Reconciling Career and Family Life in NHS Nursing and Midwifery: Dilemmas in Ward Management
Introduction
Within the next twenty years the population
of Scotland will decline from 5.11 million to under 5 million (GROS 2002)
presenting significant challenges for the National Health Service Scotland
(NHSS). Increased workloads associated with an aging population will have to be
met by a shrinking tax fund as the ‘dependency ratio’ between the elderly and
working age population rises (Duncan 2002). Staff shortages already exist
across the NHS but are particularly acute in nursing, a workforce which is
itself ‘greying’ (Buchan 1998; 1999). In 2000 approximately 21,000 (7%) of
nurses left the nursing register with a net result of 9,200 vacancies (full
time equivalent) (Watson et al. 2003). A number of policy initiatives
aim to tackle this recruitment and retention crisis including efforts to make
nursing more ‘family-friendly’ and to improve career structure and pay.
The NHS Improving Working Lives
initiative (Department of Health 2000) follows the logic of the government’s
Work-life Balance campaign, that there is a ‘business case’ for helping
employees reconcile their work and home life in the form of increased labour
market competitiveness, improved morale, increased productivity, retention
rates and reduced absences (Bevan et al. 1999; Dex and Scheibl 2001; DTI
and Scotland Office 2001). All NHS employees (in England and Wales) should be
working for an organisation that can demonstrate its commitment to flexible
working arrangements such as part-time working, flexitime and annualised hours.
Except for pay, health policy is a devolved matter for the Scottish Parliament.
Flexible working is mentioned in policy documents (Scottish Executive 2001) and
benchmark guidelines on family-friendly policies have been developed (PIN 2000)
but NHSS does not have specific targets for introduction.
In terms of pay and career structure, the
current grading clinical grading system is instrumental in nurses’
dissatisfaction with skills, workloads and responsibilities often going
unrecognised (Meadows et al. 2000). The distance between the ‘rungs’ of
the ladder are considerable: the majority of nurses are stuck at the top of
their grade. Agenda For Change (Department of Health 2003) is a
competency based career structure designed to promote continuous development
and to pay staff for the job they do rather than the post that they fill.
Career progression and work-family
reconciliation are inextricably linked. To reconcile work and family life and
minimise childcare costs, mothers often work part-time but this comes at a
price (Dex 1999). Part-time workers have less control over their working time,
tend to be occupied in lower-skilled positions and receive less training and
lower pay (EFILWC 2001) and nursing is no exception. 45% of Royal College of
Nursing membership work part-time (RCN 2002) yet they, and those who take
career breaks, are disproportionately segregated in the lower grades (Lane
2000; Whittock et al. 2002).
Following an overview of the study, this
paper focuses on the effects of the devolution of ‘New Public Management’ to
ward level. The impact on a current cohort of ‘Ward Managers’ of their ever-expanding
role is discussed as well as the implications for nursing careers and the
current policy approach.
The Study
The NHS Trust researched (“The Trust”) was
formed in 1999, employed 6,766 nursing
and midwifery staff over several sites and had four divisions: Medical,
Surgical, Women and Children and Clinical Support Services. These divisions
were split into “directorates” representing broad clinical fields run by
Operational Managers who were responsible for several wards or units, usually
on a single site. Depending on the size of the service, the Operational Manager
or the Assistant Operational Manager was the line manager for the ward. In this
paper, any direct line manager of a Ward Manager will be referred to as an “Ops
Manager”.
Previous research has found several
barriers, and facilitators, to implementing flexible working and
family-friendly policies. The nature of the task performed by the employee, the
ease with which the employee can be substituted, work organisation, workplace
culture as well as organisational characteristics such as size and union
presence influence employee access to, and utilisation of these policies (Lewis 2001; Bond et al. 2002; Dex and
Smith 2002; Rapoport et al. 2002; Yeandle et al. 2002). It was
therefore important that a range of nursing and midwifery jobs with differing
staff, resource and service pressures were represented from across the
hospitals which made up the Trust. Sampling proceeded on a top-down basis with
local permissions to conduct further interviews being obtained at each level.
The Principal Nurses identified the Ops Managers (usually clinical grade H or
I) in the relevant areas who provided details of all the Ward Managers (G
grade) in their jurisdiction. 2 Ward Managers were randomly selected who, in
turn provided a list of their D (entry level), E (experienced) and F (senior)
grade “staff nurses” with one or two being selected from each ward. 40
interviews were conducted covering job roles and responsibilities, career
history, satisfaction and plans, domestic and other non-work commitments,
working hours, and decision-making responsibilities for other staff with
particular reference to flexible working and other family-friendly policies.
Findings
An initial analysis both confirms and
extends the findings of previous research on the sources of dissatisfaction and
stress among nurses. The focus for this paper is personal and professional
dilemmas faced by Ward Managers in delivering
nursing care in a clinical and managerial capacity. Understanding their
changing role and their ability, or inability, to reconcile work and family
life is fundamental to understanding the dynamics of nursing careers and the
prospects for recruitment and retention policy.
