Journal of Nursing Management, 1983,1,12@-132

Opinion article

Management as an integral part of nursing*

lntroductlon

Florence Nightingale (1869) had a succinct definition of nursing as

putting the patient in the best condition for nature to act

To begin, it might be helpful to see managers and management in nursing as ‘putting nurses and nursing in the best condition to act’. Each nurse is a manager in terms of the way he or she organizes patient care. Some nurses manage others while doing so, and some are involved exclusively in management of people and resources, although they may no longer be involved in nursing practice.

The case for sound management in nursing is very clear; nurses are everywhere. We are the biggest single group of health care employees in both public and private sectors. As a result, our salaries consume a huge proportion of health care budgets. Our numbers mean that we also have the greatest influence on how resources are spent on patients. Perhaps, most importantly, our presence in every sector of health care means that we can affect the quality of patient care more significantly than any other single professional group. Whether nurses manage their work well, or whether they manage themselves well will determine, to a large extent, whether patient care is good or bad. We therefore need to invest in nursing management at all levels, not least because it makes sound economic sense to do so.

We have yet to get this message through fully to all of those in health care-especially to those who have control over resources. So often management of nurses is interpreted as control of nurses. I have a maxim to offer here-the more you control the less you create. High quality nursing practice is essentially a creative act. Nurses need the freedom, confidence and knowledge to be creative in their caring. Yet, in so many places, methods of managing care used by nurses do not lend

*This is an edited version of the opening paper given at the IIIrd International Nursing Meeting at ALAVA, Vitoria, Spain, 1992.

themselves to the treatment of patients as human beings. At the same time, if nurses are expected to deliver individualized care, they also need to be managed in ways which respect their needs and humanity as individ- uals. The carers need to be cared for.

I would like to pursue this theme by looking first of all at the management of patient care by nurses a t practice level, and then examine some of the issues pertinent to the management of nurses themselves.

Management of care

There are many methods of organizing care open to nurses, but it is beyond the scope of my paper to dwell on these too closely today. Commonly used methods are: primary nursing, patient allocation, team nursing, case methods, case management, integrated services, key worker system. Each of these seeks to place the patient as the central focus of nursing practice activity. Yet as Pearson (1988) points out, nurses appear to remain obsessed with organizing care using task allocation (e.g. one nurse checks blood pressures, another checks weights, others change dressings and so on: the patient is not treated as a whole person, but is seen as a list of tasks to be accomplished and important elements of care, especi- ally psychological support, teaching and counselling may be overlooked). Thus, the patient’s expectations that the nurse will ‘humanize’ the system for them fail. Lanara (1984) suggests that ‘nursing is today at a critical and, one might say, tragic crossroads. The nurse is better educated, more knowledgeable and more science- orientated, yet the patient, for all the superb physical and technical improvements in his environment, feels lonely and even abandoned because nobody cares for him as a person’.

Managing care in ways other than task allocation appears to be beneficial not only to the quality of patient care but also to its cost. As Payne (1991) notes, ‘there are cost benefits if you move the patient through the system more efficiently. If you get it right in the first place, you

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don’t need to do the repairs. Money, time and frustration are wasted on dealing with complaints, complications and so on’. Thus, organizing care in patient-centred ways appears to be not only better for patients but also cheaper in the long run.

Recently, the Audit Commission (1991) and Carr-Hill et al. (1992) have highlighted how higher levels of qualified staff, using methods such as team nursing or primary nursing, were not only producing better quality of care but also at a lower cost in the long term. Qualified nurses are better equipped with knowledge and skill to make decisions and deliver care independently and efficiently. Where there are too many unqualified helpers, too much time is wasted waiting for help in giving care requiring supervision and so on. At the same time, the reports offered some hopeful signs to counter Lanara’s pessimism. They indicate that an enormous shift had taken place in British nursing over the past 10 years. Task allocation dominated about 75% of hospital settings in 1981. This now seems to have shrunk to less than 11%, while other, more patient-centred methods such as primary and team nursing, have taken over.

The way care is managed is not just simply about organizing nurses, it is an expression of the complexity of nursing actions and the values which nurses hold about themselves and their patients. Nurses first of all have to recognize for themselves the intricacy of nursing. Consider for example the immense range of nursing skills which have to be used during the nursing process. The four phases described do little to convey the enormous com- plexity of the knowledge and skills being put to use in every problem-solving situation-nurses do this often so expertly and intuitively that it belies the true breadth and depth of its nature. Thus nurses themselves, socialized into their role as victims in a medically dominated masculine world, often fail to recognize the tremendous wealth of knowledge and skill they can bring to helping people. So much of the attention is spent on the fashion- able drug treatment or the high status surgical intervention that nursing gets lost and devalued along the way and nurses do not value what they do. Nursing is a female dominated profession and, like women, they have to ‘reject trivialization’ (Greer 1991) of what they do by others. Within the health care system women and nursing remain essentially suppressed, despite the advances of recent years. Perhaps one of the first tasks in improving management of patient care, is that nurses need to like themselves a little more.

