular category divided by the total number of individuals responding to the question in that sector.

Exhibit 37: number of Staff a Manager Reporting narrow Span of Control is Responsible for in a Single Workday/Shift

number of Staff Managers (with nARROW Span of Control) is Responsible for in a Single Workday by Sector

Sector total “n” 10 or less 11-20 21-30 31-40 41-50 Greater than 51


Hospital (including Complex Continuing Care and Rehab) 140 26% 38% 21% 9% 4% 3%


Exhibit 38: number of Staff a Manager reporting Wide Span of Control is Responsible for in a Single Workday/Shift

number of Staff Managers (with WiDE Span of Control) is Responsible for in a Single Workday by Sector

Sector total “n” 10 or less 11-20 21-30 31-40 41-50 Greater than 51


Hospital (including Complex Continuing Care and Rehab) 369 10% 31% 24% 15% 7% 13%


Exhibit 39: Frequency of Contact with Staff for Managers Reporting a narrow Span of Control

Frequency of Contact with Staff for Managers with nARROW Span of Control by Sector

Sector total “n” Rarely

Less than

once a

month

Once

every two

weeks

Once a

week

2-3 times

a week

Once

daily

1-4 times

daily

Greater

than 5

times daily

Other

Community Care Access Centre 22 0% 0% 0% 18% 27% 5% 23% 9% 18%

Hospital (including Complex Con-

tinuing Care and Rehab)140 0% 0% 6% 8% 14% 11% 39% 14% 9%

Long term Care Home 3 0% 0% 0% 0% 0% 0% 33% 67% 0%


Exhibit 40: Frequency of Contact with Staff for Managers Reporting a Wide Span of Control

Frequency of Contact with Staff for Managers with WiDE Span of Control by Sector

Sector total “n” Rarely

Less than

once a

month

Once

every two

weeks

Once a

week

2-3 times

a week

Once

daily

1-4 times

daily

Greater

than 5

times daily

Other

Community Care Access Centre 37 0% 3% 3% 14% 30% 14% 24% 3% 11%


Continuing Care and Rehab)369 2% 4% 9% 7% 12% 9% 33% 10% 14%

Long term Care Home 25 0% 8% 0% 4% 12% 4% 36% 28% 8%

Exhibit 41: Skill and Autonomy of Staff Reported by Managers

Skill and Autonomy of Staff by by Sector

Sector


total “n”

Highly

Skilled/

Specialized

and

Autonomous

Less

Skilled/

Specialized

and Less

Autonomous

Mix of

BothOther total “n”

Highly

Skilled/

Specialized

and

Autonomous

Less

Skilled/

Specialized

and Less

Autonomous

Mix of

BothOther


Centre22 14% 0% 82% 5% 37 24% 5% 70% 0%




Exhibit 42: Union Status of Staff Reported by Managers

Union Status of Staff by by Sector

Sector


total “n” Unionizednon-

unionized

Mix of

BothOther total “n” Unionized

non-

unionized

Mix of

BothOther

Community Care Access Centre 22 82% 0% 14% 5% 37 57% 19% 24% 0%





Exhibit 43: types of Staff Reporting to Managers with narrow Span of Control

type of Staff Reporting to Manager with nARROW Span of Control by Sector

type of Staff Reporting to Manager total “n”Registered nursing

Staff (Rn/RPn)

Unregulated Care

Providers (e.g. PSW,

HCA, orderlies etc.)

Allied Health

Disciplines

Administrative/Facility

Support Staff (e.g. unit

clerk, housekeepers etc.)

Other


Hospital (including Complex Continu-

ing Care and Rehab)140 92% 38% 55% 74% 13%


Exhibit 44: types of Staff Reporting to Managers with Wide Span of Control

type of Staff Reporting to Manager with WiDE Span of Control by Sector

type of Staff Reporting to Manager total “n”Registered nursing

Staff (Rn/RPn)

Unregulated Care

Providers (e.g. PSW,

HCA, orderlies etc.)

