1 NURSING RESEARCH 83 A Span of Control Tool for Clinical Managers Robin Morash, RN, BNSc, MHS Clinical Manager, Geriatric Assessment Unit and Day Hospital Past Co-chair, Nursing Management Work Group The Ottawa Hospital, Civic Campus Ottawa, ON Janet Brintnell, RN, BScN Clinical Manager, Neonatal Intensive Care Unit Past Secretary, Nursing Management Work Group The Ottawa Hospital Ottawa, ON Ginette Lemire Rodger, RN, BScN, MNAdm, PhD Vice-President, Professional Practice and Chief Nursing Executive The Ottawa Hospital Ottawa, ON Abstract During the second half of the 1990s, healthcare in Canada experienced significant downsizing and reform. One of the consequences of these reorganizations has been a reduction in the number of clinical managers and a significant increase in their span of control, to the point that often their abilities to fulfil their role as clinical managers are hindered (Altaffer 1998; Counsell et al. 2001; Pabst 1993). The first-line manager plays a critical role in the delivery of healthcare, in particular, within nursing services. Therefore, providing support for the professional practice of clinical managers should become a priority.
2 84 Nursing Leadership Volume 18 Number The recent report of the Canadian Nursing Advisory Committee (2002) recommended that reasonable and manageable span of control be examined and assessed by employers to ensure that clinical managers are able to complete assigned functions and be present to meet nurses and patients needs. It is well documented that clinical managers are experiencing a more complex work environment, including advances in technology and informatics, research, increased complexity of patient care, recruitment and retention of multidisciplinary healthcare staff and redesigns of professional practice. These changes are particularly evident in large academic centres. Regardless of the environment, there is variability in managerial roles and responsibilities. This variability has led to questions relating to suitable levels of accountability and methods to measure the appropriateness of the clinical manager s span of control. The Ottawa Hospital (TOH) and its partner organizations operate on five different campuses and have the largest grouping of nurses in Canada. The merger of all these campuses brought together different organizational structures, systems and cultures. The need for standardization, evidence-based practice changes and assessments of the roles and responsibilities of the entire nursing professional group became a priority for the organization. The differences in nursing practice among the campuses led to the recognition that a standardized model of nursing clinical practice was needed to replace the five different existing models: Total Patient Care, Primary Nursing, Team Nursing, Functional Nursing and Case Management. As a part of the model design process, the various nursing roles in the corporation were reviewed and assessed. The Clinical Manager Work Group reviewed the position description and the various spans of control of clinical managers. The group identified the need to develop a tool to describe and measure the factors that affect clinical managerial roles, responsibilities and span of control. The purpose of introducing a tool was to determine whether the spans of control were appropriate. The basis for this decision was not only the number of staff and budget, but also complexity of the unit type. This paper will describe the development and implementation of a span of control assessment tool, issues encountered, processes undertaken and suggestions for future tool development. Literature Review Classical management theorists in the 1950s defined the term span of control as the number of people who report to one manager and can be measured by the number of full-time equivalents (FTEs) under the jurisdiction of a manager (Fayol 1951; Gray 1995). Some authors have suggested that additional elements should be considered as part of the span of control, such as the manager s planning, organizing and leadership functions (Altaffer 1998; Hattrup and Kleiner
3 A Span of Control Tool for Clinical Managers ). In analyzing the span of control of managers, Altaffer (1998) states that one needs to consider the scope of responsibility, including the size and number of units, number of sites, presence of managerial assistance and budgetary responsibility. An industrial perspective from the Lockheed Company offered six factors as being integral elements in an optimal span of control: similarity and complexity of functions, geographic proximity, direction in control, degree of coordination required and complexity of planning for the work (Stieglitz 1962). Other authors have identified fairly broad elements to be considered, such as nature of work, personality of members and congruence of goals. None have offered specific tools that would operationalize these elements (Hattrup and Kleiner 1993). In the literature, the impact of span of control has variously affected delivery of services. Positive impacts of a large span of control include improved communication, greater flexibility and improved employee morale (Hattrup and Kleiner 1993). Hattrup and Kleiner (1993) also conclude that effective delegation of responsibilities and authority to employees helps make their jobs more fulfilling and rewarding. Reduced financial impacts are a benefit to the organizations (Altaffer 1998; Hattrup and Kleiner 1993; Pabst 1993). Negative effects of a large span of control include changes in communication patterns and increases in the number of interactions a manager must undertake (Pabst 1993). The efficacy of frontline managers can be diminished, resulting in decreased job satisfaction for employees and increased turnover rates (Altaffer 1998; Duffield and Franks 2001). Hechanova-Alampay and Beehr (2001) discuss span of control and its correlation to safety issues in an industrial setting. They suggest that a large work group impedes the leader s ability to support the competencies of employees and the required safety management. In spite of the paucity of research in this area, the importance of the topic has been reiterated in the literature, in reports and in the work environment. So what is the appropriate span of control for clinical managers? Unfortunately, no studies were found on what constitutes an appropriate span of control. Trends in private sector industrial settings have been favouring expansion of spans of control (Hattrup and Kleiner 1993). No comparable work has been found in the healthcare literature. In fact, Meighan (1990) suggests that what has happened in the industrial sector is not necessarily comparable to the healthcare setting. There is a need to look at the impact of the large span of control in nursing and its effects on the workforce. In any case, it is imperative that nurse executives be aware of the span of control held by managers within the department for nursing as well as the ratios held by other managers in the institution (Pabst 1993: 90).
