Ever since Florence Nightingale arrived in the Crimea, nurses have been involved in managing health services. But these days nurses who take on managerial responsibility have a more ambiguous role.

They can be something of an isolated breed, shunned by those with a general management background who see them as too preoccupied with nursing issues, while hands-on nurses view them as 'not one of us'.

Their star waned from the mid-1980s when Sir Roy Griffiths decreed that general managers, and not teams of health professionals, were the right people to run the service.

But the current government has signalled a desire to open up new opportunities for clinicians in management. Those with a background in direct patient care are ideally placed to run a national health service in which the client is king. And the Department of Health's target of at least 40 per cent female senior managers at executive board level by 2004, set in The Vital Connection - an equalities framework for the NHS, published in April 2000, should pave the way for many more nurses in management.

that may be changing, ' she says. 'The last government's health reforms were very much financially driven, which didn't play to nurses' strengths.'

She detects a 'slow but steady rise' in the number of nurse chief executives. 'It is happening slowly because nurses are still discriminated against and There is a tendency to devalue nursing as a profession. People do not recognise or appreciate nurses' contribution and do not think of them as natural managers.'

This discrimination comes from both general managers and doctors, she believes. In the early 1980s Ms Hancock had first-hand experience of discrimination when she was rejected by one London teaching hospital because doctors baulked at the suggestion of a nurse as their boss.

'I think most doctors would probably prefer to be managed by a generalist rather than a nurse or other clinician as they're less likely to be challenged.'

And she feels that the sometimes strained relationship between nurses in the clinical area and colleagues who move into management is due to a number of factors. 'Those in the profession who take on a managerial role sometimes try so hard not to favour nursing that they overcompensate.

'But you can't always be the 'nice nurse' when you have to make tough decisions. Fortunately, making tough decisions is something all nurses get used to from the word go - and you can't get a better preparation for a management role than that.'

Mansour Jumaa, principal lecturer in healthcare management at Middlesex University, would like to see more nurses follow Ms Hancock's example and move into general management.

'It is good to have nurses in that role, as long as they hang on to the fact that they are still a nurse, ' he says. But he warns that there can be a conflict between being a nurse and being a manager. 'As a manager your main focus is the organisation but It is important to hang on to the fact that you are still caring for patients, albeit at a distance.'

One of those who has experienced a conflict between the two roles is Marilyn MacDougal who abandoned a career as a trust executive nurse to return to what she calls 'real' nursing. In the case studies (above and right) she and three other nurses in management describe their experience of crossing the divide.

'I always tell people I am a qualified nurse' I've never felt discriminated against, but I think you have to be quite assertive to make the transition from nursing to top management. There can be a conflict between the professional and the managerial sides of the job, but they are reconcilable. I know some chief executives who do not tell anyone they have a nursing background. I always tell people I am a qualified nurse - I am proud of it and I believe it means I bring more to the job. It helps when talking with doctors that you are speaking the same language.

I am encouraged by the proposals for matrons and senior sisters in the NHS plan, but I would like to see much more done to help nurses to move into management.

Patrick Geoghegan, qualified nurse and chief executive of South Essex Mental Health and Community trust ' 'I found wearing two hats very hard' I ended up as director of nursing at Milton Keynes District General Hospital. When we were given trust status I took on an executive nursing role, and that was the most difficult time for me. You move away from the clinical element and then one day you realise You have crossed the barrier and the medical staff do not see you as a nurse any more. Professionally I was head of nursing, but I was also a member of the trust board. In my nursing capacity I had to point out that we were short of staff. But as a member of the board I understood budget constraints, and I found wearing two hats very hard. I became at odds with my chief executive. In the end I felt I had to leave.

Because I felt that the problem was not confined to my trust, but applied to the NHS, I decided to work in a nursing home in the independent sector. Although I run the home I deliver hands-on care and I love it. I can do the nursing I was trained to do.

Marilyn MacDougal, home manger, Ashby House nursing home, Milton Keynes 'Managers, in general, are not liked' Ruth Keil couldn't believe how different it was when she switched jobs this summer from being a district nursing sister to managing her newly merged trust's district nursing service.

The first thing that hits you is the lack of patient contact, but of course the patients are still there - It is just that you're one step removed from them.

But I do miss the hands-on side of things. When you're a nurse It is very clear what you are doing and why you are doing it. With management you get your job satisfaction from supporting others delivering care. I do think managers are, in general, not liked. As a nurse everyone thinks you're a wonderful person, so It is a bit of a shock to meet hostility.

Ruth Keil, manager, district nursing service, Carmarthenshire Healthcare trust ' 'I have got an insight into finding solutions' Visibility is a vital part of management and you need to be seen by the people you are managing. I have built into the job description of nurses in our trust's management, including myself, a half-day each week to be spent in patient areas. At the end of the week we all get together to discuss what issues have cropped up, and what we have learned.

My nursing background has been helpful to me as a manager. It gives me an insight into finding solutions, though I've also come across general managers who have developed that insight through a different route. I've had no problems with my working relationships with medical colleagues. We have a common goal securing the best deal for our patients.

Stephen Moss, director of nursing and patient services at the Queen's Medical Centre, Nottingham, acted as chief executive of the trust for part of last year'