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MIDDLE MANAGEMENT

The chain of commandANTHONY CARR discusses the new posts needed at middle management level so thatcontrol is maintained, from the patient to the director, but with fewer levels of accountability.

THE CHANGES outlined for thedirector of nursing service showthat a radical rethink is needed

for middle management positions. Thisarticle concentrates on a possiblemanagement structure for the New-castle Health Authority.

It.will consist of three large units eachcontaining a major medical teachinghospital, regional specialties and smallperipheral hospitals, a large mental ill-ness unit on five sites, a communityunit, a midwifery unit, and dental hos-pital and mental handicap unit. Theprinciples could apply to any district.

One important principle of the 1982reorganisation is that much of thedecision-making should be taken nearerthe scene of activity. Converting thisAnthony Carr, SRN, NDNCert, Queen's Nurse,is chief nursing officer of the Newcastle HealthAuthority"

principle specifically to nursing suggestsremoving a layer of nursing manage-ment. This would allow the director ofnursing service to. be more closely as-sociated with the ward than her divi-sional nursing officer predecessor.

A possible adverse reaction frommanagement nursing staff could be thatthey have had enough of changing theirjobs: "Salmon" and "Mayston"schemes in the early 1970s, reorganisa-tion in 1974, and now reorganisation in1982. I must admit it shows that nursemanagers have a tremendous capacityto change their work without becomingtotally disillusioned.

There are several considerationsbefore an intermediate grade is pro-posed. The over-riding question to beasked is the one posed in health circularHC (80)8, paragraph 26(i): "In con-sidering whether to establish a particu-

lar post the first consideration should bethe work to be done. Authoritiesshould, for example, avoid full-timeposts at district level or below in anydiscipline or function unless they aresure that there is the work to warrantthem. This should be the sole criteria forestablishing posts."

Changes in the way services areorganised locally also affect the way amanagement structure is devised. Thegreater financial control over unitbudgets brings greater accountability tobear on the director of nursing serviceand consequently through his or herchain of command. The regional healthauthority will operate grading surveil-lance over nursing posts between wardsister and director of nursing service (seeHN(81)34).

There is one other factor whichshould be included for consideration for

Nursing Mirror, September" 22 1982 59

MIDDLE MANAGEMENT

intermediate posts. The ratio of nursemanagers to other nursing staff hasreduced nationally since the late 1960s.In Newcastle a comparison of posts con-tained within management costs withother nursing staff since 1970 showsalmost without exception a reduction.111 1970, 1.49 per cent of staff were inpositions of senior nursing officer andabove, as against a total of 2,625.employed nurses.

Despite the reorganisation of theNHS and the addition of the localauthority nursing services, includingmidwifery in 1974, the ratio of seniormanagers had reduced to 1.04 per centand the actual number of senior nursingstaff had reduced by four. .•

In 1976 a new 800-bedded hospitalbegan to open but the ratio of seniorstaff was again showing a reduction to0.98 per cent. This reduction has con-tinued up to the present time with 35senior nurses managing 4,788 staff. Ifthe grade of nursing officer is included,the ratios are 4.76 per cent in 1970,reducing to 2.63 per cent in 1982. (Thiswill be discussed further next week.)

At present two grades of nurses arefound at middle management level -senior nursing officers and nursing of-ficers and, in addition, one grade of areasupport post entitled area nurse.

The Nurses and Midwives WhitleyCouncil has provisionally negotiated astructure which will allow healthauthorities to be more flexible in theirmanagement arrangements. Essential-ly, the staff at middle management andat support level at district can be fittedinto a grading structure as shown below.

New Corresponds toGrade

8 existing nursing officer grade 27 existing nursing officer grade 1 and

existing senior nursing officer grade 26 existing senior nursing officer grade 15 divisional nursing officer grade 44 divisional nursing officer grade 43 divisional nursing officer grade 32 divisional nursing officer grade 11 divisional nursing officer grade 04

New grading structure.

Two types of post have been identi-fied by the Nurses and Midwives Whit-ley Council, either a staff.support postor management! clinical post.