4 86 Nursing Leadership Volume 18 Number Method The methods utilized to develop the tool that would capture the span of control of clinical managers included a literature review, surveys, focus groups and field testing. A literature review was carried out using Medline and CINHAL, searching for relevant articles and books, as well as an Internet search from 1990 to The key search words were span of control, clinical manager and manager responsibility. Historical sources prior to 1990 were used as required through the ancestry approach, tracking citations from one source to the other (Cooper 1982). Two surveys were conducted, one with a selected group of hospitals and the second with TOH clinical managers. The hospital survey was carried out to determine whether there was any work in progress on the span of control of first-line managers. A survey was distributed to 22 magnet hospitals in the United States 1 and six Ontario facilities recognized by the provincial government as benchmark hospitals. The survey included three questions addressing the span of control and the scope of practice of a first-line manager: Has your organization standardized the span of control of your frontline clinical managers? What number of units would a frontline manager typically have? How many services would frontline managers typically have? The response rate in the magnet hospital survey was 64% and in the benchmark hospitals was 67%. The results revealed that none of the surveyed facilities had a standardized span of control for front-line managers, and the number of units and services under the clinical manager s responsibility varied greatly. To assist in the design of a tool and to determine the elements that should be included in a span of control tool, a survey of TOH clinical managers was conducted. The elements selected to construct the tool came from the literature on the topic. The first part of the survey addressed questions relating to the size of the unit, number of units managed, number of staff, size of budget and availability of organizational support. The second part addressed questions relating to time spent on major areas of responsibility. The response rate was 51%, and the results revealed very different scopes of responsibility. Although scope of responsibility varied, a consistent pattern was observed. The majority of managers surveyed spent much of their time coordinating staffing issues, coordinat- 1. A magnet hospital is a facility for nursing excellence accredited by the American Nursing Credentialing Center.
5 A Span of Control Tool for Clinical Managers 87 ing patient flow and working on committees. There was very little time left for staff development, CQI activities and performance appraisals. The results of the managers survey and the review of the literature guided the Clinical Management Work Group in the development of a tool that includes three key categories and their relevant indicators. A focus group with clinical managers was held regarding the initial draft. Changes to the span of control tool were made and followed by another focus group. With this initial draft and subsequent drafts of the tool, two consecutive focus groups were held with clinical managers. A consensus was reached that the indicators chosen were relevant when considering a span of control tool. The final draft was presented to a larger consultative group consisting of clinical directors, nurse educators, advanced practice nurses and nursing professional practice department members. The tool was then finalized and field-tested, using the last 12 months of operation on each unit. Several managers utilized the tool to identify their own span of control in order to verify its effectiveness. The consensus reached at both the focus groups and the field-testing phase represented expert opinion. Tool Presentation The design of the span of control tool is based on a framework of the existing Model of Nursing Clinical Practice Staff Mix Guide tool (Ottawa Hospital Nursing Professional Practice 2002) developed by the Model of Nursing Clinical Practice Work Group. The Clinical Management Span of Control Decision- Making Indicator tool (Appendix 1) includes three decision-making categories used to classify eight indicators. These three categories are unit-, staff- and program-focused. The unit-focused category includes two indicators: complexity of the unit and material management. Complexity of the unit is measured through the following variables: hours of operation, unpredictability, high patient turnover, risk of litigation and number of adverse incidents. The five material management variables are time spent dealing with specialized equipment, maintenance and replacement, purchasing, vendor interactions and quality monitoring. Four indicators are outlined under the staff-focused category. These are volumes of staff directly reporting to the clinical manager, skill/autonomy of staff, staffing stability and diversity of staff. The skill/autonomy indicator and staffing stability require additional variables to complete the assessment. The skill/autonomy indicator includes percentage of novice nurses and percentage of non-professional staff, while the staffing stability indicator includes turnover rates and absenteeism. The final category, program-focused, has two indicators that measure the diver-
