- Email: [email protected]
Context and culture—The influence on role transition for first-line nurse managers
In! J. Nun.
Pergamon
Srud., Vol. 31, No. 6, pp. 555- 560. 1994 Copyright ~0 1994 Elsewer Science Ltd
Prmted
III Great
Bnta~n. All rrghts reserved 002s 7489194 $7.00 + 0.00
0020-7489(94)EOO12-8
Context and culture-the influence on role transition for Jirst-line nurse managers C. M. DUFFIELD, R.N., B.Sc.N., D.N.E., M.H.P., Ph.D., F.C.N.(N.S.W.), F.C.H.S.E. J. LUMBY, R.N., D.N.E., B.A., M.H.P.Ed., Ph.D., F.C.N.(N.S.W.), F.R.C.N.A. Unir,ersit? of Technology.
Sydney, P.O. Box 123, Broadway, NS W 2007, Australia
Abstract-The role of nurse managers at all levels is the subject of much debate in Australia. It has been argued that their role is not essential and increasingly new organisational structures are being implemented which do not include nurse managers. This paper describes reasons why nurses, who are mainly female, face conflict when making the transition to the role of manager in the male dominated health care system of today. It argues that the values which nurses are able to bring to these positions are those increasingly valued by the communuity they serve. It is not nurses who should change, but the values held by the organisations in which they are employed if society’s needs are to be well served.
Nurse managers in Australia, whether they are at the first-line or executive level, are increasingly finding their positions deleted from organisational structures. It has been argued that their roles are not essential and as they have not traditionally managed well. will not be missed. In this climate it is timely to consider not only where nurses have come from but also the context and culture of health care management today in order to critique the validity of such claims. The transition from the role of clinician to manager is not easy. Nurse managers emerge from a practice focus, are grounded in a management system dominated by masculine values and as a consequence, may experience conflict. Role confusion is a frequently documented consequence of this transition (Cederberg, 1986; de1 Bueno and Walker, 1984; Garity, 1983; Lanigan and Miller, 1981; Patrick, 1987; Swaffield, 1987; Taylor and Kramer, 1985). This paper will explore these themes more fully. 555
/
556
c’. M. DUFFIELD
und J. Ll’MBY
As the provision of care became established in hospitals under the influence of Florence Nightingale’s model, positions of authority were introduced to coordinate the flow of information and resource allocation. Historically in nursing “Matron” was the most highly skilled nurse, responsible for management, discipline and education throughout the hospital. At the ward level, care was coordinated and supervised by the most experienced nurse clinician, the “Charge Nurse”. Appointment to this role was usually on the basis of clinical expertise, since this nurse was responsible for the quality of nursing care and staff supervision. Of great significance for the future development of nursing in this country is that in this model nurses were to carry out orders rather than be independent decisionmakers. As a consequence of this history, many of the traditions and structures in nursing which now exist can be traced back to Nightingale’s influence. For example, it has been argued that a feature of today’s Australian health care institutions is the highly regimented approach to the organisation of nursing staff who do as they are told by those with more authority, for example, medical staff, nurse administrators and educators (Leddy and Pepper, 1989; Martin and Cuthbert, 1992). While much in nursing has changed since those early days, the Charge Nurse role and the basis of appointment to this role, remained relatively unchanged until 1986 when, throughout Australia, the roles of specialist clinician and nurse manager were separated. In New South Wales for example, Nursing Unit Managers replaced the Charge Nurse role. At the same time the role of Clinical Nurse Specialist was also introduced. For many Charge Nurses and the nursing profession generally, this was a significant alteration to the well-established status quo whereby the Charge Nurse, as the most experienced clinician, was responsible for the clinical management of the ward. With the introduction of these new positions, Nursing Unit Managers were required to relinquish many of their clinical “hands on” functions to Clinical Nurse Specialists, while adopting a more managerial focus. The role confusion which subsequently resulted for many in this transition was exacerbated by the potential for conflict arising from differences in the values held by nurse managers and those of the organisations which employ them. Gender is important in addressing this issue of differences in value systems. Approximately 89% of Nursing Unit Managers in New South Wales are female (Duffield, 1992). However, the work culture in Australia in which these nurse managers must function is still strongly based on masculine values (Still, 1988)-values which are based on competition and individualism rather than collaboration and shared knowledge and power which have been identified as feminine values. Successful managers must demonstrate a superior ability which separates them from their