Reconciling Career and Family Life in NHS Nursing and Midwifery: Dilemmas in Ward Management

 Image result for Nursing Careers


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.

 Image result for Nursing Careers

 The Study

The Trust

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.

 Image result for Nursing Careers


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.

No comments