Coping with increased managerial tasks: tensions and dilemmas in nursing leadership

Setting

The study includes three public nursing homes located in three different municipalities of various sizes (1000–23,000 inhabitants) in the northern part of Norway. The nursing homes were strategically selected to ensure variation in size, new and old buildings and work tasks (Creswell, 2007). Nursing homes A and B had 39 and 27 beds, respectively, both divided into three wards. Nursing home C had 90 beds divided into nine wards. The nursing homes functioned as separate entities and were controlled by the municipalities’ central administration from ‘arm’s length’ through use of managerial tasks, such as incentives and contracts, auditing, standards, staff regulations, reporting systems and different clinical guidelines. Strong public regulations ensured that the nursing homes had a structural and organisational similarity, although the content in work varied in line with residents’ changes in needs. The workforce was dominated by nurses with 3 years of higher education.

Participants

This study is part of a larger study which focused on the organisation of daily work and contradictory management requirements in Norwegian nursing homes. In this study it was of interest to recruit participants holding various positions in nursing homes. To do that the unit manager at each nursing home was contacted by email with information about the study. Unit managers forwarded information on the project to front-line managers and the nurses working on each of the wards. Those who first volunteered to participate and fulfilled the sample criteria were recruited. In addition to holding various positions, the participants had to be working full-time with at least 1 year of experience of working in nursing homes. One unit manager, two front-line managers and three nurses were recruited at each nursing home, totalling 18 participants (see Table 1). There were 15 women and three men with an average work experience of 11 years. The unit managers held an overall management position and were in charge of the nursing homes. Front-line managers were next in the hierarchy, holding a leader and supervisor position on each of the wards. Nurses were positioned under front-line managers and operated closest to the residents.

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Table 1.

Study participants, interviews and observations.

Nursing home	Interviews	Observations
	Unit managers/ front-line managers	Daily handovers
NH A	3	11
NH B	3	11
NH C	3	11
	Nurses	Staff and leader meetings
NH A	3	2
NH B	3	3
NH C	3	2
Total	18	40

Data collection

Data were collected from January to February 2012. We interviewed staff and observed daily shift handovers and meetings to collect rich data about the organisation of daily work and contradictory management requirements. During a 1-week stay at each nursing home, we alternated between conducting observation and performing individual semi-structured interviews (Kvale and Brinkmann, 2009). To the greatest extent possible, we attempted to combine observations with follow-up interviews with the participants observed.

The interviews were based on an interview guide, which focused on the aims, responsibilities and decision-making in how daily work was organised. The same interview guide was used regardless of the participants’ position. Each interview was conducted by the first author during the participant’s working hours and lasted approximately 60 minutes. The interviews were recorded and transcribed.

Everyday, three handovers occurred in each ward at the nursing homes (morning, afternoon and night). These were arenas with access to typical situations in which daily work was organised and performed. During daily handovers, staff at work met to receive updated information about the residents and make decisions for each shift. In addition, we chose to observe planned staff and leader meetings that took place during the week. These were arenas where unit managers, front-line managers and nurses met to evaluate and discuss the work on a more strategic level. In each nursing home we observed 11 daily handovers and three meetings, totalling 100 hours of observation (see Table 1). Field notes were taken continuously and later transcribed into written text.

Analysis

In analysing the data we used template analysis, which, according to King (1998), refers to a group of techniques for thematically organising and analysing qualitative data. As such, template analysis is a form of thematic analysis and it overlaps with qualitative content analysis (Schreier, 2012).

First, we reread the interviews and observational data and started to identify patterns. To organise the data we used the main questions from the interview guide as predefined themes. Second, we started to analyse the organised text within each theme. It became apparent early in the process that nursing leadership was central, although nursing leadership was not asked about as a separate theme in the interview guide. Third, we searched for units of meaning containing various aspects of nursing leadership performance in daily work. By going back and forth between the interviews and observation texts the units of meanings were organised into 50 categories. Fourth, we further organised the categories, searching for thematic similarities. As a result of this process, we ended up with three main themes, these being leading daily care from a distance, lack of support in problem-solving and difficulties in adopting new managerial language. The Results section is presented according to these themes. The software program Nvivo was used to support the analysis process.

Ethical consideration

The study was approved by the Norwegian Social Science Data Service. Informed consent was collected from all participants with the information that they could withdraw from the study at any time. Anonymity and confidentiality were assured according to the guidelines for research ethics in social sciences, law and humanities.

Leading daily care from a distance

As a response to increased managerial tasks, the participants expressed increased responsibilities. In nursing home A, the unit manager had been delegated responsibility for running home care services in addition to the nursing home. Similarly, the unit manager at nursing home C was responsible for running two nursing homes. In the same nursing home, the front-line managers explained that they used to be responsible for one ward with 10 beds, whereas now they were responsible for three wards, with 30 beds in total. The nurses on the wards experienced a similar situation across the nursing homes. We were told that in addition to patient care, they were delegated responsibility for laundry, preparing food and documenting quality of care.

