Transformation of The Nurse Leader Paper
Transformation of The Nurse Leader PaperTransformation of The Nurse Leader PaperNurs
Admin Q Vol. 43, No. 3, pp. 230–245 c 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright Reexamining Nurse Manager Span of Control With a 21st-Century Lens Anna
Omery, DNSc, RN, NEA-BC; Cecelia L. Crawford, DNP, RN; Ann Dechairo-Marino, PhD, RN,
NEA-BC; Beverly S. Quaye, EdD, RN, NEA-BC, FACHE; Jim Finkelstein, MBA, BA The primary
aim of this literature review was to examine the quantity, quality, and consistency of
evidence regarding the span of control (SOC) speci?c to nurse managers. A secondary aim
was to meaningfully translate the evidence and offer guidance to 21st-century nurse
leaders. The review results were categorized using Donabedian’s (2003) Structure-Process-
Outcomes model. The Structure-Process-Outcomes approach was used to review the
literature and consider SOC recommendations for today’s health care environment.
Structures outlined the conditions for current SOC, which included material resources,
human resources, and organizational characteristics. Processes were de?ned as activities or
actions stemming from identi?ed structures that led to outcomes. Examples included
management/administrative activities, as well as frontline staff participation in these tasks.
Outcomes were performance measures of human resources, ?nancial, and quality metrics.
The review revealed that an SOC model built on a simplistic full-time employment ratio is
outdated. Yet, nurse managers remain in their role in the face of these simplistic models
despite feelings of inadequacy, exhaustion, and failure because they passionately care about
patients and staff. New attitudes and integration of advanced technologies, pioneering tools
including SOC assessment tools, and ongoing competency developments will result in
different needs of SOC as health care moves deeper into the modern era. This evidence is
offered to inform and drive conversations focused on providing optimal nurse manager SOC
for maximum effectiveness within unique and ever-evolving care environments. Key words:
manager span of control, nurse managers, span of attention, span of authority Author
Af?liations: Clinical Practice (Dr Omery) and Evidence-Based Nursing Practice (Dr
Crawford), Kaiser Permanente Southern California, Regional Patient Care Services,
Pasadena; Providence Holy Cross Medical Center, Mission Hills, California (Dr Dechairo-
Marino); California State University, Fullerton, School of Nursing, College of Health and
Human Development, Fullerton (Dr Quaye); and FutureSense, LLC, San Rafael, California
(Mr Finkelstein). The authors declare they have no con?icts of interest, including ?nancial,
consultant, institutional, and other relationships that might lead to bias or a con?ict of
interest Correspondence: Cecelia L. Crawford, DNP, RN, Evidence-Based Nursing Practice,

Kaiser Perma- B EFORE the restructuring of health care in the 1990s, novice nurses worked
closely with nurse leaders in an “apprenticeship system” that fostered professional
development.1,2 This vital mentoring process facilitated the growth of nursing
professionals. Transformation of The Nurse Leader PaperORDER NOW FOR CUSTOMIZED,
PLAGIARISM-FREE PAPERSHowever, nurse managers’ (NMs’) span of control (SOC)
widened during the turbulent 1990s, with staff nurses spending less nente Southern
California, Patient Care Services, 393 E Walnut St, Pasadena, CA 91188 (Cecelia.L.
