NURSING RESEARCH

A Span of Control Tool for Clinical

Managers
Robin Morash, RN, BNSc, MHS
Clinical Manager, Geriatric Assessment Unit and Day Hospital
Past Co-chair, Nursing Management Work Group
The Ottawa Hospital, Civic Campus
Ottawa, ON

Janet Brintnell, RN, BScN

Clinical Manager, Neonatal Intensive Care Unit
Past Secretary, Nursing Management Work Group
The Ottawa Hospital
Ottawa, ON

Ginette Lemire Rodger, RN, BScN, MNAdm, PhD

Vice-President, Professional Practice and Chief Nursing Executive
The Ottawa Hospital
Ottawa, ON

Abstract
During the second half of the 1990s, healthcare in Canada experienced significant
downsizing and reform. One of the consequences of these reorganizations has been a
reduction in the number of clinical managers and a significant increase in their span of
control, to the point that often their abilities to fulfil their role as clinical managers are
hindered (Altaffer 1998; Counsell et al. 2001; Pabst 1993). The first-line manager plays
a critical role in the delivery of healthcare, in particular, within nursing services.
Therefore, providing support for the professional practice of clinical managers should
become a priority.

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The recent report of the Canadian Nursing Advisory Committee (2002) recommended that reasonable and manageable span of control be examined and
assessed by employers to ensure that clinical managers are able to complete
assigned functions and be present to meet nurses and patients needs. It is well
documented that clinical managers are experiencing a more complex work environment, including advances in technology and informatics, research, increased
complexity of patient care, recruitment and retention of multidisciplinary
healthcare staff and redesigns of professional practice. These changes are particularly evident in large academic centres. Regardless of the environment, there is
variability in managerial roles and responsibilities. This variability has led to
questions relating to suitable levels of accountability and methods to measure the
appropriateness of the clinical managers span of control.
The Ottawa Hospital (TOH) and its partner organizations operate on five different campuses and have the largest grouping of nurses in Canada. The merger of
all these campuses brought together different organizational structures, systems
and cultures. The need for standardization, evidence-based practice changes and
assessments of the roles and responsibilities of the entire nursing professional
group became a priority for the organization. The differences in nursing practice
among the campuses led to the recognition that a standardized model of nursing clinical practice was needed to replace the five different existing models: Total
Patient Care, Primary Nursing, Team Nursing, Functional Nursing and Case
Management.
As a part of the model design process, the various nursing roles in the corporation were reviewed and assessed. The Clinical Manager Work Group reviewed
the position description and the various spans of control of clinical managers.
The group identified the need to develop a tool to describe and measure the
factors that affect clinical managerial roles, responsibilities and span of control.
The purpose of introducing a tool was to determine whether the spans of control
were appropriate. The basis for this decision was not only the number of staff and
budget, but also complexity of the unit type. This paper will describe the development and implementation of a span of control assessment tool, issues encountered, processes undertaken and suggestions for future tool development.
Literature Review
Classical management theorists in the 1950s defined the term span of control
as the number of people who report to one manager and can be measured by
the number of full-time equivalents (FTEs) under the jurisdiction of a manager
(Fayol 1951; Gray 1995). Some authors have suggested that additional elements
should be considered as part of the span of control, such as the managers planning, organizing and leadership functions (Altaffer 1998; Hattrup and Kleiner