The participants spoke of these expansions in responsibilities as tensions, resulting from both trying to safeguard professional values and at the same time carry out managerial tasks. In particular, front-line managers expressed that there was no longer enough time to engage in patient care, and instead they ended up doing administrative work. Although many of the administrative tasks were not new, they had increased in number and scope, leaving less time to participate in guiding patient care. Front-line managers spent more time performing administrative tasks such as hiring temporary staff, attending administrative meetings, and following up on and ensuring regular reports on economy, sick leave and quality indicators, as expressed in the following quote:

I’m sure 80% of my time is spent doing administrative work. I think front-line managers have become expensive secretaries. I would like to spend more time in the clinical environment, but I no longer have time for it. (Beate, front-line manager, nursing home C)

Lack of front-line managers in daily care was similar in all the nursing homes. During the handovers we observed that front-line managers were not present, which triggered a need to delegate responsibility for care tasks further down to the nurses on the wards, as expressed here by Siri, a front-line manager in nursing home A: ‘I have to delegate many care tasks to the nurses on the wards because I get overloaded with administrative tasks, delegated from my leader.’

Further, unit managers at nursing home A told us that there were no financial resources available to hire extra personnel to carry out administrative tasks. Therefore, increased tasks had to be solved through delegation. Similarly, in nursing home B we found that increased delegations were solved by taking nurses out of daily care duties every second week to take responsibility for administrative tasks, which used to be done by front-line managers. During these so-called ‘administration days’ the nurses said that they now had more time to update patient care plans, complete necessary documentation, make checklists and forms to control the quality and efficiency of care, conduct meetings with relatives, and so on. Due to this shift in task responsibilities, nurses were also seen as the new front-line managers: ‘My experience is that nurses on the wards function as front-line managers. They are the ones controlling daily care tasks, whereby I only check in randomly’ (Oda, front-line manager, nursing home B). As shown in this quote, front-line managers saw themselves more as inspectors leading daily work from a distance. This lack of ‘hands-on’ leadership in patient care became even clearer when we looked at our observational data. In all of the nursing homes, neither the unit managers nor front-line managers wore uniforms like the rest of the staff did. Their offices were located in separate areas, far from the wards, which meant it was difficult for them to be aware of what was happening on the wards themselves. In addition, at the handovers we were told several times by nurses that there was no longer any expectation that front-line managers would be involved in patient care.

Lack of support in problem-solving

Many of the participants expressed that daily tasks were increasingly regulated by standards. All the municipalities operated with a service declaration that the nursing homes had to fulfil. This involved reporting on performance indicators for economy, quality and personnel administration. All three unit managers told us that in contrast to earlier years when they were supported by central administration, they now had to do all the reports by themselves. When interacting more closely with new administrative systems, they experienced that many of the reports had become so pervasive that other important tasks, such as creating a good working environment, had to be set aside. For instance, we were told that there was no longer time to prioritise yearly appraisal interviews with the staff, as expressed here by Siv, a unit manager at nursing home B: ‘I have personal responsibility for almost 100 people. I know we are measured on completion of performance appraisal but I haven’t had time to do that in years.’

In addition, many front-line managers across the nursing homes said they found it inefficient to spend so much time on following up reports with staff on sick leave instead of working directly with the staff who were at work. This made personnel seem like a cost in the budget instead of a resource in daily care. Instead of being motivators and good role models, front-line managers lacked time to follow up nurses in daily care. For instance, one front-line manager at nursing home C said that even though she knew it was important for the quality of care, she did not have time to supervise nurses in the care of individuals with dementia, which was one of her areas of expertise.

Lack of support in leadership not only created a feeling of inadequacy in safeguarding professional challenges, but also contributed to increased confusion among nurses in problem-solving. Many nurses across the nursing homes expressed that they saw front-line managers’ participation in daily work as pivotal to ensure delivery of high-quality care. During many of the handovers we observed that challenges in patient care were postponed in anticipation of discussing the cases with a front-line manager. This often related to patient treatment, the ordering of new medical equipment and evaluating needs for hiring extra staff. One nurse in nursing home C pointed out that due to a lack of leadership, she found it hard to reach decisions on how to handle irregularities in care, which in turn left room for subcultures to develop:

Earlier we saw the front-line manager much more. Now she keeps saying that I must take more responsibility in guiding the staff in dementia care. I do this often, however I don’t like to be the one making tough decisions. After all, they are my colleagues. So many times I just report adverse situations to the front-line manager, but often she will not have time to follow it up. (Bodil, nurse at nursing home C)

As the quote illustrates, nurses felt they had neither the means nor the formal authority to solve important issues in care. Such lack of clarity in problem-solving caused nursing leadership to be seen in a critical light.

Difficulties in adopting new managerial language

There were participants who expressed a willingness to accept new managerial tasks. They said that increased reporting requirements gave them an opportunity to advocate for more resources to improve quality of care. However, in order to influence decision-making, unit managers expressed they had to be armed with information from the nurses on the wards to support their position when negotiating with central administration. During the handovers at nursing home C, we observed that nurses used both standard documentation and self-made registration lists to demonstrate the scope of services they provided and the need for more resources to ensure quality of care. The documentation was then given to the unit managers who would plead their case. A similar use of documentation was expressed by Siva, unit manager at nursing home B:

In situations where employees do not get time to do everything they should do, I need them to document it and why they don’t have the time to do it. I need to have this specific documentation to support further arguments about the need for more resources.

This translation of professional work to a managerial language was seen as problematic. Nurses in particular expressed concern that increased managerial language might put less emphasis on professional values and quality of care. During the handovers we observed several occasions where nurses expressed frustration about the situation, telling their colleagues that they were willing to call in sick in response to demands for increased efficiency. Similarly, a unit manager in nursing home C told us that the ambiguity she experienced when talking about professional values together with efficiency demands was so pervasive that it was reason enough to quit her job. Thus, adopting a new managerial language at the sacrifice of professional values contributed to increased confusion regarding how to perform daily care.