Span of Control (Final)

Leading Practices for Addressing
Clinical Manager Span of Control in Ontario

February 2011
i
Ontario Hospital Association
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,
identied 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 identies 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 Ofcers, 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 atter
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.
ii
Table of Contents
1.0 Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . 1

2.0 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

3.0 Overview of Literature Findings . . . . . . . . . . . . 7
3.1 Span of Control Dened . . . . . . . . . . . . . . . . . . . . 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 Prole . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
4.4 Staff Prole . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
4.5 Span of Control Impact on Specic
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 Dening 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: Denition,
Key Concepts and Emerging
Themes . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Span of Control Dened . . . . . . . . . . . 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
1
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 ndings 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 signicant downsizing and reform. Many
hospitals were required to make difcult decisions in order
to manage their scal restraints while balancing patient
care needs. One common cost reduction strategy has
been to atten 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
signicantly 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 workers
10
.
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 denitions 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
dened 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 managers
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 identies methods to assess
span of control and the impact of the relationship between
the clinical managers span of control and staff, unit, and
patient outcomes.
2
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/Childrens
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 ndings 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 exibility
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.
3
Organizations identied a number of strategies that
are being implemented that may assist in alleviating the
negative impact of a wide managers 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 identied in
only the hospital sector. Some sample documents can be
found in Appendix E.
Enablers and barriers were identied to support the
strategies, with leadership education being cited by all
three sectors as the most signicant enabler. Other enablers
included communication, staff education, technology,
manager role clarity and a professional practice structure.
Only a few barriers were identied and included staff
accountability, recruitment and manager supports.
Based on ndings of the literature, survey and interviews
the Hay Group has identied key recommendations they
suggest/recommend organizations implement. These
recommendations are grouped in the following categories:
Dening span of control
Leading practices to address span of control
Measuring the impact of span of control
Defning Span of Control
A consistent denition of span of control is required
for monitoring and measuring span of control. The
OHA currently utilizes the denition of span of control
as identied in the OHA-PricewaterhouseCoopers (PwC)
Human Resources Benchmarking Survey. The Hay Group
recommends that the OHA membership use this denition
and that OHA take the lead in gaining consensus for a
consistent denition 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.
Specic recommendations were provided to further guide
the OHA Strategic Human Resources Provincial Leadership
Council and the OHA in next steps and are as follows:
4
RECOMMEnDAtiOnS:
It is recommended that:
(1) The OHA and its members use their current denition
of span of control as identied 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 denition and/or develop a consensus
denition 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/Childrens
Hospital of Eastern Ontario led span of control project
determine criteria and a tool for assessing manager
span of control.
(4) OHA members organizations dene 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.
5
2.0 Introduction
Over the past two decades, healthcare in Canada has
experienced signicant downsizing and reform. Many
hospitals were required to make difcult decisions in order
to manage their scal restraints while balancing patient
care needs. Many organizations chose to atten their
organization structure and reduce managerial positions
in order to retain the maximum number of caregivers
possible
43
. 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 workers
10
.
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 practice
37
.
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 identied elements to include
in a denition 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 identies methods to assess
span of control and the impact of the relationship between
the clinical managers span of control and staff, unit, and
patient outcomes.
The 2002 nal report of the Canadian Nursing Advisory
Committee
20
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 Council
i
, has suggested there is a need for a
practical summary of leading practices, successful strategies
and tools to alleviate the impact of a clinical managers
large span of control.
The Strategic Human Resources Provincial Leadership
Council and the OHA have identied 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 2008-2011
ii
.
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 Ofcer. Membership is made up of 12 hospital leaders
(Chief Executive Ofcers, Chief Human Resource Ofcers, 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 OHAs Provincial Health HR Strategic Plan, go to www.oha.com
under Services/Health Human Resources.

6
The objectives of the study were to:
Summarize key ndings 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.
7
With growing pressure on scal 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 nances, 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 signicantly reduced time for staff
mentorship, motivation, coaching and evaluation.
In this chapter, an overview of ndings from the literature
is presented
iii
. A more detailed account of ndings is
included in Appendix B.