A Span of Control Tool for Clinical Managers

1993). In analyzing the span of control of managers, Altaffer (1998) states that
one needs to consider the scope of responsibility, including the size and number
of units, number of sites, presence of managerial assistance and budgetary
responsibility. An industrial perspective from the Lockheed Company offered six
factors as being integral elements in an optimal span of control: similarity and
complexity of functions, geographic proximity, direction in control, degree of
coordination required and complexity of planning for the work (Stieglitz 1962).
Other authors have identified fairly broad elements to be considered, such as
nature of work, personality of members and congruence of goals. None have
offered specific tools that would operationalize these elements (Hattrup and
Kleiner 1993).
In the literature, the impact of span of control has variously affected delivery of
services. Positive impacts of a large span of control include improved communication, greater flexibility and improved employee morale (Hattrup and Kleiner
1993). Hattrup and Kleiner (1993) also conclude that effective delegation of
responsibilities and authority to employees helps make their jobs more fulfilling and rewarding. Reduced financial impacts are a benefit to the organizations
(Altaffer 1998; Hattrup and Kleiner 1993; Pabst 1993). Negative effects of a large
span of control include changes in communication patterns and increases in the
number of interactions a manager must undertake (Pabst 1993). The efficacy of
frontline managers can be diminished, resulting in decreased job satisfaction for
employees and increased turnover rates (Altaffer 1998; Duffield and Franks 2001).
Hechanova-Alampay and Beehr (2001) discuss span of control and its correlation to safety issues in an industrial setting. They suggest that a large work group
impedes the leaders ability to support the competencies of employees and the
required safety management.
In spite of the paucity of research in this area, the importance of the topic has
been reiterated in the literature, in reports and in the work environment. So what
is the appropriate span of control for clinical managers?
Unfortunately, no studies were found on what constitutes an appropriate span of
control. Trends in private sector industrial settings have been favouring expansion
of spans of control (Hattrup and Kleiner 1993). No comparable work has been
found in the healthcare literature. In fact, Meighan (1990) suggests that what has
happened in the industrial sector is not necessarily comparable to the healthcare
setting. There is a need to look at the impact of the large span of control in nursing and its effects on the workforce. In any case, it is imperative that nurse executives be aware of the span of control held by managers within the department
for nursing as well as the ratios held by other managers in the institution (Pabst
1993: 90).

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Method
The methods utilized to develop the tool that would capture the span of control
of clinical managers included a literature review, surveys, focus groups and field
testing.
A literature review was carried out using Medline and CINHAL, searching for
relevant articles and books, as well as an Internet search from 1990 to 2003. The
key search words were span of control, clinical manager and manager responsibility. Historical sources prior to 1990 were used as required through the ancestry
approach, tracking citations from one source to the other (Cooper 1982).
Two surveys were conducted, one with a selected group of hospitals and the
second with TOH clinical managers. The hospital survey was carried out to determine whether there was any work in progress on the span of control of first-line
managers. A survey was distributed to 22 magnet hospitals in the United States1
and six Ontario facilities recognized by the provincial government as benchmark
hospitals. The survey included three questions addressing the span of control and
the scope of practice of a first-line manager:
Has your organization standardized the span of control of your frontline
clinical managers?
What number of units would a frontline manager typically have?
How many services would frontline managers typically have?
The response rate in the magnet hospital survey was 64% and in the benchmark
hospitals was 67%. The results revealed that none of the surveyed facilities had
a standardized span of control for front-line managers, and the number of units
and services under the clinical managers responsibility varied greatly.
To assist in the design of a tool and to determine the elements that should
be included in a span of control tool, a survey of TOH clinical managers was
conducted. The elements selected to construct the tool came from the literature
on the topic. The first part of the survey addressed questions relating to the size
of the unit, number of units managed, number of staff, size of budget and availability of organizational support. The second part addressed questions relating
to time spent on major areas of responsibility. The response rate was 51%, and
the results revealed very different scopes of responsibility. Although scope of
responsibility varied, a consistent pattern was observed. The majority of managers surveyed spent much of their time coordinating staffing issues, coordinat1. A magnet hospital is a facility for nursing excellence accredited by the American Nursing
Credentialing Center.