Allied Health

Disciplines

Administrative/Facility

Support Staff (e.g. unit

clerk, housekeepers etc.)

Other


Hospital (including Complex Continu-

ing Care and Rehab)

369 95% 48% 60% 81% 15%


Grand total 431 94% 47% 58% 79% 16%

note: this question allowed respondents to select multiple responses. As such the total “%”s for each sector will not add up to 100%. Percentage calculations for each category were made based on the number of respondents selecting a particular category divided by the total number of individuals responding to the question in that sector.

Exhibit 45: Percentage of Staff Working to Full Scope of Practice

Percentage of Professional Staff Working to Full Scope of Practice by Sector




Hospital (including Complex Continuing Care and Rehab) 139 71% 369 78%


Exhibit 46: Percentage of Respondents Reporting a negative or Very negative impact on Communication

Percentage of Respondents Reporting negative or Very negative

Sector narrow Span of Control Wide Span of Control

total “n” % n/Vn total “n” % n/Vn





Exhibit 47: Percentage of Managers who had implemented initiatives to Alleviate SOC impact on Communication

Percentage of Respondents who have implemented initiatives to Alleviate SOC impact on Communication by Sector

Sector total “n” Yes


Hospital (including Complex Continuing Care and Rehab) 499 75%


Exhibit 48: Percentage Reporting a Positive or Very Positive impact of initiatives on Communication

% Positive Response for impact of initiative

Sector total “n”Greater than

2 years1 to 2 years

6 months

to < 1 year

Less than

6 Months

Planned for

implementationGrand total



Care and Rehab)322 39% 30% 20% 10% 0% 100%


Exhibit 49: Percentage of Respondents Reporting a negative or very negative impact on Manager Access to Staff

Percentage of Respondents Reporting negative or Very negative impact of Span of Control on Access to Manager






Exhibit 50: Percentage of Managers who had implemented initiatives to Alleviate SOC impact on Manager Access to Staff

Percentage of Respondents who have implemented initiatives to Alleviate SOC impact on Manager Access by Sector






Exhibit 51: Percentage Reporting a Positive or Very Positive impact of initiatives on Access to Staff



2 years1 to 2 years

6 months

to < 1 year

Less than

6 Months

Planned for




Care and Rehab)171 42% 25% 23% 11% 0% 100%


Exhibit 52: Percentage of Respondents Reporting a negative or Very negative impact on Staff Retention

Percentage of Respondents Reporting negative or Very negative impact of Span of Control on Staff Retention






Exhibit 53: Percentage of Managers who had implemented initiatives to Alleviate SOC impact on Staff Retention

Percentage of Respondents who have implemented initiatives to Alleviate SOC impact on Staff Retention by Sector





Exhibit 54: Percentage Reporting a Positive or Very Positive impact of initiatives on Staff Retention


Sector total “n”Greater

than 2 years1 to 2 years

6 months to

< 1 year

Less than 6

Months

Planned for




and Rehab)203 53% 27% 11% 7% 1% 100%



Exhibit 55: Percentage of Respondents Reporting a negative or Very negative impact on Staff Attendance/Absenteeism

Percentage of Respondents Reporting negative or Very negative impact of Span of Control on Staff Attendance






Exhibit 56: Percentage of Managers who had implemented initiatives to Alleviate SOC impact on Staff Absenteeism

Percentage of Respondents who have implemented initiatives to Alleviate SOC impact on Staff Absenteeism by Sector





Exhibit 57: Percentage Reporting a Positive or Very Positive impact of initiatives on Staff Absenteeism



2 years1 to 2 years

6 months to

< 1 year

Less than 6

Months

Planned for




and Rehab)192 59% 26% 13% 3% 0% 100%


Exhibit 58: Percentage of Respondents Reporting a negative or Very negative impact on Staff injury Rates

Percentage of Respondents Reporting negative or Very negative impact of Span of Control on Staff injury Rates







Exhibit 59: Percentage of Managers who had implemented initiatives to Alleviate SOC impact on Staff injury Rates