Crawford@kp.org). DOI: 10.1097/NAQ.0000000000000351 230 Copyright © 2019 Wolters
Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Reexamining
Nurse Manager Span of Control time with their nurse leaders. The negative effects of
increased SOC continued into the 21st century, with dramatic in?uences on staff
development, job satisfaction, and structural empowerment.1,3-5 Nurse managers have
seen their relationship management/ staff empowerment diminish and job satisfaction
decrease.2,5-7 Ensuring that NMs have reasonable SOCs not only assists in their personal,
leadership, and clinical development but also allows them to empower frontline nurses in
practicing to the full scope of their professional role.2,8,9 Patient outcomes are enhanced by
strong competent nurses at the bedside and in the boardroom. This narrative review of the
literature will present the integration of research, commentary, opportunities, and potential
solutions, with the focus on NMs’ SOC. The impacts of outcomes and correlates, such as the
scope of complexity and leadership style, are also presented. We offer evidence-based
recommendations for nurse executives and other nurse leaders to consider regarding
appropriate SOC and administrative decisions for their organizations. THE REVIEW Review
aim and design The primary aim of the review was to examine the quantity, quality, and
consistency of evidence regarding the SOC phenomenon speci?c to NMs. A secondary aim
was to meaningfully translate the evidence and offer guidance to 21st-century executive
leaders and NMs. Methodology, appraisal, and evidence abstraction Review phases included
creation of clinical and searchable questions and terms; data retrieval; evidence appraisal;
data interpretation and synthesis; and a narrative summary. The review question was
crafted by the Nursing Leadership Council of the Hospital Association of Southern
California.10 A systematic database search structured the review’s sec- 231 ond phase. The
review started in January 2014 and the search was updated until October 2016. The search
yielded 61 relevant articles. Several rounds of review, elimination, and other article
identi?cation resulted in 28 ?nal citations. Evidence evaluation took place during the third
phase, with article ranking and grading. Review articles were examined for more than 4
months during the fourth phase of data abstraction (Table 1). The strength of the evidence
was graded as moderate to high quality (Table 2). Transformation of The Nurse Leader
PaperWe urge nurse leaders to view low to moderate quality evidence as a springboard for
dialogue, innovation, and investigation, rather than an automatic stop.31 Evidence
synthesis and limitations Data analysis and interpretation took place during the ?nal phase
to establish common categories used in the narrative overview, evidence summary, and
recommendations. Result limitations included self-report surveys, mixed response rates,
and variations in participants’ demographics. Ten articles were published by Nursing
Management and may represent article homogeneity. Some articles may not be

generalizable to the United States, as many authors were based in Canada. Finally, the
evidence spans decades, with 1 article from 1988, 5 articles from the 1990s, 15 citations
during the 2000s, and 7 articles published between 2012 and 2013. REVIEW RESULTS We
categorized review results using Donabedian’s (2003) Structure-Process-Outcomes
model.32 We took the model’s concept and adapted it for NM SOC. The Structure-
ProcessOutcomes approach was used to review the literature and consider SOC
recommendations for today’s health care environment. Structures outlined the conditions
for current SOC, which included material resources, human resources (HR), and
organizational characteristics. Processes were de?ned as activities or actions stemming
from identi?ed structures that led to outcomes. Examples Copyright © 2019 Wolters Kluwer
Health, Inc. Unauthorized reproduction of this article is prohibited. Case Study Alidina and
Funke-Furber (1988)12 Altaffer (1998)13 Nonexperimental Design Systematic Review
Grounded Theory Study Armstrong-Stassen and Cameron (2003)3 Brown et al (2013)14
Carney (2004)15 Explore factors known to in?uence NM retention and intention to stay
How organizational structure aligns/impacts with strategic management of NM role
Examine relationship of nurses’ personal, job, and organizational dimensions Examine
organizational and staf?ng on nurse job dissatisfaction, burnout, and quality of care
Discussion of SOC concept, structures, implications, and in?uencing factors Examine FL NM
vs non-NM scope, SOC, and perception of effectiveness Multisite Cross-sectional Survey
Aiken et al (2002)11 Descriptive Survey Design Purpose Evidence Source Reference Table
1. Literature Review References Common concerns were dissatisfaction, burnout, and
quality of care Managerial /adequate staf?ng plays key roles for quality of care, job
dissatisfaction, burnout, and nurse retention Optimal SOC is necessary for NM role and
responsibilities Understanding certain in?uencing factors can optimize NM SOC NMs scored
greater effectiveness than non-NMs, even though they supervise more staff, have fewer
assistive personnel, and paid less Respondents did not rank themselves as highly effective
in any dimension; suggests that unstable care environment contributes to negative
perception of effectiveness Organizational control predicted changes in and trust.
