What do managers want from nurses and vice versa? Chief executive Alan Randall and nursing adviser Eileen Shepherd give some pointers

As we prepare to go off on our annual holidays, my partner and I both feel we have earned a good rest. The pressures of the NHS over the last year have taken their toll on both of us.

My partner, Susan, qualified as a midwife a couple of years ago. She works in a busy acute hospital maternity department, working a pattern of two long days followed by two night shifts and then five days off. As an E-grade midwife she earns about£19,000 a year.

As a chief executive of 16 years' standing, I work on average 60 hours a week, mainly Monday to Friday, but with many evening commitments. I frequently take work home. I earn over four times as much as my partner.

Susan worries about the pressures on me and the long hours that I work. I worry about the heavy levels of responsibility she carries as a midwife, the demands of shift work and the frequent inadequacy of staffing levels.

Yet as we prepare to head for some sun, we both feel a deep sense of satisfaction at having given of our best for an NHS that we passionately support.

I sense that many frontline nursing, midwifery and other staff share the public perception that there are too many overpaid managers who do nothing but push paper around. They despise us for not understanding the pressures that they are under and for failing to appreciate how they maintain a service, despite totally inadequate facilities. They complain that they never see the chief executive.

'We wouldn't recognise him even if he bumped into us.'

The most hurtful perception is that, as a chief executive, I do not care about patients and my sole interest is in cutting costs.

Those criticisms do hit home and they hurt. Like so many other people in the NHS, I joined the service for altruistic reasons. I dearly want to see a high-quality service and I know that can only be achieved if staff genuinely feel appreciated.

Just because I do not wear a uniform (apart from the grey suit) and do not provide hands-on patient care, does not mean that I lack compassion. I want nurses and others to judge me by my actions and commitment. I do not want them to label me according to a pre-conceived prejudiced view about managers.

Yet I concede that some of the criticisms, particularly those about not being out and about or in touch with the frontline staff, are justified. In recent years the pressures from on high to deliver results for an increasingly impatient government and to meet unreasonable deadlines set by regional offices and health authorities, has made it more and more impossible to spend time on the wards.

The system is unforgiving in demanding of your time to attend meetings - for example, to review your progress on financial recovery plans, delivering waiting-list targets or on implementing the NHS plan.

Time has to be found for explaining your actions to the community health council, primary care groups, royal college visitors, health and safety inspectorates, medicines inspectorates, auditors and others.

This is not a plea for sympathy.With the salary that comes with the job, no sympathy is deserved. It is a salary which might be poor in comparison with that of managers of similar-sized organisations in the private sector, but which is obscenely large compared with that of frontline nursing staff.

But if it is not a plea for sympathy, it is a plea for understanding and respect. It is a plea that nurses recognise that managers face intense pressures, coupled with a high sense of insecurity in their jobs; that they care as much about the service and patient care as those in the front line.

In an ideal world, managers and nursing staff would show each other mutual respect. There would be recognition that both are necessary for the effective running of a hospital. The prejudices that get in the way of this happening stem largely from ignorance. We did not train together and we all too rarely meet outside the sadly hierarchical structure of the hospital workplace.

The barriers between us need to be smashed down. There is no place in a modern NHS for privileges and status symbols, for reserved parking places or separate dining rooms that help to fuel pre-conceived prejudices. The onus is on managers to demand that the system allows them time to meet with and listen to frontline staff. In return, those staff must be open and honest.

Mrs Smith was admitted to the ward following a myocardial infarction, she had a history of dementia and was now in hospital waiting for a residential home place. She was very confused and it had taken time for her to get used to the ward.

Last week the bed co-ordinator identified Mrs Smith as fit to sleep on the surgical unit. Concerned that transfer would result in increased confusion, the staff nurses initially disagreed, but after persuasion transferred Mrs Smith. The bed was empty overnight and Mrs Smith needed sedation to calm her down.

As a nurse, I found it difficult to reconcile what I regard as a bed management issue with the needs of my patients. While acknowledging that the managerial agenda is about maintaining a system at breaking point, from the perspective of the ward nurse it appears that decisions made by managers consistently make the process of caring more difficult. The result is that nurses ration care, in the full knowledge that the compromises will become greater as demands on the service increase.

Clinical nurses need managers to ensure that robust policies are in place to allow patient care to be discussed in an open and blame-free culture.

While the notion of learning organisations has been with us for some time, it is clear from the recent findings of the Commission for Health Improvement that the link between managers' perception of what is happening and the practice of nursing and medicine are, at times, poles apart.

Nurses have little faith in managers who never cross the threshold of the ward unless there is a problem, or in those who walk through the wards, hoping that this raises morale. Nurses want managers to be visible, to listen and to facilitate change to improve care.

Poor resources have a daily impact on nurses' ability to provide planned care. Nurses waste valuable time sorting out linen and catering problems, hunting down essential equipment and portering patients and equipment. Nurses want managers to ensure these services run efficiently.

The modern matron, benchmarking and consultant nurses offer nurses a chance to make real improvement in the provision of essential care to patients. Yet managers fail to recognise the value of essential care: feeding, bathing and toileting patients are too easily dismissed as 'basic'.

The forthcoming benchmarks on essential care spell out not only the importance but also the complexity of 'basic' nursing work. The philosophy that underpins these benchmarks can only be realised in practice if managers look beyond the tasks that make up nurses' work and consider the difference an experienced nurse can make in meeting patient need. In a system that relies on a task-based approach to care, this will require a major investment in nursing. If we fail to support nurse-patient relationships, benchmarking will become little more than a paper exercise.

The systematic dismantling of the ward sister as a clinical leader has left nursing without clear direction. Decisions about clinical nursing are frequently made by those who do not nurse. The modern matron could be a powerful and motivating force in our wards, but this influence needs to extend to the wider hospital.

My fear is that implementation of the modern matron will be orchestrated by those with no direct contact with clinical nursing. If this happens, it is likely that the modern matron will raise public expectation, but amount to little more than a frilly hat and a new uniform. The legacy of the named nurse is testimony to an initiative that had the potential to revolutionise care, but top-down implementation wasted the opportunity.

I accept that the political agenda often mitigates against the prospect of making changes. However, ward nurses have to absorb the impact of every fad.

Expectations have been raised and shattered so many times, preceptorship and clinical supervision remain illusory. It is difficult to have faith that the experiences of nurses and patients will improve.

While many problems are national, at a local level developing a dialogue between managers and nurses can offer an insight into delivering care more effectively.

So, when you consider modern matrons, benchmarking, consultant nurses or critical care training, step back, take time to visit the wards, talk to nurses. We all know that management walkabouts, hospital staff satisfaction surveys and hospital newsletters only skim the surface and do not address the real issues. Am I suggesting consensus management? Of course I am, but I am a nurse.