A new report shows that lowering nurse manager span of control improves clinical and financial outcomes.

Amid high burnout and turnover rates, nurse leaders should take a closer look at a key piece of the workforce puzzle: nurse managers.

Nurse managers need time and support from leadership to complete their tasks. According to a report published by the American Organization for Nursing Leadership (AONL) and Laudio, this could be accomplished by lowering span of control.

Span of control refers to the number of employees that nurse managers are in charge of supervising. According to the report, the median span of control for nurse managers is 46 employees, but 25% of all inpatient nurse managers have spans of control higher than 78.

The problem

According to Rudy Jackson, senior vice president and CNE at UW Health and a HealthLeaders Exchange member, nurse managers often have to perform many different duties. As a result, they’re often stretched thin.

"We put so much incredible pressure on our nurse managers to manage finances, culture, patient experience, quality, [and] keep turnover rates [and] length of stay down," Jackson said. "Yet we have all of these things that we put on their shoulders before they're able to get those things done."

Jackson said UW Health is making a significant investment in reducing span of control for nurse leaders. They’re looking at metrics like total headcount per nurse manager vs. how many pilots they are working on, as well as workforce diversity.

Jackson said a recent study has helped the health system understand what “we can eliminate off their plate” to make their jobs easier.

High spans of control also impact turnover rates.

According to the report, managers with higher spans of control face more turnover costs and incremental overtime.

Nurse managers are often swamped with busy work, leaving little time for job development. Jackson said that with more time, nurse managers could develop relationships with their teams, improve quality outcomes, improve the patient experience, and ultimately reduce costs, turnover and vacancy rates.

"What I need are leaders," Jackson said, "and reducing that span of control is going to allow us to move those individuals into a leadership role where they're truly able to guide their teams." 

The solution

The ultimate goal of lowering span of control is to give time back to nurse managers while also keeping costs down.

The report says that a financial case can be made for reducing span of control, when possible, even if it means splitting larger departments into smaller ones. According to the report, leaders should consider reducing or reallocating administrative tasks to offload the nurse manager's burden, while leveraging technology.

Additionally, the report says that giving more time to nurse managers to meaningfully interact with staff lowers RN turnover rates, which in turn lowers hiring costs.  

To Jackson, the answer to this issue will vary depending on the size of a health system and its resources.

"When you look at the control data for an organization like UW Health and you compare us to others, we do have a lot of resources that support our managers," Jackson said.

"It's a matter of trying to understand what exactly are those individual things that are impacting our leaders," Jackson continued, "and how can I leverage technology to offset some of that burden?"

UW Health developed a nurse manager council so that nurse managers have a venue to voice innovative solutions, questions, problems, and concerns. Jackson said UW Health will soon be conducting time studies with managers across the health system to better understand where nurse managers are spending their time.

"One of the solutions I heard recently from a CNE was [that they] give [their] managers a day off once a week, and … in theory, that would work pretty well," Jackson said. "The reality is that the work doesn't stop."

"As CNEs, we need to start thinking about innovative solutions, leveraging technology, offering the appropriate support," Jackson said, "but [doing] so in a manner that doesn't add additional cost to organizations that already exist on razor thin margins."

What about assistant nurse managers?

According to the report, the assistant nurse manager plays a critical role in this strategy.

The study found that 56% of nurse managers are supported by at least one nurse manager. Of that number, 4% of nurse managers have all team members reporting to the assistant nurse manager and 18% share the direct reports, while 78% have all team members as their direct reports, without including the assistant nurse manager.

The report says that RN turnover is lower when assistant nurse managers are part of high span of control teams, which ultimately reduces costs. However, the data also shows that too many assistant managers can become counterproductive and lead to high turnover, possibly because roles are less clear.

Jackson has experienced working in environments with and without assistant nurse managers, and UW Health is now trying something new.

"What we've challenged our team with is start looking within," Jackson said. "What resources do we have internally that can allow us to start to decrease that administrative burden to those managers so that we can get them out of their office and elevate the roles of some of the others?"

UW Health deploys full-time charge nurses called care team leaders (CTLs). Jackson said they are looking at how CTLs can help offload the burden from nurse managers.

UW Health is also leveraging technology to help with administrative burdens.

"We're looking at technology to remove the burden of scheduling," Jackson said. "We've got to be able to put pressure on our IT departments to find those solutions that help nurses and help the organization make our leaders more efficient, [and] support our nurses even better."

In health systems where creating new roles is not possible, Jackson recommended making existing roles more supportive to the nurse managers.

"I think there's a lot of different ways to utilize the assistant manager role," Jackson said, "but I don’t think we need to be stuck with the solution that the assistant manager is the only way we're going to fix the manager span of control."

The old ways of growing the nursing workforce are no longer working, so it’s time for some new strategies.

The greatest challenge facing nursing leaders today is workforce development. Health systems are in dire need of solutions that improve both recruitment and retention.

These challenges come at a time when workplace violence is as prevalent as ever, and burnout is cited as a huge reason for nurse leader turnover. Virtual nursing and other new technologies like AI have also had an impact on the workforce and need to be considered when strategizing.

Here are four ways CNOs can move forward and build a strong, healthy, and happy workforce.

Click here to read the accompanying cover story. 

Geisinger is leveraging virtual nursing technology to improve quality of care. 

On this week’s episode of HL Shorts, we hear from Rebecca Stametz, vice president for digital innovation at Geisinger, about the virtual nursing models at Geisinger. Tune in to hear her insights.

The HealthLeaders Mastermind series is an exclusive series of calls and events with healthcare executives. This Virtual Nursing Mastermind series features ideas, solutions, and insights on excelling your virtual nursing program. Please join the community at our LinkedIn page.

To inquire about participating in an upcoming Mastermind series or attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com.