Percentage of Respondents who have implemented initiatives to Alleviate SOC impact on Staff injury Rates by Sector





Exhibit 60: Percentage Reporting a Positive or Very Positive impact of initiatives on Staff injury Rates


Sector total “n” Greater than

2 years

1 to 2 years 6 months to <

1 year

Less than 6

Months

Planned for

implementation

Grand total


Centre23 43% 35% 13% 9% 0% 100%


Continuing Care and Rehab)277 62% 23% 12% 4% 0% 100%


Exhibit 61: Percentage of Respondents Reporting a negative or Very negative impact on Staff Engagement

Percentage of Respondents Reporting negative or Very negative impact of Span of Control on Staff Engagement






Exhibit 62: Percentage of Managers who had implemented initiatives to Alleviate SOC impact on Staff Engagement

Percentage of Respondents who have implemented initiatives to Alleviate SOC impact on Staff Engagement by Sector






Exhibit 63: Percentage Reporting a Positive or Very Positive impact of initiatives on Staff Engagement



2 years1 to 2 years

6 months to

< 1 year

Less than 6

Months

Planned for



Centre29 41% 41% 3% 14% 0% 100%




Exhibit 64: Percentage of Respondents Reporting a negative or Very negative impact on Staff Satisfaction

Percentage of Respondents Reporting negative or Very negative impact of Span of Control on Staff Satisfaction






Exhibit 65: Percentage of Managers who had implemented initiatives to Alleviate SOC impact on Staff Satisfaction

Percentage of Respondents who have implemented initiatives to Alleviate SOC impact on Staff Satisfaction by Sector





Exhibit 66: Percentage Reporting a Positive or Very Positive impact of initiatives on Staff Satisfaction


Sector total “n” Greater than

2 years

1 to 2 years 6 months to

< 1 year

Less than 6

Months

Planned for

implementation

Grand total


Centre22 59% 36% 0% 5% 0% 100%





Exhibit 67: Percentage of Respondents Reporting a negative or Very negative impact on Client/Resident/Patient Safety

Percentage of Respondents Reporting negative or Very negative impact of Span of Control on Clinet/Patient/Resident Safety






Exhibit 68: Percentage of Managers who had implemented initiatives to Alleviate SOC impact on Client/Resident/Patient Safety

Percentage of Respondents who have implemented initiatives to Alleviate SOC impact on Patient Safety by Sector





Exhibit 69: Percentage Reporting a Positive or Very Positive impact of initiatives on Client/Resident/Patient Satisfaction



2 years1 to 2 years

6 months to <

1 year

Less than 6

Months

Planned for



Centre28 57% 21% 18% 0% 4% 100%




Exhibit 70: Percentage of Respondents Reporting a negative or Very negative impact on Client/Resident/Patient Satisfaction

Percentage of Respondents Reporting negative or Very negative impact of Span of Control on Patient Satisfaction







Exhibit 71: Percentage of Managers who had implemented initiatives to Alleviate SOC impact on Client/Resident/Patient Satisfaction

Percentage of Respondents who have implemented initiatives to Alleviate SOC impact on Patient Satisfaction by Sector





Exhibit 72: Percentage Reporting a Positive or Very Positive impact of initiatives



2 years1 to 2 years

6 months to

< 1 year

Less than 6

Months

Planned for



Centre23 61% 22% 9% 4% 4% 100%





Briffett, Julia, Executive Director of Clinical Services, Specialty Care Trillium Centre

Churchill, Debra, Interim Chief Nurse and Professional Practice, Ontario Shores Centre for Mental Health Sciences

Donylyk, Paula, Senior Director Client Services, North West CCAC

Fram, Nancy, Vice President Professional Affairs and Chief Nursing Executive, Hamilton Health Sciences Centre

Fryers, Marla, Vice President Programs and Chief Nursing Officer, Toronto East General Hospital

Furlong, Darlene, Senior Vice President Patient Care Service, Dryden Regional Health Centre