While managing care depends very much on each nurse’s individual values and the extent to which they have developed their knowledge and skills, there are other factors at work. It is very difficult for nurses to treat their

patients as human beings when they do same support themselves.

not receive the

The managers and the YES climate

Far too many nurses work in a climate which fails to encourage them to develop, to involve them in decisions about care or supports them in order to practise care in individualized ways. Martin’s (1984) research identified a number of key reasons why nurses fail to care for patients and develop very rigid, routine and institutionalized approaches to care. Lack of management support emerges as one of these. A more recent report in the UK (Price Waterhouse 1988) showed how this lack of support also contributed to large numbers of nurses leaving the pro- fession. Feeling unsupported contributes considerably to nurses anxiety at work and this is compounded when confronted with the ‘stew’ of the illness experience (Frank 1991). When nurses feel uncertain about coping with what confronts them, they are much more at risk of lapsing into depersonalized forms of care-the tasks becoming a ‘shield against anxiety’ (Menzies 1961).

To reverse this, nurses have to develop alternative ways of coping. They need managers who can develop a strong team spirit-crucial to the success of nursing teams. They need managers who can lead and offer a vision of the future, who can inspire and motivate their staff. Unfortunately, many of those in management positions suffer from one of the fatal flaws which occurs in health care and other systems right across the world; people who are experts in what they do are often promoted to positions where they not only manage others giving that expertise, but sometimes other groups of workers as well. Thus, it is common to find the doctor or nurse, excellent in their field of practice, placed in a managerial position on the mistaken assumption that expertise in practice must somehow equate with expertise in management.

It needs to be clearly recognized that the management of nursing (an individual nurse organizing his or her day- to-day care) is quite a different set of talents and skills from the management of nurses. A nurse is essential for the former, but it is open to debate whether a nurse is necessary for the latter. Management skills form quite a different set of universal skills which, in theory, are applicable to any setting. Furthermore, nurses and nursing need more than management-a system of people with skills of organization and decision-making for people and resources. They need leadership, people who can see the needs of patients as well as nurses, who can generate involvement and team spirit, and who can inspire and lead nurses toward a vision of a better future.

Such managers recognize that failure is represented by

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their organization falling apart when they are absent. The successful managedeader is not missed when they are away because they have empowered their staff. They have encouraged a climate, what I call a ‘yes’ climate-where spending money and time on staff development is seen to be as important as spending the same on patient care. Indeed, this is seen as investment in staff, not a drain on the service. Such managerdleaders demonstrate that the language and actions of caring apply as much to staff as they do to patients.

Those managers who fail in this field generate a ‘no’ climate-where staff morale is poor, team spirit is under- mined, involvement in decisions is minimal and staff development offered grudgingly. The ‘no’ managers become ‘soggy sponges’ (Plant 1987) in the system- keeping knowledge and information to themselves. By their actions, the hospital or unit becomes a ‘sick organiz- ation’ where the managers devote their attentions to keeping control of the status quo. The patients are cared for, but the hospital and the staff have become sick! Meanwhile, the staff learn to subvert the system and the managers by forming ‘front line organizations’ (Scheff 1967), giving the impression of following management orders but going about things in their own way as soon as the manager’s attention is no longer focused on them. Such an approach is a recipe for chaos and the creation of institutionalized care.

Managers in these circumstances will use the term ‘professional’ to control nurses (Salvage 1985). Failure to obey is a failure to be professional (if only Florence Nightingale had placed assertiveness instead of obedience high on her priorities for the nursing curriculum!) which may ultimately be used as an excuse for dismissal.

‘Yes’ managers empower their staff through develop- ment and involvement in the decision-making process. They ‘turn the servant into the master through the use of expertise’ (Wilkes 1981).

Here it is recognized that the role of the manager is also that of change agent-not always controlling the change, but acting in a supportive role with others to enable and empower staff to make changes themselves. In this way, changes which the staff come to feel they own are more likely to be adopted than those which are imposed on them. Elsewhere (Wright 1989) I have likened the failure to do this as a ‘shifting sand effect’-the manager feels that a great impression is being made in the sands of the setting where they work by forcing change upon the workforce (using the power coercive or rational empirical methods). However, when they move on, the sands return to fill the impressions-nothing has changed because methods which involve and engage staff in the change process (the normative-re-educative or

‘bottom-up’ approach) have not been used. The ‘yes’ manager recognizes this truth-that we all have to be involved in the business of change.

