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Managing ward managers for roles in HRM in the NHS: overworked and
under-resourced Sue Hutchinson and John Purcell Managing ward managers
for roles in HRM in the NHS.

Article  in  Human Resource Management Journal · November 2010

DOI: 10.1111/j.1748-8583.2010.00141.x

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 doi: 10.1111/j.1748-8583.2010.00141.x

Managing ward managers for roles in HRM in the

NHS: overworked and under-resourced
Sue Hutchinson, Bristol Business School, University of West of England
John Purcell, Warwick Business School, University of Warwick
Human Resource Management Journal, Vol 20, no 4, 2010, pages 357–374

Drawing on case study research in seven NHS Trusts, this article considers the role and management
of ward managers and paramedic supervisors, focusing on their human resource management (HRM)
responsibilities. In the National Health Service (NHS), these front-line managers are critical to the
delivery of effective HRM and thereby strongly influence organisational performance and service delivery.
However, despite the mounting literature on leadership and performance in health care, little is known
about this body of managers who have been generally neglected by academics and practitioners. This
article seeks to address these shortcomings by considering the content and practice of these junior
managers’ role, their work experiences and factors that influence their ability to deliver effective HRM.
The findings reveal that the roles of these managers have been enhanced and extended to include an
extensive portfolio of HR duties but is subject to considerable constraint. The multiplicity of roles these
managers are required to perform has magnified issues of role conflict and ambiguity, heavy workloads
and stress. Fundamentally, however, these managers lacked support from senior managers and the HR
function.
Contact: Ms Sue Hutchinson, School of Human Resource Management, Bristol Business
School, Frenchay Campus, University of West of England, Bristol BS16 1QY, UK. Email:
susan2.hutchinson@uwe.ac.uk hrmj_ 357..374

INTRODUCTION

The role of front-line managers has transformed over the last few decades as this body of
managers have taken on greater responsibility for business management, particularly in the
area of HRM (Hales, 2005, 2006/07). Significantly, these responsibilities have been added to the
traditional supervisory workload and placed considerable demands on a role that was already
subject to constraint, leading to mounting concerns about the ability of these junior managers
to undertake their roles effectively. Recent management research identifies these managers
as key HR agents in business organisations, who can significantly influence employee
performance-related attitudes and behaviours, and thus organisational performance (Truss,
2001; Purcell and Hutchinson, 2007). Given, then, the critical role these front-line managers play,
it is therefore surprising that this stratum of management has been generally neglected by
academics and practitioners. Little is known about how their roles are defined and experienced,
and what factors may influence their ability to carry out their HRM roles effectively. It is this
gap that this article seeks to address.
Any study of junior managers needs to be contextually sensitive in order to consider factors
that are likely to shape their line management role and influence their capacity to undertake
their roles effectively (Currie, 2006). This article focuses on junior or front-line managers in five
acute and two ambulance trusts in the NHS. Our specific interest is in ‘ward managers’, which
include paramedic supervisors in the ambulance service, who are at the lower levels of the
management hierarchy. It is these managers who, because of their proximity and relatively

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Please cite this article in press as: Hutchinson, S. and Purcell, J. (2010) ‘Managing ward managers for roles in HRM in the NHS: overworked and
under-resourced’. Human Resource Management Journal 20: 4, 357–374.
Managing ward managers for roles in HRM in the NHS

frequent interactions with employees (Becker et al., 1996), have the potential to significantly
influence employee attitudes and behaviours. In the NHS, the front-line management role has
transformed over the last few decades to include budgetary matters, HRM responsibilities,
quality and policy implementation (Bolton, 2005). Against a background of ongoing service
redesign, there is increasing evidence that improved productivity and better patient outcomes
are strongly influenced by these managers. Yet their role is undeniably challenging and
complex.
The article is structured as follows. In the first section, we consider developments in the role
of front-line managers, building on the work of Hales and others to consider, in particular, the
implications of their heightened management role, particularly in HRM. We then consider the
role of these managers in the context of the NHS, emphasising the challenging and vital roles
these managers undertake. A brief outline of the methodology follows. The main body of this
article is found in the presentation of the findings, which explores, first, the content and practice
of the ward manager role, with emphasis on their HRM responsibilities, and, second, managers’
experiences, both positive and negative, and the factors that inhibit effective HRM. We also
report on senior managers’ perspectives of the role, including HR professionals, noting any
perceptual differences. The article concludes with a discussion of these findings and
implications for practice.