colleagues. However, women have been shown to experience conflict about competitive success, perhaps because of their increased need for affiliation (Gilligan, 1982). These gender differences are reflected in the ways in which men and women then view their work. Hennig and Jardin (1977) found that for men, a job is part of their career and is related to advancement and upward progression, while for women, a job and a career are two separate issues. A career for a woman is related closely to the attainment of personal goals. This is perhaps due to the historical place of women in society where they have been required to care in order that men and children can survive (Spring Rice, 1981). As a consequence of their gender nurses do not usually seek positions which require assertion and authority (Dwyer et ul., 1992). The introduction of “manager” in the title Nursing Unit Manager implies a degree of authority, challenging much of what nurses have traditionally valued. These values have been perpetuated by the training system of nursing in Australia which
INFLUENCE
ON ROLE
TRANSITION
FOR MANAGERS
557
has traditionally fostered adherence to a vocational focus and the norms of subservience, devotion and deference to medical authority (Short and Sharman, 1987). Consequently. nursing students have been found to be more dependent and submissive than students in general (Till, 1980). This process of socialisation does not cease when a nurse graduates. Nurse managers have long learned about their role and functions from other nurse managers, frequently in a superior-subordinate relationship (Clawson, 1985; Lees, 1980; Pembrey, 1980). Modelling behaviour on the performance of others raises serious doubts about the capacity of nurse managers to develop. This process has the potential to perpetuate the status quo rather than enhance the ability of nurses to critically analyse their roles within the current context of a dynamic health care system. Perhaps more importantly, it makes the transition from “Charge Nurse” to “Nursing Unit Manager” more difficult in the absence of role models. It is little wonder that role confusion has resulted for many. In addition, the complexity of the nursing role has also been poorly understood and apparently devalued. The stories that nurses told about their practice have been hidden from public knowledge through lack of publications and the fact that nurses mainly transmit their knowledge orally (as in the ritual of handover) (Parker and Gardner, 1991). As a result of this history, the disciplinary knowledge embedded in nursing practice has not been written or spoken about in a way which provides a body of knowledge for understanding and explication. More importantly, nurses have not been able to articulate fully the ways in which they have managed. Therefore, despite the history of nurses managing their wards and staff as well as the care of those patients on their ward, nursing’s voice has not become part of the common discourse in health care, but more particularly, management in this country. When the development of nursing and its traditions is compared to that which has happened in management, reasons for the cognitive dissonance faced by nurses who move into management become evident. Managerial positions in public and private enterprise in Australia have been, and still are, dominated by males. As men developed the models and perpetuated the replicas, management styles and processes are firmly based on white, male, middle-class values (Still, 1988). This inevitably causes a dilemma for individuals situated outside this social structure and culture as women and nurses have been. In addition, there is very little structure to support women (and nurses) in management positions if they attempt to work in a framework of feminine values. The values in today’s profit-oriented management climate are reflected in words such as cost-effectiveness, efficiency and outcomes (Finkler, 199 1; Hodges and Poteet, 199 1; Palmer and Short, 1989). However, nurses value caring, cooperation, concern, empathy, collaborative team decision making and an orientation towards quality care (Kramer, 1990: Nyberg, 1990a,b; Ray, 1989). These have also been identified as feminine values. Nurses are said to find the leadership role difficult because it conflicts with their socialisation as caring, helpful individuals (Conway and Hardy in Marchetti, 1985). First-line nurse managers, by the nature of their role, may be required to implement organisational policies with which they may not agree. One can understand therefore why those nurses who have been deeply involved in health care may have had problems moving into roles prescribed and guided by the apparently different set of values which occur today in our corporate style health care system. By way of contrast, medical staff who are mainly male and who frequently make a similar transition from clinician to manager do not seem to face the same difficulties as nurses. Of course Australian society has already constructed their pathway to management through
558
C. hf. DUFFIELD
und J. LUMB Y
