Analysis

Under pressure – why the nurse director’s job can feel so thankless

Directors of nursing are under increasing pressure to achieve high standards of care while balancing budgets and juggling the everyday demands of their roles.

They face an unprecedented imperative to ensure their organisation provides safe patient care – while maintaining nurse staffing levels, balancing budgets and dealing with bureaucracy.

One of the first studies into the stresses and resilience of senior nurses since the 2013 Francis report into care failings at the Mid Staffordshire NHS Foundation Trust shows they are feeling the strain.

Picture credit: Daniel Mitchell

Nursing directors reported experiencing a conflict between their responsibilities for the quality of care and the demands of making cuts at a time of financial constraint and warned any further savings would put patient safety at risk, (see Nursing Standard news page 9, November 18).

But their concerns do not stop there. Other factors that are increasingly bearing down on them include keeping up with the demands of regulatory bodies, dealing with complaints and major incidents, feelings of personal vulnerability and accountability post-Francis, and the sheer volume of emails received every day (see box, below).

What nurse directors are saying about their roles

‘I cannot possibly control what 2,000 nurses do across a massive geographical county. I have to rely on what people tell me and the fact that my systems and processes are robust enough to pick up concerns and correct things before they go wrong.’

‘The level of personal accountability being placed on directors of nursing post-Francis… I don’t dispute the fact that we should have levels of accountability but it’s board accountability, not just pick on the nurse…’

‘Monitor’s scrutiny on us is huge… we have two commissioning bodies that we work with… they all want things in a slightly different way and it’s kind of bureaucracy stuff.’

‘No one has ever been sacked for doing the right thing. You absolutely do the right thing and that’s about doing the right thing for your patients and no one would ever question you on that.’

Forty nursing directors from England and Wales were interviewed for the study by researchers at Cardiff University’s school of healthcare sciences between February and July last year.

Frustration

All participants said they accepted the responsibilities that come with their senior position, but workload was a major problem. They expressed frustration at the number of hours required to read and write strategy papers, keep abreast of developments, respond to emails and meet the constant demands for data from quality-monitoring bodies such as NHS England and Monitor.

Many of these monitoring bodies require the same information in different formats, the nurses noted.

For many, these administrative tasks get in the way of regular visits to clinical areas to spend time with nursing staff. One director answered more than 200 emails in a day from various agencies and government organisations, including the chief nursing officer, and tried to balance this with the need to be visible on the wards, adding: ‘It can feel intolerable… the tension is incredible.’

The report concluded that ‘excessive and largely pointless demands for data can and should be ameliorated’ to free up time for planning. Lead researcher Daniel Kelly says the considerable pressures directors of nursing face raise significant concerns about recruitment and retention because there is high turnover in these roles.

An investigation by Nursing Standard in August 2014 revealed that 29% of nurse directors had been in post for less than 12 months and 55% had been in their job for less than three years. Vacancy rates were around 20%.

‘It isn’t just about getting people to step into these jobs. It is getting them to stay in these positions,’ says Professor Kelly.

Four study participants reported relief at being close to retirement.

One respondent, who reported working 14-hour days and being passionate about doing a good job, said: ‘I aim to get out at 55 – I’ve got two years left. I’m planning to retire because I cannot sustain the job I’m doing, and I genuinely believe I’m good at my job.’

Retired nursing director of 28 years Irene Gray – who now works as a nursing consultant and coach in the NHS and independent sectors – says the role of the nurse director is more challenging than ever.

‘Increasingly, they have become the vessels for failures in the system and many directors of nursing have felt the unreasonableness of some of the criticism levelled at nursing,’ Ms Gray says. ‘The challenge for any director is to become part of a team that is united, not only in its intentions, but in its support to each other.’

Building trusting relationships with board-member colleagues and the chief executive, as well as with front line nurses through regular visits to clinical areas, were strategies that participants said help build resilience (see box, below).

Support in post: senior nurses’ coping strategies

Formal preparation and training for the role as a new appointee.

Spending time in clinical areas to build up good working relationships with the nursing staff who deliver care.

Building trusting relationships with other board members and the chief executive to ensure everyone has the same goal.

Establish good peer support networks in external, local and national organisations for brainstorming and debriefing.

Having a mentor.

Maintaining a good work-life balance.

RCN executive nurse network lead Naomi Chapman says: ‘There is a corporate responsibility here.

‘Nurses need to feel they are working in the right culture, that is one of shared ownership and responsibility around finances and quality of care, where all board members are striving towards the same goal.’

Unite national officer for health Barrie Brown adds that the fragmented structure of the NHS and a lack of resources means ‘the stresses and strains of the system are being funnelled through nurse directors’ because they have responsibility for the biggest workforce group – nurses.

An NHS Employers spokesperson says the organisation argued for a long-term financial commitment to the NHS in its submission to the government’s comprehensive spending review, to try to ease pressures faced by the health system and free up healthcare professionals, including nurse directors, to fulfil their roles.

In response to the report, which Professor Kelly says will be published on the Cardiff University website in coming weeks, the Department of Health says it is aiming to make more than 23,000 extra nurses available in the next four years.

In the meantime, Professor Kelly says nurse directors need greater preparation before they step into these ‘crucial’ roles and more support in post to ensure they have the resilience to fulfil such a high-pressure job.

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