Ninety-Six Direct Reports and a Team Model Nobody Designed: Management Functions, Span of Control and Care Delivery at a Long-Term Acute Care Hospital
Student Name
American College of Education
NUR5103: Leadership and Management Theory in Nursing
Module 2 Assignment
Instructor Name
March 9, 2027
The Structure as It Stands
The composite long-term acute care hospital introduced in Module 1 has 40 beds on two floors, most of them for patients being weaned from mechanical ventilation. One nurse manager is responsible for both floors around the clock. The manager's direct reports number 96: 52 registered nurses, 14 licensed practical nurses, 22 certified nursing assistants and 8 unit secretaries. There are no assistant managers. Charge nurses rotate from shift to shift, are chosen from whoever has the most experience on duty and have no authority over schedules, evaluations or discipline. The manager reports to the director of nursing, the author of this paper, who has held the post for four months.
The Management Functions
Marquis and Huston (2021) describe the manager's work through the classic functions of planning, organizing, staffing, directing and controlling. Measured against that description, the LTACH's management is carried out almost entirely in its most urgent forms.
Planning is short range. The manager's week is spent on the next schedule and the next admission; the unit has no written goals for the year, and the weaning protocol described in Module 1 was introduced without a plan for how staff would learn it. Organizing is informal. Who does what on a shift depends on the charge nurse of the day, and the division of work between registered nurses and practical nurses varies by floor. Staffing absorbs most of the manager's time: in the past quarter the manager filled 214 open shifts by phone and text, and 38% of registered nurses left in the past year. Directing reaches the staff mainly through email and a monthly meeting that night staff rarely attend. Controlling is the weakest function. Annual evaluations are eight months overdue for a third of staff, and the unit's quality data, including breathing trial rates, ventilator-associated events and falls, are reported to the quality department but not reviewed with staff.
Each function is being performed, but only the part of it that cannot be postponed; everything that would prevent tomorrow's problem is waiting for a free hour that never comes. That pattern is typical of a manager whose span of control has outgrown the job.
Span of Control
Span of control is the number of people who report directly to a manager. Research in nursing suggests that very wide spans carry costs for staff, patients and managers. In a study of 51 units in seven hospitals, McCutcheon et al. (2009) found that wider spans of control were associated with lower nurse job satisfaction and lower patient satisfaction, and that as spans widened, even transformational leadership could not overcome the negative effect. Wong et al. (2015), studying front-line nurse managers, found that span of control together with the manager's core self-evaluation predicted how overloaded managers felt, how much control they had over their work and how satisfied they were, while the number of direct reports on its own was linked to adverse events on the unit.
At 96 direct reports spread across all shifts on two floors, the LTACH's span of control is well beyond what any single manager can supervise closely. The research does not give a single correct number, and the right span depends on the stability of the staff, the complexity of the patients and the support available to the manager. All three point in the wrong direction here: turnover is high, the patients are among the most complex in the hospital, and the manager has no assistant.
The Care Delivery Model
Until two years ago the LTACH used total patient care, with each registered nurse caring for three or four patients and doing nearly all of their care. When registered nurse vacancies rose, practical nurses and nursing assistants were hired to fill the gaps. No new model was designed. In practice the floors now use a loose form of team nursing: a registered nurse may be responsible for five or six patients and share them with a practical nurse whose assignment overlaps two registered nurses, while a nursing assistant covers the whole hall. Nobody on the unit could say which tasks belong to the practical nurse, and staff on the two floors answered differently.
The evidence on care delivery models is not decisive, but it does not favor improvisation. A systematic review of 14 studies found that team nursing was associated with fewer medication errors and adverse intravenous events and with lower pain scores, while no model showed an advantage in role clarity or job satisfaction (Fernandez et al., 2012). A study of medical and surgical units that combined five years of administrative data with primary data collection linked fewer registered nurses, heavier workloads and unstable unit environments with negative outcomes, including falls and medication errors (Duffield et al., 2011). The LTACH has the second set of conditions without the structure that made team nursing work in the first.