THE CHANGING ROLE OF FRONT LINE MANAGERS

There is a growing body of evidence (Hutchinson and Purcell, 2003; Hales, 2005, 2006/07) that
the role of front-line managers has undergone a significant development over the last few
decades, moving from a traditional focus on routine supervision to that of ‘mini-general
manager’ with responsibility for a much broader range of business management activities. Up
until the late 1980s, the traditional supervisory model was characterised as ‘overseeing work’,
directing, monitoring and controlling a work area on a day-to-day basis (Hales, 2006/07) with
a view to ‘keeping production going’ (Thurley and Wirdenius, 1973). However, as the ‘man in
the middle’ (Roethlisberger, 1945), the role was beset with problems, as these managers found
themselves confronted by divided loyalties, caught between the competing demands of more
senior management and the shop floor. In their classic study on supervisors, Child and
Partridge identified them as ‘lost managers’ (Child and Partridge, 1982) who had been deprived
of influence over decision making, suffered tension and stress arising from multiple conflicts,
and lacked support from their own managers. They were also managers whose commitment
had also been lost.
From the late 1980s onwards, evidence began to emerge that the role was becoming more
‘managerial’ (Storey, 1992; Lowe, 1993; Cunningham and Hyman, 1995; Hales, 2005, 2006/07),
although detailed analysis of the role remains scarce. Managers acquired new business
responsibilities such as budget management, cost control, managing quality, people
management and managing external relationships with suppliers/clients/customers. In one of
the few, detailed, studies of the role, Hales argues that managerial responsibilities have been
redistributed, with first-line managers acquiring some of the business tasks formerly associated
with middle managers, although their core function still remains one of ‘performance
orientated supervision’ (Hales, 2006/07). This concurs with our own earlier research, which
indicates that organisational expectations of the role have increased and that these new
responsibilities have been taken on without managers relinquishing their old roles (Hutchinson
and Purcell, 2007). Some have also argued that these changes have necessitated a change in
management style, with a move away from a traditional command and control style to one of

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facilitating and leading teams, and greater emphasis on the softer people management skills
(Storey, 1992; Cunningham and Hyman, 1995; MacNeil, 2003).
Driving these changes are a range of factors including heightened competition, restructuring,
de-layering, the growth in teamwork, new technology and the need for cost-efficiencies
(Cunningham and Hyman, 1999; Maxwell and Watson, 2006). The growth in people
management responsibilities has also come in response to the rise in ‘HRM’ and changing
nature of HR roles (Storey, 1992; Caldwell, 2003; Renwick, 2003; Hope Hailey et al., 2005; Francis
and Keegan, 2006). It is now common practice to find responsibility for much of the operational
side of HR resting with the line, leaving HR professionals free to focus on the more strategic
aspects of their role (see, for example, Francis and Keegan, 2006). The enthusiastic adoption of
the business partnership model (Ulrich, 1997) in recent years is one manifestation of this.
The distinctive characteristic of the ‘modern’ front-line manager is therefore the requirement
to perform multiple roles, some of which have been acquired from other functions and
managers. This multiplicity has magnified issues of role conflict and workload pressures, which
were inherent in the traditional supervisor role. It is not surprising then, to find mounting
evidence that line managers struggle to implement their HR role effectively. Research reports of
a lack of consistency and fragmentation in the application of HR policies by line managers, and
a gap between intended HR practices and those experienced by employees themselves (see, for
example, Khilji and Wang, 2006). Compounding issues of workload and role conflict are poor
HRM skills and knowledge, insufficient training, a lack of commitment and pressure to focus on
short-term priorities and costs (for example, see Perry and Kulik, 2008). Further evidence
suggests that line management involvement in HRM lacks institutional reinforcement and relies
on managers’ own personal motivations and commitment for fulfilment (McGovern et al., 1997).
The problematic nature of these managers’ roles is profoundly important when we consider
the wide body of theoretical and empirical evidence that line management behaviour can
significantly impact on employees’ performance-related attitudes and behaviours. As HR agents
of the organisation, front-line managers can influence employee job satisfaction and
commitment by the way in which they implement and enact HR policies (Truss, 2001; Purcell
and Kinnie, 2007). Supervisory support and mentor relationships have been shown to
ameliorate the negative effects of psychological contract breach (Zagenczyk et al., 2009).
Furthermore, theory on perceived supervisor support (PSS) asserts that the degree to which
supervisors value employees’ contributions and care about their well-being can influence
employees’ views and impressions of the organisation (Kottke and Sharafinski, 1988). In their
analysis of PPS, Maertz et al. (2007) go as far as to say that ‘A supportive supervisor may be
able to cover for the shortcomings of organisational policies and top management decisions
that seem unsupportive . . .’ (p. 1072). In other words, the behaviour of front-line managers,
particularly in discharging their HRM responsibilities, is too important to be ignored. Although
public policy is starting to pay particular attention to line managers’ involvement in aspects of
HRM (see, for example, Acas, 2009; MacLeod and Clarke, 2009; UKCES, 2009), few academic
researchers have chosen to study this body of managers. Storey’s assumption that the adoption
of HRM has meant ‘much greater attention is paid to the management of managers themselves’
(Storey, 2007) appears to have been ignored.