3.1 Span of Control Dened
A scan of the literature reveals that denitions 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 dened 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 denition proposes that span of control is
measured by the number of FTEs under the jurisdiction of
a manager
14
. Similarly, in Altaffers study
2
of two complex
health care organizations, the following denition was
provided; number of people supervised by a manager as
measured by the total number of FTEs.
OHAs Working Defnition of Span of Control
The OHAs working denition of span of control is the
total number of workers reporting to a manager. This
denition is based on the Saratoga US Hospital metrics
denitions which the OHA uses in its HR Benchmarking
survey (see Appendix B span of control dened).
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
organization
2,17,31,36,43
:
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
8
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 workow, 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, qualications, 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 managers span
of control
3.1.2 Ideal Span of Control
Span of control is a multidimensional concept that, as
noted above, is inuenced 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
theory
34
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 theory
13
proposed that
every 5-6 workers needed a rst line supervisor, Del
Bueno and Pabst suggest current management opinion
is that a supervisor could manage between 100 and 200
individuals
9,43
. 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 Control
Although a review of the literature conrms 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
9
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 OHAs Skill Mix: Work and Redesign
Conference (December 2009) includes assessment in three
broad categories which are further broken down into
specic 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 Stafng 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 Patients
A handful of health care specic studies have examined
the impact of span of control on various managerial,
staff and patient dimensions. Factors that are considered
to be inuenced by manager span of control include
communication, employee morale, staff fulllment, 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 ndings.
The research study being led by the University of Western
Ontario and the Childrens 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 nances, operations, human resources
often across multiple clinical areas in a program
management structure. Many managers spend a large
amount of their day coordinating stafng issues, patient
ow and working on committees
8,32,37
. As a result, not
only do they feel increasingly overwhelmed
48
, but they
consequently have little time left for staff development
and quality improvement activities
37,41
(see impact on staff
and patients below). Doran et al.s hallmark study
10
of the
impact of span of control and leadership and performance
10
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 efcient
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, conict
and ambiguity were often identied as sources of stress.
Large SOC was seen as adding complexity to nurse
manager roles
47,48
. The ndings are re-enforced in stress
and coping literature related to the nurse manager role in
the post re-engineering period
46
.
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
undertake
43
.
3.3.1.3 Management and Decision Making
Altaffers study
2
that compared span of control of rst line
nurse managers (large spans of control) with rst 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 scal management, negotiation and conict
management as well as change management.
In fact, studies have shown that even when managers
possess the desired leadership style, their ability to
inuence positive outcomes may be impacted by their
span of control
10
. 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
staff
7,38
.
Feldmans study
15
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
identiable 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 fullled and rewarded
17
. On
the other hand, multi-layered organizations, typically
identied with smaller spans of control, are seen to have
a signicant (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 originated
31
.
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
available
6
. How much time a manager spends interacting
with employees is dependent on other competing demands
and the overall distribution of managerial resources
36
.
Managers who are over extended and have overly wide
spans may limit access to staff and the mentorship that
managers wish to offer
1
.
Growing spans of control limit the attention, support,
clinical supervision and feedback the manager can provide
to an employee often with detrimental impacts.
11
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. Cathcarts study
7
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 inuence
employee perceptions of empowerment
7,29,38
. As
demonstrated in Lucas study
29
of two Ontario community
hospitals, while emotionally intelligent nurse managers
were able to promote empowering work environment, span
of control was a signicant 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 Dorans study
10
of seven
Canadian teaching and community hospitals (51 units),
did not nd span of control to be a predictor of nurses
job satisfaction, it did nd 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
Hechanovas study
22
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. als study
10
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
Grifths review
16
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 nding is consistent with ndings in other
professions. Nurses who reported that reduced access to the
support and resources from nurse managers limited their
ability to provide high quality care
19
.
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, identied and implemented solutions and
monitored outcomes.
12
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 identied 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 identied
the need for clinical infrastructure support and
administrative/operations infrastructure support for
responsibilities that were not identied as key
elements and that could be easily delegated
8
. 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 areas
7
.
There recent work by The Ottawa Hospital relative
to span of control at is referenced only in the Morash
article
37
. High level details regarding the Span of
Control Assessment tool were presented at the OHAs
Skill Mix: Work and Redesign Conference in December
2009. For more information of the Span of Control
Assessment Tool see Appendix B, Table 1. Specic
strategies to mitigate the negative impact of large spans
of control were not cited in either of these references.
13
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 ndings from the survey
is described below. Detailed tables of survey ndings can
be found in Appendix C and an analysis of stakeholder
interview ndings is presented in Section 5.0.
The Span of Control Survey was developed based on
ndings 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 prot, not-for-prot, municipal
etc.) distributed across the ve OHA regions were
utilized as the sample for long-term-care.
For the purposes of the survey distribution, managers
were dened 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
denitions 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 dened
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 rst few sections of the survey including the managers
demographic prole and staff prole were developed to
gain an understanding of the current state analysis of the
various factors contributing to Ontario managers span of
control. Given the complexity of factors that inuence span
of control, the survey did not dene 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 inuenced by manager span of control
include communication, employee morale, staff fulllment,
staff turnover rates as well as patient and staff safety and
satisfaction.
Based on the ndings 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
14
communication
5. Impact on staff injury rates
In the sections that follow, ndings from the survey,
including the overall response rates, organizational and
manager prole and a prole of the staff being supervised
are described. The impact of the span of control on each of
the nine dimensions identied above, as well as strategies
that have been implemented by organizations and their
relative impact are described in detail in the sections below.
All ndings are presented on a sector specic 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 articially skew
ndings. Findings for the manager and staff prole 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 Rates
Given that initial communication regarding participation
in the OHAs 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
Centre
73 79% 10%
Hospital (including
Complex Continuing
Care and Rehab)
627 75% 86%
Long term Care Home 33 37% 5%
15
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%
Womens and Childrens 59 10%
Other Hospital Unit 121 21%
total Managers Responding to
Question
585 nA*
*note: this question allowed respondents to select multiple responses. As such the total ns 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 Culture
Survey respondents were asked to describe their
organizations culture based on four culture types
identied in Duxbury, Higgins and Lyons recent article
12
.
Respondents from Long-Term Care Homes were most
likely to agree or strongly agree that their organizations
supported each of the cultures identied 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 sufcient 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
ndings 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
16
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
ndings 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 ns for the
question when categorized by narrow and wide span of
control do not total the numbers in the earlier exhibits.
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
Sector total n
% Agree or
Strongly Agree
143 37%
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
Sector total n
% Agree or
Strongly Agree
381 37%
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
ns when categorized at this level.

