WARD MANAGERS: People who manage wards feel their accountability is being increased while their control of resources is being diminished. Claire Laurent reports

Ward sister, charge nurse, ward manager, modern matron. Call them what you will, those who run the wards determine the quality of care patients receive.

They face the daily juggling of staff shortages, patients' needs, relatives' requests, doctors' demands and managers' expectations. And the responsibilities are not diminishing.

Elizabeth West, senior research fellow at the Royal College of Nursing Institute, points out that the role of ward sister has always been crucial. 'There is enormous research on the key interface that he or she provides between the managerial level of the hospital and what's actually going on with the patients.And the role has developed enormously over recent years because There is a whole new management component to being a ward sister.'

It is this management component, along with a loss of control over ward cleaning and nutrition, that has led to ward sisters and charge nurses being described in a recent report as 'highly dedicated and committed practitioners who were often at breaking point'.

1The author, Isobel Allen, interviewed senior nurses in five specialist focus groups: one each for medicine, surgery, accident & emergency, critical care and paediatrics at nine hospital trusts in London.

The report found that nurses at this level were shouldering a heavy burden of responsibility with very little support, and the constant feeling that there was little they could do to influence change.

It built on earlier research into stress among consultants, and found many similarities between the two groups. They both felt accountable to a variety of stakeholders, while increasingly losing control of their own clinical and professional territory.

The major stress for those in charge of wards was anxiety about whether and how their wards or units were to be staffed each day. There were particular concerns about the level of competence of unknown agency nurses, as well as the pressure personnel shortages put on their own staff, and themselves, to work extra hours to ensure the ward was safe.

The report found an 'urgent need for the medical, nursing and management hierarchies within trusts to establish a common purpose and clear lines of communication and discussion between the key players'. It recommended that trusts 'examine urgently the question of retention of nursing staff in order to alleviate some of the worst pressures on ward sisters and charge nurses'.

In the report, ward sisters and charge nurses spoke of the difficulties of trying to meet flexible work demands, regarding this as an added pressure. The report recommended that the development of flexible work patterns should be a 'management responsibility and the practical difficulties of organising flexible working should be recognised and discussed with those who have to implement it'.

There is no doubt, says Dr West, that the lack of autonomy nurses feel has to be addressed if they are to stay in the profession. 'The way you organise nurses' work has an important impact on how they feel about their job and, most importantly, patient care.'

Research by Linda Aiken looked at reports from 43,000 nurses from more than 700 hospitals in the US, Canada, England, Scotland and Germany in 1998-1999.

2She found that nurses in distinctly different healthcare systems reported similar shortcomings in their work environments and the quality of hospital care. In England, 36 per cent of nurses were found to have high burnout scores on the Maslach Burnout Inventory (third out of the five countries - the US was top with 43 per cent) and more than 53 per cent of English nurses under 30 were planning to leave the service in the next year.

Fewer than half of the nurses in each country reported that management in their hospitals was responsive to their concerns, provided opportunities for nurses to participate in decision-making or acknowledged nurses' contribution to patient care.

One contentious issue for nurses, and a heavy burden on ward sisters and charge nurses, is staff rostering.Ward managers have to be sure the ward is covered with the right skill-mix but nurses increasingly want a say in when they work.

The amount of control nurses can exert over their working environment depends on whether they are being treated as true professionals, says Dr West. 'These are key variables we have begun to explore in the UK.'

But some managers believe the situation is improving.

Nigel Kee, director of nursing and patient care at the Surrey and Sussex healthcare trust, considers that the general view of ward sisters and charge nurses in his trust would be that things have been 'bloody awful but are changing'.

He believes modern matrons will improve the lot of ward sisters and charge nurses. They are senior sisters who 'will have the authority to make sure wards are kept clean and the basics of care are right for the patients according to the NHS plan. Such a role at a senior level with strong links to both management and nursing is one that has been missing since the demise of the nursing officer.

'The worst nursing structure any trust could have would be one where There is a director of nursing and the next layer down is ward sister and charge nurse. Too many trusts have that structure, ' he says.