the expectation that the manager will be male and in health care will be a doctor. Australian nurses have usually worked for an average of 10 years before being appointed as a first-line manager (Duffield, 1992). Extrapolated to nurse executives, Rawson (1986, 1988) found that they have spent an average of 56% of their career time in hospital clinical work and 38% in hospital management, a total of 94%. This result is in direct contrast to doctors who have spent only 38% of their time in clinical work and 28% in hospital management (a total of 66% of their career time) prior to their appointment as a senior executive (Rawson, 1986). These figures can be analysed from several perspectives. However, it is obvious that doctors move into senior management after a shorter period of time in the clinical areas than do nurses. Rawson (1986) concluded in his study that nurse executives were limited in their breadth of outlook as a result of the overwhelming amount of time spent in the clinical areas. These conclusions are interesting given the fact that practice in an area has been said to provide the basis for praxis which encourages awareness of self and others as values live through action (Freire, 1972; Chinn, 1990). However, when gender differences in reasoning and career and job orientation, as well as the historical and social background of women and nurses in particular are considered, one can see how and perhaps why, nurse managers choose (or are directed into) a different path than the medical staff. Little work has been undertaken in Australia to examine the actual role of nurse managers in the health care sector, and in particular, the role of females in nurse management. The competencies expected of first-line nurse managers in New South Wales have been identified and validated as a preliminary step in defining the role (Duffield, 1989a,b). However, this study, as with many, failed to capture the essence of what it is nurse managers (mainly female) do and how they do it. While the role may be defined as managerial, it must be remembered that nursing is about relationships, responsibility and interconnections (Pearson, 1984; Watson, 1988). These tend to be context-bound and nurses engage in their work mainly as active participants in a total environment of humanity and health care. One can equate this very much with the way women function in society and are thus more likely to see the total picture rather than in specialised compartments (Still, 1988). As nurses in management positions are mainly women with extensive clinical experience, one can assume that they will bring with them into the management role a strong tendency to continue to function in the way they have functioned in the past. Some of these qualities must be cultivated and valued in the preparation of nurse managers for the future. Most providers of health care in the Western world are faced with escalating costs. Inevitably, endeavours to contain costs focus on those who are the “critical mass” in the health care system, nurses. In Australia the “professional integrity senior decision-making
of nursing is being challenged as being no longer individually relevant echelons of our health care services” (Staunton, 1991, p. 3).
in the
This view, held by many senior bureaucrats, may threaten the very integrity of what nurses and nursing represent. Nursing care has been based on an ethic of caring, described by Noddings (1984) as “a longing for goodness”. This includes equity of care delivery and fund dispersal and collaborative decision-making involving carers and consumers. The latter must feel that they can trust those who are the professionals, and this will only come about if the actions and behaviours of the professionals reflect the values of those they represent. The expectation that nurse managers may suffer role conflict is understandable. After
INFLUENCE
ON ROLE TRANSITION
FOR MANAGERS
559
all, most are women attempting to function in structures predetermined by values which oppose many of their personal values. However, society today values constructive caring and leaders who come with a history which grounds them in humanistic values, not in competitive, corporate values. These are the very values which nurses bring from their clinical practice to the management role. Managers have the influence and power to ensure that a high quality of care is delivered to their clients. To do so they must have the experience gained from an awareness of “hands on” caring in expert nursing practice. Rather than change our expectations of nurses moving into management roles, health care would be better served by ensuring that the values brought to these roles by nurses are appreciated. The erosion of nurse managers’ roles in our health care system must be challenged. An outmoded and ineffective corporate management mode1 which lacks a human perspective is not the way forward in health care.
References Cederberg, A. M. (1986). Changing roles: from nurse educator to novice executive. Nurs. Mgmr 17,69970. Chinn, P. L. (1990). Nursing patterns of nursing and feminist thought. Nursing Hlth Care February 71-75. Clawson, J. G. (1985). Is mentoring necessary? Training and Development Jl3639. de1 Bueno, D. J. and Walker, D. D. (1984). Developing prospective managers, part I. A unique project. J. Nur.\. Admin. 14, 7-10. Duffield. C. (1989a). The role of nursing unit managers in New South Wales-a Delphi survey. Austr. Heal/h Rw.