4.3 Manager Prole
Managers were asked to identify whether they had narrow
or wide span of control. As stated earlier, narrow and wide
span of control were not dened 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%.
Reporting narrow and Wide Spans of Control
Reported Span of Control by Sector
Sector total n
narrow Span of
Control
Wide Span
of Control
Centre
63 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.
17
4.3.1 Characteristics of Managers with Wide Span
of Control
As stated previously, while many factors are considered
to inuence a managers span of control, a review of
the literature did not provide a set denition 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 Masters/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. nance/
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%
18
4.3.3 Years in Management
For all three sectors, managers who reported a wide
span of control were more likely to have over ve 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
Sector
narrow 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
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%
19
4.3.5 Manager Supports
The survey ndings 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 nd
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 specically noted the need for clinical
leader positions to be lled 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 identied 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
Supports
37% 52% 40%
Data Manager/Decision Support/
Quality Management
13% 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 Managers
17% 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 Review
3% 1% 0%

20
4.4 Staff Prole
4.4.1 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 resources
36
. Managers who are over extended
and have overly wide spans may limit access to staff and the
mentorship that managers wish to offer
1
.
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
at structures and associated with managers supervising
units in which the employees perform routine tasks with
little variation
27
, or when managers are supervising highly
skilled or specialized staff who have extensive knowledge of
the work and require less supervision
35
(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
Specic Dimensions
A handful of healthcare specic studies have examined
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 ndings.
21
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 specic
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 managers 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 managers
span of control and impact on a specic 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 identied initiatives that they believe are the
most relevant to span of control.
A summary of the overall ndings 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 Specifc 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 Safety
2% 8% 9% 8%
Client/Patient/
Resident
Satisfaction
5% 7% 9% 7%
22
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 Specifc 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 Safety
69% 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
ndings from the survey add to literature ndings 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 specic purposes. A summary of leading practices is
provided in section 6.2.
23
Exhibit 13: initiatives Related to Enhancing the Effectiveness and
Frequency of Communication
Span of Control impact on Communication
Menu of initiatives
CCAC 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, posters
0% 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 meetings
0% 12% 8%
Staff forums/town halls 9% 9% 25%
Phone/Blackberries, tele/Video
conferencing
9% 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 nurse
0% 5% 0%
Performance Appraisals 9% 4% 0%
Appreciation/recognition/team building
days & events
0% 3% 0%
Organizational/program action plan
updates
0% 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 managers 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 managers
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 stafng issues,
patient ow 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.
clinical supervision and feedback that a manager can
provide to an employee often with detrimental impacts.
24
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 managers
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, offce
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
meetings
0% 6% 0%
Revaluate manager involvement in
non-unit meetings and workload
0% 4% 0%
Managerial supports (secretarial,
charge nurse etc.)
0% 3% 0%

CCAC: 2 + years
LtC: 2 + years

4.5.3 Impact on Staff Retention
Interestingly, only hospital managers reporting a wide span
negative impact of their span of control on staff retention
(See Appendix C, exhibit 52).
to higher rates of employee retention, with at least one
Canadian study
10
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).
organizations are provided in exhibit 15 on the next page.
25
Exhibit 15: initiatives Related to Enhancing Staff Retention
Span of Control impact on Staff Retention
Menu of initiatives
CCAC Hospital LtC
n= 9 n= 108 n= 12
Educational opportunities 0% 42% 8%
Manager fexibility (scheduling, work
hours etc.)
11% 21% 33%
Work life balance, wellness activities,
EAP, OD initiatives
0% 20% 8%
Staff appreciation/recognition 44% 19% 33%
new grad/late career initiatives 0% 15% 0%
Culture of safety, respect, code of
conduct
0% 11% 0%
Staff involvement in decision making, unit
councils etc.
33% 11% 0%
Positive feedback, staff empowerment,
leadership opportunities
0% 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
organization
0% 3% 0%
Manageable span of control 0% 2% 0%
Safe working environment, standards of
care
0% 2% 0%
implementing changes suggested
through surveys etc.
0% 2% 0%
Performance/Attendance management 22% 2% 0%
Student placements 0% 2% 0%

CCAC: 1 - 2 years
LtC: 2 + years

It is likely that a managers ability to successfully implement
the following initiatives may be directly impacted by their
span of control:
Manager exibility (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
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).
organizations are provided on the next page.
26
Exhibit 16: initiatives Related to
Enhancing Staff Attendance/Reducing Absenteeism
Span of Control impact on Staff Absenteeism
Menu of initiatives
CCAC Hospital LtC
n= 13 n= 113 n= 8
Attendance management policies and
awareness programs
92% 84% 75%
Work life balance, wellness initiatives,
EAP, Return to work support
0% 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 fexibility and open
communication
0% 3% 0%
Span of Control impacts ability to
follow up with attendance mangement
0% 2% 0%
Performance management 0% 2% 0%
CCAC: 1-2 years
LtC: 2 + years

span of control:
Sharing of data
Manager exibility 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 nding differs from
studies that have found that span of control was positively
correlated to unsafe behaviors and safety accidents
22
(See
Appendix C, exhibit 58).
Two thirds of respondents to this question reported that
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).
organizations are provided below.
Exhibit 17: initiatives Related to Reducing Staff injury
Span of Control impact on Staff injury
Menu of initiatives
CCAC Hospital LtC
n= 10 n= 171 n= 12
Supportive safety equipment,
ergonomic assessments and training
30% 36% 17%
Health/Safety education and training 30% 36% 83%
Staff engagement in problem solving,
safety groups, taskforces
0% 15% 0%
Environmental evaluations and
inspections
30% 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
modifcation
0% 2% 0%
Appropriate staffng 0% 1% 0%
Health and safety committee/reps,
meetings
60% 0% 33%
CCAC: 2+ years
LtC: 2 + years

