Feature

Who’s helping who...

Managers are supposed to help, not hinder nurses’ work. But what is the reality, asks Barry Clifton

.As a working nurse I am increasingly disturbed by the growing tendency to heavy management style in the health service, and by the emphasis on the establishment of chains of command, on hierarchy, grading and structure. These leave the ‘front-line’ working nurse with less professional autonomy, less opportunity to establish any sort of personal relationship with their patients.

Empire-building managers and administrators, abetted by the officers of nursing’s professional bodies, are setting up codes of practice that are being used to control the behaviour of nurses on the wards by saying what they ‘should’ or ‘ought’ to do. The result is that nurses are unable to pursue their main concern — the improvement of the quality of life of their individual patients.

This is creating an ever-broadening split between those who work on the wards, and those who increasingly practice remote control over them.

There is a strong and frequently-expressed feeling among nurses that they would like to see managers more often. They would like to suppose that managers had some inkling of what was involved in ward work — the physical grind, the handling of dirty bedclothes, the mopping of blood and faeces, the disposal of secretions from every orifice of the body. Combined with an accuracy of clinical judgement, a cool head in the face of sudden emergencies, a constant cheerfulness and unfailing patience, this is the humdrum of ward life. There are insights here that cannot be gained from the annual Christmas procession.

All too often managers appear to see nurses as automatic machines, interchangeable and disposable. As the health workers closet to the patients for the longest period, nurses’ opinions are either unsought or, if offered, ignored. Beds are closed and turnover increased, but nobody visits the ward to see the results in terms of fatigue, ill-health and absenteeism amongst the staff.

But the result of allowing staff levels to fall, and of closing beds, is that the wards are increasingly filled with acutely ill patients receiving increasingly intensive care.

’Managerialism’, as we may term the current health service virus, is concerned chiefly with setting up systems of control, monitoring standards of performance and measuring things that are numerically measurable — like the length of time a patient stays, and how much each stay costs. Of course, nobody measures whether the patient goes away feeling better, whether they take away a renewed ability to stay healthy, or a life-long terror of hospitals. For managers who treat healthcare as equivalent to the manufacture of ball-bearings, such considerations can have no place.

Because of the governmental encouragement, managers have come to see themselves as crucial to the functioning of the NHS. They see their relationship to professionals dealing with patients at the ‘front- line- as that of employer to employee, or commanding officer to private. They assume the divine rightness of their passion for cost-efficiency and a smooth-running production line.

Nurses, of course, carry on working for their patients rather than for health authority, seeing managers as a set of administrators appointed to facilitate nursing and medical care of patients, rather than as a board of directors controlling their work-force.

But instead of nursing being more about human relationships, it is going back to being about ‘getting through the work’, ‘machine-minding’ and domestic chores. Efforts to create person-to-person relationship are being discouraged by government and management, even as they are being more strongly advocated by educators.

I prefer to think that nursing is about valuing people as individuals and helping them to feel better about themselves, physically and emotionally. Among the advances that nurses have made towards becoming creative professionals was the setting up in the 1970s of a career structure in which nurses were responsible for nurses. It was not perfect but it was a start. Another was the setting up nursing development units run by nurses for people needing nursing care rather than medical treatment. Among the very first were those at Burford and at Oxford.

The Griffths report and the establishment of general management demolished the career structure, and it is illustrative of subsequent developments that last year the nursing unit at Oxford was closed.

The low morale on our hospital wards can’t begin to improve until we all realise that it is the front-line professionals, such as nurses and junior doctors, who do the job that the NHS was designed for, and that it is the task of managers and administrators to make that job easier.