Greer, Brenda, Director of Resident Care, Fairvern Nursing Home

Haughton, Dilys, Senior Director Client Services, Central West CCAC

Matthews, Sue, Vice President Patient Services and Chief Nursing Executive, Niagara Regional Health System

McCullough, Karen, Vice President Acute Care and Chief Nursing Executive, Windsor Regional Hospital

Rodger, Dr. Ginette, Senior Vice President Professional Practice and Chief Nursing Executive, The Ottawa Hospital

VanDeVelde-Coke, Susan, Executive Vice President , Chief Health Professions and Chief Nursing Executive, Sunnybrook Health Sciences Centre

Appendix D: Key Informant Interview Participants


E1 Role Profile, Patient Care Manager, Sunnybrook Health Sciences Centre

E2 Model of Care - Coordinated Care Team, Toronto East General Hospital

E3 Model of Care – Coordinated Care Team evaluation results, Toronto East General Hospital

E4 Model of Care – Potential Core Team Compositions, Toronto East General Hospital

E5 Role Description, Manager, Windsor Regional Hospital

E6 Organization Chart, Vice President Acute Care & Chief Nursing Executive portfolio, Windsor Regional Hospital

Appendix E: Sample Documents


E1: Role Profile, Patient Care Manager, Sunnybrook Health Sciences Centre


PatientFocus

Access to care

Coordination of care

Communicationto patients

and families

Encourage People

Support Full Scope of Practice

Education & Mentorship

Process Redesign

Communication& Coordination

Among Providers

Ensure Value

CollaborativeSpirit

Inspire Innovation

Efficient Care Delivery

Effective Utilization ofProfessional Staff

Increase Staff Support Resources

Foster Interprofessional Collaboration

Consultations with partnersorganizations

Organizational Readiness

Promote Interprofessional Education

Technology Synergies

“The best place to give and receive care”

TEGH Coordinated Care Team

E2: Model of Care - Coordinated Care team, toronto East General Hospital


Results - Year 1 Pre/Post Evaluation

Patient Safety

Reduced:- Patient to patient transmission of infection by28%

- Falls by 31%- Medication incidents by 33%- Patient mortality by 43%- Pressure ulcers > 70 yrs by 32%

Patient Satisfaction

Improved:- Availability of nurses by 14%- Getting to bathroom in time by 57%

- Call bell response time by 19%- Teamwork, responsiveness, attentiveness, support and quality of care

Patient complaints decreased by 23%

E3: Model of Care – Coordinated Care team evaluation results, toronto East General Hospital

Results - Year 1 Pre/Post Evaluation

Staff/MD Satisfaction

Benefits of the model:-Role clarity 75%-Collaboration and teamwork78%

-Contributes to overall unitsuccess 75%

-Working at full scope 55-67%

Staff identified they know patients better, patients are more confident of care

Physicians note improved teamwork, fewer complaints

Resource Impact

- Increase in direct care by 66 minutes per patient per day

while reducing cost in some units by up to 6%

- Decrease in illness hours 10%,use of nursing resource teamRN (15%) & RPN (5%), andconstant care aids by 65% ($160,000)

- Increase in agency use 6.8% ($1521) and overtime 23% ($23,373)


Potential Core Team Compositions at the Med/Surg Unit Level

PSPSW

RN

RPN

PCARPN

PSPSW

RN

PCARPN

RN

E4: Model of Care – Potential Core team Compositions, toronto East General Hospital