Although nurses reported low organizational control, more than 1 dimension of control is
involved in sense of powerlessness NM retention and intention to stay are multifactorial
Executive leadership is responsible for the of NM in relation to SOC, workload, and
work/life balance issues Transformation of The Nurse Leader PaperHierarchy and
management layers contribute to NM sense of exclusion in strategy development NM must
enable trust and demonstrate leadership by willingness to work in multidisciplinary care
models (continues) Conclusions 232 NURSING ADMINISTRATION QUARTERLY/JULY–
SEPTEMBER 2019 Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized
reproduction of this article is prohibited. Explore relationships between SOC and staff
engagement relationships Examine relationships between NM leadership styles, SOC, and
patient and nurse outcomes Assess nurse retention challenges and strategies, as perceived
by Lebanese NM Performance Improvement Project Descriptive Correlation Survey Design
Descriptive Survey Design Literature Review Descriptive Survey Design Comparative
Descriptive Survey Study Cathcart et al (2004)1 Doran et al (2004)8 El-Jardali et al
(2009)16 Force (2005)4 Hansen et al (1995)17 Johansson et al (2013)18 Examine

differences in self-related health between FL NM and RNs on various psychosocial factors
Examine NM personality traits and staff perceptions of NM leadership Outlines
characteristics of NM leadership style that enhances nurse retention Purpose Evidence
Source Reference Table 1. Literature Review References (Continued) Retention challenges
include salary, shifts, working hours, and better internal and/or external career
opportunities Challenges will continue if aforementioned issues are not addressed More
information is needed on NM SOC and leadership/ management capacities 5 themes:
transformational leadership; transformational leadership; extroverted personality; Magnet
hospital structures; tenure; graduate education Themes demonstrate that leadership traits
lead to nurse job satisfaction and retention Nurses favorably rated NM on leadership style,
power, and in?uence NM personality modestly linked motivation to manage and select
leadership aspects First-line NMs can cope with high-demand situations if they have high
control over their work High degree of job control and managerial allows all nurses to
function in stressful work environments (continues) Transformation of The Nurse Leader
PaperStrong relationship between SOC and employee engagement Routine review of NM
SOC may address negative impact of large SOC on employee engagement No leadership style
can overcome a wide span of control Executive leadership must develop guidelines
regarding number of staff NM can effectively lead and supervise Conclusions Reexamining
Nurse Manager Span of Control 233 Copyright © 2019 Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited. Examine effects of empowerment on
staff perceptions of justice, respect, and trust in management Examine NM leader
empowering behavior to staff perceptions of empowerment, job stress, and work
effectiveness Examine determinants of FL NM job satisfaction Case studies describing the
relationship between empowerment and CQI via concept of SOC Model linking nurse
perceptions of NM emotional intelligence leadership style, structural empowerment, and
impact of NM SOC Nonexperimental Predictive Design Nonexperimental Predictive Design
Systematic Review Expert Opinion Laschinger and Finegan (2005)5Transformation of The
Nurse Leader PaperLaschinger et al (1999)6 Lee and Cummings (2008)20 Lewis21
Nonexperimental Predictive Design Determine how nursing leadership can improve NM
turnover and vacancy rates Performance Improvement Project Jones et al (2012)19 Lucas
et al (2008)2 Purpose Evidence Source Reference Table 1. Literature Review References
(Continued) (continues) Do more, faster: Reduced SOC increases responsiveness, willing to
lead projects, and connecting with ive personnel Staff empowerment a dramatic impact on
NM SOC NMs may not be able to empower their staff if SOC is large, even if they have strong
emotional intelligence Senior management must ensure that NMs have reasonable SOC to
empower staff to full scope of nursing practice and role Highlights importance of NM
leadership traits within changing health care settings NM behaviors impacted perceptions
of formal/informal power and access to empowerment structures Higher perceived access
linked to lower job tensions and increased work effectiveness Addressing SOC, workload,
increased supervisor , and empowerment may in?uence FL NM job satisfaction
Redistribution of operational and administrative resources positively impacted turnover
