The relationship among nurse manager leadership style, span of control, staff nurse practice environment, safety climate, and nurse-sensitive patient outcomes

Despite the compelling need for strong nursing leaders who establish vision and create an evidence-based environment that fosters quality and safety, many hospitals have increased responsibilities of nurse managers, potentially compromising leadership at the bedside. The aim of this study was to elucidate relationships among safety climate, staffing, education level, manager leadership styles, practice environment, and patient outcomes. This study also compared two methods to measure nurse manager span of control. A correlational study was conducted in nine hospitals in a healthcare system. The instruments-Hospital Unit Safety Climate Survey, Practice Environment Scale, Multifactor Leadership Questionnaire, and a demographic survey-were distributed electronically to 1,579 registered nurses working in adult inpatient departments. Nursesensitive patient outcomes, staffing measures, and department demographics were obtained from hospital databases. Managers also completed The Ottawa Hospital Clinical Management Span of Control Tool, a 17-item instrument resulting in a total department complexity score. Data analysis was conducted at the unit level (N = 41). Questionnaires were received from 466 nurses (29.5%) and 41 managers (82%). Nurses reported a moderate to high unit safety climate. Nurses' perceptions of safety climate did not predict nurse-sensitive patient outcomes. Nurse staffing variables iv and department type were significantly associated with patient fall rates (R2 =.387) and healthcare-acquired pressure injuries (R2 = .342). Relationships among safety climate, nurse manager leadership styles, and practice environment were identified by department type. In critical care departments, there was a positive relationship between practice environment and transformational leadership style and a negative relationship between laissez-faire leadership style and practice environment. In noncritical care departments, transformational leadership style was positively associated with safety climate. In a comparison of high, medium, and low span of control using two methods of classification, 41.5% of the departments were categorized differently using the number of direct reports compared to department complexity score. These findings suggest efforts to promote transformational leadership in nurse managers and minimize laissez-faire leadership may impact patient safety climate in hospitals. Future research on nurse manager span of control is warranted.