27
span of control:
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 ndings from the
literature
7
, 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 councils
17% 40% 20%
Opportunity for staff input, staff
involvement
46% 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 successes
4% 13% 0%
Communication and contact with
manager
0% 10% 20%
increased use of it/communication
tools
25% 8% 0%
Patient safety rounds, safety triads 0% 7% 0%
Staff involvement in lean/process
improvement activities
0% 7% 0%
Planning days, team building activities 0% 6% 0%
Engagement opportunities with senior
leadership
0% 5% 0%
informal leadership opportunities/staff
champions
0% 4% 10%
Social activities 8% 4% 0%
Manager access (including open door
policy)
0% 3% 20%
Performance appraisals 0% 1% 0%
CCAC: 1-2 years, 2+ years
LtC: 2 + years

28
span of control:
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
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 nurses job
satisfaction
10
.
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).
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
events
23% 32% 17%
Staff empowerment, input in decision
making
8% 21% 17%
Manager access and timely response
(including open door policy. Visibility,
fexible hours etc.)
8% 14% 17%
Open communication forums, staff
meetings
38% 14% 33%
implementing changes from survey
suggestions
8% 10% 0%
Education support, professional
development opportunities
0% 9% 0%
Social activities 8% 9% 17%
Wellness and work life improvement
initiatives
0% 8% 0%
Manager fexibility (scheduling etc.) 0% 8% 0%
Performance appraisals, opportunity to
connect with managers
0% 5% 0%
Appropriate staffng/workload 0% 3% 0%
Manager-union meetings 8% 0% 0%

LtC: 2 + years
29
span of control:
Staff empowerment, input into decision making
Manager access and timely response
Communication forums/staff meetings
Manager exibility (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 ndings 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.
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 Canadas
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
diffcult
0% 2% 0%
Appropriate staffng 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%

LtC: 2 + years
30
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
negative impact of their span of control on client/resident/
patient satisfaction (See Appendix C, exhibits 70).
These percentages, although small, are consistent with
ndings from Dorans study
10
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.
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).
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 feedback
7% 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
discharge
0% 9% 0%
Patient/family education and
communication
0% 9% 8%
timely follow up of concerns 7% 8% 0%
Patient advocate/patient relations 0% 7% 0%
Reporting and sharing of metrics/
performance
0% 7% 8%
Wait time strategies/processes 0% 4% 0%
Appropriate staffng; Employee skills &
attitudes
0% 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%