Roles and Responsibilities
In 1991, the Audit Commission found there
was insufficient devolution of management responsibility to charge nurses (ward
managers) and recommended that budget management, recruitment and retention and
skills mix be devolved to ward level (Willmot 1998). However, through the
1990s, charge nurses continued in a largely clinical role. The decision to
leave the ward and move up to Clinical Nurse Manager would be the first
managerial post where the focus was on providing clinical leadership for nurses
in the ward.
The New Public Management (NPM) ethos as
described by Hood (1991) and Gray and Jenkins (1993) had been present in the
constituent hospitals of the Trust before 1999 but the divisional structure
introduced in 2000 ensured that managerialism was for the first time fully and
directly felt at ward level. The post of Clinical Nurse Manager, a leader of
nurses, was transformed into Ops Manager, a general management position. In
some areas non-nurses occupied the post, reducing clinical leadership and
support for the wards. Budgetary responsibilities were increased as were those
for waiting time targets, bed management, complaints procedures, health and
safety, clinical standards and service planning. Responsibility for personnel
also widened to include junior doctors and other health professionals. These
additional responsibilities for the new Ops Manager forced a devolution of
management functions down the Charge Nurses who were re-branded “Ward
Managers”. Typically Ward Managers were responsible for the day-to-day running
of the ward, staffing issues such as recruitment, development and discipline,
clinical leadership and protocols, stores and budget management as well as an
expanding clinical role resulting from junior doctors’ reduced working
hours.
Getting the job done – working hours andtime management
None of the Ward Managers thought their
clinical and managerial roles impossible to reconcile but that the
expansion of responsibility had not been accompanied by a commensurate
expansion in resources to do justice to both roles. The majority of ward
managers were contracted to work 37.5 hours per week but another contractual
obligation, 24 hour responsibility for the ward, meant the job was effectively
‘hours as required’, signifying an expectation of constant availability for
work (Epstein et al. 1999). To varying degrees, all Ward Managers and
Ops Managers were working in excess of their contracted hours none were paid
for these hours. They were supposed to take time back in lieu but few felt able
to. Line manager’s attitudes were seen
to be important in working hours.
“I have a very
good working relationship with my senior line manager. I have a very flexible
diary. If I’m working late can come in late the next day.”(“Kath”, H Grade Ops Manager)
While Kath said that similar opportunities
to take time back were open to the ward managers, this comment from one of her
Ward Managers shows that, theoretical support is, in itself, not enough:
“On a normal
week you can add 2 extra hours onto every day but it can be worse. I used to
note down extra hours but I gave up the ghost. It’s a waste of time because so rarely got it
back. [Kath’s] supportive but if I’m off they have to get agency and that defeats
the purpose.”(“Mary”, Ward Manager)
While some blamed themselves and said they
could delegate tasks more and organise themselves better, Ward Managers were
not ‘supernumerary’ i.e. additional to clinical staffing requirements and even
in areas which had designated
‘management days’, the staffing situation did not permit the Ward
Manager to be away from the ward. Prioritisation of the clinical role pushed
managerial tasks into their own time:
“Even if I try
to get work done here I’m always interrupted so I have to take it home. The
service is being restructured … and decisions are often being made on my days
off so I have to come in…” (“Laura”, Ward Manager)
Overall, Ward Managers felt that the
managerial responsibilities devolved to them were not beyond their capabilities
but that they should not be expected to perform them while being “in the numbers”. Feelings of conflict and
frustration that they were under-performing in both roles were very apparent.
Many expressed concern that they were not providing enough support for junior
and student nurses. Across the board, the appeal was for a more clearly defined
role and supernumerary status.
Not getting the job done – sources ofstress and long working hours
The responsibility to ensure that ward had
the correct ‘skill mix’ 24 hours a day was a significant source of stress for
Ward Managers (see also Allen et al. 2001; Newman et al. 2002).
This responsibility had to balanced with helping staff to reconcile their work
and home life. Nursing is a 24/7, customer facing, specialist job with staff
shortages, job characteristics which make flexible working difficult (see Bond et
al. 2002; Yeandle et al. 2002). Ward managers understood and
sympathised with the ‘business case’ rhetoric and most were finding ways to be
flexible, but low levels of staffing made it very difficult to meet these
requests without putting pressure on other staff:
“… the ones who
don’t request flexibility might get landed with the crap shifts. Just because
you don’t have children doesn’t mean that you have to work every weekend and
Christmas.” (“Lynne”, Clinic
Manager)
The use of bank or agency staff to fill the
gaps was commonplace but considerable time had to be spent on orientation and
supervision and their use had to be approved by the Ops Manager. In some areas,
the higher hourly rate meant to was considered “good management practice” to
fill the short-fall by only two thirds or less. This policy was driven by a
Trust level cost-reduction programme that infuriated Ward Managers in the hard
pressed areas who felt that it put undue pressure on the permanent staff
leading to increased sickness absence, creating the need to use more agency
staff. In some wards, if a suitable replacement could not be found, the ward
manager would work the additional shift themselves, sometimes being paid at a
lower grade. Willmot (1998) describes this behaviour as jumping in with
clinical skills for temporary relief rather than using management skills to
find a more permanent solution. In our Trust, Ward Managers felt they had had
little power to do anything else.
