The besieged ward manager: can we afford to continue to ignore the role?

Abstract

Traditionally, intensive care environments can be viewed through a social interactionist lens as discrete ‘subcultural worlds’ (Fischer, 1995). Fischer (1995, p. 554) defines a subculture as, ‘…a set of people who share a defining trait, associate with one another, are members of institutions associated with their defining trait, adhere to a distinct set of values, share a set of cultural tools and take part in a common way of life’. Intensive care units can be viewed as isolated from the rest of the hospital, and practitioners who inhabit these environments adopt norms and values that are different to those adopted by those who inhabit and create the broader culture of an acute hospital. Therefore, on occasion we as critical care practitioners may be confounded by differences between the subcultural worlds of intensive care and acute wards, especially where we consider them strange or in contradiction to our own considerations and priorities. Such difference may seem exacerbated by limited contact with acute care colleagues when direct contact is only made when patients are either admitted or discharged from the unit or through outreach services. A number of recent policy initiatives have urged greater liaison and guidance to ensure more comprehensive communication of patient needs, particularly at the point of patient transfer [National Institute for Clinical Excellence (NICE), 2007, Clinical Guideline 50]. More recently, the NICE (2008) consultation document on intensive care rehabilitation raises the importance of providing specific physical and psychological support to facilitate patient recovery from an episode of critical illness. To fully understand how we might improve care for these patients, we need greater insight into the experiences of ward managers as it is they who are charged with the responsibility to transform practice and care delivery on the wards. McWhirter’s doctoral study into the contemporary role of the ward manager has illuminated some key challenges that face our colleagues. Using a grounded theory approach, she interviewed 9 ward managers (initially for 1–3 h and then with half an hour follow-up interviews on 12 occasions), 21 stakeholders (30 min to 1 h each interview) and undertook 35 h of participant observation on nine acute care wards. Data were analysed using dimensional analysis (Schatzman, 1991). Her findings concluded that without addressing the factors that impede the functioning of a ward manager to lead clinical change at ward level, the welcomed initiatives set out in the consultation document to improve patient’s rehabilitation or to improve the recognition of patient deterioration in an acute care setting, might flounder. Importantly, managers charged with the responsibility to implement any guideline need to take account of the circumstances in which ward managers’ work and their impoverished resilience to embrace yet more change. Without addressing these factors, we may not see the improvements in patient care that we all seek to achieve. The role of the contemporary ward manager is complex, diverse and dynamic. Its historical and traditional anchors have provided the role with a scaffold through which the modern methods of delivering health care in hospitals have been delivered. When ward managers describe their daily workload, they often talk about the frustrations they face, depicting feelings of helplessness and despair, particularly in meeting the expectations of hospital management. In her editorial, Scholes (2008) discusses the need for practitioners to develop resilience to rebuild and retain pride in what they do. In addition to this, there is also a need for hospital management to understand exactly why ward managers continue to work in an environment that requires them to address competing priorities, targets and uphold some apparently ‘non-sensical management systems’ (Scholes, 2008, p. 284). Operational managers need to recognize the skills and values that make up effective ward leadership, and they need to focus on rediscovering the expertize among ward managers that has been suffocated by the growing wave of administration and bureaucracy (Rankin and Campbell, 2006). The delivery of acute hospital care has changed dramatically over the past 20 years. Its focus on centralisation, standardization and targets has resulted in fast throughput and high turnover of patients (Nelson and Gordon, 2006). Individualised patient care has been replaced by systematic and process-driven pathways (Rankin and Campbell, 2006). While many have benefited from these changes, at ward level, it appears to have created an overwhelming misalignment between the values of the senior operational management within the hospital and those of the experienced ward managers. While hospitals frequently speak of their commitment to providing the highest available quality of health care, it would appear that in relentlessly busy acute wards, ward managers gave accounts of care that fell short of meeting this pledge. The promise of an NHS ‘designed around the patient’ (NHS Plan, DH, 2000) makes little connection with the experiences of ward managers who spoke of their struggle to provide sufficiently safe levels of staffing or who had little influence over timings of admission and discharge, length of stay and other issues that effected the patients’ experiences. Thus, ward managers reflected upon the frustration of attempting to deliver the objectives of their organisation while at the same time recognising that there were frequent situations when organisational constraints prevented them from doing so. Handling this dichotomous contradiction created role strain that had to be handled to continue to present themselves as ‘competent’ ward managers. The ability to create a public face for the benefit of others, which differs from the emotions that are felt inwardly, is described by both Hochschild (1983) and Fineman (1993) as ‘Emotional Management’ or ‘the management of feeling to create a publicly observable facial and bodily display’ (Hochschild, 1983, p. 7). Learning to hide ones feelings, appearing calm during times of emergency or when dealing with stressful situations is part of any nurse’s daily working life (Smith, 1992). Hochschild (1983, p. 7) describes it as ‘labour that requires one to induce or suppress feeling in order to sustain the outward countenance that produces the proper state of mind in others…’. The purpose of emotional labour is for organisations to promote a positive organisational image. Organisations ‘subvert the workers “true self” by reinterpreting the emotions they naturally feel in work situations’ (Theodosius, 2008, p. 22). Hochschild suggests that health care organisations exploit the commercial value of this principle, essentially by paying nurses to ‘care’. Undertaking emotional labour draws on the individual’s sense of self. It stems from individuality developed from memories, personal relationships and personal experiences. Hochschild (1983) argues that organisations that utilize emotional labour teach employees new ‘rules’ around feelings and emotions. Employees adopt these prescriptive emotions, which results in the suppression of their own true