'All this talk about the modern matron is really saying there is not enough time and support given to nurses on the ward to be able to do their job effectively. They will be the support for the ward managers.

'At the moment, charge nurses are expected not only to run the ward from a clinical care perspective, they are supposed to manage all budget, paperwork and human resource functions, and influence strategy. It is quite a big task to be an expert clinically and managerially, ' says Mr Kee.

June Andrews, director of nursing at Forth Valley Acute Hospitals trust, Falkirk, recently completed a 'back-to-the-floor' series of clinical placements as an auxiliary nurse in her own trust. She points out that the pace in wards has definitely quickened in the last decade. Greater throughput means a 36-bed ward may have 20 admissions and discharges a day.

And staff are always caring for very sick people.

This inevitably affects ward sisters and charge nurses. 'They are expected to do more in less time - the time pressure is enormous. And there is much more overt accountability.'

But this is far from unique. 'When I look at my medical colleagues, when I look at the porters, when I see people trying to feed people on 50p a meal, I would have difficulty pointing to anyone in the system who is not hugely stretched.'

Her 'back-to-the-floor' experience reinforced her belief that charge nurses and ward sisters need more support and development training.

'The research has been there for a long time: they are the ones who make the biggest significant difference to the quality of care provided in any clinical unit.When I was a ward sister I learned my vital skills the hard way, but you do not have to learn that way, ' she says.

'There are people who can teach leadership so this terrible tension between professional issues and organisational issues can be managed.'

Ms Andrews believes: 'It is important for charge nurses and ward sisters to understand the tough choices managers make because if you can understand it, you can influence it. To make people do what you want, you have to make it what they want.'

Leadership can be taught and will make a tremendous difference to ward managers trying to persuade managers that a ward's problem is also a manager's problem, and the solution will benefit both, she says.

The Royal College of Nursing leadership programme has been rolled out to 96 trusts in England. Trusts in Scotland, Wales and Northern Ireland are all considering taking on the programme.While nurses make up most of numbers on the programme, physiotherapists, occupational therapists, doctors and other disciplines may also take advantage of it.

The programme trains a local facilitator to deliver the course locally to 12 clinical leaders in a trust, and the whole course lasts about 18 months. 'The strength of the programme is we bring people together, and that provides networks of support between them, ' says Geraldine Cunningham, codirector of the RCN leadership programme.

'It is about putting them in a position where they are taking responsibility for the areas they can influence, moving them away from having large areas of concern and small areas of influence.'

She continues: 'Traditionally, charge nurses and ward sisters were prestigious roles and That is been eroded because they're bogged down by a lot of management work and they're less visible in the clinical area.We are focusing on leadership development, helping them to be confident about themselves, to articulate what their needs are and be confident in their ability to improve patient care.'

June Andrews believes ward managers are in a position to know what their strengths and weaknesses are and what sort of information or learning they would most benefit from.

This is why, she says, the leadership development programme can be of benefit: 'You do not get to be a ward sister or charge nurse without a considerable amount of experience.

'You are then in a position to know what tools you need, to do what you want to do.'

Nick Lawton,40, charge nurse, dermatology, Queen's Medical Centre, Nottingham 'As a charge nurse, you are in the driving seat and have to empower other people to take things forward.I was involved in setting up the day treatment unit but now we have a co-ordinator to run it.

The sentiment behind the modern matron is right, the public wants someone visible who they can go to with a problem, and really that should be the ward manager.But as the ward manager, you are bogged down with other things and so you're not as visible as you should be.You are taken up with off-duty maintenance for 60 nurses, checking sickness and absence reports and unsocial hours forms.Put the money in admin support rather than another layer of nurse management. . . so that we, as clinical nurse managers, can get on with the job we are trained for.I have been a charge nurse for three years.I am ward-based, but in the absence of the H grade I have responsibility for the whole department, including outpatients.We see about 45,000 patients a year through outpatients.The ward is 18-bedded and we treat 20 patients a day in the day treatment unit and see 100 patients a day through therapy and around 10 a day in the wound assessment area.