6 88 Nursing Leadership Volume 18 Number sity of the units: budgetary and statistical responsibilities. Diversity of the unit variables are defined as the number of directors, VPs and portfolios the manager reports to, the number of designated services requiring regular meetings with chiefs and the overall number of units for which the manager is responsible. Budgetary and statistical responsibilities look at the total size of the budgets for all the units that a manager oversees. Measurement of Variables The Model of Nursing Clinical Practice Staff Mix Guide tool also assisted the working group in categorizing the weight of each variable. Using the information from the survey of TOH clinical managers, each variable was categorized as low, medium or high, using TOH current data. For example, responses from the survey indicted that the range of managed budgets went from $500,000 to $11 million. Therefore, a budget of less than $2 million was weighted as low, $2 4 million was weighted as medium and more than $4 million was weighted as high. The consensus was that there should be a further numerical weighting added to the tool to distinguish between the scope of responsibility of each manager. The numerical weights were arbitrarily set following numerous discussions by the members of the work group. The low, medium and high titles were given the respective numerical values of 1, 2 and 3 points. Each variable was then given an additional numerical weight derived from collective experience of the members of the work group. Low, medium and high points were then multiplied by the additional numerical weight to give a final value to the variable. The tool was then field-tested on 20 diverse units. The consensus was that the results reflected the current span of control and adequately differentiated the diverse scopes of responsibility. As a result, the tool was received by the larger group of managers and was approved and implemented. Limitations One of the limitations of the tool is the arbitrarily assigned weight of each variable and the coarseness of the categorization. Although it was field-tested, studies should be done to establish the tool s validity, reliability and generalizability, and it should be tested in other healthcare settings. Conclusion Our decision to address the span of control of the clinical manager stemmed from an identified need as a new model of nursing clinical practice was considered at TOH. The literature indicates that there has been very little work carried out on the effects of managerial span of control. Pabst (1993: 90) states that an underlying issue that has not been addressed is the question of an optimal span
7 A Span of Control Tool for Clinical Managers 89 of control. In order to move toward an optimal span of control, the first step is to develop a comprehensive tool, the second step to validate the tool and the last step to identify an optimal span. In the tool development at TOH, the indicators and variables were well substantiated from both the available literature and rounds of consultation with clinical managers. The tool is a decision aid to be used when assessing the expanding roles of the clinical managers. It represents a starting point for managers in assessing their span of control. The tool has not been prescriptive, but it has aided in examining various issues that have arisen over time. A yearly review of a manager s span of control would ensure that ongoing changes are captured. Further testing is required to validate the tool and to verify the robustness of the categorization and weights. Correspondence should be directed to: Robin Morash, The Ottawa Hospital, Civic Campus; References Altaffer, A First-Line Managers: Measuring Their Span of Control. Nursing Management 29(7): Canadian Nursing Advisory Committee Our Health, Our Future: Creating Quality Workplaces for Canadian Nurses. Ottawa: Health Canada. Cooper, H.M Scientific Guidelines for Conducting Integrative Research Reviews. Review of Educational Research 52(2): Counsell, C.M., M. Gilbert and J. McCain The Evolving Role of the Nurse Manager. Journal of Nursing Administration 31(2): 52. Duffield, C. and H. Franks The Role and Preparation of First-Line Managers in Australia: Where Are We Going and How Do We Get There? Journal of Nursing Management 9(2): Fayol, H General and Industrial Management. New York: Harper and Row. Gray, S.P Leaner Management Structures Prepare Hospitals for Change. Healthcare Strategic Management 13(3): Hattrup, G.P. and B.H. Kleiner How to Establish the Proper Span of Control for Managers. Industrial Management 35(6): Hechanova-Alampay, R., and T. Beehr Empowerment, Span of Control, and Safety Performance in Work Teams after Workforce Reduction. Journal of Occupational Health Psychology 6(4): Meighan, M.M The Most Important Characteristics of Nursing Leaders. Nursing Administration Quarterly 15(1): The Ottawa Hospital Nursing Professional Practice, Model of Nursing Clinical Practice Toolbook. Unpublished manuscript. Pabst, M.K Span of Control on Nursing Inpatient Units. Nursing Economics 11(2): Stieglitz, H Optimizing Span of Control. Management Record 24:
8 90 Nursing Leadership Volume 18 Number Appendix 1 TOH Clinical Management Span of Control Decision-Making Indicators This tool is designed to assist in weighing the span of control for Clinical Managers. Span of control is defined as control of managers based on the number, skill, stability and diversity of staff; the complexity of the unit(s); and the budget and diversity of the program for which the manager is responsible. The following table is an overview of the indicators used in this tool. Please proceed to page 2 for ranking of each of the individual indicators. UNIT-FOCUSED Complexity Low Medium High Material Management Low Medium High STAFF-FOCUSED Volume of Staff Skill Level/ Staffing Stability Diversity of Staff Autonomy of Staff Low Low Low Low Medium Medium Medium Medium Med. High High High High High PROGRAM-FOCUSED Diversity Low Medium High Budget/Statistical Low Medium High Please circle a value of high, medium or low for each indicator, based on the corresponding definitions. Then multiply the point for that value times the weight to provide a total. Then add up all of the totals for each indicator and place your grand total on page 5. Example: For hours of operation, if a unit is open 24/7 then you would circle high and multiply 3 points times a weighting of 2 for a total of 6. If a manager has 2 units and one is 24/7 and one are weekdays only, you would choose the higher rating. UNIT-FOCUSED INDICATORS Complexity Hours of operation Unpredictability High patient turnover Risk of litigation No. incidents
9 A Span of Control Tool for Clinical Managers 91 Hours of Operation Definition of Level Point Weight Total Low Weekdays only, Medium Extended hours 2 2 High 24/7 (services available, 3 2 including standby) Unpredictability Definition of Level Point Weight Total Low Never or rarely (0 1 /wk) have 1 3 reassignment of staff on a shift. Medium Sometimes (2 5 /wk) have 2 3 reassignment of staff on a shift. High Frequently (>5 /wk) have 3 3 reassignment of staff on a shift. Unit Capacity Definition of Level Point Weight Total Low Never or rarely (0 1 /wk) exceeds 1 2 the capacity of the department/unit. Medium Sometimes (2 5 /wk) exceeds the 2 2 capacity of the department/unit. High Frequently (>5 /wk) exceeds the 3 2 capacity of the department/unit. Actual Litigation Definition of Level Point Weight Total Low All other units 1 2 Medium Surgical units, OR, Emerg., PACU 2 2 High Obstetrics 3 2 Risk Management Definition of Level Point Weight Total Low <2.5 hrs/wk 1 2 Medium hrs/wk 2 2 High >5.5 hrs/wk 3 2 Risk management is defined as time spent on actual or preventative activities including CQI, comment cards, patient complaints, incident reports, quality assurance, etc. Material Management Units with specialized equipment Units with a large amount of equipment Time taken to deal with vendors, maintenance, replacement, ensuring completeness Material Management Definition of Level (% of time) Point x Weight Total Low <4 hrs/wk 1 2 Medium 4 8 hrs/wk 2 2 High >8 hrs/wk 3 2
10 92 Nursing Leadership Volume 18 Number STAFF-FOCUSED INDICATORS Volume of Staff No. staff directly reporting to Clinical Manager Volume of Staff Definition of Level Point Weight Total Low < Medium Medium-High High > Skill Level/Autonomy of Staff Experience (% of novice nurses) % of non-professional staff % of Novice Nurses Definition of Level (%) Point Weight Total Low <5 1 3 Medium High > A novice nurse is defined as a new grad or a nurse new to a particular unit or as defined as novice by Benner. % of Non-professional Staff Definition of Level (%) Point Weight Total Low < Medium High > Staffing Stability Turnover rate Absenteeism Turnover Rate Definition of Level (no. of new hires/yr) Point Weight Total Low < Medium High > Absenteeism Definition of Level Point Weight Total (no. staff above hospital average) Low Medium High >14 3 2
11 A Span of Control Tool for Clinical Managers 93 Diversity of Staff No. categories of staff directly reporting to Clinical Manager Diversity of Staff Definition of Level Point Weight Total Low Medium High >6 3 2 PROGRAM-FOCUSED INDICATORS Diversity No. directors, VPs and portfolios to report to No. designated services r/t regular meetings with chiefs, departments No. units No. Directors Definition of Level Point Weight Total Medium High >1 3 2 No. Designated Services Definition of Level Point Weight Total Medium High >2 3 3 No. Units* Definition of Level Point Weight Total Medium High >1 4 4 For those managers who have >1 unit spread across the campus(es) and not side by side, please add an additional 2 points to your total for no. units. *Regional programs are considered a unit Budget/Statistical Total size of budget for all units combined Budget Definition of Level ($ million) Point Weight Total Low <2 1 2 Medium High >4 3 2 Grand Total Support All these factors are based on the assumption that ESP support will be standardized and that the Educational Span of Coverage is in place and all units have standardized educational support. Scoring: The total score is out of a possible 130 points Span of control is below acceptable, capable of growth Appropriate span of control Excessive span of control; requires assistance