THE CONTEXT OF THE NHS

Successive NHS Plans have emphasised the importance of leadership as a vital element in
contributing to the NHS becoming a model employer and delivering improved performance
and productivity (see, for example, Department of Health 2002). The extensive literature on

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leadership and performance in health care has predominantly been confined to the leadership
role of top managers, and some have criticised this as being at too high a level to impact on
the attitudes and behaviours of employees working at the operational level (Ferlie et al., 1996;
Procter et al., 1999). A much smaller but growing body of research has specifically explored the
role of middle managers in health care, showing them to be key strategic actors and agents of
change (see, for example, Currie, 2006). Few studies, however, consider the role of lower level,
front-line managers, such as a ward managers, despite the fact that the role has been given
heightened significance under a range of initiatives including new public sector management,
Agenda for Change (AfC) and the skills escalator (McBride et al., 2006; Bach and Kessler, 2007).
In delivering HRM, these managers are critically important in maintaining effective teamwork,
performance appraisal and training to front-line staff, which studies have consistently shown
to have an impact on organisational performance in health-care settings (Borrill et al., 2002; West
et al., 2002; Woollard et al., 2003; Michie and West, 2004). Research on the HR–performance chain
(Purcell et al., 2003) showing that line managers can trigger positive discretionary behaviour by
the way in which they implement HR policies is very pertinent in this context, for discretionary
behaviour is central to the motivation of professional workers.
In health care, the role of ward managers has changed significantly over the last few decades
(Bolton, 2005; Wise, 2007) in response to sweeping changes in public and health service policy
and practice. In 1991, the Audit Commission proposed that health-care professionals such as
charge nurses (now ward managers) should have more autonomy over management issues and
recommended that budget management, recruitment and retention, skills mix and staff
rostering be devolved to ward level (Willmott, 1998; Wise, 2007). Less time was to be devoted
to direct patient care and more to managing staff, and the charge nurse’s role was to become
more enabling and facilitative rather than management by routine and control. Consequently,
managers became responsible for the daily running of a work area and its resource. This
distinctive strategy of recreating professionals as managers (Bolton, 2005) sought to produce a
more efficient and cost-effective service, and improve the quality of care and clinical outcomes.
Critics of this role change, however, have emphasised the difficulties in making the transition
from health-care professional to manager, claiming that these managers feel underprepared and
poorly supported when they take up their role. In evaluating this changing role in one, Trust
Willmott found that while charge nurses were enthusiastic about the changes, there had been
insufficient consultation during the change process, inadequate support and a lack of role
clarity (Willmott, 1998). Wise’s study in a large Scottish trust found that the ward manager role
held little appeal because of a loss of patient control, work–life conflict, stress and perceptions
of poor pay and rewards (Wise, 2007).
As health-care professionals, these managers also face multiple commitments and experience
competing loyalties among the patients, team, organisation and profession (Buchanan et al.,
2007), which further inhibits their management role (Forbes and Hallier, 2006). In her study of
NHS nurse managers, Bolton found that 89 per cent of ward managers agreed with the
statement ‘I see myself as a nurse first and manager second’, concluding that it is commitment
to their role as heath-care professionals that acts as the largest social constraint on their
management role (Bolton, 2005).
Other research points to additional challenges and inconsistencies in the role. The NHS staff
survey suggests variability in line management behaviour in the application and conduct of
performance appraisals. Results from the 2008 survey (Healthcare Commission, 2009) found
that only 64 per cent of staff had been appraised, and only just over a quarter (27 per cent) felt
it was well structured, in that it improved how they worked, set clear objectives and left them
feeling that their work was valued. In their study of HRM in the health sector, Boaden et al.

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(2007) report concerns over the relative lack of priority given to HRM by line managers
compared with other aspects of their role, citing heavy workloads, pressure from performance
targets, lack of confidence in implementing HR policies and poor management skills as
contributory factors.
In sum, these managers are increasingly critical to the delivery of effective HRM and thereby
strongly influence organisational performance. It is apparent that in the NHS, the ward
managers’ role has become more diverse, complex and challenging. Yet this body of managers
have been given little exposure in the academic research. The critical questions arising from this
review, and which underpin the following research, are therefore:

1. How are ward managers’ roles defined and practised in the NHS, particularly in HRM?
2. What are the work experiences and perceptions of ward managers?
3. What are the factors influencing ward managers’ ability to deliver effective HRM?

METHODS

The article is based on a study, funded by the Department of Health, and undertaken during
the period 2005–2008, which sought to explore the management of front-line managers and how
this affected the delivery of HRM. Recognising that the definition of the role had to be
contextually sensitive (Currie and Procter, 2001), initial discussions held with a sample of health
sector managers concluded that, for the purposes of this research, these were managers at the
lower levels of the management hierarchy who had non-managerial clinical staff reporting to
them – typically ward managers and paramedic supervisors who were band 7 under AfC.1
A multiple case approach was adopted, comprising five acute hospitals and two ambulance
trusts all from the south of England. The trusts were selected on the basis of a range of factors
including trust type, performance (the trusts reflected a diverse spectrum of performance based
on nationally assessed ratings), size, location and access. In the five largest trusts, two sub-units
of the organisation were studied (typically directorates such as medicine in acute trusts and
stations in the ambulance trusts), which allowed the research team to drill down into the
organisations and focus on ward managers in some depth. In the case of the two smaller trusts,
the unit of analysis was the whole trust.
All of the trusts were going through varying degrees of change and uncertainty at the time
of the research. The ambulance trusts were being restructured across England through a process
of mergers, and some of the acute trusts were in severe financial deficit, which necessitated
redundancies. At the same time, all of the acute trusts faced staffing shortages in some of the
areas studied. The AfC was being rolled out, and a new pay and reward system had recently
been determined in all trusts. Undoubtedly, these changes were very much in the minds of
some of the individuals interviewed. NHS research ethics approval was sought and granted
for multi-centre research. Additionally, some trusts required approval from their local research
and development committees. An advisory group, comprising representatives from the
participating trusts, met early on in the research process to consider the research approach,
including issues of access to participants, and survey design.
Qualitative and quantitative data were obtained from extensive interviewing with a range
of staff. These included structured interviews with ward managers using a detailed
questionnaire, which sought to explore their interpretations and experiences of their role. A
mixture of open and closed questions was used, the open-ended questions allowing us to
examine some responses in more depth. Key themes explored in the survey were job role and
responsibilities, attitudes to the job (work intensity, stress, influence, job satisfaction),