A Span of Control Tool for Clinical Managers

ing patient flow and working on committees. There was very little time left for
staff development, CQI activities and performance appraisals. The results of the
managers survey and the review of the literature guided the Clinical Management
Work Group in the development of a tool that includes three key categories and
their relevant indicators.
A focus group with clinical managers was held regarding the initial draft. Changes
to the span of control tool were made and followed by another focus group. With
this initial draft and subsequent drafts of the tool, two consecutive focus groups
were held with clinical managers. A consensus was reached that the indicators
chosen were relevant when considering a span of control tool. The final draft
was presented to a larger consultative group consisting of clinical directors, nurse
educators, advanced practice nurses and nursing professional practice department
members. The tool was then finalized and field-tested, using the last 12 months
of operation on each unit. Several managers utilized the tool to identify their own
span of control in order to verify its effectiveness. The consensus reached at both
the focus groups and the field-testing phase represented expert opinion.
Tool Presentation
The design of the span of control tool is based on a framework of the existing Model of Nursing Clinical Practice Staff Mix Guide tool (Ottawa Hospital
Nursing Professional Practice 2002) developed by the Model of Nursing Clinical
Practice Work Group. The Clinical Management Span of Control DecisionMaking Indicator tool (Appendix 1) includes three decision-making categories used to classify eight indicators. These three categories are unit-, staff- and
program-focused.
The unit-focused category includes two indicators: complexity of the unit and
material management. Complexity of the unit is measured through the following
variables: hours of operation, unpredictability, high patient turnover, risk of litigation and number of adverse incidents. The five material management variables
are time spent dealing with specialized equipment, maintenance and replacement,
purchasing, vendor interactions and quality monitoring.
Four indicators are outlined under the staff-focused category. These are volumes
of staff directly reporting to the clinical manager, skill/autonomy of staff, staffing
stability and diversity of staff. The skill/autonomy indicator and staffing stability
require additional variables to complete the assessment. The skill/autonomy indicator includes percentage of novice nurses and percentage of non-professional
staff, while the staffing stability indicator includes turnover rates and absenteeism.
The final category, program-focused, has two indicators that measure the diver-

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sity of the units: budgetary and statistical responsibilities. Diversity of the unit
variables are defined as the number of directors, VPs and portfolios the manager
reports to, the number of designated services requiring regular meetings with
chiefs and the overall number of units for which the manager is responsible.
Budgetary and statistical responsibilities look at the total size of the budgets for
all the units that a manager oversees.
Measurement of Variables
The Model of Nursing Clinical Practice Staff Mix Guide tool also assisted the
working group in categorizing the weight of each variable. Using the information from the survey of TOH clinical managers, each variable was categorized as
low, medium or high, using TOH current data. For example, responses from the
survey indicted that the range of managed budgets went from $500,000 to $11
million. Therefore, a budget of less than $2 million was weighted as low, $24
million was weighted as medium and more than $4 million was weighted as high.
The consensus was that there should be a further numerical weighting added
to the tool to distinguish between the scope of responsibility of each manager.
The numerical weights were arbitrarily set following numerous discussions by
the members of the work group. The low, medium and high titles were given the
respective numerical values of 1, 2 and 3 points. Each variable was then given an
additional numerical weight derived from collective experience of the members
of the work group. Low, medium and high points were then multiplied by the
additional numerical weight to give a final value to the variable.
The tool was then field-tested on 20 diverse units. The consensus was that the
results reflected the current span of control and adequately differentiated the
diverse scopes of responsibility. As a result, the tool was received by the larger
group of managers and was approved and implemented.
Limitations
One of the limitations of the tool is the arbitrarily assigned weight of each variable and the coarseness of the categorization. Although it was field-tested, studies
should be done to establish the tools validity, reliability and generalizability, and
it should be tested in other healthcare settings.
Conclusion
Our decision to address the span of control of the clinical manager stemmed
from an identified need as a new model of nursing clinical practice was considered at TOH. The literature indicates that there has been very little work carried
out on the effects of managerial span of control. Pabst (1993: 90) states that an
underlying issue that has not been addressed is the question of an optimal span

A Span of Control Tool for Clinical Managers

of control. In order to move toward an optimal span of control, the first step is to
develop a comprehensive tool, the second step to validate the tool and the last step
to identify an optimal span. In the tool development at TOH, the indicators and
variables were well substantiated from both the available literature and rounds
of consultation with clinical managers. The tool is a decision aid to be used
when assessing the expanding roles of the clinical managers. It represents a starting point for managers in assessing their span of control. The tool has not been
prescriptive, but it has aided in examining various issues that have arisen over
time. A yearly review of a managers span of control would ensure that ongoing
changes are captured. Further testing is required to validate the tool and to verify
the robustness of the categorization and weights.
Correspondence should be directed to: Robin Morash, The Ottawa Hospital, Civic Campus; e-mail:
rmorash@ottawahospital.on.ca.