12, 14-32. Duffield, C. (1989b). The competencies expected of first-line nursing managers-an Australian context. .I. A&. Nurs. 14,997-1001. Duffield, C. (1992). Future responsibility and requirements for first-line managers in New South Wales. Image: .I. Nurs. Scholarship 24, 3943. Dwyer. D. J., Schwartz. R. H. and Fox, M. L. (1992). Decision-making autonomy in nursing. J. Nurs. Admin. 22, 17-23. Finkler, S. A. (1991). Variance analysis: part 1. Extending flexible budget variance analysis to acuity. J. ,vurs. Admin. 21, 19-25. Freire, P. (1972). Pedadogy of the Oppressed. Seabury, New York. Garity. J. (1983). Developing head nurses: one hospital’s solution. Nurse Educutor 8, 3842 Gilligan, C. (1982). In a D@rent Voice. Harvard University Press. Cambridge. Hennig, M. and Jardin, A. (1977). The Managerial Woman. Doubleday, New York. Hodges. L. C. and Poteet. G. W. (1991). Financial responsibility and budget decision making. J. Nurs. Admin. 21, 30-33. Kramer. M. (1990). The Magnet hospitals: excellence revisited. J. Nurs. Admin. 20, 3544. Lanigan. J. and Miller, J. (1981). On the scene: Stanford Hospital-Developing nurse managers. Nurs. Admin. Q. 5, 21-24. Leddy, S. and Pepper, J. M. (1989). Conceptual Bases qf Professional Nursing. J. B. Lippincott, Sydney. Lees, S. (1980). Developing effective institutional managers in the 1980’s-part I: a current analysis, .I. Adv. Nurs. 5, 209%220. Marchetti, J. (1985). Role change, stress...and you! Moving up from clinical nurse to management. Nurs. Succrs.~ Todo? 2,3(&33. Martin, R. and Cuthbert. M. (1992). Outline of evaluation systems for nurse managers. In Management in Nursing (Cuthbert. M., Duffield. C. and Hope, J., Eds). Harcourt Brace Jovanovich, Sydney. Noddings, N. (1984). Caring: A Feminine Approach to Ethics and Moral Educution. University of California Press. London. Nyberg, J. (1990a). Theoretic explanations of human care and economics: foundations of nursing administration practice. Adc. Nurs. Sci. 13, 74-84. Nyberg, J. (1990b). The effects of care and economics on nursing practice. J. Nurs. Admin. 20, 13- 18. Palmer, G. R. and Short, S. D. (1989). Health Care and Public Policy An Australian Ana1.vsi.y.The Macmillan Company, Melbourne. Parker, J. and Gardner, G. (1991). The silence and the silencing of the nurse’s voice: a reading of patient progress notes. Austr. J. Adr. Nurs. 9, 3-9. Patrick, P. K. S. (1987). Head nurses: clinicians or managers? Nurs. Mgmt 18, 58-59. Pearson, A. (1984). The essence of advanced nursing care is being there. Nurs. Mirror 159, 16.
560
C. M. DUFFIELD
and J. LUMBY
Pembrey, S. E. M. (1980). The Ward Sister-Key to Nursing. Whitefriars Press, London. Rawson, G. (1986). Senior Health Service Managers: Characteristics and Education Needs. Australian Studies in Health Service Administration, School of Health Administration, Sydney. Rawson, G. K. (1988). Directors of nursing in Australia: a profile. Nurs. Outlook 36, 1988202. Ray, M. A. (1989). The theory of bureaucratic caring for nursing practice in the organisational culture. Nurs. Admin. Q. 13, 3142. Short, S. D. and Sharman, E. (1987). The nursing struggle in Australia. Image: J. Nuts. Scholarship 19, 197P200. Spring Rice, M. (1981). Working Class Wives. Virago, London. Staunton, P. (1991). Editorial. The Lamp 48, 3. Still, L. V. (1988). Becoming a Top Woman Manager. Allen and Unwin, Sydney. Swaffield, L. (1987). The ward sister. Nuts. Times 83, 25-26. Taylor, D. and Kramer, M. (1985). The head nurse: manager? clinician? or both? In Current Issues in Nursing (2nd edn) (McCloskey, J. C. and Grace, H. K., Eds). Blackwell Scientific Publications, London. Till, T. S. (1980). Sex-role identity and image of nursing. Nurs. Res. 29,295-300. Watson, J. (1988). Nursz,zg: Human Science and Human Care: A Theory of Nursing. National League for Nursing, New York. (Received 20 September 1993; infinalform
9 December 1993; acceptedforpublication
14 December 1993)
Pergamon
Srud., Vol. 31, No. 6, pp. 555- 560. 1994 Copyright ~0 1994 Elsewer Science Ltd
Prmted
III Great
Bnta~n. All rrghts reserved 002s 7489194 $7.00 + 0.00
0020-7489(94)EOO12-8
Context and culture-the influence on role transition for Jirst-line nurse managers C. M. DUFFIELD, R.N., B.Sc.N., D.N.E., M.H.P., Ph.D., F.C.N.(N.S.W.), F.C.H.S.E. J. LUMBY, R.N., D.N.E., B.A., M.H.P.Ed., Ph.D., F.C.N.(N.S.W.), F.R.C.N.A. Unir,ersit? of Technology.
