Chapter 1 Be Clear About the Role of the Ward Manager
When you become a nurse manager your responsibilities change. Most of your education and experience to date will have been focused on clinical practice, but the manager’s role requires a very different set of skills. You are required to manage a team of staff with a set budget and are responsible for maintaining an environment in which people can work well.
Being a good nurse does not necessarily mean that you are naturally a good nurse manager. The two roles are very distinct. As a nurse, you are responsible for providing patients with a high standard of care. As a nurse manager, you are responsible for providing patients with a high standard of care through others. It takes time and experience to learn the art of being a good manager. Clarifying exactly what is expected of you in your role is the first major step.
Ward managers carry 24-hour responsibility for the ward. This means you are required to ensure that systems and processes are in place for patients to receive a high standard of care from your team, day and night, irrespective of whether you are there or not. It also means that you could be liable for poor patient care when you are not there if it is evident that you did not do everything to ensure that those systems and processes were in place. This includes:
The individual nurses in your team are registered professionals and therefore responsible and accountable for their own actions or inactions, under the terms of their registration. However, as their manager, you may be liable if you do not provide the right working conditions for your team to provide good care.
The term ‘24-hour responsibility’ does not mean that you should be accessible out-of-hours. It is a common misconception that the ward manager should be available at all times. There have been instances when on-call or site managers have called ward managers at home or on their mobile phones to sort out issues. You do not receive any payment for this, so it is unwise to encourage it. Home distractions or tiredness could also impair your response.
It is different if you have not done your job properly. For example, if some staff do not turn up for work on your ward one day and it is not clear on the roster who should be working that shift, then that is your responsibility. It means that you did not ensure adequate cover in your absence, and therefore need to be contacted to clarify matters. However, if members of your staff call in sick when you are not there, leaving shifts uncovered, it is the responsibility of the shift leader, matron or site manager to deal with the problem.
It is also not appropriate for members of your own team to be calling you at home. Your role is to enable them to make their own decisions and not to have to call you out-of-hours for advice. It is the responsibility of both you and your organisation to ensure that other senior managers are there to turn to for advice and support in emergencies when you are not there. This is usually the matron during office hours and some sort of on-call or site manager out-of-hours. If there is no such system properly in place, you could be liable for failing to address this omission.
The Nursing and Midwifery Council (NMC) does not offer any specific guidance on the accountability of nurse managers. However, it does include the aspect of being accountable for how and when to delegate. The NMC code (NMC 2008) requires that, when delegating, you must:
In 2002, one of the reasons for removing a matron from the register was cited as placing ‘unreasonable demands on staff’. A unit manager was also removed for ‘failing to take appropriate action when a patient was assaulted by a member of staff’. In other words, as a manager who is also an NMC registrant, you are failing to uphold the code if you do not put the interests of the patients first in any managerial decisions that you make. This is also made clear in the code of conduct for NHS managers (Department of Health 2002) which states that ‘the care and safety of patients’ should be your first concern and you must ‘act to protect them from risk’.
If you are working under extreme pressure or there are staffing shortages out of your control, you must report it to the appropriate senior manager and be able to demonstrate that you have made every effort to remedy the situation. Again, this is made clear in the NMC code which also adds that ‘you must report your concerns in writing if problems in the environment of care are putting people at risk’ (NMC 2008).
You should also be alert to pressures being felt by your staff, since overworked staff may act inappropriately. In 2011, the NMC found ‘basically a good nurse’ with ‘no evidence of general incompetence’ who was ‘dedicated to a career in nursing’ guilty of misconduct when she failed to summon assistance or commence resuscitation on a pulseless patient and completed the patient’s fluid charts retrospectively. In another case, the High Court held that the NMC had been unduly lenient in not finding unfitness to practise on the part of a midwife who failed to provide support to a junior colleague undergoing preceptorship and subsequently spoke in a bullying and intimidatory manner towards the person who had reported her. It is important to raise concerns over staff pressures rather than raise your voice to staff.
The NMC has produced clear guidelines for raising concerns to help all nurses and midwives (NMC 2010) and the Royal College of Nursing (RCN) in Northern Ireland has produced some good guidelines which are particularly relevant for ward managers and shift nurses-in-charge (RCN 2010). These guidelines also detail what you should include when raising your concerns in writing, such as:
If your line manager fails to address your concern, then you should raise it with your organisation’s designated person. Every organisation is required to have a designated person with specific training and responsibility for dealing with escalated concerns. For nurses and midwives, it’s usually (but not always) the director of nursing. Only ever consider taking your concerns further (e.g. regulatory organisation, MP or media) once you have exhausted these routes within your own organisation, and never do so until you have sought advice from the NMC, RCN or other trade union. Public Concern at Work is an independent charity which also offers free advice in such situations (www.pcaw.co.uk).
OK, so your job title is a ‘manager’. This does not automatically make you a good leader. Your job is to manage staff and resources to ensure that patients on your ward receive a good standard of care. If you lead well, your job as a manager will be made far easier. The job of a manager is to ensure people get things done, whereas a leader guides and inspires people and asks them how we can get things done. A good leader also enables their team to question whether the things need doing in the first place.