References
Altaffer, A. 1998. First-Line Managers:
Measuring Their Span of Control. Nursing
Management 29(7): 3640.

Meighan, M.M. 1990. The Most Important

Characteristics of Nursing Leaders. Nursing
Administration Quarterly 15(1): 6369.

Canadian Nursing Advisory Committee. 2002.

Our Health, Our Future: Creating Quality
Workplaces for Canadian Nurses. Ottawa: Health
Canada.

The Ottawa Hospital Nursing Professional

Practice, 2002. Model of Nursing Clinical
Practice Toolbook. Unpublished manuscript.

Cooper, H.M. 1982. Scientific Guidelines for

Conducting Integrative Research Reviews.
Review of Educational Research 52(2): 291302.
Counsell, C.M., M. Gilbert and J. McCain. 2001.
The Evolving Role of the Nurse Manager.
Journal of Nursing Administration 31(2): 52.
Duffield, C. and H. Franks. 2001. The Role and
Preparation of First-Line Managers in Australia:
Where Are We Going and How Do We Get
There? Journal of Nursing Management 9(2):
8791.
Fayol, H. 1951. General and Industrial
Management. New York: Harper and Row.
Gray, S.P. 1995. Leaner Management Structures
Prepare Hospitals for Change. Healthcare
Strategic Management 13(3): 1415.
Hattrup, G.P. and B.H. Kleiner. 1993. How
to Establish the Proper Span of Control for
Managers. Industrial Management 35(6): 2829.
Hechanova-Alampay, R., and T. Beehr. 2001.
Empowerment, Span of Control, and Safety
Performance in Work Teams after Workforce
Reduction. Journal of Occupational Health
Psychology 6(4): 27582.

Pabst, M.K. 1993. Span of Control on Nursing

Inpatient Units. Nursing Economics 11(2):
8790.
Stieglitz, H. 1962. Optimizing Span of Control.
Management Record 24: 2529.

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Appendix 1
TOH Clinical Management Span of Control Decision-Making Indicators
This tool is designed to assist in weighing the span of control for Clinical Managers.
Span of control is defined as control of managers based on the number, skill, stability and diversity
of staff; the complexity of the unit(s); and the budget and diversity of the program for which the
manager is responsible.
The following table is an overview of the indicators used in this tool. Please proceed to page 2 for
ranking of each of the individual indicators.
UNIT-FOCUSED
Complexity
Low
Medium
High
STAFF-FOCUSED
Volume of Staff
Low
Medium
Med.High
High
PROGRAM-FOCUSED
Diversity
Low
Medium
High

Material Management
Low
Medium
High

Skill Level/
Autonomy of Staff
Low
Medium

Staffing Stability

Diversity of Staff

Low
Medium

Low
Medium

High

High

High

Budget/Statistical
Low
Medium
High

Please circle a value of high, medium or low for each indicator, based on the corresponding definitions. Then multiply the point for that value times the weight to provide a total. Then add up all of
the totals for each indicator and place your grand total on page 5.
Example: For hours of operation, if a unit is open 24/7 then you would circle high and multiply
3 points times a weighting of 2 for a total of 6. If a manager has 2 units and one is 24/7 and one
are weekdays only, you would choose the higher rating.

UNIT-FOCUSED INDICATORS
Complexity
Considerations:
Hours of operation
Unpredictability
High patient turnover
Risk of litigation
No. incidents

A Span of Control Tool for Clinical Managers

Hours of Operation
Low
Medium
High

Definition of Level
Weekdays only, 84
Extended hours
24/7 (services available,
including standby)

Point
1
2
3

Weight
2
2
2

Total

Unpredictability
Low

Definition of Level
Never or rarely (01/wk) have
reassignment of staff on a shift.
Sometimes (25/wk) have
reassignment of staff on a shift.
Frequently (>5/wk) have
reassignment of staff on a shift.