Over the last few months consider-able time has been spent in Newcastleidentifying the responsibilities of wardsisters (Nursing Mirror, March 31).Once implemented it will restore con-

siderable authority to the ward sister or.charge nurse, particularly in the area of24-hour responsibility.

This means total control of the wardenvironment and its policy. However,there is the continued problem of thehours worked by staff to provide cover.A sister working throughout the yearwith minimum sickness and study leavewill be on duty for 204 days or 56 percent ofthe days available. Even when onduty the sister will only cover seven-and-a-half hours of the 14hours available onday duty.

It is estimated that to keep one gradeof staff continually represented as beingin charge of a ward on day duty wouldrequire a back-up of another 2.24 staff.On night duty the back-up required isanother 1.5 staff. These figures illus-trate the large numbers of staff neededin 24 hours to manage the patient carefacilities on a ward. To give a safe ser-vice to patients' support from above interms of co-ordination, and below fromstaff nurses, is essential.

Nursing superintendentIn Newcastle it is proposed that wards

of a similar specialty will be groupedtogether and known as a nursing depart-ment. The nursing staff will be co-ordinated by a nursing superintendent.

The criteria for such a post will be:"A post of nursing superintendent willbe established where the size or com-plexity of a nursing specialty is such thatit requires either co-ordinating over a24-hour period or, exceptionally, re-quires co-ordination of other depart-ments during day duty only".

Night duty will be reorganised so thata designated night sister will report tothe nursing superintendent on all mat-ters relating to patient care and nursingpolicy. The nursing superintendent willmonitor all the nursing services and ap-point most of the staff who will work inthe department, and will normally beresponsible direct to the director ofnursing service. The responsibilities ofnursing superintendent are to be dividedinto five sections.Personal to nursing superintendent.Responsible for keeping up-to-date andprofessionally aware of changes in clini-cal development and practice of nursingin the local managed area, within thedistrict and within the profession.

She must be aware of changes nation-ally and locally in nursing education andto supervise students at basic and post-basic level.

The nursing superintendent is alsoresponsible for ensuring that effective

methods of management practice areknown, taught, accepted and used bysisters and charge nurses.

She identifies the training needs ofsisters/charge nurses and helps them toidentify their own staff's needs.To the local department of nursing. Ashead of the department, the nursingsuperintendent ensures the provision ofan efficient, effective, cost consciousnursing service to all patients and clientswithin the depattment.

Deficiencies of staff, materials andother resources are reported to thedirector of nursing or other designatedsenior nurse as outlined in the manage-ment structure of each' 'unit of manage-ment" .

She manages the nursing staff in thedepartment through the designatedsisters and charge nurses or theirdeputies. Within the manpower avail-able, each ward and nursing departmentmust be staffed at an optimum level.

Sisters and charge nurses who haveexpertise in various aspects of nursingpractice should be identified and theirexpertise made available throughout thedepartment of nursing to the unit ofmanagement and district as needed;

The nursing superintendent formu-lates appropriate nursing policy withinthe broad policy laid down at districtand unit of management leveland wherea policy does not exist she proposes oneto the director of nursing.

The director of nursing will delegateauthority to allo~ the nursing superin-tendent to employ and allocate staff inthe grades of nursing auxiliary/assist-ant, state enrolled nurse, senior stateenrolled nurse and staff nurse: She willbe present at the selection of sister orcharge nurse appointments and have theright of veto over the employment ofimmediate subordinates.

The disciplinary procedure will be us-ed up to and including final warning forthose grades of staff responsible for ap-pointing and up to and including firstwarning to sisters or charge nurses.

She monitors standards of patientcare through working and visiting pa-tient and client areas; talking to staff atformal meetings and informal discus-sions; meeting regularly with medicalconsultant staff, paramedical staff andother disciplines and organisations asrequired; reviewing or investigating,complaints and incidents; and reviewingabsence and sickness records.

She also identifies staff training needsand arranges for secondment, refresh-ment and retraining as appropriate.Night d co-ordination. Department

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60 Nursing Mirror, September 22 1982

District Postsbelow

Chief Nursing Officer

Presentgradingequiv.