LtC: 2 + years
span of control:
Manager rounds/accessibility
Timely follow up of concerns
Incident monitoring and follow up
31
4.6 Summary of Survey Findings
At present, healthcare related literature on span of
control does not clearly dene 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
Masters/PhD. CCAC and hospital managers were also
more likely to have received leadership education
Greater than ve 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 inuenced by manager span of control
include communication, employee morale, staff fulllment,
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 ndings. The
feedback received from the survey support ndings in eight
of nine dimensions explored:
communication
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:
Managers provided examples of using an open door policy
to encourage staff interaction, where possible ensuring
that their ofce 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 nally,
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.
32
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.
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.
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.
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 specic staff recognition
opportunities.
Manager fexibility
Several managers noted the importance of exibility when
interacting with staff. This included exibility in employee
scheduling and work hours as well as specic 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.
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.
33
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 denition 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 nally
evaluation.
In the sections that follow, ndings from the interviews are
described.
5.1 Demographics
The 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
34
Interviewees were asked to describe their organization
structure to provide context to their portfolio composition.
The organization structure identied 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, nancial, human
resources, decision support, clinical educators, leadership
education professional practice leaders, advanced practice
nurses, professional practice councils, patient ow/
navigation, RAI coordinator, after hours on site support
and schedulers.
Community care primarily had nance, 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 ow, 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 dened
the managers span of control as narrow with 20 direct
reports while another senior leader identied the span of
control as wide with 16 direct reports. In the long-term
sector both senior nurse leaders identied their managers
as having a wide span of control with 50 and 100 direct
reports. The hospital sector identied a combination of
narrow and wide manager span of control. The three
hospitals which identied 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 sufcient to evaluate span
of control.The senior nurse leaders identied 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 specically the community care
sector stafng 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 stafng 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.
35
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 Control
Organizations identied a number of strategies that
are being implemented that may assist in alleviating the
negative impact of a wide managers 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 Prole, 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.
36
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 specic 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 ow, staff support and service
recovery. These roles may or may not have responsibility
for scal 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 nancial resources. As well,
the PCMs are responsible for unit planning, implementing
their units 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 prole 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 identied a strong relationship between
manager span of control and employee engagement. As a
result, they added four additional nurse managers to their
structure.
37
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 specic 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 dened 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 specic 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.
38
5.3.2 Full Scope of Practice
Full scope of practice as a strategy was identied in only
the hospital sector and was implemented for a number
of organization reasons, one of them being to support
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 Identied Practices
Other strategies to support manager span of control that
were identied by respondents included:
Implementation of stafng ofce/clerks/central
scheduling to assist the managers with scheduling and
replacement of staff
Development of patient population specic 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
Practices
The review of the literature did not identify specic 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 Control
Enablers were identied by respondents as key strategies
that organizations could undertake to help support
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.
39
In long-term care, one facility provided mandatory
leadership education on-site while another facility provided
nancial assistance for managers to attend leadership
education sessions.
All hospitals supported leadership education for their
managers by either providing on-site education or
providing nancial 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
centres 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 specied 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 stafng) 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
specic to their patient population and have been
successful in attracting new graduates.
40
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 identied as an enabler to the
implementation of the changes in practice within all three
health sectors. Computerized scheduling and payroll were
identied 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 dening 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 identied 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
identied 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 Control
Only 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 identied as being the result of
the signicant 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 identied the need for managers to take a more
proactive role in their own professional and leadership
development.
41
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 identied as not
sufcient in all three health sectors. This nding was also
supported in the survey ndings 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 identied the need for clinical
infrastructure support and administrative supports that
could provide assistance to the manager.
5.7 Evaluation
Half 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 reected 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 identied the benets 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) identied 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.
42
One academic health science centre evaluated the
impact of a decrease in the managers portfolios 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 Findings
Demographically, 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 insufcient 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 identied 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 specic metrics while others reported anecdotal
observations.
Enablers and barriers were identied, 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
43
6.1 Dening Span of Control
The scan of the literature reveals two broad category
denitions 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 denition was utilized. It should
be noted that a consistent denition 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 identied a denition of span of control
in their Human Resources Benchmarking Survey that may be
prudent to use this denition across the three sectors for
consistency in reporting.
RECOMMEnDAtiOnS:
(1) The OHA and its members use their current
denition of span of control as identied in the
OHA-PwC Human Resources Benchmarking Survey for
the purposes of consistency of reporting.
the current OHA-PwC Human Resources
Benchmarking Survey denition and/or develop a
consensus denition of span of control that would
allow for consistency of reporting across all
three sectors.
6.2 Leading Practices to Address
Span of Control
Even 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 ndings 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 identied 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
44
These practices are broader in nature and correspond
more closely to the initiatives identied 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 exibility
Use of Email/Other IT for communication and
accessibility
6.2.1 Assessing Manager Span of Control
The rst 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/Childrens
may be of assistance in estimating the appropriate span of
control and developing a tool to assess manager span of
control.
RECOMMEnDAtiOn:
results of the University of Western Ontario/
Childrens 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 attened 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.
45
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 study
45
, 84% of nurses were
leaving or considering leaving their jobs as a result of their
relationship with their manager.
Research conducted by the Hay Group
18
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 research
19
identies 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/redening 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 identied
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:
(4) OHA members organizations dene and clarify the
role of the manager within their organization to
minimally include:
ensuring managers have adequate authority to
act, and
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 identied in the
interviews included identifying leadership education
opportunities, developing an inter-professional
infrastructure, assessing clinical, clerical and technological
supports.
46
identifying Leadership Education Opportunities
Leadership education has been identied as a key initiative
to support the managers 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 ndings 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 specic 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 identied
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 outcomes
21
.
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
identied as supporting the practice of disciplines, their
specic 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.
47
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 identied 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, stafng and scheduling.
Again, clerical functions, stafng and scheduling can
consume a signicant amount of the managers 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 sufcient 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 identied as an enabler to
streamlining and enhancing key processes which take
up a signicant 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
specic metrics to measure the impact of managers span
of control on staff and patients, the literature does identify
factors that impact various staff and patients dimensions
that are considered to be inuenced by manager span of
control.
The following nine dimensions were identied 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 ndings yielded
a high degree of support with both supporting eight of
the nine dimensions. The one dimension the survey and
interview ndings did not support was impact on staff
injury rates.
Metrics to measure the impact of span of control of
these dimensions were not specically identied in the
survey; however, the interview respondents did identify
metrics their organizations used to evaluate the strategies
implemented.
48
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 ndings, 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:
(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
infection rates)