Sydney, P.O. Box 123, Broadway, NS W 2007, Australia
Abstract-The role of nurse managers at all levels is the subject of much debate in Australia. It has been argued that their role is not essential and increasingly new organisational structures are being implemented which do not include nurse managers. This paper describes reasons why nurses, who are mainly female, face conflict when making the transition to the role of manager in the male dominated health care system of today. It argues that the values which nurses are able to bring to these positions are those increasingly valued by the communuity they serve. It is not nurses who should change, but the values held by the organisations in which they are employed if society’s needs are to be well served.
Nurse managers in Australia, whether they are at the first-line or executive level, are increasingly finding their positions deleted from organisational structures. It has been argued that their roles are not essential and as they have not traditionally managed well. will not be missed. In this climate it is timely to consider not only where nurses have come from but also the context and culture of health care management today in order to critique the validity of such claims. The transition from the role of clinician to manager is not easy. Nurse managers emerge from a practice focus, are grounded in a management system dominated by masculine values and as a consequence, may experience conflict. Role confusion is a frequently documented consequence of this transition (Cederberg, 1986; de1 Bueno and Walker, 1984; Garity, 1983; Lanigan and Miller, 1981; Patrick, 1987; Swaffield, 1987; Taylor and Kramer, 1985). This paper will explore these themes more fully. 555
/
556
c’. M. DUFFIELD
und J. Ll’MBY
As the provision of care became established in hospitals under the influence of Florence Nightingale’s model, positions of authority were introduced to coordinate the flow of information and resource allocation. Historically in nursing “Matron” was the most highly skilled nurse, responsible for management, discipline and education throughout the hospital. At the ward level, care was coordinated and supervised by the most experienced nurse clinician, the “Charge Nurse”. Appointment to this role was usually on the basis of clinical expertise, since this nurse was responsible for the quality of nursing care and staff supervision. Of great significance for the future development of nursing in this country is that in this model nurses were to carry out orders rather than be independent decisionmakers. As a consequence of this history, many of the traditions and structures in nursing which now exist can be traced back to Nightingale’s influence. For example, it has been argued that a feature of today’s Australian health care institutions is the highly regimented approach to the organisation of nursing staff who do as they are told by those with more authority, for example, medical staff, nurse administrators and educators (Leddy and Pepper, 1989; Martin and Cuthbert, 1992). While much in nursing has changed since those early days, the Charge Nurse role and the basis of appointment to this role, remained relatively unchanged until 1986 when, throughout Australia, the roles of specialist clinician and nurse manager were separated. In New South Wales for example, Nursing Unit Managers replaced the Charge Nurse role. At the same time the role of Clinical Nurse Specialist was also introduced. For many Charge Nurses and the nursing profession generally, this was a significant alteration to the well-established status quo whereby the Charge Nurse, as the most experienced clinician, was responsible for the clinical management of the ward. With the introduction of these new positions, Nursing Unit Managers were required to relinquish many of their clinical “hands on” functions to Clinical Nurse Specialists, while adopting a more managerial focus. The role confusion which subsequently resulted for many in this transition was exacerbated by the potential for conflict arising from differences in the values held by nurse managers and those of the organisations which employ them. Gender is important in addressing this issue of differences in value systems. Approximately 89% of Nursing Unit Managers in New South Wales are female (Duffield, 1992). However, the work culture in Australia in which these nurse managers must function is still strongly based on masculine values (Still, 1988)-values which are based on competition and individualism rather than collaboration and shared knowledge and power which have been identified as feminine values. Successful managers must demonstrate a superior ability which separates them from their colleagues. However, women have been shown to experience conflict about competitive success, perhaps because of their increased need for affiliation (Gilligan, 1982). These gender differences are reflected in the ways in which men and women then view their work. Hennig and Jardin (1977) found that for men, a job is part of their career and is related to advancement and upward progression, while for women, a job and a career are two separate issues. A career for a woman is related closely to the attainment of personal goals. This is perhaps due to the historical place of women in society where they have been required to care in order that men and children can survive (Spring Rice, 1981). As a consequence of their gender nurses do not usually seek positions which require assertion and authority (Dwyer et ul., 1992). The introduction of “manager” in the title Nursing Unit Manager implies a degree of authority, challenging much of what nurses have traditionally valued. These values have been perpetuated by the training system of nursing in Australia which