Core Team Composition Critical and Acute Cardiology

RN

RPN

PCARPN/RN*

PS

RN

PCA

RN

RN

RN

*As patient acuity changes -

staffing adjustment

9 patients6 Patient Critical Cardiac Care3 Patients Acute Cardiac Care

11 patientsAcute Cardiac Care


E5: Role Description, Manager, Windsor Regional Hospital

JOB DESCRIPTION

Position Title: Manager, Medicine Program Job Code(s): PCS – 04 Grade 7 Reports To: Director of Medicine Program Union: Non Union Department: Acute Care, Met Campus Revision Date: December 2010 Position Purpose: Responsible for overall leadership of the assigned patient care program/units in the development and delivery of innovative programs and services to ensure the delivery of quality care to all patients/families in the program. The incumbent is responsible to promote and foster a patient/family-centered, team-based approach to care delivery as well to support, promote, and lead through example, the adoption of the organization’s mission, vision and values. Qualifications: Current Certificate of Registration with the College of Nurses of Ontario required. Bachelor’s Degree in Nursing required, Master’s Degree in Nursing preferred. Minimum 5 years current, relevant medicine experience and outpatient clinics required. Previous Nursing Administration experience preferred or evidence of relevant learning activity in

administration. Previous Medicine experience required. Membership in professional organization. Experience in safety order sets and medication reconciliation Management skills for budgeting, supervision, & planning; French Language proficiency an asset.

Skills/Abilities: Well developed interpersonal skills Excellent communication with individuals at all levels of the organization. Superb writing and content development skills with strong presentation, oratory, and verbal skills. Excellent organizational, time management, planning and project management skills Ability and commitment to work within a collaborative, team-based approach Ability to identify developmental needs of employees reporting to the position Able to deal with people sensitively, tactfully, diplomatically, and professionally at all times. High level of critical and logical thinking, analysis, and/or reasoning to identify underlying

principles, reasons, or facts. Excellent problem solving skills and the ability to think analytically, innovatively and independently. Demonstrated ability to lead and facilitate change. Demonstrated commitment to maintaining/enhancing professional competence through

participation in appropriate continuing education activities and clinical research. Competence in Microsoft Office computer programs.


Essential Job Outcomes:

Specific Responsibilities Related to the Program assuming overall accountability and responsibility for the patient care and services provided maintaining current knowledge of issues and trends in patient care and facilitating best practice facilitating implementation of corporate projects within the program, i.e., Clinical Pathways,

information automation in collaboration with project coordinators developing unit specific philosophy, goals objectives and standards of patient care in

collaboration with the Patient Care Team and ensuring that these are congruent with the hospital mission, vision & values and standards

coordinating all care and services provided for patient group in collaboration with other managers and providers

developing systems to monitor and manage unit operations, progress toward established goals, and patient care outcomes

acting as a resource person to the Charge Nurse(s), physicians, and support staff, in relation to the care of patients and unit operations

assuming accountability for facilitating the resolution of identified patient care issues in collaboration with the Patient Care Team

acting as a role model for staff and demonstrating commitment to patient/ family-centered care implementing quality improvement initiatives for the program in order to enhance the quality of

patient care ensuring that all staff are informed and in compliance with relevant policies and procedures Resolves diverse staff and operational issues and provides input into issues that impact across

patient/ stakeholder care units/ programs Develops and leads the implementation of new/ innovative approaches. Researches best practices related to portfolio and provide input to related benchmarks/ metrics Foster the development and dissemination of innovative solutions/ practices, primarily within the

organization Keeps senior management informed of any potential risks. Exercises judgment on complex/ sensitive decisions within standard policy, elevating

contentious issues with recommendations. Performs other duties as assigned from time to time to benefit the program/organization.

Corporate/Strategic Responsibilities Responsible for management of programs within the portfolio: plans and implements new

programs; implements program expansion, program enrichment, and program changes; develops and implements outcome and evaluation studies; and monitors and analyzes service area statistics.

Budget and report preparation: prepares, monitors, and is responsible for the budgets allocated to the service area; ensures that programs within the service area operate within available resources and that these resources are utilized effectively; organize and interpret monthly statistics of program activities and prepare monthly reports; and organize and write annual reports as needed.

Contributes to the planning, and manages the implementation of, operating goals and objectives related to stakeholder care programs.

Provides input to and monitors quality results and initiates related improvement processes for client safety

Identifies the need for, recommends and implements, practice and process improvement initiatives.

Program, policy, and procedures development: plan, develop, and implement services to be provided by the programs which are responsive to community and family needs; develop written program policy and procedures which are clearly communicated to all staff; and meet periodically and communicate with other staff to utilize feedback in the development of services.