The following section from an American study (McClure et al. 1983) exemplifies the kind of management approach of the ‘yes’ manager:

Staff nurses state that their leaders are visible in the institution and are accessible for support and prob- lem resolution. Nurse administrators-both top and middle managers-make rounds on patient units, stop to talk to nurses, discuss patients and nursing problems, and listen attentively and respond to what nurses say. Nurses feel free to discuss their concerns with these administrators, whether they relate to patient care, administration, interpersonal relation- ships or personal matters. They know that their administrators care and that their (the staff’s) opi- nions are valued.

Far too few nurses experience a style of management like this. Nurses in practice are managers of care; they manage patients’ bodies and minds; they are chaos man- agers. In every nursing situation there is so much that can go wrong, so many problems arising that chaos manage- ment is much of what nursing is all about. If nurses are to face this chaos positively, skilfully and maintain the dignity and humanity of those for whom they care, then they need managers who can support them in doing so by the style, method and strategies outlined above.

Nursing management is often glibly described, and many books and papers have been written and courses planned, which enumerate and debate the skills required. Yes, the manager is an accountant, a staff appraiser, a counsellor, a decision maker and so on. What I have tried to suggest is that nursing management demands much more than this. The manager must also be a leader. Behind every effective nurse in practice is an effective managerlleader. This may seem to be a great expectation to impose upon managers. To inspire and motivate staff is no easy task if managers have not been offered training and development or do not get support from their man- agers, or the wider organization.

Furthermore, empowering and freeing-up staff has consequences for the manager which may not always make them feel comfortable. Empowered staff may ask difficult questions, demand attention, and request resources. Perhaps it is safer and simpler to keep things tightly under control for ‘sometimes it is safer to be in chains than to be free’ (Kafka 1916). Producing greater openness in the system does produce other challenges. However, most managers will readily agree that a team of staff who are confident, assertive and know what they are about, are far easier to manage than a gang of slaves who constantly demand their attention and supervision.

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Good managedeaders are made not born. Managers who are also nurses can bring great benefits to the wider organization and this should reinforce our argument for better resources. The strength of having a nursing back- ground and of having actually cared for patients as well as knowing how the organization works, is a tremendous asset to health care. When this is combined with an effective management and leadership style, then there is great potential for nurses to exert authority and take a much bigger role in the management of health services.

In addition, nurses can bring nursing values into man- agement which are an anathema to the desk-thumping, power seeking ‘macho’ management style. Nursing values are based on teamwork, developing expertise, mutual support-the only way for patients to derive full benefit from the health professionals, which nurses must learn at an early stage. They are based on respect for persons, on solving problems, on working together in co-operation. Such values are the experience of nurses and underpin their actions. If we can transmit them more widely, then nurses can work together to be a real force for social change. When we do that, the rest of the world, and not just health care, will be a better place.

Reference8

The Audit Commission (1991) The Virtue of Patients-Making the Best Use of Ward Nursing Resources, HMSO, London.

Carr-Hill R., Dixon P., Cibbs 1. et al. (1992) Skill Mix and the Effectiveness of Nursing Care, Centre for Health Economics, University of York.

Frank A. (1991) At the Will of the Body, Houghton Mifflin, Boston.

Greer C. (1990) The Change, Hamish Hamilton, London. Kafka F. (1916) Metamorphosis, reprinted (1974), Penguin,

Lanara V . (1984) Heroism as a Nursing Value, Evniki, Athens. McClure M.L., Poulin M.A., Sovie M.D. & Wandelt M.A. (1983)

Magnet Hospitals-Attraction and Retention of Professional Nurses, American Academy of Nursing, Kansas City.

Menzies I. (1961) The functioning of social systems as a defence against anxiety, reprinted 1988. In Menzies-Lyth 1. (1988) Containing Anxiety in Institutions. Free Association Books, London.

Nightingale F. (1869) Notes on Nursing, What It Is and What It Is Not, republished (1980), Churchill Livingstone, Edinburgh.

Payne C. (1991) Management Issues in Primary Nursing, Unpublished paper, Presented at Primary Nursing Conference, Huddersfield, June 1991.

Harmondsworth.

Pearson A. (Ed) (1988) Primary Nursing, Croom Helm, London. Plant R. (1987) Managing Change and Making it Stick, Harper

Collins, London. Price Waterhouse (1988) Recruitment and Retention of Nurses,

(Report commissioned by the DOH) Price Waterhouse, London. Salvage J. (1985) The Politics of Nursing, Heinemann, London. Scheff T. (1967) Mental Illness and Social Processes, Harper Row,

Wilkes R. (1981) Social Work with Undervalued Groups,

Wright S.G. (1989) Changing Nursing Practice, Arnold, London.

London.

Tavistock, London.

S.G. WRIGHT MBE, RGN, RCNT, RNT, DipN, DANS, MSC,

FRCN

Director The European Nursing Development Agency

Tameside General Hospital Ashton-under-Lyne

Lancashire, OL6 9R W UK

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