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management and HR support, and general views on working in the trust such as commitment,
organisational citizenship behaviour (OCB) and intention to quit. Job role categories were
developed from previous research (Hutchinson and Purcell, 2003; Hales, 2005), pilot interviews
with ward managers and early discussions with the advisory group. Some of the questions
used validated scales from the Workplace Employee Relations Survey 2004. Our preference was
to administer the questionnaire on a face-to-face basis since our previous research (Purcell et al.,
2003) had shown this to make a valuable contribution to the research process by allowing the
interviewer to explore the meaning and significance of responses. However, difficulties in
releasing staff for interviews, itself interesting early evidence of workload pressures, meant that
this approach had to be supplemented with a postal survey, although only for a minority of the
sample. In total, 117 ward managers were interviewed, representing a response rate of between
30 per cent and 95 per cent according to trust.
Detailed interviewing was also undertaken with 51 more senior trust managers (such as
directorate directors, heads of nursing, operational managers, and HR professionals) to gather
contextual information and understand senior managers’ perceptions and expectations of the
role. This also allowed us to explore any perceptual differences between senior and ward
managers, which other research suggests might impact negatively on management performance
and, ultimately, service delivery (Maxwell and Watson, 2006).
All the data gathered were analysed in a structured and methodical way. Quantitative data
were analysed using the SPSS software package, and the qualitative data were summarised
according to the research questions and emergent themes.

WARD MANAGERS’ ROLES AND RESPONSIBILITIES

Six key areas of responsibility likely to define the role of ward managers were explored in the
survey: general performance/quality issues, people management/HRM, planning and
scheduling of work, managing operational costs, dealing with clinical work and communication
outside the immediate team. The findings (Table 1), suggest that the role combined a mixture
of traditional supervisory work and newer management activities, with most (over 80 per cent)
claiming that their role comprised elements of all of these groupings, although there were
variations between acute and ambulance trusts.
Nearly three quarters of managers (71 per cent) had some responsibility in all six areas, 21
per cent in five, 7 per cent in four and only one had jurisdiction in just three areas. The most
common areas of responsibility, which all respondents saw as part of their role, concerned
general performance/quality issues (such as ensuring quality of care for patients, conducting

TABLE 1 The management responsibilities of ward managers (n = 117)

Area of responsibility Acute trust Ambulance trusts All

(per cent yes) (per cent yes) (per cent yes)

Performance/quality issues 100 100 100

People management 100 100 100
Planning and scheduling work 93 80 91
Managing operational costs 92 35 82
Dealing with clinical work 93 100 94
Communication outside immediate team 97 100 97
Other 58 15 50

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audits, risk assessment, health and safety, and dealing with complaints) and people
management/HRM, suggesting that these were core activities of the role. The more traditional
supervisory aspects of the role were captured under two groupings: ‘clinical work’ and
‘planning and supervising’ work, and these two areas formed part of the role for 94 per cent
and 91 per cent of managers, respectively. Clinical work involved directing and supporting the
team, and maintaining and improving not only staff skills but also patient care, which were
often necessary to cover for staff shortages. Planning and scheduling work, such as
management of the duty rota, ensuring the right skills mix and off-duty rostering were less
common activities for managers in the ambulance trusts, where the work was undertaken by
area administrators (a recently created role in one trust developed to specifically lighten the
workload of paramedic supervisors) or a central control team.
Communication beyond the immediate team, both within the trust and externally, was a key
component of the role for nearly all managers, reflecting the demand to manage the patient
pathway (in acute trust, from admission to discharge) and improve communication between
patients and patient experts. This interaction with other professionals (such as General
Practitioners, pharmacists and those working in emergency services) and outside organisations
(including suppliers of equipment and contract cleaners) was reported to be a growing part of
the job and is akin to the role of ‘boundary spanners’ more commonly assigned to middle
managers (Floyd and Wooldridge, 1997; Dopson and Fitzgerald, 2006). This implies a shifting of
responsibilities, with ward managers taking on the crucial networking role formerly associated
with their more senior managers, concurring with earlier work by Hales. Another more recent
responsibility, certainly for those in the acute trusts, was managing operational costs, which
meant operating within a set budget and taking decisions on staff costs, plus expenditure on
supplies and equipment. Other elements of the job not captured in the six categories included
project work, promoting the profession, supporting students and counselling relatives.