Managing Relationships Ensures the regular supervision of staff: responsible for managing, coordination and leadership

to the interdisciplinary teams to ensure quality of assessment and treatment services; Manages collaborative relationships with, and the expectations of, patients/ stakeholders,

medical practitioners, clinical and hospital leaders, community partners, suppliers, volunteers and other team members to monitor, assess and improve satisfaction levels.

Facilitates the building of consensus and engagement among staff within portfolio to ensure the development and achievement of specific goals, priorities and directives.

Manages internal and external relationships ensuring community needs and industry trends are captured and communicated.

Participates in and may lead committee initiatives that involve multidisciplinary representation. Coaches and mentors staff Develops a highly performing portfolio team Recommends and executes actions/ plans relative to recruitment, performance management/

evaluation, development, and discipline/ termination as applicable. Ensure compliance with relevant legislation

Enhances quality of care and contributes to the development of a client centered, team-based, learning environment by: consistently contributing as a member of the team and practicing the values of Windsor

Regional Hospital; participating as a member of project teams or committees as appropriate; participating in activities of organizational renewal and development; sharing expertise and knowledge with other team members and other teams throughout the

organization; demonstrating respectful, courteous, caring attitudes in all interactions;

maintaining and fostering confidentiality in all aspects of written and verbal communication; Contributes to improve outcomes of safety, increased quality and deliver of care to reduce complications, infection and mortality rates by: Maintaining and promoting a safe and clean working environment for all employees, students,

visitors, patients/clients, family members and physicians and fulfilling the duties of workers under Section 28 of the Occupational Health and Safety Act.

Reporting and documenting any observed risks or hazards to management personnel and taking immediate corrective action whenever safe and feasible.

Acting in accordance with hospital patient safety policies and programs. Responding to safety risks to clients and takes action in situations where client safety and well-

being are compromised. Reporting any observed risks to the appropriate authority whose actions or behaviours towards

clients are unsafe or unprofessional.

Reviewed by Title

Approved by Title NOTE: This job description is not intended to be all-inclusive. Employee may perform other related duties as negotiated to meet the ongoing needs of the organization.


VP

Acu

te C

are

, Ch

ief N

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xecu

tive

Execu

tive A

ssistan

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Dire

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Dire

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Dire

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Se

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Clin

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E6: Organization Chart, Vice President Acute Care & Chief nursing Executive portfolio, Windsor Regional Hospital


Dire

ctor O

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A

dm

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Man

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1) Alidina, S. & Funke Furber, J. (1988) First-line Nurse Managers: Optimizing the Span of Control. Journal of Nursing Administration Vol. 18 (5) pp. 34-35

2) Altaffer, A. (1998) First Line Managers: Measuring their Span of Control. Nursing Management Vol. 29(7) pp.36-40

3) American Organization of Nurse Executives (January 2002). Acute Care Hospital Survey of RN Vacancy and Turnover Rates.

4) Anthony, M.; Standing, T.; Glick, J.; Duffy, M.; Paschal, F.; Sauer, M.; Sweeney, D.; Modic, MB. & Dumpe, M. (2005) Leadership and Nurse Retention: The Pivotal Role of Nurse Managers. Journal of Nursing Administration Vol.35(3) pp. 146-155

5) Canadian Institute for Health Information 2001, 2002, 2003, 2004 as cited in Spence Laschinger, H. K. et al. (2008) A Profile of the Structure and Impact of Nursing Management in Canadian Hospitals. Healthcare Quarterly 11 (2), 85-94.

6) Canadian Nursing Association (2006) Toward 2020: Visions for Nursing in Association of Registered Nurses of Newfoundland and Labrador (March 2007) Nursing Leadership Literature Review.