Grades

DNS 2DNS 3DNS 4DNS 5DNS 6SNO (1)SNO (2)NO (1)NO (2)

Senior Asst. CND ~ i+34

Assistant CNO C 56

- r 78

Unit Postsbelow

Director of Nursing Service

Senior Asst. Director of NursingAssistant Director of Nursing

Nursing Superintendent/Night Superintendent

..Grading structure for the proposed posts .

Main dutiesThe night nursing superintendent's

main duty is co-ordination. She willallocate and reallocate available staff;see that staff conform to agreed nursingand department policy; act as nursingconsultant; liaise and be a point ofreference to medical staff; take chargeof the whole of a hospital or part of alarge hospital during the night; liaisewith all other non-nursing departmentsas required, such as pharmacy and fireofficer; share in selection and disciplineof staff.

The night nursing superintendent willbe responsible to a senior assistantdirector of nursing service and will workclosely with the nursing superintendentsof nursing departments. Grading ofthese posts will be grades eight to six.

policies must be understood and con-tinued on night duty.

The nursing superintendent receivesregular reports from a designated nightsister regarding the nursing service onnight duty and liaises with the night nur-sing superintendent on the department'saffairs. She is present at appointmentand disciplinary committees involvingnight staff at sister or charge nurse level.Nursing support and clinical interest.Most of the nursing departments will beorganised so that a major specialty willbe clearly defined. The nursing super-intendent will develop a clinical interestand be able to demonstrate and advisesisters and other staff in the clinicalsituation. It will be important for her toindicate to the director of nursing ser-vice that at least the equivalent of onesession a week is given to this activity.General unit administration. Depend-ing on the management arrangements ofthe unit, the holder of this post mayhave to take charge of the whole unit atvarious times of the day or at weekends.It is expected grading for these posts willbe grades eight to six.

The night nurse in charge of the wardreports to the ward sister or her deputyin the evening and the following morn-ing. The nursing superintendent willhave a designated night sister or deputyreporting on matters relating to thedepartment. It is important even withthese changes that a designated seniorperson is present on duty during thenight. The post will be titled "nightnursing superintendent" .

The criteria for 'the establishment ofthe post will be: "A night nursingsuperintendent will be established in anursing unit of management wherenight duty co-ordination of staff is re-quired above that required by the nurs-ing superintendent of a nursing depart-ment. "

Senior assistant directorsResponsibilities placed on the direc-

tor of nursing service are such that onone hand he or she will be expected towork fully with the unit administratorand senior medical consultant but at thesame time be near the patient care areas.

In some of the larger units there willbe more than 12 subordinates reportingdirect to the director. It is reasonable toplan for some senior staff officer sup-port to the director of nursing service.This support could be. a staff officersupport post, part support and part-management, or totally management.Areas of work which need to be coveredinclude:night duty co-ordination;manpower forecasting;service planning and development.co-ordination with department ofeducation on basic and post-basic train-ing;general personnel function;staff appraisal co-ordination;recruitment and advertising;

career development;in-service training;allocation and induction of staff;occupational health services;control of infection;professional development of trainedstaff;management of a majority specialty ser-vice such as geriatrics;acting-up for director of nursing ser-vice.

Criteria for appointment of seniorassistant director of nursing: "A post ofsenior assistant director of nursing willbe established where a director of nurs-ing service requires co-ordination ormanagement of a service or serviceswhich could not be carried out fully bynursing superintendents in charge Iofnursing departments. The function willbe co-ordinated throughout the 24 hourservice". Grading will be between fiveand two.

There will be a need in some nursingdivisions to have another grade posi-tion, either to support senior assistantdirectors of nursing or the director ofnursing service herself.

The criteria for the establishment ofthis type of post is: "A position of assis-tant director of nursing will be estab-lished where it is shown that the directorof nursing service requires support thatcannot be provided by senior assistantdirectors of nursing. Alternatively, apost can be established to support seniorassistant directors of nursing in theirown function."The job description for this position

will of necessity be highly varied accord-ing to the local needs of each nursingdivision."

Grading for this post will be eight tofour 0

Next week: More about middle manage-ment.

Nursing Mirror, September 22 1982 61