49
6.4 Future Research
Although 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 specic
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 ndings from studies
conducted by The Ottawa Hospital, Cambridge Memorial
Hospital and University of Western Ontario/Childrens
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/Childrens Hospital of Eastern
Ontario span of control project to its members with
in Ontario academic hospitals as well as the
reliability of the Ottawa Hospital span of control
assessment tool.
50
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 Ofcer
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 Ofcer
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
51
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 denition of span of
control as identied in the OHA-PwC Human
Resources Benchmarking Survey for the purposes of
consistency of reporting.
the current OHA-PwC Human Resources
Benchmarking Survey denition and/or develop a
consensus denition of span of control that would
allow for consistency of reporting across all
three sectors.
results of the University of Western Ontario/Childrens
determine criteria and a tool for assessing manager
span of control.
(4) OHA members organizations dene and clarify the
role of the manager within their organization to
minimally include:
ensuring managers have adequate authority to act,
and
(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
infection rates)
(6) The OHA communicate the results of the University of
Western Ontario/Childrens Hospital of Eastern
Ontario span of control project to its members with
in Ontario academic hospitals as well as the reliability
of the Ottawa Hospital span of control assessment tool.
Appendix A: Recommendations
52
Appendix B: Literature Review: Denition,
Key Concepts and Emerging
Themes
Introduction
With growing pressure on scal 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 nances, 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 signicantly reduced time for staff
mentorship, motivation, coaching and evaluation.
Span of Control Dened
A scan of the literature reveals that denitions 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 resources
42
.
Most typically, span of control has been dened as the
number of people supervised by the manager, i.e. the
number of people assigned to a manager, not the number
of FTEs
7, 38
.
Variations to this denition include the number of workers
that a supervisor can effectively manage/oversee
27,43
and
in the business industry, span of control is broadly dened
as the area of activity, number of functions or subordinates
etc. for which an individual or organization is responsible
36
.
total number of FtEs being supervised by a manager
The alternative denition proposes that span of control is
measured by the number of FTEs under the jurisdiction of
a manager
14
. Similarly, in Altaffers study
2
of two complex
health care organizations, the following denition was
provided number of people supervised by a manager as
measured by the total number of FTEs.
OHAs Working Defnition
The OHA supports the denition of total number of
workers reporting to a manager. Based on the Saratoga
US Hospital Metric denitions, the OHA is using the
following denitions 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 dened as executives
(i.e., the top three (3) tiers of your organizations Canadian
operations (i.e., the CEO, and the next two (2) levels
53
of reports), plus managers (i.e., all employees classied
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:
Dened 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: Dened as
an employee working less than normal full-time hours (as
dened 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 classied as Nurse Manager. Nurse Managers
are dened 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: Dened 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:
Dened as an employee working less than normal full-
time hours (as dened 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.
54
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
organization
2,17,31,36,43
:
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 workow, 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, qualications, 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 managers span
of control.
Ideal Span of Control
Span of control is a complicated phenomenon that, as
noted above, is inuenced 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 role
27
. 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 theory
34