7) Cathcart, D. et. al (2004) Span of Control Matters. Journal of Nursing Administration. Vol. 34(9) pp. 395-399

8) Dawson, C. et. al (2005) The Michigan Leadership Model: Developing a Management Infrastructure. Journal of Nursing Administration Vol. (7/8) pp. 342-249

9) Del Bueno, D.J. (1991) Managers: Function and Form in the New Organization as cited in Prince, S. (1997) Shared Governance: Sharing Power and Opportunity. The Journal of Nursing Administration Vol. 27(3) pp. 28-35

10) Doran, D. et.al (2004) Impact of the Manager’s Span of Control on Leadership and Performance. Canadian Health Services Research Foundation.

11) Duffield and Franks (2001) The Role and Preparation of Front-Line First Managers in Australia: Where are we Going and How do we Get There? as cited Meyer, R. (2008) Span of Management; Concept Analysis. Journal of Advanced Nursing Vol. 63(1) pp. 104-112

12) Duxbury, L.; Higgins, C. & Lyons, S. (2010) The Etiology and Reduction of Role Overload in Canada’s Health Care Sector. Retrieved from www.sprott. carleton.ca/news/2010/docs/complete-report.pdf

13) Etzioni, A. (1964) Modern Organizations in McConnell, C. (2005) Larger, Smaller and Flatter: The Evolution of the Modern Health Care Organization. The Health Care Manager Vol. 24(2) pp. 177-188

14) Fayol, H. (1951) General and Industrial Management as cited in Morash, R. (2005) A Span of control Tool for Clinical Managers. Nursing Leadership Vol. 18(3) pp. 83-93

15) Feldman, P.; Bridges, J. & Peng, T. (2007) Team Structure and Adverse Events in Home Health Care. Medical Care Vol.45(6) pp. 553-561

16) Griffiths, P.; Renz, A; Hughes, J. and Rafferty, A.M. (2009) Impact of Organization and Management Factors on Infection Control in Hospitals. Journal of Hospital Infection Vol. 73 pp. 1-14

17) Hattrup, G. P. & Kleiner (1993) How to Establish a Proper Span of Control for Managers in Morash, R. (2005) A Span of control Tool for Clinical Managers. Nursing Leadership Vol. 18(3) pp. 83-93

18) Hay Group (2006) Nurse Leadership: being nice is not enough.

Appendix F: References


19) Hay Group (2008) Leadership Success Factors.

20) Health Canada (2002) Our Health, Our Future Creating Quality Workplaces for Canadian Nurses. Report by Canadian Nursing Advisory Committee

21) Health Force Ontario (July 2007) Interprofessional Care: A Blueprint or Action in Ontario

22) Hechanova, A.R. & Beehr, T. (2001) Empowerment, Span of Control and Safety Performance in Work Teams After Workforce Reduction. Journal of Occupational Health Psychiatry Vol. 6 pp. 275-282

23) Kubica, A. & White, S. (2007) Leading from the Middle: Positioning for Success. American Journal Health System Pharmacists. Vol. 64 pp. 1739-1742

24) Landry, M.; Landry, H. & Hebert, W. (2001) A Tool to Measure Nurse Efficiency and Value. Home Healthcare Nurse Vol. 19 (7) pp. 445-449

25) Laschinger et. al (1999) Leader Behaviour Impact on Nurse Empowerment as cited in Lucas, V.; Laschinger, H.K. & Wong, C. (2008) The Impact of Emotional Intelligent Leadership on Staff Nurse Empowerment: The Moderating effect of Span of Control. Journal of Nursing Management Vol. 16 pp. 964-973

26) Laschinger, H. K. S. (1996) A Theoretical Approach to Studying Work Empowerment in Nursing: A Review of Studies Testing Kanter’s theory of Structural Power in Organizations as cited in Meyer, R. (2008) Span of Management; Concept Analysis. Journal of Advanced Nursing Vol. 63(1) pp. 104-112

27) Layman, E. (2007) Job Redesign and the Health Care Manager. The Health Care Manager Vol. 26(2) pp.98-110