We would like domestic services to be back under our management.Also when you look at catering services, trusts around the country are tendering these out to private organisations so you are losing control over the quality of food.As ward manager, you are calling these people and saying this is not acceptable so you are a middle person with so many people to deal with.

Kate Conlon,47, medical ward manager, Surrey and Sussex Healthcare trust 'There was a good period about 10 years ago when they brought in ward management and we sisters then started to look at budgets and have more control over the ward environment.But as trusts got bigger and ward sisters had less chance to have an input, we felt like the forgotten level of management.

A lot of people have found the role too much.You are clinically accountable, you are managerially responsible.Everyone is demanding of you at all levels.Patients and relatives expect much more out of the system as well as better explanations, and lots of junior staff comment they feel very uncomfortable with that.It would help if someone were there to guide and support them.I have been a ward sister since 1980 and I had originally thought I would like to stay as a ward manager, but the thought of the senior nurse role is quite attractive.It does give you the chance to support people, to develop and also still have an effect on patient care.But you would need to be clinically competent and be seen to be clinically competent.I have a big fear that roles become non-clinical very quickly, and you can lose touch with what's happening and the real pressure of what It is like to be the one trained nurse who look after 28 patients.

Teresa Mackey,34, ward manager, Garrod ward, Lewisham Hospital trust 'I have been a ward manager for just over two years, but I was an F grade here for 18 months before that.The real pressure is from the increase in patient activity, and on an acute medical ward we are nursing more acutely or critically ill patients which, four or five years ago, would have been on a high dependency unit or intensive treatment unit.We are running courses for D, E and F grades in conjunction with ITU nurses to brush up on our patient assessment skills so we can safely manage critically ill patients.

We have a good team of mature nurses who have been here quite a while,11 of them for more than five years.

I am coming in as quite a junior ward sister so to have quite experienced E and F grades who are motivating the D grades is a nice mix.

The health service is in the media every other day. . . we are constantly in the eye of the patients, relatives and visitors and that can be hard, particularly for the junior staff.The other thing that is new is managing the budget.

In the past, ward managers were not so careful.Now we have to account for every penny we spend.We have to go through our budget statement every month.We get support from our senior nurse and some of the ward managers are quite used to it, but It is not why I came into nursing.

We have a ward managers forum meeting once a month where we have an outside speaker and then discuss issues within the directorate and give support to each other.Sometimes It is the only time you get to see your colleagues - I do not know what I would do without it.

Phyllis Wilkieson,35, ward manager, all-age stroke rehabilitation ward, Stirling Royal Infirmary, Forth Valley Acute Hospitals trust, Falkirk.

'I've been a ward sister for 11 years.Probably the biggest change was when we were given trust status.They introduced a devolved management structure and we went from seven directorates to three.They took the layer of nurse management out above us, and put in a general manager who was no longer a nurse manager.We were very sceptical, but I personally thought it worked really well, though I think it depended on how much autonomy they gave you to run your unit.

One of the biggest changes nowadays is that you are involved in the human resources side of things, which is good because before your nurse manager would decide what staff you would get.But it does take up your time.You're out of the ward more than you used to be.

I think It is my responsibility to make sure the structure is in place to cover that.The named-nurse system that was introduced in Scotland has helped.It is given me a chance to get an overall view, so as ward sister I am not trying to do everything.I've developed an orientation package for new staff and I usually get one of my senior staff nurses to do it.Before, the ward sister would normally have done that, but because you're in meetings and various other things, your time in the clinical area is getting less and less.

The newly qualified staff nurses need more support than they used to.It is not any reflection on them as individuals, I think a lot of it is a confidence thing.They spend their training in different areas, as well as hospital, but they do not have the hospital experience that modular training used to give.

Patients are much more informed than they used to be.The stroke unIt is younger patients are much more likely to ask questions, but to be honest I think That is our job.We are there to reassure people if they have had a stroke and reassure patients and families about their treatment.It doesn't always have to be verbal communication.We have a stroke resource room with leaflets and videos and it doesn't need to be a nurse sitting and talking - it could be a physiotherapist or occupational therapist.It is very much about using the skills of the team.