Ward managers’ role in HRM

In terms of people management, most had large spans of control, with an average team size
of 26 staff. Just under a quarter (23 per cent) had responsibility for 40 staff or more, 34 per cent
supervised between 16 and 39 people, and the remainder (43 per cent) between 2 and 15. Over
a third had some responsibility for multiple teams – ranging from two to as many as seven.
Clearly, the size of ‘people’ demand was huge, far greater than equivalent managers in other
sectors, and larger than many consider to be good management practice. Hales’s study of 135
organisations across a range of sectors (Hales, 2005) showed that in only 30 per cent of
organisations did junior managers have spans of control greater than 10, and evidence from our
own earlier research (Hutchinson and Purcell, 2007) found most teams to comprise of between
5 and 20 people. Acas guidelines suggest successful teams to be mostly made up of between
6 and 15 members (Acas, 2009).
These managers also had wide-ranging HR responsibilities. Based on previous research plus
our initial interviews with key trust players, 23 HR practices were identified as likely to be
carried by these managers (Table 2). HR activities excluded from the list were determining
financial rewards and other aspects of the benefits package such as sick pay and pensions,
which were shaped by trust or national policy. It was clear, however, that managers had
extensive delegated powers in most other areas. Employee selection, performance management
practices, training, providing recognition, communication and involvement, teamwork, and
health and safety were undertaken by 90 per cent or more of respondents. A very slightly
smaller percentage (80–89 per cent), but still a significant proportion, had responsibility for
recruitment, maintaining staff records, activities associated with the ‘improving working lives’

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TABLE 2 HR responsibilities of ward managers

HR duties Per cent with

responsibility
(n = 117)

Recruitment 88
Selection 91
Induction 91
Maintaining staff records 87
Deciding and planning training and development needs of staff 95
Providing formal training 80
Providing informal training including coaching and guidance 98
Mentoring 70
Performance appraisal/development reviews 92
Agreeing performance development plans 89
Discipline and grievance handling 96
Absence management 96
Giving recognition 92
Pay banding decisions 56
Upward communication 98
Downward communication 100
Listening and responding to staff suggestions 99
Coordinating the work of teams/shifts 92
Maintaining effective teamwork 98
Counselling staff 89
Health and safety 95
Improving working lives 86
‘Other’ people management duties 10

initiative and counselling (usually informal). Comparisons with other studies (Hales, 2005;
Maxwell and Watson, 2006) show these HR responsibilities to be greater than those performed
by equivalent managers in other sectors and organisations.
Given the evidence that certain HRM policies and practices can contribute to high-quality
health care (Borrill et al., 2002; West et al., 2002), the importance of these line managers’
extensive role in HRM is clear. Managers’ involvement at all stages of the recruitment and
selection process, from writing job descriptions to short-listing applicants, arranging and
conducting interviews, and making the final selection, directly impacts on the quality of staff
employed. Undertaking performance appraisals, identifying training needs and managing
underperformers clearly underpin the drive towards a strong performance management culture
and ensure that staff are equipped with skills to provide better patient care. Maintaining
effective teamworking, critical for all health-care professionals, is associated with knowledge
sharing, reduced stress, innovation and effectiveness in the quality of patient care (West et al.,
2002).

Role priorities
Exploring which aspects of the job took priority and time was vital to understanding how
managers managed their multiple roles. Pilot interviews revealed that this was a difficult task
for managers to do and that the simplest way of capturing the division of tasks was to separate

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the work into clinical and non-clinical activities, or, to use the language of our interviewees,
between ‘management’ and ‘clinical supervision’. Even then, however, the definition of
‘management’ was rather ambiguous. Some trusts provided guidelines or statements defining
this workload division. In four trusts, the balance was 80 per cent clinical, 20 per cent
non-clinical, equating to four days a week clinical work and one day ‘management’. Some
trusts encouraged managers to come into work in ‘mufti’ (not wearing their uniform) on their
designated ‘management’ day/s. This symbolic gesture was seen as necessary to prevent
management time being taken over by clinical work. In one trust, ward managers went away
from the ward on their ‘management day’ to prevent them from being dragged in to do clinical
work.
Line managers were asked how much time they spent, on average, over a month, on these
two areas. Their responses revealed wide variations. Overall, 44 per cent of the managers
considered that their clinical role dominated, 41 per cent considered the non-clinical and 15 per
cent felt, on balance, their work to be evenly split between the two areas. In reality, however,
work priorities varied on a daily basis. One manager gave the example of how her clinical work
increased from 50 per cent to 90 per cent because three team members were off sick. In theatres,
the intensity of the working environment, multidisciplinary nature of surgical teams and a
national shortage of theatre nurses meant that the people management part of the job
dominated. It was apparent that there was ‘no one size fits all’ approach to the division of work,
and the prioritising of tasks varied according to an array of factors including team size, staffing
levels, financial constraints, changing targets and deadlines, and personal choice. As other have
found (McGovern et al., 1997), the management of people was perceived to be discretionary and
not subject to the same levels of scrutiny and measurement as clinical activities. When under
pressure, many managers confessed that it was the management role that suffered and was
afforded a low priority, as they retreated into what they felt they did best, which was being a
good clinician.

