Many managers in the NHS come from a business rather than clinical background. A Scottish study examined frontline nurses’ perceptions of general managers
The introduction of business principles in the NHS to increase efficiency and value for money has involved bringing in managers who are not necessarily experienced in healthcare, but can offer the right business skills. To learn more about frontline nurses’ perception of senior managers and areas of potential conflict, interviews were conducted with 31 frontline NHS nurses in a Scottish hospital between July and September 2010. Many participants had a poor understanding of senior managers’ role. They believed the non-clinical background of some managers meant they could not understand the pressures at the front line. Understanding the relationship between senior managers and frontline nursing staff, and involving nurses in decision making, can lead to better understanding and shared goals. One way to increase the credibility of managers could be for them to spend time at the front line experiencing what it is like to give patient care.
Citation: Hoyle L (2015) How NHS managers are perceived by nurses. Nursing Times; 111: 21, 20-21.
Author: Louise Hoyle is a lecturer at Edinburgh Napier University.
- This article has been double-blind peer reviewed
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- This article is a summary of an article published in the Journal of Advanced Nursing (Hoyle, 2014)
Since the 1980s there has been a drive to run the NHS more like a commercial business, to increase efficiency and value for money. This has led to organisational changes (Numerato et al, 2012), and the introduction of general managers into the service (Evans, 2009; Griffiths, 1983). These managers may have significant management experience, but not necessarily related to healthcare (Hunter, 2007). And until recently the reforms have not been particularly successful in recruiting or retaining managers from outside the NHS (Exworthy et al, 2009).
The need to improve recruitment and retention of managers has led to the introduction of direct-entry programmes, such as graduate manager schemes, to recruit ”highly talented, emotionally intelligent leaders who demonstrate our shared values of care and compassion, dignity and respect, openness, honesty and responsibility, quality and teamwork” (NHS Education for Scotland, 2015). Such schemes are open to managers from outside the NHS, as well as those who have been promoted within the NHS and nursing.
This article reports on a study of nurses’ perceptions of senior managers within the NHS (Hoyle, 2014). These managers are usually responsible for a specific function within an organisation - for example, communications and corporate affairs, performance and quality management, project management, purchasing and contract management and strategic management. This is different from middle managers, such as modern matrons and lead nurses, who have at least one manager reporting to them, or junior managers such as ward managers, who have no other managers reporting to them.
The general manager is a senior management role, and should focus on leadership, cost improvement, motivating staff and meeting the “overall objectives of the service” (Chambers, 2009). This can sometimes be seen as conflicting with the priorities of nursing staff, whose main focus is patient care (Coupland et al, 2005). These perceived differences can cause tensions between nurses and managers.
The aim of the study was to learn more about frontline nurses’ perception of senior managers - particularly those who do not have a nursing background - to gain a greater understanding of the relationship between them and help them work together more effectively.
The research team carried out qualitative, semi-structured interviews with 31 frontline nurses (bands 5-7) in a large Scottish inner city hospital between July and September 2010. The purpose was to explore nurses’ perceptions of the role of managers. Ward managers and nurses from emergency departments, and medical and surgical wards took part.
Most participants appreciated the pressures and difficulties faced by ward managers and lead nurses, but few had empathy for senior managers, whom they saw as focused on budgets, audits and targets, rather than patients’s needs. This perceived conflict between “management-minded” senior managers and “medically minded” nurses meant participants did not necessarily believe managers’ decisions were in the best interests of patients.
Many participants also felt their workload was increased by having to explain clinical decisions to senior managers, who lacked relevant experience or had been removed from practice for too long to know what it was like to work on the wards. Such beliefs could lead nurses to question the authority and validity of senior management decisions.
Several participants believed they had a more important role than managers, but that the work of nurses was not respected and valued by senior management. This led some to question the legitimacy and authority of managers.
Some participants thought the NHS employed too many managers at the expense of frontline nursing staff. Media reports at the time claimed numbers of managers were increasing, while a reduction in nursing staff was threatened. However, the basis for this is questionable: a King’s Fund report shows the number of NHS managers in Scotland fell or was static between 1999 and 2009 (King’s Fund, 2011). In the words of Learmonth (1997) “it could be that there is a commonly held view by members of the public that a service which managers are trying to make ever more efficient, rational and controlled cannot at the same time be caring and people-centred”.
There was also a feeling that nurses were not consulted about the implications of management decisions, so decisions often lacked their support. Nurses can be a powerful influence in the success of management policy at ward level. However, it was clear participants felt unable to influence these decisions, and this led to them resisting policies they did not agree with.
If nurses do not see the decisions being made by managers as legitimate, or appreciate the need for the managers who make these decisions, this can lead to conflict and resentment, which in turn can have a negative impact on the working environment. Management support and a positive working environment are needed for a healthy workplace (Schmalenberg and Kramer, 2009). Where nurses are challenging the legitimacy of management decisions - and sometimes the role of management itself - this can negatively affect the quality of patient care.
Davies (2013) highlighted the need for senior managers to engage with frontline staff for the benefit of staff and patients, while the Francis report recommended the NHS should increase visible leadership (Francis, 2013). One way to achieve this is for senior managers “to go back to the front and experience first-hand the realities of care delivery from the perspectives of patients and staff” (Davies, 2013). Such a strategy could help them to be more visible to frontline staff, and enable them to take nurses’ views and patient care into account in their decision-making.
Tensions can arise between managers and nurses as a result of perceived conflicts in what they are trying to achieve. It is important to understand the relationship between senior managers and frontline nursing staff, and to involve nurses in decision-making processes to enable shared priorities and understanding.
Learning more about nurses’ perceptions of senior management allows us to identify some of these tensions and difficulties, and to develop strategies to improve and maintain working relationships, so enhancing patient care (Box 1).
The study did not investigate how senior managers perceive their role. It would be interesting to explore these and compare them with the perceptions of frontline staff.
Box 1. Improvement strategies
- Engage with frontline staff and ensure you are visible to them
- Help them to understand your role
- Ask for their views
- Involve them in decision-making
- Take time to experience life on the front line
- Take nurses’ views and patient care into account in decision-making
- Nurses often have a poor understanding of senior managers’ role and see a conflict between what they are trying to achieve
- Managers are seen by nurses to base decisions around targets, audits and budgets, and not patient care
- Many nurses are concerned about the non-clinical background of some managers
- Nurses can feel disempowered when it comes to management decisions, which can lead them to resist changes
- Spending time on the front line can help managers to improve decision-making and staff engagement
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