Limiting nurse managers' head counts trims turnover, drives savings, report finds

Provider organizations that keep a handle on their nurse managers’ workloads are rewarded with significantly lower registered nurse turnover and reduced workforce spending, according to a recent report citing data from dozens of acute care hospitals and hundreds of outpatient sites.

The findings outline a return on investment for “right-sizing” nurse managers’ spans of control, or how many direct reports they are assigned, as well as other supportive investments into assistant nurse managers or platforms that can either reduce administrative burden or promote “consistent, purposeful interactions” between nursing teams.

“Ensuring the nurse manager receives the time, latitude and support they need to execute critical work is essential in promoting a healthy culture, attracting and retaining staff, delivering excellent patient experience, and elevating patient outcomes,” the American Organization for Nursing Leadership (AONL) and data analysis platform Laudio Insights wrote in the report.

Across the sample of 8,106 managers and 105,862 employees, the groups found that nurse managers were responsible for a median 46 subordinates. A quarter of inpatient nurse managers had head counts of 78 people or higher, with larger tallies among those working in emergency departments (median of 83) and ICUs (median of 80).

More than half of nurse managers (56%) had at least one assistant nurse manager under their purview, though organizations infrequently used the assistants to trim managers’ span of control, according to the report. For instance, 78% of nurse managers who had an assistant still had all their team members as direct reports, 18% shared their direct reports with the assistant nurse managers and only 4% had all their team members reporting to the assistant nurse managers.

The nurse managers’ broad span of control can “compromise” their ability to connect with subordinate nurses, AONL and Laudio wrote.

Managers with higher counts, on average, will face more financial challenges due to turnover and greater incremental overtime. Within the emergency department, for instance, head counts of less than 70 showed a 14% turnover rate while those with over 115 people had 23% turnover.

Overloaded managers also tended to take more corrective actions than those with lower head counts, “implying that maintaining accountability is a more time-consuming challenge with larger teams,” according to the report.

The findings suggest there’s a financial case to reduce nurse managers' span of control “when possible,” with the groups noting that “there may be instances where a financial justification can be made to support splitting large departments into two smaller ones.”

Assistant nurse manager hires could also be an answer for larger teams, they wrote, as their presence “typically” lessened RN turnover. Teams with no assistant nurse managers had turnover rates three percentage points higher on average than those with one or two assistant nurse managers.

“For a team with 50 RN [full-time equivalents], this would be a difference of 1.5 RNs per year, a savings of $78,500,” according to the report.

However, too many assistant nurse managers “appears to be counterproductive” as they were associated with increased turnover within the sample, according to the report. The groups theorized that the effect could be due to a lack of role clarity, which organizations should address when placing assistants within a team.

The report’s general findings on nurse manager workload and team interactions could also be used to justify that other investments to support these employees could drive a return, the groups wrote. Executives could work with human resources and information technology leaders to spot areas where they can either support or offload responsibilities, such as recruitment or scheduling, from nurse managers, they wrote.

“Nurse managers have one of the hardest jobs in healthcare. They have 24-hour responsibility caring for their nursing team and patients,” Robyn Begley, CEO of AONL along with chief nursing officer and senior vice president of of workforce at the American Hospital Association. “Nurse leaders can use this data to make operational adjustments in real time to support these vital frontline leaders.”