colin hales, carole doherty and mark gatenby

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Colin Hales, Carole Doherty and Mark Gatenby. Continuity and tension in the definition, perception and enactment of the first-line management role in health care. Outline. Research questions What is first-line management Method Findings - Ward managers/ward sisters - PowerPoint PPT Presentation


  • Continuity and tension in the definition, perception and enactment of the first-line management role in health care

    Colin Hales, Carole Doherty and Mark Gatenby

  • OutlineResearch questionsWhat is first-line managementMethodFindings- Ward managers/ward sisters - Service managersComparison of the rolesImplications for practice

  • Research QuestionsHow has the FLM role been both shaped and experienced in health care?

    How is the FLM role in healthcare defined, both formally and in terms of others expectations? What is the balance between routine supervision, performance management, team leadership and wider resource management responsibilities and what are the tensions between these? How do FLMs interpret, experience and enact their role?

  • What is the role of first-line managers?

    The first level of management to whom non-managerial employees report. The role is:

    centred on the day to day supervision of a limited organisational operational sub-unit/work group

    responsibility for the key functions of keeping production going and translating strategy into operational reality

    Tasks included supervision, monitoring and reporting of operational activities

  • What is the role of first-line managers?

    Changes has been towards

    Re-division of managerial labour to produce an expanded FLM roleDownward shift has often been to professionalsDecision making and accountability confined largely to operations

    Are they coaches of self managing teams/ mini-general managers of cost centres/business units with commensurate authority over budgeting, staffing decisions and accountability for performance?orHas their supervisory core has been strengthened by needed to handle a growth in operational activity or comply with more external regulation?

  • MethodMixed paradigm combination of critical realism and sense-making A critical realist lens - focus on the structural conditions which constrain and enable FLMs actions and interactionsA sense-making lens - focus on the detailed processes of FLMs actions and interaction

    Case study approach: - two types of FLM role (the ward sister/charge nurse as a practitioner-manager and one general line manager) - two hospital trusts (Alpha and Beta) hospitals selected for typicality

  • Data collection methodsOrganisational documents, in-depth interviews and ethnographic observations.

    Data on how the FLM roles are constituted by the connection between others' expectations and FLMs' own role perceptions and interpretations were collected in four stages:

    Identifying the FLMs role sets Eliciting role set members expectations of the FLM roleEliciting FLMs perceptions of their own roleInvestigating FLMs sense-making of others expectations

  • Data collection methodsEthnographic observations took two forms:

    Firstly, 7 FLMs, 3 in Alpha and 4 in Beta were work shadowed over the course of one or more working days. 10 days of work shadowing were conducted in total

    Secondly, the research team were invited to sit in on and observe a series of training days for Ward Sisters at Beta. These took the form of presentations by senior managers on topics and issues considered to be of relevance to the WS role, followed by small-group and subsequent plenary discussion of these topics

  • Findings.Expectations of the Ward Sister/Charge Nurse RoleNursing and clinical work The pure professional roleClinical credibilityTeacherDoing fair share of nursing workMentorManagement within the clinical roleManagement beyond the clinical roleBeing in charge the captain of the shipHuman resource managementConflict resolutionPerformance monitoring/reportingShaping the ward environmentRole ModelSupervisor and standard bearerManaging patient throughputFinancial managementFormal complaints handling

  • Tensions

  • Ward Sister/Charge Nurse interpretation and enactment of their roleIn general they re-affirm their identity as senior nurses by holding to the central importance and unchanging nature of patient care and the role of the WS as central to healthcare delivery.