Consequences for nursing careers – can’t
climb, won’t climb
Long working hours and stress made the
posts of Ward Manager and above difficult for anyone to undertake, especially
those with dependent care responsibilities. Some Ops Managers were open to Ward
Managers working part-time, as a job share, or having some flexibility in their
working hours to meet non-work commitments but without significantly
redesigning the job, such changes work cannot work. With the support of her ops
manager, Paula was able to start and finish earlier than the other Ward
Managers to pick her children up from school. However, she still felt her job
had become incompatible with being a parent and has left the NHS to work for a
private nursing agency.
“In recent
times I’ve felt I’ve had no life, been totally exhausted. When you try to
switch off from work you feel like you’re compromising your profession and you
can’t switch off from your family. The two just don’t marry up – it’s an either
/ or situation… A [ward manager’s] job is too much for anyone even without
children – life’s too short.” (“Paula”, Ward
Manager)
This is not the usual glass-ceiling
scenario of career winners at the expense of career losers. Senior nursing jobs
are more than inaccessible or unsustainable for people with care
responsibilities, they are undesirable to all. Unlike previous generations of
nurses, not a single staff nurse, regardless of age, gender or family status
saw ward management as part of their career future nor did any of the Ward
Managers want to become Ops Managers. David, a young D grade staff nurse with
no family responsibilities said he wanted to ‘climb the ladder’ but when asked
if that included being a ward manager he replied:
“I don’t know
if I want to go as high as that. [Our ward manager] has left because of the
job. I saw what it did to her, I’d be
happy staying at an F.” (“David”, D Grade Staff Nurse)
“I don’t want to
go higher than an F because I look at [my ward manager] and it’s a terrible
job. There’s no motivating factors. You get no support from higher up. The
responsibility for the ward is vast – higher
management has no idea of what ward work involves.” (“Kirsty”, Acting F Grade Staff Nurse)
The reduction in clinical contact also put
staff nurses off and was the main reason for Ward Managers not wanting
promotion. For those who wanted to progress, the non-managerial G Grade role of
Clinical Nurse Specialist was the preferred route. Other than specialisation,
the desirable job in ward nursing appeared to be a senior E grade post where
clinical contact was high, management responsibility low and pay sometimes
higher than F and G grade. Ward Managers did not anti-social hours so their
take home pay was often less than the E grades: an understandable source of
frustration and bitterness.
This paper has presented some of the early
findings of a project examining how NHS nurses and midwives reconcile their
career and family life. The most striking findings were those relating the
working lives and work-life balance of the Ward Managers. Like all workers in
the public services, NPM has been part of their working lives for a number of
years but only recently has managerialism been fully and directly felt at ward
level. The transformation of Clinical
Nurse Manager into a generalist management post seemed to be instrumental in
this devolution. The dilemmas, personal and professional, which faced Ward
Managers as they tried to meet extended managerial and clinical
responsibilities were significant and, for some, too much to bear. The Trust
was losing experienced nursing staff and there was no-one in the wings to
replace them. Working hours were long,
stress high and rewards not commensurate. What does this mean for the policy
agenda?
The drive to increase recruitment and
retention through a commitment to flexible working and other family friendly
policies had infiltrated the Trust but was being implemented in an ad hoc
fashion. A supportive culture and line management is sometimes seen as the key
to implementing these policies but good will alone is not sufficient. The Ward
and Ops managers in this Trust were sympathetic to employees’ needs to
reconcile work and family life and understood the ‘business case’ behind it but
lacked the resources to be as flexible as they wanted to be. What may be needed
is a fundamental rethink of how in-patient health-care is resourced and
delivered. Promises by central government of flexible working practices for all
staff were therefore somewhat empty. The policy agenda has failed to address
this interaction between work-family policy utilisation and career progression.
With its focus further study as a route to professional development and
progression, Agenda for Change may further disadvantage those with the greatest
pressures on their time. Further, the formal availability of ‘family-friendly’
and flexible working policies (such as that promised by Improving Working
Lives) is a necessary, but not sufficient step to helping employees
reconcile work and home life (Bond et al. 2002). Little attention has
been paid to the considerable implementation issues which face a 24/7 service
and to the work-life balance of employees at ward manager level and above.
The future of the Ward Manager’s role will
be a watershed in determining the success of Agenda for Change for nurses and
for NHS management as a whole. Recognising and rewarding responsibilities and
lack of anti-social hours payments in monetary terms is a crucial starting
point but this alone is unlikely to make ward management an aspiration for
junior nurses. Ward Managers needed their role to be more clearly defined and
to be given the time, resources and power to fulfil clinical and managerial
responsibilities.
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