December 12, 2024 Higher spans of control tied to higher turnover

What the data says
Two of the most common specialties, Emergency Departments (EDs) and Women’s Health units, are shown in the chart above, showing that RN turnover is the highest in the largest quartile spans of control. A similar pattern exists in other specialties. This and other data in this article is from “Quantifying Nurse Manager Impact,” a Spring 2024 joint publication between AONL and Laudio Insights.

Departments with the highest quartile spans of control may also experience higher turnover because of the stresses placed on the managers’ ability to support and coach each team member. Higher spans of control may limit the ability of managers to have a sufficient level of purposeful team member interactions. 

The chart below shows that there is a middle range of span of control where RN turnover is at its lowest for Med Surg and ICUs. For Med Surg, the range is 45-80 headcount per manager; for ICUs, the range is 75-100.  

When departments in the lowest quartile spans of control experience higher turnover, it is likely because they are not operating at scale from a staffing perspective to provide scheduling flexibility to team members. For example, the Med Surg departments in the lowest span of control quartile have a significantly lower percentage of per diems (5% of the headcount vs 10%) and part-time employees (15% vs 22%) than the rest of Med Surg departments.

Turnover is lower, on average, with the use of assistant managers in high span of control teams; however, the presence of too many assistant managers appears to be counterproductive.

Inclusive of all sites of care and specialties, the chart below shows that among departments in the top quartile span of control, those with up to four assistant nurse managers have lower turnover on average. However, larger departments with five or more assistant nurse managers have higher turnover, possibly because too many such roles in one department represent short-term solutions to a variety of potential structural or cultural challenges. Many assistant nurse managers could also be coincident with a lack of clarity in role definition and therefore, they may be more frequently called upon to carry out direct patient care responsibilities.

What it means 

1. Departments with the highest spans of control have substantially higher turnover in general - suggesting that an ROI-based business case can be made to adjust or support those departments.
2. Assistant managers provide value to their managers and have a positive financial impact – though adding more than two has limited/negative impact.

One West Coast ICU Director shared recently the role of her assistant managers:

“ AUMs (Assistant Unit Managers) help me significantly. I delegate to them, so I can take care of other things. AUMs may also act as the relief coordinator on some days if needed. The team sees the AUMs as a management role. They see them as coaches and educators.

We share the leadership of our team. As a manager, I have a set of employees that I do the reviews for, while each AUM has theirs that they do reviews for. The AUMs do a lot of counseling and recognition. The team knows my door is open; I also walk around the floor to be available to everyone if they need me. We share accountability conversations: AUMs do them for their team members, but if the event is more serious, I will step in…

AUMs mostly take a patient leadership role. But if they are not there or if a patient requests the manager, I also step in to support. Quality and safety are shared responsibilities. I deal with the quality team leader and get information from them. I take updates back to the AUMs and we share with the team together…

• Sanam Jafari, RN, BSN, Manager, Diabetes/Respiratory Unit Long Beach Medical Center, MemorialCare [1]

What the implications are for healthcare leaders 

1. Reduce the highest spans of control, if possible, by dividing those departments into smaller ones.
   1. • For example, an organization can reduce the size of a large ED by segmenting off a specialty, such as cardiovascular, behavioral health, or pediatrics.
      • With the national average cost of each RN turnover estimated to be $52,358 (NSI 2023), the additional cost of an incremental nurse manager and any costs for physical adjustments could be financially positive if the change reduced turnover by two or three RNs a year. For example, consider a Med Surg department with 100 RNs (i.e., in the top quartile) that splits into two departments of 50 RNs. If that change reduced the overall turnover from 21% to 17% turnover, it would equate to 100 * 4.0% = 4.0 fewer FTE terminations per year. At the cost mentioned, this equates to a cost reduction of about $200,000 per year.
      • Similarly, if such a change reduced incremental overtime by 30%-40%, it could also provide financial justification, given that each hour of incremental overtime costs a national average of $77.50 (as cited earlier).
      • Admittedly, these changes are often challenging as they may require both physical and virtual layout changes and coordination from many other teams, including finance, Environmental Services, and any affected managers and team members.
2. Add assistant nurse managers where they will have the greatest positive financial impact - but know that, while they improve turnover, they do not completely counterbalance the attrition increases seen for the highest spans of control.
   1. • The difference between no assistant nurse managers and one or two is coincident with an average of a 3-point reduction in turnover (a difference between 21% and 18% on average, as shown above). For a team with 50 RN FTEs, this would be a difference of 1.5 RNs per year, a savings of $78,500.
      • In such a situation, promoting a team member to assistant nurse manager with the goal of reducing team turnover could be a financially positive investment. However,ssistant nurse managers need made-for-purpose job descriptions, clear responsibilities, leadership onboarding, and ongoing support from their manager to maximize their ability to act as part of a coordinated local leadership team.
      • Teams with five or more assistant nurse managers may need formal span breakers (i.e., additional nurse managers). In this situation, executives might make a positive financial case for splitting the team into two different departments with two separate nurse managers.

NOTE: Some of the charts and wording in this article were previously published in “Quantifying Nurse Manager Impact” in Spring 2024, a joint publication between Laudio Insights and AONL.

References

• Cost of RN turnover: NSI Nursing Solutions, Inc., 2023 NSI National Health Care Retention & RN Staffing Report

[1] Disclosure: A MemorialCare affiliate has made an investment in Laudio. Any quotes or content attributed to MemorialCare or any of its staff do not constitute a product endorsement or testimonial.