    The clinical work is still really important to me. actually hands-on with a patient is [important]- I really like doing that, I wouldn't want to lose that at the moment. ... Obviously my priority is the patients (WS 2, Alpha)

    the job description says twenty-four hour responsibility which, you know, I took the job, I knew what it was about (WS 3, Alpha)

  • Ward Sister/Charge Nurse interpretation and enactment of their role

    They comply with those targets and procedures which they cannot avoid by box ticking and sometimes gaming the system and falsify audit scores:

    we lie about some of our audit data because if we didn't lie, then we'd be told off so sometimes it's easier to lie about it rather than do it properly (WS 6, Beta)

    Clinical Governance meetingit was horribleI can still feel the palpitations from sitting there! It was horrible really intimidating. (WS 12, Beta)

  • Ward Sister/Charge Nurse interpretation and enactment of their roleJuggle tasks - usually by attending to immediate clinical issues at the expense of management tasksI have it all planned in my mind so I come in at half past seven, telephone's ringing, somebody's off sick and then somebody else is off sick and then I think to myself, 'Right, that's those business cases gone today, another day to do those'! What can I do? Knit nurses, that's what I say (WS 10, Beta) We were trying to actively recruit a staff nurse and I knew that we kept missing her during the morning, then a child needed a nebuliser so I assist[ed] the child,, then the nurse rang up and so I went into the office and discussed briefly, what the role was about how to apply [I] then clicked straight back into taking the nebuliser off and doing the observation on the child again which I found quite weird at first, so it's difficult to do your clinical and your management and not switch off either (WS 2, Alpha)

  • Service Manager Role Set Expectations and Tensions

    Who are first-line non-clinical managers?- They are variously labelled, Specialty Managers, Service Managers, Operations Managers and Clinical Business Unit Managers

    Common responsibilities and relationships are found in the job descriptions that, at least formally, help to define the role:working closely with the General Manager, this post will play a key role in ensuring that the Specialist Medicine Directorate meets the requirements of the performance agenda.

    The job description reinforces this relationship by outlining the relative responsibilities of the role:work with the general manager to ensure junior doctor rosters are compliant and provide the required support for the service supported by their manager, the role will be responsible for policy implementation, and service development in their area

  • ConsultantsSenior managersJunior staffOperations ensuring the smooth running of processes by reacting to and attempting to solve day to day problems in the system

    Human resource management primarily of administrative staff including medical secretaries, whom SMs manage on behalf of the consultantsFinance and performance management - monitor breaches, account for breachesService Development - to provide the nuts and bolts to enable the implementation of consultants ideas for service development

  • Service Manager Role Set Expectations and TensionsFrom the doctors perspective, there is a lot of management for managements sake and some aspects of the SMs role are seen to reflect this:

    management likes to go in for play thisTPOT irritates grown-up people to be honest and there is an awful lot of that so a [SM] has to be, I think, careful not to put the backs up people that have to work and deliver. (General Surgeon, Alpha)

    Similarly some Ward Sisters take the view that there are too many managers:Business managers have lots of meetings, not sure what about, they dont decide much or make things happen. (Ward Sister, MHDU, Beta).

  • Service Manager interpretation and enactment of their roleSMs believe that they are personally responsible and accountable for the performance of their SBUs. They [finance] want to know what I'm going to be spending, is the activity we're doing making us money, how much money, how much activity we're going to put through, how much am I paying my doctors. (SM 1, Alpha)

    Ultimately it is the consultants who are the arbiters of the cost-efficiency and effectiveness of the SBUs work performance and they make this clear to the SMs: I've been told ... 'I will make sure that the operations are done but if you haven't got enough capacity that's down to you rather than down to me.' they're there to treat the patients, you're there to be the bureaucrat and see the numbers. (SM 4, Alpha)There are a few really nasty bullies that are consultants but that's just because they think they're God. (SM, 6 Alpha)

  • Service Manager interpretation and enactment of their roleSMs enact their environment to manage the role pressure by constructing an identity as dedicated, responsible individuals holding things together at the centre of their respective SBUs, cajoling, fixing and juggling both people and processes to maintain the units functional integrity on a daily basis: The minute I'm off on holiday, everything kind of falls apart, and I come back to over a thousand emails. (SM 9, Beta)

    They work long hours and dont do lunch

    I work part-time four days which means I work usually 40 hours a week, and that gives me some child care flexibility. If I was full time I would have to work a least 45 hours a week. (SM 4, Alpha)

  • Service Manager interpretation and enactment of