rates, internal transfers, internal promotions, vacancy rates/days open, NM MSN Evaluation
of scope/SOC can determine operational and administrative tiers needed for NM success

Structural empowerment has direct effect on interactional justice, respect, and
organizational trust NMs have pivotal role in creating/maintaining staff trust Conclusions
234 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2019 Copyright © 2019
Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Nonexperimental Predictive Design Mixed Methods (Retrospective Analysis; Survey Design)
Descriptive Correlational Survey Design Mixed-Methods Study Descriptive Correlational
Survey Design McHugh et al (2013)22 McNeeseSmith (1999)9 Morash et al (2005)23
Patrick and Laschinger (2006)24 Evidence Source McCutcheon et al (2009)7 Reference
Purpose Examine relationship of NM motivation to leadership behaviors, staff job
satisfaction, productivity, organizational commitment, and patient satisfaction
Design/implement SOC tool using evidence, surveys, focus groups, and ?eld testing (Ottawa
Hospital Clinical Management SOC Decision-Making IndicatorsTransformation of The Nurse
Leader PaperTOH tool) Examine relationship between structural empowerment and
organizational and effect on NM role satisfaction Examine relationships between
leadership style, job satisfaction, patient satisfaction, and SOC, moderating effect of SOC as
above Determine whether Magnet hospitals have lower mortality/failure-to-rescue than
non-Magnet hospitals Table 1. Literature Review References (Continued) (continues)
Combination of organizational and empowerment is a signi?cant predictor NM role
satisfaction Perceptions of organizational may play an important role in retaining NM and
attracting future nurse leaders Tool includes 3 decision-making categories (unit, staff,
program-focused) to classify 8 indicators (unit complexity; material management; staff
volume; skill/autonomy; stability; diversity; budgetary; and statistical responsibilities)
Need for standardization, EBP changes, and assessment of roles/responsibilities of entire
nursing group Magnet hospitals had lower mortality/failure-to-rescue odds Better work
environment is a distinguishing factor between Magnet/non-Magnet hospitals and key to
better outcomes Better outcomes partly attributed to investments in quali?ed educated
nurses and environments ive of quality care “Attention of nurses to your condition”
positively correlated with productivity, job satisfaction, organizational commitment, and all
5 leadership practices NM motivation positively correlated with achievement, motivation,
and 5 leadership practices Higher SOC decreased positive effects of transformational/
transactional leadership on outcomes Management by exception and laissez-faire
leadership styles increased negative impacts on job satisfaction Conclusions Reexamining
Nurse Manager Span of Control 235 Copyright © 2019 Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited. Nonexperimental Predictive Survey
Study Mixed Methods (Focus Group; Survey) Wong et al (2012)28 Wong et al (2013)29
Examine combination of FL NM characteristics and SOC of job and unit outcomes Validate
TOH tool and examine relationships between FL NM SOC and manager work outcomes
Review of a research study investigating NM stressors and coping experiences Determine
optimal number of patient rooms in acute care settings Thematic examination of 2004
National Critical Care Survey Findings Report to determine implications for nursing
administrators Purpose Reduce larger units to subunits/clusters ranging 6-12 rooms New
clusters increased nursing engagement when NM SOC averaged 50 or less direct reports 4
themes: leadership, practice environment, staf?ng, and professional advancement and

recognition Leadership is about people and relationships and is transformational Assess
NM SOC and make appropriate changes in structures Monitor the impact of changes in SOC
on unit-based and organizational outcomes Authors allude to 2 areas for needed
intervention: SOC and therapeutic dialogue NM SOC variability is a major threat to NM
ability to achieve work satisfaction, engage staff, and affect organizational commitment
Manageable SOC essential for quality job/unit outcomes Only SOC predicted adverse unit
outcomes Combination of SOC and self-evaluation predicted job satisfaction, work control,
and role overload Neither self-evaluation nor SOC predicted unit turnover NMs report high
role overload/job demands, limited job work, and moderate SOC satisfaction Increasing
system demands contribute to expanded work responsibilities/role overload TOH score
signi?cant indicator of NM job satisfaction, job demands, work contro Transformation of
The Nurse Leader Paper