Senior managers’ perceptions and expectations of the role

Interviews with senior managers revealed a more consistent and less ambiguous picture of the
ward manager role. There was a unanimous view that it was the clinical role that dominated,
although some recognised difficulties in maintaining trust guidelines. Comparing senior
managers’ perceptions with the accounts of ward managers themselves revealed that, in
practice, ward managers had a much greater involvement in the non-clinical aspects of the role
than envisaged by senior managers. One consequence of this disparity was an inevitable
increase in workload, with ‘management’ work covered on overtime or at home in personal
time, or it simply did not get done.
Perceptual differences were also apparent in terms of job responsibilities. Some senior
managers expressed higher expectations of the role in terms of expecting ward managers to
engage in a ‘visualising’ activity and understand the links between operational and strategic
matters, as this director reports:

To be effective they need to be able to link organisation strategy with operational

delivery . . . they must have awareness of Trusts objectives, be clinically excellent,
put the patient first and staff second.

The biggest danger, from their perspective, was for the ward manager to ‘go native’ and
work solely for the benefit of the team.

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MANAGERS’ EXPERIENCES OF THEIR WORK

Long working hours and the need to take work home were a key characteristic of this group
of managers, with nearly all (91 per cent) reporting that they worked overtime on a regular
basis and well over half took work home regularly. As one ward manager commented:
Management only allows one me 1 day a week to do non-clinical activity. Therefore,
most of the work is done out of paid hours in our time.

These experiences were reflected in the very high levels of work intensity and stress shown in
Table 3, reinforcing the earlier findings of demanding and multiple roles.
Despite these very negative experiences, managers expressed high levels of organisational
commitment, as indicated in the responses to the top three questions in Table 4. High levels of
organisational commitment have long been a feature of the NHS (Kersley et al., 2006). However,
health professionals are also known to face multiple commitments and experience competing
loyalties (Buchanan et al., 2007). Exploring these differences (Table 4) revealed that loyalty was
strongest towards the patient and to the team or work group. When asked to prioritise these
loyalties (which most felt hard to do), over half said that loyalty to patients was the most
important (51 per cent) and 35 per cent said that loyalty to their team was the most important.
This would support the work of others, which finds greater loyalty to the profession and client
rather than the employer (Buchanan et al., 2007).
These multiple, and potentially conflicting, commitments have implications for workload,
stress and other employee outcome measures such as job satisfaction, OCB (Eisenberger et al.,
2002) and intention to quit. OCBs are particularly important in this context because they
measure discretionary behaviour, behaviours that are a matter of personal choice, and have
been related to organisational, group and individual performance (Coyle-Shapiro et al., 2004).

TABLE 3 Ward managers’ experiences of their job (n = 117)

Per cent Strongly Agree Neither Disagree Strongly

agree disagree

My job requires that I work very hard 56 37 5 2 –

I never seem to have enough time to 37 42 12 8 1
get my work done
My job is stressful 22 58 14 4 2

TABLE 4 Ward managers’ commitment and loyalty (n = 117)

Per cent Strongly Agree Neither Disagree Strongly

agree disagree

I share the values of the trust 11 55 24 7 2

I feel proud to tell people who I work for 17 50 21 10 2
I feel loyal to the trust 17 57 17 6 3
I feel loyal to my profession 49 48 3 – 1
I feel loyal to my team 72 27 – – 1
I feel loyal to the patients 79 21 – – –

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Correlation analysis (Table 5) shows strong associations between some of these employee
outcomes and perceptions of workload and stress (Appendix 1 lists the variables used in the
statistical analysis). Those who perceive their job to be stressful and intense are less satisfied
with their job, and those who are more stressed are more likely to think of leaving.

Factors influencing ward managers’ effectiveness in HRM

In order to understand some of the constraints facing these managers and the supportive
conditions that are necessary to help them discharge their HR roles effectively, opinions were
sought on different levels of support (Table 6).
Support from the team, colleagues and line manager were rated most highly, whereas
support from senior management, the trust and HR were rated least highly. Further analysis
(Table 5) revealed significant correlations between certain employee outcomes and support
from the HR function, senior managers and the trust, although there is less evidence of such
strong relationships with support from line managers, colleagues or the team. This suggests
that the important influences on line managers lie outside the boundary of their immediate
work area.
To understand these findings further, an open-ended question was asked concerning the
barriers that prevented managers from performing their HRM role effectively. Six main
interlinked issues emerged: heavy workloads and stress; role conflict and ambiguity; a general
lack of resources; inadequate training; and lack of support from senior management and HR.
Heavy workloads, stress and role conflict are clearly evident from the earlier findings.
Exacerbating these issues were tensions within the multiple management roles, between, for
example, budgeting constraints and providing appropriate staffing levels for effective patient
care, as this ward manager suggests:
In the ideal world we need more staff to provide clinical services – this means we
could provide more of a service on wards but I can’t because the budget would
increase.

