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Thinking the Unthinkable: Do Ward Managers really need to be Nurses?

December 3, 2013

This week, dear readers, in a shameless bid for publicity I’m going to write about leadership. Leadership, as far as I can see, is where the big bucks are in nurse-related blogging. Politics, feminism and popular culture? Nobody (almost) gives a stuff about that. But pen something along the lines of: “I never really ‘got’ leadership until, at the end of one particularly frazzled day, a normally shy member of staff approached me and said ‘I wanted to thank you for keeping it together today and for…well, for being totally you‘. And I looked in the mirror and suddenly it was like some glorious flower was unfurling right there in front of me and I thought: ‘OMG, that’s sooo true! To be an amazing leader, ALL YOU REALLY HAVE TO DO IS BE YOURSELF!’” and you get loads of swooning comments (“Truly inspirational so proud of you”) and a ton of ‘likes’ and mentions on Twitter. Want some of that? Course I do!


If the internet is anything to go by, there are plenty of nurses out there who are eyeing themselves up as future leaders. And it’s heartening that both NHS England and the universities are recognising the need to formally channel this pool of talent and energy through the NHS Leadership Academy and the National Junior Leadership Academy. Additionally, in last week’s Nursing Times, Sue Haines (writing in a personal capacity) suggested that the Caremakers scheme is now functioning as a de facto training ground for ‘nurses with a passion for clinical leadership’. Personally, I find that last one a bit scary: I doubt that there’s a place for my – shall we say – more subversive intelligence within Caremaker orthodoxy and I wonder how I and others like me will fit into the happy-clappy wonderland it seems designed to create. On the other hand, I’m genuinely glad (yes, really!) that young professionals are being helped to plan their careers in a way that I never was.

There is a problem though: we are enticing nurses with promises that they can be leaders – but what they’ll end up as, by and large, is managers. And – as highlighted by Victor Adebowale in the Health Service Journal last week – they are not the same thing. ‘What makes leadership different from management’ wrote Adebowale ‘is the requirement to invest emotionally in…change and the means to achieve it. This is because leadership deals with ambiguity and change’.

Management, by contrast, is all about steadying the ship: safety, staffing, targets, compliance and throughput are its stock-in trade. Important? Yes. Sensible use of our best clinicians’ time? Well, let’s put it this way: if you revealed at the interview for your nursing degree that paperwork, not patients, was your all-consuming passion, you’d be shown the door, and pronto. But given that by the time you’re a Band 7, paperwork is what you’ll be spending most of your time doing, that may well turn out to be the wrong call. Recruitment for values? Get real. In the current environment, there’s a lot to be said for recruitment for typing speed.

Because – despite the government’s assurances – it seems unlikely that nursing’s administrative burden is going to diminish. New initiatives on ‘transparency’ combined with the requirements of Clinical Commissioning Groups mean that demand for data is set to soar. But as Haines points out in her article, fear of administrative overload is already an important factor in deterring the most able candidates from applying for Ward Manager posts. What’s the solution? Well people, we’re going to have to think the unthinkable: we’re going to have to ask (dramatic pause)  if Ward Managers really need to be nurses. Like it? Thought not – but it does make sense: if we leave ward management to professional administrators, we can liberate our best clinicians to become Ward Leaders.

To be honest, this isn’t blue-skies thinking. Way back in the the late 1980s or early 1990s I remember reading a very admiring article in the Nursing Times about a ward that had exactly this kind of set-up. Apparently everyone knew it as ‘the ward where the nurses have time for the patients’ or words to that effect. Unfortunately, it seems to have been an idea that failed to catch on – but could it be time to revisit? What might be the gains?

Well, let’s look at what a non-clinical Ward Manager (or Ward Administrator, if ‘manager’ is too hard to swallow) could do. Working in close collaboration with clinical staff, they could: arrange the off-duty and cover gaps; control budgets and ordering; collate audits and targets and detect trends; manage patient throughput including following-up on non-appearing transport; oversee general cleaning; keep track of training, annual leave and appraisals. Ward Leaders, meanwhile, after handing over all this desk-bound stuff to someone else, would be free to lead from the front on clinical care; teach and develop all grades of staff and students; spend time listening to patients and families; disseminate best practice and facilitate innovation and research at the ward or department level.

Hurdles need to be overcome of course. There would undoubtedly be a lot of negotiation around how Ward Administrators’ pay bands should compare with nurses’ and how their management structure would interact with nurses’. It would also be a trade-off: nurses would need to be clear that in return for the Holy Grail of a career structure that both keeps them at the bedside as they advance along it and rewards inspirational leadership and clinical excellence, the price would be the surrender of automatic sole responsibility for the ward or department. That is a high price – and some will say it’s too high.