INFLUENCE
ON ROLE
TRANSITION
FOR MANAGERS
557
has traditionally fostered adherence to a vocational focus and the norms of subservience, devotion and deference to medical authority (Short and Sharman, 1987). Consequently. nursing students have been found to be more dependent and submissive than students in general (Till, 1980). This process of socialisation does not cease when a nurse graduates. Nurse managers have long learned about their role and functions from other nurse managers, frequently in a superior-subordinate relationship (Clawson, 1985; Lees, 1980; Pembrey, 1980). Modelling behaviour on the performance of others raises serious doubts about the capacity of nurse managers to develop. This process has the potential to perpetuate the status quo rather than enhance the ability of nurses to critically analyse their roles within the current context of a dynamic health care system. Perhaps more importantly, it makes the transition from “Charge Nurse” to “Nursing Unit Manager” more difficult in the absence of role models. It is little wonder that role confusion has resulted for many. In addition, the complexity of the nursing role has also been poorly understood and apparently devalued. The stories that nurses told about their practice have been hidden from public knowledge through lack of publications and the fact that nurses mainly transmit their knowledge orally (as in the ritual of handover) (Parker and Gardner, 1991). As a result of this history, the disciplinary knowledge embedded in nursing practice has not been written or spoken about in a way which provides a body of knowledge for understanding and explication. More importantly, nurses have not been able to articulate fully the ways in which they have managed. Therefore, despite the history of nurses managing their wards and staff as well as the care of those patients on their ward, nursing’s voice has not become part of the common discourse in health care, but more particularly, management in this country. When the development of nursing and its traditions is compared to that which has happened in management, reasons for the cognitive dissonance faced by nurses who move into management become evident. Managerial positions in public and private enterprise in Australia have been, and still are, dominated by males. As men developed the models and perpetuated the replicas, management styles and processes are firmly based on white, male, middle-class values (Still, 1988). This inevitably causes a dilemma for individuals situated outside this social structure and culture as women and nurses have been. In addition, there is very little structure to support women (and nurses) in management positions if they attempt to work in a framework of feminine values. The values in today’s profit-oriented management climate are reflected in words such as cost-effectiveness, efficiency and outcomes (Finkler, 199 1; Hodges and Poteet, 199 1; Palmer and Short, 1989). However, nurses value caring, cooperation, concern, empathy, collaborative team decision making and an orientation towards quality care (Kramer, 1990: Nyberg, 1990a,b; Ray, 1989). These have also been identified as feminine values. Nurses are said to find the leadership role difficult because it conflicts with their socialisation as caring, helpful individuals (Conway and Hardy in Marchetti, 1985). First-line nurse managers, by the nature of their role, may be required to implement organisational policies with which they may not agree. One can understand therefore why those nurses who have been deeply involved in health care may have had problems moving into roles prescribed and guided by the apparently different set of values which occur today in our corporate style health care system. By way of contrast, medical staff who are mainly male and who frequently make a similar transition from clinician to manager do not seem to face the same difficulties as nurses. Of course Australian society has already constructed their pathway to management through
558
C. hf. DUFFIELD
und J. LUMB Y