Point
1

Weight
3

Total

Medium
High

Unit Capacity
Low

Definition of Level
Never or rarely (01/wk) exceeds
the capacity of the department/unit.
Sometimes (25/wk) exceeds the
capacity of the department/unit.
Frequently (>5/wk) exceeds the
capacity of the department/unit.

Actual Litigation
Low
Medium
High

Definition of Level
All other units
Surgical units, OR, Emerg., PACU
Obstetrics

Point
1
2
3

Weight
2
2
2

Total

Risk Management
Low
Medium
High

Definition of Level
<2.5 hrs/wk
2.55.5 hrs/wk
>5.5 hrs/wk

Point
1
2
3

Weight
2
2
2

Total

Medium
High

Point
1

Weight
2

Total

Risk management is defined as time spent on actual or preventative activities including CQI,
comment cards, patient complaints, incident reports, quality assurance, etc.
Material Management
Considerations:
Units with specialized equipment
Units with a large amount of equipment
Time taken to deal with vendors, maintenance, replacement, ensuring completeness
Material Management
Low
Medium
High

Definition of Level (% of time)

<4 hrs/wk
48 hrs/wk
>8 hrs/wk

Point
1
2
3

Weight
2
2
2

Total

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STAFF-FOCUSED INDICATORS
Volume of Staff
Considerations:
No. staff directly reporting to Clinical Manager
Volume of Staff
Low
Medium
Medium-High
High

Definition of Level
<30
3170
71100
>101

Point
1
2
3
4

Weight
5
5
5
5

Total

Point
1
2
3

Weight
3
3
3

Total

Skill Level/Autonomy of Staff

Considerations:
Experience (% of novice nurses)
% of non-professional staff
% of Novice Nurses
Low
Medium
High

Definition of Level (%)

<5
5 15
>15

A novice nurse is defined as a new grad or a nurse new to a particular unit or as defined as novice
by Benner.
% of Non-professional Staff
Low
Medium
High

Definition of Level (%)

<10
1020
>20

Point
1
2
3

Weight
3
3
3

Total

Staffing Stability
Considerations:
Turnover rate
Absenteeism
Turnover Rate
Low
Medium
High

Definition of Level (no. of new hires/yr)

<10
1020
>20

Point
1
2
3

Weight
3
3
3

Total

Absenteeism

Definition of Level
(no. staff above hospital average)
06
714
>14

Point

Weight

Total

Low
Medium
High

1
2
3

2
2
2

A Span of Control Tool for Clinical Managers

Diversity of Staff
Considerations:
No. categories of staff directly reporting to Clinical Manager
Diversity of Staff
Low
Medium
High

Definition of Level
13
46
>6

Point
1
2
3

Weight
2
2
2

Total

PROGRAM-FOCUSED INDICATORS
Diversity
Considerations:
No. directors, VPs and portfolios to report to
No. designated services r/t regular meetings with chiefs, departments
No. units
No. Directors
Medium
High

Definition of Level
1
>1

Point
2
3

Weight
2
2

Total

No. Designated Services

Medium
High

Definition of Level
12
>2

Point
2
3

Weight
3
3

Total

No. Units*
Medium
High

Definition of Level
1
>1

Point
2
4

Weight
4
4

Total

For those managers who have >1 unit spread across the campus(es) and not side by side, please add
an additional 2 points to your total for no. units.
*Regional programs are considered a unit
Budget/Statistical
Considerations:
Total size of budget for all units combined
Budget
Low
Medium
High
Grand Total ______

Definition of Level ($ million)

<2
24
>4

Point
1
2
3

Weight
2
2
2

Total

Support
All these factors are based on the assumption that ESP support will be standardized and that the
Educational Span of Coverage is in place and all units have standardized educational support.
Scoring: The total score is out of a possible 130 points.
060
Span of control is below acceptable, capable of growth
6190 Appropriate span of control
91130 Excessive span of control; requires assistance

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