These tensions were heightened by financial constraints and a general lack of resources
(time, money and people), a common feature of working in the NHS.
Time is not given to us for performing administration tasks – we have to manage
IPRs/appraisals as best we can – priority is not given to performing IPRs but it’s
seen as vital when audits are carried out that they are done.

Inadequate training to develop HRM skills was a further constraint. Although nearly all (98
per cent) had received some form of training over the previous year, for the majority, this was
for clinical needs. A significant proportion (37 per cent) claimed not to have received any
management training. None of the trusts appeared to have a formalised approach to developing
these skills, and training tended to be conducted in an ad hoc and reactive way, unless there was
a formal capability issue. Even when structured training was available, financial constraints and
releasing managers often prevented access to this type of training. A quarter admitted that they
had experienced difficulties in accessing training in the last 12 months. There were no shortages
of comments from the ward managers on this:
Lack of training is one of the main inhibitors – there is nothing I can do about it
– the budget just does not cover it.

The limitations are that I am a clinician but also a manager – and I have never been
trained on that.

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TABLE 5 Bivariate correlations for certain variables

1 2 3 4 5 6 7 8 9 10 11

1. Job intensity –
2. My job is stressful 0.523** –
3. Satisfaction with team support -0.020 -0.025 –
4. Satisfaction with colleague support 0.047 0.027 0.211* –
5. Satisfaction with line manager -0.044 -0.063 0.040 0.317** –
support
6. Satisfaction with senior 0.053 -0.002 0.005 0.250** 0.394** –
Managing ward managers for roles in HRM in the NHS

management support
7. Satisfaction with HR support -0.005 0.010 0.067 0.109 0.200* 0.424** –
8. Satisfaction with trust support -0.055 -0.175 -0.048 0.119 0.374** 0.691** 0.473** –
9. Job satisfaction -0.195* -0.381** 0.340* 0.127 0.404** 0.455** 0.240* 0.477** –
10. Organisational commitment -0.067 -0.168 -0.038 0.132 0.108 0.381** 0.256** 0.509** 0.451** –
11. Organisational citizenship 0.209* 0.064 0.229* 0.197* 0.172 0.242** 0.180 0.152 0.245* 0.252** –
behaviour
12. Intention to quit 0.152 0.249** -0.068 -0.049 -0.118 -0.350** -0.150 -0.473** -0.369** -0.550** 0.000

* p < 0.05, ** p < 0.01.

© 2010 Blackwell Publishing Ltd.

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TABLE 6 Ward managers’ satisfaction with support (mean

scores) (n = 117)

How satisfied do you feel Mean score

with the support from

Team 4.17
Colleagues 4.00
Line manager 3.71
Senior management 3.16
HR 3.29
Trust 3.14

5 = highly satisfied; 1 = highly dissatisfied.

As a manager, I learn a lot of people management on the job. Mandatory managerial

courses would help.

Most trusts preferred to give emphasis to less formal training approaches such as coaching
and mentoring, although managers also perceived these to be far from adequate. Just under
half (43 per cent) were satisfied with the coaching, guidance and mentoring they received.
Learning by doing seemed to be the most common approach or ‘learning from mistakes’, as one
manager put it, but this requires a performance culture in which staff can openly admit to
errors, something that was notably lacking in some trusts.
Of fundamental importance to these managers was active support from senior management,
in terms of providing recognition, time and role clarity. There was also a perceived need for
senior managers to act as good role models or champions, to have a more inclusive
management style and to communicate and listen. Some felt senior managers to be out of touch
with the reality of working on the front line, producing unrealistic targets and goals.
The relationship between HR and the line is critical if managers are to deliver their HRM
roles effectively (Perry and Kulik, 2008), yet just over half were dissatisfied with the support
they received from the HR function. Criticisms of HR included being slow to respond,
bureaucratic, producing volumes of policies (one manager noted how the absence policy was
26 pages long), too distanced from the front line, providing impractical advice and frequently
changing their policies. As one manager observed:
It’s very difficult to keep up to date with HR policies and procedures and how to
apply them – I’ve not the time to do this. After you have been given the advice the
policy changes.

Questioning senior managers about the difficulties these managers faced revealed some
similarities but also some striking differences. While none questioned the clinical ability of their
ward managers, there was a widespread perception that some lacked the necessary skills and
competencies to perform their HRM role effectively. This was largely attributed to inadequate
experience and poor training and development. A few also recognised a failure at the selection
stage to identify skills and behaviours that were appropriate for good people management. All
trusts admitted to selecting managers almost exclusively on their clinical ability and giving
‘management’ skills a low priority while at the same time recognising that a good clinician does

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Managing ward managers for roles in HRM in the NHS

not necessarily make a successful manager. Although there was awareness of the potential for
role conflict, resource constraints and heavy workloads, few questioned the impact this might
have on the ability of ward managers to manage effectively. Significantly, what was not referred
in these interviews, but seen as critical by ward managers themselves, was support from the
top of the organisation. Senior managers’ response to questions about support was to turn to
the role of the HR function, which was perceived to offer adequate advice and guidance to
ward managers in their HRM role.