Transformational leadership is about influencing others to do things. The transformational leader is charismatic and inspirational. They are more considerate towards individuals. They stimulate people to be more creative and to challenge the system if necessary. The opposite of transformational is transactional. Transactional leadership applies to the older managerial style of setting tasks, giving rewards to those who achieve them and ‘punishing’ those who do not.
It is debatable as to whether transformational leadership is the model that is actually being used throughout practice at the moment, or whether it is entirely appropriate, since the current emphasis on meeting performance indicators can be viewed as largely transactional. However, a transformational leader will not only ask their team how indicators can be met, they will also question them and look at alternative solutions if they are detrimental to the overall patient care. So even in a transactional organisation, you can be transformational in your approach.
Get the team together and ask them about where they all want to be in the future, or more realistically in a year’s time. Facilitate them to set specific objectives together that they are all willing to work towards.
Continually question and look for ways of improving care in your ward. Encourage your staff to question decisions made by others (including other health professionals), by having the appropriate knowledge, confidence and support in order to do so.
The inquiries into Maidstone and Tunbridge Wells (outbreaks of Clostridium difficile) and Mid-Staffordshire (higher than average mortality rates) clearly showed failures in leadership, not only at the top of these organisations but throughout the organisations, as clinicians felt powerless to do anything. Scandals such as these have highlighted the need for all clinicians to be leaders, and develop the skills to take action in such situations. Shared leadership is about all health care workers being able to see what needs doing or what needs to change and having the skills to work with others in order to do it. Clinicians should develop the leadership skills to work in partnership with experienced non-clinical managers and vice-versa.
The NHS Leadership Framework is based on shared leadership, although it still contains elements of transformational style as well as general management competences (National Leadership Council (NLC) 2011). It has five core domains based on:
Staff can progress through various stages. Members of your team should be encouraged to develop competences at stage 1, which is within their own team. This stage is about developing good working relationships with their co-workers, and developing the skills to both recognise problems and work with others to solve them. The next stages, 2, 3, and 4, build on the skills of people in managerial positions, including that of ward manager, to build on the skills entailed in working across teams, the organisation and the whole health care system.
Various development programmes are available for ward managers through the NLC (www.nhsleadership.org.uk), King’s Fund (www.kingsfund.org.uk/leadership) and RCN (www.rcn.org.uk/development/practice/leadership). It’s worthwhile accessing one of these types of programmes which are focused on clinical leadership rather than general management.
If you make decisions that affect your staff or patients based on the advice of one person alone, you cannot blame them if your decision was the wrong one. If there is a serious incident, for example, and you take a course of action that your manager advised, you may remain fully responsible for the outcome of that decision. So get advice from others as well before you make that decision. Make sure all your decisions are informed ones.
Try not to rely on your line manager as your only source of advice. They are not necessarily the best people to guide you in your work. Not all line managers have been ward managers and know what the role entails. And of those who have had experience, how can you be sure that their experience is any better than yours and that they are giving you the right advice?
Sometimes nurses rely too heavily on the next person above them within the hierarchical system. This can be a mistake as, nowadays, being more senior does not necessarily mean that you have more relevant experience. That’s not to say you should ignore the advice and guidance of your line manager. Indeed, there are some very good and experienced matrons and service managers. However, it is always advisable to seek guidance from a variety of sources so that you can make an informed choice.
As a ward manager, you should find yourself a mentor; preferably someone several ranks higher than you. If possible, try and get one of the board directors to be your mentor. Most board or assistant board directors are keen to mentor someone from the clinical setting within their own organisation. A senior manager from another hospital or even a non-health care setting would be advantageous, particularly in helping you with human resource (HR) issues (see Ch. 10 for further information on mentorship in management).
It would also be wise to have a clinical supervisor. You need to have someone who is more expert than you in your specialist area to help you reflect and learn from your clinical practice. This could be a nurse specialist, consultant doctor/nurse or another more experienced ward manager (see Ch.5 for further information on clinical supervision).
Do not rely solely on your line manager or colleagues for advice regarding personnel issues. You may be able to benefit from their experience with similar issues but make sure you also consult with HR before making any decisions. If you have problems with your staff, such as inappropriate behaviour, sickness/absence problems or incompetence, your HR department will be able to provide the most up-to-date information with which you can then make the most appropriate decision.
Make sure you build up the appropriate networks before any problem arises. You should be meeting with your HR advisor on a monthly basis to build up a good working relationship. This will help enormously in times of crisis.
If you are going to make any changes at all which may involve extra staff or resources, always consult with your finance advisor first. It is their job to calculate the cost of any changes and to advise you what the best course of action is in terms of resources. They can help you become involved in the business planning process for your directorate and you will become far more knowledgeable and effective in accessing appropriate resources. As with HR, you should be meeting with your finance advisor on a monthly basis.
Another incredibly valuable resource often ignored by many ward managers and deputy ward managers is that of other more experienced ward managers. Why do so many ward managers work alone without searching out support from their more experienced peers? If you don’t have some sort of group where ward managers get together to share experiences, guide and support each other, it would be a good idea to develop one yourself (see p. 177).