We should be clear though, that the biggest obstacle is not nurses, but the government. Robert Francis’ recommendation that ‘ward nurse managers should operate in a supervisory capacity, and not be office-bound or expected to double up…as part of the nursing provision on the ward’ (recommendation 195) doesn’t go anywhere near as far as I have suggested is necessary to create proper leadership at ward level. But even it has been merely ‘accepted in principle’ (or ‘rejected’ as the more plain-spoken of us would put it) by the government. In doing so, they have failed to grasp the most basic lever of cultural change. The message they’ve sent out is “Yes, we want nurse leaders. Yes, we’re going to create nurse leaders. But then we’re going to make it impossible for them to lead.”

Some readers will no doubt question the wisdom and motivation behind a plan to plant mini-managers on every ward, and see it as a recipe for conflict. But Ward Managers are hopelessly conflicted already. The demands placed upon them are so many and so various (and in future are likely to become more, rather than less so) that the role is completely unsustainable in its current form. If we went back to the drawing board, we’d never be satisfied with a solution whereby the most experienced clinicians are also the ones furthest removed from the patients. We need new systems – ones that put service users at the centre, and – crucially – build on the talents of all those embryonic nursing leaders we’ve invested in. Or do we want them to end up so disillusioned that that they simply up sticks and take their skills elsewhere?


For Victor Adebowale’s article, see:
For Sue Haines’ article, see:                                                                                                                                                                                                                                                         

  1. This isn’t really unthinkable – for many years I have thought that ward administrative tasks should be done by a non-nurse. Leave the bean counting to bean counters and let the nurses get on and do what they trained to do. They should be out there, leading by example and developing their teams. There would be no reason to discuss salaries – they would be different jobs with different knowledge and skill sets. Just because nurses have been picking up these tasks over the years, doesn’t mean that they are the remit of nurses. The admin manager would report to the Nurse Leader, ensuring that the Nurse was the person with overall responsibility for the ward.

    Leadership is much more than “just be me”. That is perhaps why we suffer from such poor leadership in this country – too many people “just being me” with no insight as to their impact on others. Far from inspirational ……

  2. Thanks for joining the debate. I think your comment ‘Just because nurses have been picking up these tasks over the years, doesn’t mean that they are the remit of nurses’ sums it up nicely. As with mentoring, we seem to have ‘just arrived’ at a situation without anyone ever stopping to critically evaluate whether it is the best model in terms of the interests of staff and patients and the management and development of the system.
    Nurses as a group have had far too much ‘stuff’ dumped on them over the years. Arguably this is in part because they are so bad at saying ‘no’. It’s an area where a strong collective nursing voice is badly needed.

  3. Sue Haines permalink

    Interesting debate. Ward Sister in our trust led development of ward administrator role to do the very ‘desk bound’ work you’ve outlined. This administrator role is to support ward sister with the managerial tasks associated with managing and running a large team & clinical department, very different to receptionist role. Admin role reports to ward sister who oversee and sets work. Published nursing times
    Has had a big impact on the sister’s ability to be a visible clinical leader in practice, spend time with patients &teaching. Excellent clinical leadership role model, now sharing across Trust. Nurses need, as you say, that collective voice to influence so they can focus on what is important for patients

  4. Thank you for commenting, and for including a link that really adds to the article. I think we need to move forward – the administrative load on Ward Managers is far, far in excess of what it ever was when the job description was first mooted, and roles need to adapt to take account of that. We need leaders who can be a good advertisement for nursing, act as role models for others to aspire to, and restore trust. This cannot happen while the best and most experienced nurses are stuck behind desks.

  5. tiltic permalink

    Believe when Grading came in there was debate as to whether ward manager had to be nurses and there being an uproar that YES they had to be . I feel this was a missed opportunity . If non-nurse was manager they would by necessity be supernumerary to the nursing team.

  6. Absolutely, and unfortunately I think we are going down the same road with Francis and the response to it: yet another missed opportunity. Although one has to respect Robert Francis for his achievements, I do think that his nursing recommendations betray a fundamental lack of understanding of the profession – for example, there is much confusion in his report around what is really meant by ‘named nurse’ – and I question the wisdom of handing over responsibility for defining the changes we undoubtedly need to someone who has no experience of working on a ward. We are going to be living with Francis and its fallout for a long time to come, but many of the recommendations either don’t go far enough or are taking us in the wrong direction altogether.
    As Sue Haines points out above, some Trusts are already successfully implementing the ideas I have outlined – and well done to them. But in the current political climate, and without an explicit mandate on this, changes are likely to be piecemeal and ‘subject to local conditions’ (which is just a cop-out – how much variation in ‘local conditions’ can there be in a small country with a single health care system?).

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