DISCUSSION AND IMPLICATIONS

In the pursuit of a more efficient and cost-effective service, the NHS has sought to transform
health-care professionals into managers. Our research shows that budget management,
purchasing, management of the patient pathway as well as an extensive portfolio of HR duties
have been added to the traditional clinical duties, with clear implications for how well these
managers are able to deliver their roles effectively. The fact that ward managers were expected
by senior management to devote up to 80 per cent of their time to the traditional clinical duties
of a charge nurse is indicative of the paradox at the heart of the professionalisation of front-line
management. Most ward managers had huge people management responsibilities with
exceptionally large spans of controls, particularly when compared with practice in other
non-health sectors, some managing multiple teams. Given the increasing evidence of a link
between HRM and the quality of patient care, the criticality of their role is evident. The reality
was, however, that HRM was afforded a low priority as the more clinical aspects of the role
took precedence. Indeed, senior managers believed that clinical work should and did dominate.
HRM was also perceived as discretionary by the ward managers, and we found no evidence
that it was contained in any formal or informal performance expectations such a job
competencies for this grade of manager. As a consequence, ‘management’ work, including
people management, was covered outside normal working hours or simply did not get done.
Paradoxically, however, giving precedence to clinical work and allowing the management of
people to take second place is likely to be counterproductive to the goal of achieving effective
patient care.
As the role has enhanced and extended, so have the challenges. Problems of role conflict,
heavy workloads and stress, which were inherent in the traditional supervisor role, have been
magnified. The multiplicity of roles that these managers were required to perform clearly
created tension and ambiguity, not only between maintaining high professional standards and
business targets, but also within the management role itself, there was conflict such as
balancing budgets while trying to maintain staff levels and morale. The disparity between
senior managers’ expectations and perceptions of the role, and ward managers’ experiences of
their job in terms of balancing workload responsibilities has only served to heighten this
ambiguity. When under pressure, again, the HRM role was likely to suffer as managers
retreated into their comfort zone of being a good clinician. Lack of appropriate skills and
knowledge, partly because of poor investment in training and difficulties in releasing staff for
formal training, was another key constraint. While some of this was because of a general lack
of resources in terms of time and money, there was an absence of any structured approach to
management development. Learning people management skills by ‘doing’ or on the job was a
common approach, but to be effective requires a blame-free performance culture, allowing
managers to openly admit mistakes and difficulties to colleagues and more senior managers.
This was notably lacking in some trusts.

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 Sue Hutchinson and John Purcell

Fundamentally, these line managers felt unsupported, isolated and were overlooked as a
vital group. Critical to support is the relationship between the HR function and the line. Yet just
over half of ward managers felt they lacked support from the HR function, which was
perceived to be too distanced from the workforce, producing mountains of policies that were
impractical and difficult to implement, bureaucratic and often slow to respond. Some senior
managers also recognised a failure to appoint people based on their ‘management skills’ as a
further problem. All trusts admitted to selecting managers primarily on the basis of their
clinical skills but at the same time recognised that the best expert nurse or paramedic does not
necessarily make a good manager.
The implications for the HR function are clear. They need to clarify job expectations through
the performance management process, develop a strategy on training, design HR policies that
can be understood and implemented by ward managers, provide administrative support and
select managers on the basis of behavioural competencies suited to good people management,
not just clinical skills. However, improved HR support is not sufficient on its own. Senior
management support was also lacking, particularly from top management in terms of
providing recognition, role clarity, time and realistic targets to enable them to provide effective
team leadership. Significantly, this lack of support from the top was not something recognised
by many senior managers in part because they did not see team leadership as an important
function. To them, ward managers should have been reflecting and reinforcing trust-wide
values and strategic priorities rather than work solely for the benefit of the team.
Ironically, despite this rather bleak picture of the role of NHS ward managers, these
managers were a highly committed and dedicated group of professionals whose loyalty to the
patient and their team has remained resolute. Their commitment to the trust, while quite high,
was always less than that to their team, their profession and to patient care. The danger is that
if health-care front-line managers continue to have such heavy workloads and contradictory
expectations placed upon them, organisational commitment may start to erode, and ‘going
native’ and looking after their own patch is the best they can be expected to achieve.

Note
1. The body of managers studied are hereinafter referred to as ‘ward managers’, who were
the majority of managers participating in the research.

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APPENDIX 1: VARIABLES USED IN STATISTICAL ANALYSIS

Organisational commitment (alpha = 0.819) five-point scale

• I share many of the values of my trust

• I feel loyal to the trust
• I feel proud to tell people who I work for

Organisational citizenship behaviour (OCB) (alpha 0.698) five-point scale

• I volunteer to help others if they need it

• I usually work overtime or extra hours when required
• I volunteer to do tasks outside my normal job description

Job satisfaction (alpha 0.83) five-point scale

How satisfied do you feel with:
• The sense of achievement you get from your work
• The scope for using your own initiative
• The amount of influence you have over your job
• The amount of responsibility you are given
• Your current workload
• Your job security
• The opportunities to use your skills and abilities
• The work itself

Intention to quit (alpha 0.887) five-point scale

• I often think about leaving this trust

• I will probably look for a new job at a new organisation in the next 12 months
• As soon as I can find another job, I will leave this trust

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