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 theory
13
proposed that every
ve-six workers needed a rst 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/manager
27,44
.
Current management opinion suggests that a supervisor
could manage between 100 and 200 individuals
9,43
. 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:
55
Dorans 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 workers
10
.
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.
Pabsts study
43
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.
Manions research
30
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 managers ability to
incorporate the practices identied above.
Shirey et. als study
48
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 identied as
contributors to manager stress levels.
Cathcarts study
7
on span of control and employee
engagement included managers that had SOC ranging
from ve 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) study
3
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 nally, 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 ndings 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 Patients
Literature 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 staff
1,2,7,28,43,44
. Nancy News 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 at
structures and are associated with managers supervising a
units in which the employees perform routine tasks with
little variation
27
, or when managers are supervising highly
skilled or specialized staff who have extensive knowledge of
the work and require less supervision
35
.
56
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 tasks
27
.
A handful of healthcare specic studies have examined
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 ndings.
The research study being led by the University of Western
Ontario and the Childrens 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 Managers
Over 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 nances, operations, human
resources often across multiple clinical areas in a program
management structure. Many managers spend a large
amount of their day coordinating stafng issues, patient
ow and working on committees
8,32,37
. As a result, not only
do they feel increasingly overwhelmed
48
, but they have little
time left for staff development and quality improvement
activities
37,41
(see impact on staff and patients below). Doran
et al.s hallmark study
10
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 efcient 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, conict
and ambiguity were often identied as sources of stress.
Large SOC was seen as adding complexity to nurse
manager roles
47,48
. The ndings are re-enforced in stress
and coping literature related to the nurse manager role in
the post re-engineering period
46
.
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
communication
17
, and conversely, a narrow span of control
as dened by more levels in the organizational structure
results in more meetings and a more signicant amount of
time spent coordinating these activities
31
. 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 undertake
43
.
57
Management and Decision Making
Altaffers study
2
that compared span of control of rst line
nurse managers (large spans of control) with rst 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 scal management, negotiation and conict
management as well as change management.
In fact, studies have shown that even when managers
possess the desired leadership style, their ability to
inuence positive outcomes may be impacted by their
span of control
10
. 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
staff
7,38
.
Feldmans study
15
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
identiable 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 fullled and rewarded
17
.
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 control
31
. On the other hand, multi-
layered organizations, typically identied with smaller spans
of control, are seen to have a signicant (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 originated
31
.
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
available
6
. How much time a manager spends interacting
with employees is dependent on other competing demands
and the overall distribution of managerial resources
36
.
Managers who are over extended and have overly wide
spans may limit access to staff and the mentorship that
managers wish to offer
1
.
clinical supervision and feedback that managers can
provide to an employee often with detrimental impacts.
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.
Engagement and Empowerment
Several studies address the impact of large spans of control
on employee engagement. Cathcarts study
7
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 inuence
employee perceptions of empowerment
7,29,38
. As
demonstrated in Lucas study
29
of two Ontario
community hospitals, while emotionally intelligent nurse
managers were able to promote an empowering work
environment, span of control was a signicant moderator
of the relationship between nurses perceptions of their
emotionally intelligent behaviors and feelings of workplace
empowerment. Laschinger
26
suggests that employee
empowerment is determined by access to resources,
information, support and opportunity which allow staff to
inuence working conditions positively.
58
Satisfaction and Retention
to higher levels of staff satisfaction and higher rates
of employee retention. While Dorans study
10
of seven
Canadian teaching and community hospitals (51 units),
did not nd span of control to be a predictor of nurses
job satisfaction, it did nd 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.
Manions research
30
that included 26 managers from a
broad array of hospital departments examined critical
factors in nurse retention. Factors identied 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 Meades study
found that for rural hospitals, where nurse managers had
a signicantly higher percentage of mentors, there was
signicantly lower turnover for RNs. The link between
nurse retention and the quality and continuity of care had
already been established in literature. These ndings are
reinforced by nurses who reported that reduced access to
support from their managers negatively impacted their
ability to provide high quality care
25
.
Staff Safety
Hechanovas study
22
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 Patients
Satisfaction
Doran et. als study
10
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
Grifths review
16
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 nding is consistent with
ndings 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
care
25
.
Interestingly, a larger study
33
that examined nurse manager
span of control and effectiveness and included 36 hospitals
and 190 units did not nd many signicant ndings based
on span of control. The authors did report on ndings that
may have been signicant had the sample sizes been larger,
however, ndings 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 dened in the study (one-45 staff, 46-71 staff and
72-152 staff).
Tools to Assess Manager Span
of Control
Although a review of the literature conrms 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
59
The development of the Michigan Leadership Model
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 (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 OHAs Skill
Mix: Work and Redesign Conference includes assessment in
three broad categories which are further broken down
into specic 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 Stafng 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 Control
A review of the literature provides very few case examples of
organizations that recognized the negative impacts of large
spans of control, identied 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 identied 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 identied the need
for clinical infrastructure support and administrative/
operations infrastructure support for responsibilities that
were not identied 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
60
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 specic 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 rates
8
.
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
ndings post implementation of the shared governance
model could perhaps be attributed to unit reorganization,
leadership transition and budget constraints between pre
and post implementation surveys
44
.
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 units
7
.
Other Considerations
Other solutions identied in the literature include obvious
strategies such as increasing management positions to
reduce the number of direct reports and enhancing clerical
support.
Layman
27
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--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.
61
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)
62
63
64
65
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 NM
span of control. Available studies are inconclusive or indicate
that NM leadership style is as important an indicator as the
number of employees supervised.
4
FACTORS INFLUENCING SPAN OF CONTROL
There is no magic ratio for NM span of control. A myriad of
factors involving the nature of the work, the qualities of the
nurse, the attributes of the manager, and organizational char-
acteristics must be considered.
5
The nature of nursing work is knowledge-based and varies
by clinical setting and specialty practice. Variability, turbulence,
and complexity are common characteristics of nursing practice
in todays healthcare environment. Nursing works interdiscipli-
nary nature adds a level of interdependency that complicates
practice. Availability of technology that provides work support
such as feedback systems and artificial intelligence has an impact
on nursing productivity and span of control.
Nursing staff member qualities such as skills, experience,
seniority, qualifications, capabilities, and morale greatly affect the
need for manager involvement. Nurses need and often expect
professional 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 managers capacity
related to span of control.
Key organizational characteristics that influence span of
control are the level of senior leadership support and the
stability of the organization. As with nursing work, the diver-
sity, turbulence, and complexity of the organization has a
significant 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 PYRAMID
Figure 1 is a graphic representation of factors influencing
span of control as they relate to nursing work, nursing
staff, the NM, and the organization (N.N., unpublished
data, 2009). At the top of the pyramid, characteristics that
support a narrow span of control are listed. At the bottom
of the pyramid, factors that are conducive to a broad span
of control are noted.
The number of characteristics to consider is
overwhelming. In the 1960s, industrial businesses attached
numerical values to work characteristics in an attempt to
develop guidelines for the optimal span of control.
6
This
work was simplistic and did not result in meaningful
guides. The sheer number of factors indicates just how
complex the determination of an optimal NM span of
control can be.
A list of frequently asked questions in Table 1 addresses the
key considerations related to NM span of control.
Figure 1. Factors Influencing Span of Control
66
Appendix C: Additional Survey Tables
The following tables provide detailed information for
survey ndings 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
Agree
Agree
neither
Agree nor
Disagree
Disagree
Strongly
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
Sector total n
Strongly
Agree
Agree
neither
Agree nor
Disagree
Disagree
Strongly
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
Sector total n
Strongly
Agree
Agree
neither
Agree nor
Disagree
Disagree
Strongly
Disagree
% Agree
or Strongly
Agree
Care and Rehab)
567 15% 56% 18% 10% 1% 72%

67
Exhibit 25: Percentage of Respondents Reporting a Culture of Balanced Work life

Balanced Worklife Culture by Sector
Sector total n
Strongly
Agree
Agree
neither
Agree nor
Disagree
Disagree
Strongly
Disagree
% Agree
or Strongly
Agree
Community Care Access Centre
66 11% 30% 27% 24% 8% 41%
Care and Rehab)
563 13% 44% 22% 17% 4% 57%
Long term Care Home
29 10% 52% 31% 3% 3% 62%

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
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
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 three
More than
three
total n One two three
More than
three
Centre
22 18% 36% 14% 32% 41 22% 24% 12% 41%
143 43% 29% 10% 17% 381 16% 21% 17% 46%
Long term Care Home 3 33% 67% 0% 0% 26 19% 15% 27% 38%
68
Exhibit 29: Percentage of Managers Reporting Budgetary Responsibility

