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How to Reduce Spans of Control in Nursing

How to Reduce Spans of Control in Nursing
by Mike Ellrich

Story Highlights

  • Nurses in larger workgroups have lower employee engagement
  • One way to reduce span of control is with clinical coordinators
  • A Gallup client improved its outcomes by using this tactic

Less is more. We've all heard the expression. Does this idea apply to nursing spans of control -- the number of direct reports a nurse manager has?

Historically, flat management structures have given RNs advantages such as greater autonomy and more direct access to nursing leadership. But recently, spans of control in nursing have grown as healthcare organizations seek to keep up with ever-increasing costs and a need for greater efficiency.

Amid new pressures and shrinking margins, nurse managers are being asked once again to take on additional direct reports. Today, spans of control exceeding 40 direct reports are common for many inpatient units.

The troubling thing about this trend is that growing spans of control inhibit managers' efforts to meet employee engagement needs. Gallup analytics show that many managers with larger spans of control struggle to provide individualized ongoing learning and development opportunities.

Gallup studies on healthcare organizations indicate that as spans of control exceed 15 employees, employee engagement levels steadily drop. And, compared with smaller workgroups, larger workgroups have greater difficulty improving and maintaining engagement.

On the other hand, Gallup finds that hospitals with engaged staff have better patient and employee outcomes, including fewer infections, fewer slips and falls, less turnover, and higher productivity.

So if growing spans of control continue to go unchecked, nurse and patient outcomes will take a hit. And healthcare leaders will face more nurse burnout, decreased engagement and increased safety incidents.

Reducing Spans of Control With Clinical Coordinators

One powerful and cost-effective strategy for reducing spans of control among nurses is implementing a "clinical coordinator" program.

Clinical coordinators are front-line nurses who facilitate ongoing individualized development -- including goal setting, accountability and strengths coaching -- with a small group of front-line nurses.

Employees need frequent one-on-one interactions with their managers to clarify expectations, celebrate successes, identify barriers, maintain accountability and get immediate feedback.

In fact, Gallup analytics show that employees who strongly agree they have had conversations with their manager in the past six months about their goals and successes are 2.8 times more likely to be engaged.

Clinical coordinators are highly accessible, so they can help nurses resolve challenges and perform their best every day. By asking questions such as "Is there anything you're struggling with today?" or "How can I help remove barriers?" and following up on employee goals, clinical coordinators act as performance coaches who develop, support and communicate that they care for each caregiver.

For example, clinical coordinators can develop one-on-one connections with nurses and find learning and development opportunities that match each nurse's unique aspirations. And, because clinical coordinators maintain their front-line responsibilities, their peers tend to consider them relatable, credible and knowledgeable.

Assigning a few hours of weekly managerial work to clinical coordinators can help healthcare leaders meet employee needs without hiring additional mid-level managers.

As with every role, to optimize clinical coordinator programs, healthcare leaders need to select clinical coordinators who have the right talents and provide ongoing education and resources to build their capabilities.

Client Story: Cultivating Performance and Modeling Desired Behaviors Using Clinical Coordinators


Historically, our client Kootenai Health maintained large spans of control with its nurses. This, however, created barriers to individualized performance development.

So to proactively invest in each nurse's ongoing development and performance, based on Gallup's recommendation to reduce spans of control, Kootenai's leaders gave charge nurses some limited management responsibilities -- and developed the new job description of "clinical coordinator."

To position their clinical coordinators to thrive, Kootenai leaders provide initial classroom training and ongoing learning and development opportunities. Leaders also clarify role expectations for clinical coordinators and ensure their needs are met too.

Under the supervision of nurse managers, each clinical coordinator coaches and mentors no more than 15 employees.

In addition to their usual responsibilities, clinical coordinators meet with their nurses for quarterly check-ins to review goals and clarify expectations. Coaching and mentoring regarding safety concerns occurs in the moment as much as possible.

Kootenai's clinical coordinators not only support employee development, they also boost performance as front-line leaders who foster collaboration, implement changes, model desired behaviors and advance quality initiatives.

Nurses appreciate having someone to go to -- a trusted adviser who immediately resolves conflicts and answers their questions quickly.

Since implementing the program in 2015, Kootenai Health has seen meaningful improvement (0.20 points or greater) in nurse engagement scores.

Seeing how their efforts inspire performance and advance patient outcomes, many clinical coordinators have discovered an inner passion for leading and developing others, according to Kootenai Health RN Directors.

As a result, Kootenai leaders expect to see positive effects on succession-planning efforts and deeper employee alignment with the health system's mission and purpose.

Gallup can help your organization improve employee engagement and business outcomes too.