emotions. This ultimately serves to divide the individuals’ sense of self, creating a true self and a false self. As a consequence of this, employees can become alienated from their own sense of professional self. The emotions that are portrayed to the public and to their colleagues are determined by the organization. Using Goffman’s (1959) analysis, the ward manager developed a repertoire for ‘front-stage and back-stage’ performance. The front-stage performance was enacted to present the organisation’s expectations, but while in this role, the individual had to skilfully conceal their true feelings by adopting socially acceptable masks (Fineman 1993). As a consequence, the individual might adopt a ‘benign detachment’ (Fineman, 1993, p. 19) to disguise private thoughts that may interfere with a professional relationship. However, by sustaining such cognitive dissonance, the individual was at risk of burn out, disengagement and alienation (Hochschild, 1983). An organisation that fails to recognise these traits and does not address them will inevitably result in a disaffected and isolated workforce. The ward managers in McWhirter’s study recognised their role in motivating and supporting their ‘battle weary’ workforce (Norris, 2000) by understanding the emotions of their ward teams. They recognised the challenge of delivering care to complex and dependent patients when their clinical teams may be subject to staff shortage and/or dependence on temporary staff. The ward manager’s front-stage performance was demonstrated by working long hours to ensure their presence in the ward, often juggling office-based duties with clinical responsibilities and positively promoting the messages sent out by the hospital management to the wards. Back stage however, their professional values were often at odds with the realities of delivering fast patient throughput and standardisation. Being present on the ward might be seen as anchoring themselves to a traditional view of the ward sister as leaders of care provision (Fretwell, 1982; Ogier, 1982), despite an organisational imperative to shift the role to a more managerial activity (DH, 2000). The ward manager’s reluctance to move away from a clinical role was highly evident. Although ward managers acknowledged that dealing with organisational priorities to achieve financial stability and manage complex staffing and human resources issues have gained greater importance within their working day, they expressed frustration and distress at the diminished time that could be spent in clinical contact with patients. To compensate for this loss and ensure the patients received good care, it has become ‘normal’ for ward managers to work an extended day, often spending the evening hours back on the wards, with their patients and relatives. The ambivalence surrounding the role is exacerbated by the patients’ unchanged perception that the ward manager should be working as the clinical expert and leading their team from the front. Medical teams expect ward managers to have an in-depth knowledge of all patients on their ward and assume that they are available to undertake ward rounds. Managers, while demanding data, reports and accountability for budget statements and levels of staffing, expect that the ward managers will teach students, support struggling staff and care for critically ill patients and their families. They also expect them to adopt the latest initiative in quality service improvement without necessarily removing other responsibilities to facilitate this. The inevitable consequences of working long hours, under pressure, has resulted in an exhausted and battle weary role. This weak and fractured tier of the workforce has become too tired to challenge or question their situation. They demonstrate the behaviour of passive compliance in a cycle where they continue to take on new responsibilities and achieve this by working harder and for longer. They put up with these demands for the sake of their patients and are rewarded by the infrequent pockets of time when they were able to offer and deliver emotional work: their motivation to continue to come back into work. However, this has left them professionally compromised, demoralised and exhausted, all characteristics of varying degrees of burn-out (Skovholt, 2001). Traditionally seen as healers and carers, it appears that ward managers have become wounded storytellers (Frank, 2004). As the custodian of emotional management, the hospital culture has the ability to manipulate this. Yet, its command and controlling style of management has failed to understand the significance of emotional labour and convert this knowledge into achieving higher levels of patient safety and patient satisfaction, both issues featuring highly on the NHS agenda (Darzi, 2008). There is a wealth of evidence from the USA and Canada to suggest that levels of patient safety are much higher when nurses are valued Rankin and Campbell, 2006), and yet, it appears that in the UK, we have been unable to capture the true essence of the nursing identity and translate this into supporting a workforce that is able to combine both the academic and the emotional aspects of care that are required to deliver modern health care safely. There is no doubt that our hospital wards need competent and creative leaders, but as our health service has modernised and transformed it has delegated the responsibilities of managing ward finance, data reporting and staffing to the ward manager. Ward managers have always been a pivotal role of the National Health Service. They have a responsibility to guide and support their staff to move forward, embrace new ways of working and service improvements. Yet, they have been a neglected tier of the nursing workforce. Their role has changed dramatically, leaving them undervalued, exhausted and consequently questioning not only their sense of purpose but also their whole essence of their professional identity. It is clear that there are ward managers who are prepared to work extraordinarily hard to maintain high standards of care, despite the systems and processes in place that suppress their ability to provide emotional work. They are willing to find moments in their chaotic working day that allow them time to provide the care for their patients that they believe makes a difference. The NHS is in serious danger of losing these experienced skilful role models if we do not recognise the real, yet suppressed, identity of ward managers and understand the values and ideals that motivate them to care. Only by understanding this can we begin to place a value upon the emotional labour that they and their teams provide. It is timely to now revisit what unites us to our ward-based colleagues rather than emphasising the differences in our clinical worlds. By building on that, we will be better able to bring about the change required to embed new service initiatives to enhance care for the acutely sick and patients rehabilitating from critical illness. New systems, structures and supplementary roles may do no more than hinder the ambition to achieve such an outcome. Rather, reinvesting in the ward manager and restoring their rightful place as clinical leaders of ward teams may yield a better outcome for our colleagues, their patients and relatives.