the expectation that the manager will be male and in health care will be a doctor. Australian nurses have usually worked for an average of 10 years before being appointed as a first-line manager (Duffield, 1992). Extrapolated to nurse executives, Rawson (1986, 1988) found that they have spent an average of 56% of their career time in hospital clinical work and 38% in hospital management, a total of 94%. This result is in direct contrast to doctors who have spent only 38% of their time in clinical work and 28% in hospital management (a total of 66% of their career time) prior to their appointment as a senior executive (Rawson, 1986). These figures can be analysed from several perspectives. However, it is obvious that doctors move into senior management after a shorter period of time in the clinical areas than do nurses. Rawson (1986) concluded in his study that nurse executives were limited in their breadth of outlook as a result of the overwhelming amount of time spent in the clinical areas. These conclusions are interesting given the fact that practice in an area has been said to provide the basis for praxis which encourages awareness of self and others as values live through action (Freire, 1972; Chinn, 1990). However, when gender differences in reasoning and career and job orientation, as well as the historical and social background of women and nurses in particular are considered, one can see how and perhaps why, nurse managers choose (or are directed into) a different path than the medical staff. Little work has been undertaken in Australia to examine the actual role of nurse managers in the health care sector, and in particular, the role of females in nurse management. The competencies expected of first-line nurse managers in New South Wales have been identified and validated as a preliminary step in defining the role (Duffield, 1989a,b). However, this study, as with many, failed to capture the essence of what it is nurse managers (mainly female) do and how they do it. While the role may be defined as managerial, it must be remembered that nursing is about relationships, responsibility and interconnections (Pearson, 1984; Watson, 1988). These tend to be context-bound and nurses engage in their work mainly as active participants in a total environment of humanity and health care. One can equate this very much with the way women function in society and are thus more likely to see the total picture rather than in specialised compartments (Still, 1988). As nurses in management positions are mainly women with extensive clinical experience, one can assume that they will bring with them into the management role a strong tendency to continue to function in the way they have functioned in the past. Some of these qualities must be cultivated and valued in the preparation of nurse managers for the future. Most providers of health care in the Western world are faced with escalating costs. Inevitably, endeavours to contain costs focus on those who are the “critical mass” in the health care system, nurses. In Australia the “professional integrity senior decision-making
of nursing is being challenged as being no longer individually relevant echelons of our health care services” (Staunton, 1991, p. 3).
in the
This view, held by many senior bureaucrats, may threaten the very integrity of what nurses and nursing represent. Nursing care has been based on an ethic of caring, described by Noddings (1984) as “a longing for goodness”. This includes equity of care delivery and fund dispersal and collaborative decision-making involving carers and consumers. The latter must feel that they can trust those who are the professionals, and this will only come about if the actions and behaviours of the professionals reflect the values of those they represent. The expectation that nurse managers may suffer role conflict is understandable. After
INFLUENCE
ON ROLE TRANSITION
FOR MANAGERS
559
all, most are women attempting to function in structures predetermined by values which oppose many of their personal values. However, society today values constructive caring and leaders who come with a history which grounds them in humanistic values, not in competitive, corporate values. These are the very values which nurses bring from their clinical practice to the management role. Managers have the influence and power to ensure that a high quality of care is delivered to their clients. To do so they must have the experience gained from an awareness of “hands on” caring in expert nursing practice. Rather than change our expectations of nurses moving into management roles, health care would be better served by ensuring that the values brought to these roles by nurses are appreciated. The erosion of nurse managers’ roles in our health care system must be challenged. An outmoded and ineffective corporate management mode1 which lacks a human perspective is not the way forward in health care.
References Cederberg, A. M. (1986). Changing roles: from nurse educator to novice executive. Nurs. Mgmr 17,69970. Chinn, P. L. (1990). Nursing patterns of nursing and feminist thought. Nursing Hlth Care February 71-75. Clawson, J. G. (1985). Is mentoring necessary? Training and Development Jl3639. de1 Bueno, D. J. and Walker, D. D. (1984). Developing prospective managers, part I. A unique project. J. Nur.\. Admin. 14, 7-10. Duffield. C. (1989a). The role of nursing unit managers in New South Wales-a Delphi survey. Austr. Heal/h Rw.
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