Budgetary Responsibility by Sector
Sector
Community Care Access Centre 22 41% 41 76%
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 Dollars
1 - 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 Dollars
1 - 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%

69
Exhibit 33: Respondent Education Level of Managers

Respondent Education Level by Sector
Sector
total n Diploma
Bachelors
Degree
Masters
Degree
PhD Other total n Diploma
Bachelors
Degree
Masters
Degree
PhD Other
Centre
22 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%
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%
143 57% 24% 45% 19% 49% 23% 12% 13%
Long term Care Home 3 100% 33% 33% 0% 0% 0% 0% 0%

70
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%
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%

71
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%
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
Both
Other total n
Highly
Skilled/
Specialized
and
Autonomous
Less
Skilled/
Specialized
and Less
Autonomous
Mix of
Both
Other
Centre
22 14% 0% 82% 5% 37 24% 5% 70% 0%
140 33% 4% 63% 1% 369 34% 2% 64% 1%

Exhibit 42: Union Status of Staff Reported by Managers

Union Status of Staff by by Sector
Sector
total n Unionized
non-
unionized
Mix of
Both
Other total n Unionized
non-
unionized
Mix of
Both
Other
Community Care Access Centre 22 82% 0% 14% 5% 37 57% 19% 24% 0%
140 48% 9% 43% 1% 369 44% 8% 48% 0%

72
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
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
73
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 years
1 to 2 years
6 months
to < 1 year
Less than
6 Months
Planned for
implementation
Grand 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
Sector

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
Sector total n Yes
74
Exhibit 51: Percentage Reporting a Positive or Very Positive impact of initiatives on Access to Staff

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
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
Sector

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
Sector total n Yes

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

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

75
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
Sector

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
Sector total n Yes

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

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
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
Sector

76
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
Sector total n Yes

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
Centre
23 43% 35% 13% 9% 0% 100%
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
Sector
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
Sector total n Yes
77
Exhibit 63: Percentage Reporting a Positive or Very Positive impact of initiatives on Staff Engagement

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
Centre
29 41% 41% 3% 14% 0% 100%
239 52% 26% 15% 8% 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
Sector total n Yes

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
Centre
22 59% 36% 0% 5% 0% 100%
215 55% 24% 15% 6% 1% 100%

78
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
Sector total n Yes
Exhibit 69: Percentage Reporting a Positive or Very Positive impact of initiatives on Client/Resident/Patient 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
Centre
28 57% 21% 18% 0% 4% 100%
381 47% 33% 17% 3% 0% 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

79
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
Sector total n Yes
Exhibit 72: Percentage Reporting a Positive or Very Positive impact of initiatives

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
Centre
23 61% 22% 9% 4% 4% 100%
247 55% 29% 13% 3% 1% 100%
80
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
Ofcer, 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
81
E1 Role Prole, 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
82
E1: Role Profle, Patient Care Manager, Sunnybrook Health Sciences Centre
83
84
85
86
87
88
89
90
91
92
93
94
95
Patient
Focus
Access
to care
Coordination
of care
Communication
to patients
and families
Encourage
People
Support Full
Scope of
Practice
Education &
Mentorship
Process
Redesign
Communication
& Coordination
Among
Providers
Ensure
Value
Collaborative
Spirit
Inspire
Innovation
Efficient Care Delivery
Effective Utilization of
Professional Staff
Increase Staff
Support Resources
Foster Interprofessional
Collaboration
Consultations with partners
organizations
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
96
Results - Year 1 Pre/Post Evaluation
Patient Safety
Reduced:
- Patient to patient
transmission of infection by
28%
- 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 teamwork
78%
-Contributes to overall unit
success 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 team
RN (15%) & RPN (5%), and
constant care aids by 65%
($160,000)
- Increase in agency use 6.8%
($1521) and overtime 23%
($23,373)
97
Potential Core Team Compositions
at the Med/Surg Unit Level
PS
PSW
RN
RPN
PCA
RPN
PS
PSW
RN
PCA
RPN
RN
E4: Model of Care Potential Core team Compositions, toronto East General Hospital
Core Team Composition
Critical and Acute Cardiology
RN
RPN
PCA
RPN/
RN*
PS
RN
PCA
RN
RN
RN
*As patient
acuity changes -
staffing adjustment
9 patients
6 Patient
Critical
Cardiac
Care
3 Patients
Acute
Cardiac
Care
11
patients
Acute
Cardiac
Care
98
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 organizations mission, vision and values.

Qualifications:

Current Certificate of Registration with the College of Nurses of Ontario required.
Bachelors Degree in Nursing required, Masters 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.

99
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.
100
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.

101

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E6: Organization Chart, Vice President Acute Care & Chief nursing Executive portfolio,
Windsor Regional Hospital
102

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103
104
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 Prole 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 Managers Span
of Control on Leadership and Performance. Canadian
Health Services Research Foundation.
11) Dufeld 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 Canadas
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) Grifths, 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
105
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 Efciency 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 Kanters 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 Stafng 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 Gluicks
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 Managers
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
106
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 Managers Span of Control
on Leadership and Performance. Canadian Health
Services Research Foundation.
42) Ouchi, W. & Dowling, J.B. (1974) Dening 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.
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Stress and Work Complexity. The Journal of Nursing
Administration Vol. 40(2) pp. 82-91

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