Recommendations
Two changes are recommended together. First, the span of control should be divided. Each floor should have an assistant nurse manager with formal authority for scheduling, evaluations and day-to-day supervision, one working a day and evening pattern and the other covering nights and weekends in alternating blocks, which would reduce the manager's direct reports to the two assistants, the unit secretaries and a small group of senior staff. Charge nurses should become a fixed role held by trained nurses on each shift. The estimated cost of the two assistant positions is about $230,000 a year including benefits, against an annual cost of registered nurse turnover that the hospital's human resources department estimates at more than $1 million.
Second, the care delivery model should be redesigned deliberately as modular team nursing. Each floor would be divided into modules of five patients, each led by one registered nurse with a practical nurse assigned to that module only and a nursing assistant shared between two modules. A written grid would set out which tasks each role performs under the state's scope of practice, and it would be taught in orientation and posted on each floor. The redesign will be tested on one floor first, and its effect judged by medication events, falls, breathing trial completion and a short staff survey on role clarity at three months. The main risk is that registered nurses see modules as a heavier load; they will help set module boundaries, and the first review will ask them directly whether the model works.
Conclusion
The LTACH's management problems and its care delivery problems have the same root. A structure built for a smaller, more stable staff was stretched to cover twice the people and a new mix of roles, and nobody redesigned it because the only person who could was the manager whose time it consumed. Dividing the span of control gives the organization back the planning and controlling it has been postponing, and a deliberate team model gives those functions something clear to plan and control. The next module turns from the unit to the service line as a whole and asks where the LTACH's weaning program should be headed over the next three years.
References
Duffield, C., Diers, D., O'Brien-Pallas, L., Aisbett, C., Roche, M., King, M., & Aisbett, K. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research, 24(4), 244-255. https://doi.org/10.1016/j.apnr.2009.12.004
Fernandez, R., Johnson, M., Tran, D. T., & Miranda, C. (2012). Models of care in nursing: A systematic review. International Journal of Evidence-Based Healthcare, 10(4), 324-337. https://doi.org/10.1111/j.1744-1609.2012.00287.x
Marquis, B. L., & Huston, C. J. (2021). Leadership roles and management functions in nursing: Theory and application (10th ed.). Wolters Kluwer.
McCutcheon, A. S., Doran, D., Evans, M., McGillis Hall, L., & Pringle, D. (2009). Effects of leadership and span of control on nurses' job satisfaction and patient satisfaction. Nursing Leadership, 22(3), 48-67. https://doi.org/10.12927/cjnl.2009.21154
Wong, C. A., Elliott-Miller, P., Laschinger, H., Cuddihy, M., Meyer, R. M., Keatings, M., Burnett, C., & Szudy, N. (2015). Examining the relationships between span of control and manager job and unit performance outcomes. Journal of Nursing Management, 23(2), 156-168. https://doi.org/10.1111/jonm.12107
How this NUR 5103 Module 2 example is structured
NUR 5103 Module 2 often examines management functions, span of control and the care delivery model on a unit; your classroom's instructions decide whether you analyze your own unit and whether a recommendation is required. This example describes the structure, assesses each management function against a standard text, compares the span of control with published research, names and evaluates the care delivery model, and recommends changes with their costs and risks.
NUR5103 Module 2 questions, answered
What does NUR5103 Module 2 usually ask for?
NUR5103 Module 2 often asks you to examine how the management functions are carried out on a unit, to assess the manager's span of control and to evaluate the care delivery model, usually ending with recommendations. Your classroom's instructions decide the setting and format.
Is there an ideal span of control for a nurse manager?
Research does not give one number. It links wider spans with lower staff and patient satisfaction and with manager overload, and the right span depends on staff stability, patient complexity and the support the manager has. Judge your unit against those factors.
How do I identify my unit's care delivery model?
Describe who does what for which patients on a real shift, then match that to the named models, such as total patient care, team, primary or functional nursing. Many units use a hybrid, and saying so honestly is better than naming the model in the policy.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official American College of Education document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.