28) Lewis, A. (1993) Too Many Managers: Major Threat in CQI in Hospitals as cited in Lucas, V.; Laschinger, H.K. & Wong, C. (2008) The Impact of Emotional Intelligent Leadership on Staff Nurse Empowerment: The Moderating Effect of Span of Control. Journal of Nursing Management Vol. 16 pp. 964-973

29) Lucas, V.; Laschinger, H.K. & Wong, C. (2008) The Impact of Emotional Intelligent Leadership on Staff Nurse Empowerment: The Moderating Effect of Span of Control. Journal of Nursing Management Vol. 16 pp. 964-973

30) Manion, J. (April 2004) Nurture a Culture of Retention. Nursing Management pp. 29-39

31) McConnell, C. (2005) Larger, Smaller and Flatter: The Evolution of the Modern Health Care Organization. The Health Care Manager Vol. 24(2) pp. 177-188

32) McGillis Hall & Donner (1997) Nurse Staffing as cited in Meyer, R. (2008) Span of Management; Concept Analysis. Journal of Advanced Nursing Vol. 63(1) pp. 104-112

33) Meade, C. Nurse Manager Span of Control and Effectiveness Study. Analytic Research Associates. Charlottesville, Virginia.

34) Meier, K. Bohte, J. (2000) Ode to Uther Gulick: Span of Control and Organizational Performance. Administration and Society. Vol. 32(2) pp. 115-137

35) Meier, K. Bohte, J. (2003) Span of Control and Public Organizations; Implementing Luther Gluick’s Research Design as cited in Meyer, R. (2008) Span of Management; Concept Analysis. Journal of Advanced Nursing Vol. 63(1) pp. 104-112

36) Meyer, R. (2008) Span of Management; Concept Analysis. Journal of Advanced Nursing Vol. 63(1) pp. 104-112

37) Morash, R. (2005) A Span of control Tool for Clinical Managers. Nursing Leadership Vol. 18(3) pp. 83-93

38) McCutcheon, A., et al. (2004) Impact of Manager’s Span of Control on Leadership and Performance as cited in Lucas, V.; Laschinger, H.K. & Wong, C. (2008) The Impact of Emotional Intelligent Leadership on Staff Nurse Empowerment: The Moderating effect of Span of Control. Journal of Nursing Management Vol. 16 pp. 964-973


39) New, N. (2009) Optimizing Nurse Manager Span of Control. Nurse Leader pp. 46-48

40) Nursing Secretariat of Ontario (2010, Winter). Nursing Graduate Guarantee, 1-8.

41) Ontario Ministry of Health Report of the Nursing Task Force (1999) Good Nursing, Good Health: An Investment in the 21st Century as cited in Doran, D. et.al (2004) Impact of the Manager’s Span of Control on Leadership and Performance. Canadian Health Services Research Foundation.

42) Ouchi, W. & Dowling, J.B. (1974) Defining Span of Control as cited in Meyer, R. (2008) Span of Management; Concept Analysis. Journal of Advanced Nursing Vol. 63(1) pp. 104-112

43) Pabst, M.K. (1993) Span of Control on Nursing Inpatient Units Nurse Economics Vol. 11 (2) pp. 87-90

44) Prince, S. (1997) Shared Governance: Sharing Power and Opportunity. The Journal of Nursing Administration Vol. 27(3) pp. 28-35

45) Shaffer (2003) Stepping Beyond “Yesterday thinking”: Preparing Nurse Managers for a New World Order as cited in Meyer, R. (2008) Span of Management: Concept Analysis. Journal of Advanced Nursing. 46) Shirey, M. (1996) Stress and Coping in Nurse Managers: Two Decades of Research Nursing Economics Vol. 24 (4) pp.193-211

47) Shirey, M.; Ebright, P. & McDaniel, A. (2008) Sleepless in America. The Journal of Nursing Administration Vol. 38(3) pp. 125-131

48) Shirey, M.; McDaniel, A.; Ebright, P.; Fisher, M. Doebbeling, B. (2010) Understanding Nurse manager Stress and Work Complexity. The Journal of Nursing Administration Vol. 40(2) pp. 82-91

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