Feature Art & science | action learning

Leadership support for ward managers in acute mental health inpatient settings Gwen Bonner and Sue McLaughlin report on a study into the tensions inherent in the ward manager role in one NHS trust Correspondence [email protected] Gwen Bonner is professor of mental health nursing practice at the University of West London Sue McLaughlin is a nurse consultant in inpatient mental health services at Berkshire Healthcare NHS Foundation Trust Date of submission March 4 2014 Date of acceptance March 25 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines nm.rcnpublishing.com

Abstract This article shares findings of work undertaken with a group of mental health ward managers to consider their roles through workshops using an action learning approach. The tensions between the need to balance the burden of administrative tasks and act as clinical role models, leaders and managers are considered in the context of providing recovery-focused services. The group reviewed their leadership styles, broke down the administrative elements of their roles using activity logs, reviewed their working environments and considered how recovery focused they believed their wards to be. Findings support the notion that the ward manager role in acute inpatient settings is at times unmanageable. Administration is one aspect of the role for which ward managers feel unprepared and the high number of administrative tasks take them away from front line clinical care, leading to frustration. Absence from clinical areas reduces opportunities for role modeling good clinical practice to other staff. Despite the frustrations of administrative tasks, overall the managers thought they were supportive to their staff and that their wards were recovery focused. Keywords Ward managers, administrative tasks, role models HISTORICALLY THE role of ward manager in mental health inpatient services has been one of clinical leader, but the changing nature of mental health services has led to the development of more specialist roles, such as clinical nurse specialists and consultant nurses. This development has introduced a more complex delivery of clinical leadership in some areas.

26 May 2014 | Volume 21 | Number 2

Providing assurance that services are safe and effective for patients requires an administrative element. Formerly, this element was supported by the ward clerk role. But today’s ward managers report that administration is increasingly challenging and that it takes them away from the ‘shop floor’ and reduces face-to-face contact with staff and patients. They have fewer opportunities to provide the role modelling and senior clinical leadership required to support a recovery-focused environment. The inquiry led by Robert Francis (2013) into poor care at the Mid Staffordshire NHS Foundation Trust has provided serious challenges to trusts to provide evidence of safe and effective care in a transparent. The Department of Health (Cummings and Bennett 2012) also promotes more compassionate care with a strategy that embraces leadership development for staff who have a clinically led and patient-focused approach. The strategy has set a direction for the organisational changes needed to address some of the challenges with which ward managers have grappled in recent years in their attempt to maintain a clinical focus to their roles. There is little evidence examining in depth the changing role of ward managers in mental health settings, taking into account the effects of providing evidence of recovery-focused services, greater governance, performance measurement and all associated administrative tasks. In a literature review of recovery-focused leadership, Cleary et al (2011) found that nurses want ward environments to be underpinned by a philosophy of recovery, but that it is not always provided where they work. NURSING MANAGEMENT

Downloaded from RCNi.com by ${individualUser.displayName} on Nov 25, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.

Nicholson et al (2011) highlight that leadership that is emotionally engaging and where staff believe that they are part of the decision-making process, supported to lead this process and have an emotional connection with the process is more likely to support successful care delivery and enable necessary change. Alimo-Metcalfe et al (2007) note the positive effects of using engaging leadership styles on staff, but state that complex contextual factors affect productivity and outcomes. Although their study was related to crisis and home treatment, the complexities are likely to arise in inpatient settings. There is a need, however, to examine this in further detail. Anecdotally, ward managers increasingly report feelings of burnout, and that they do not intend to stay where they work long term. There is therefore a need to explore how leadership can be developed and supported to ensure that ward managers can fulfil the complex elements of their role in the context of recovery. The initiative described in this article considered some of the issues discussed above by working with ward managers to identify the most difficult aspects of their roles. This collaboration enabled them to reconcile some of the challenges they face and to develop helpful leadership roles. The group reported positive feelings about their wards and roles after the intervention, and there is hope that the clinical lead aspect of their role is not lost.

The project As part of a wider transformational change programme in Berkshire Healthcare NHS Foundation Trust, 12 workshops were provided over a year for a group of ten inpatient ward managers to consider the issues discussed above. The workshops were developed and led by the authors to: ■■ Understand the challenges of the group members’ roles. ■■ Identify core cultures and values to support their wards. ■■ Identify areas for change to improve patient and staff experience. ■■ Provide a non-threatening supportive space for peer support. The workshops were initially structured around activity log books and environment evaluations, then adapted to the themes the group identified as priorities using an action learning approach. The sessions were underpinned by relevant theoretical input, such as leadership theories and recovery philosophy, to support discussion between ward managers and inform opinion in an evidence-based way, and group members NURSING MANAGEMENT

undertook exercises that helped them to examine the components of their roles and their leadership styles. Although the content of the workshops was influenced by the ward managers, attention was also paid to trust goals.

Findings Leadership styles The ten group members reviewed their leadership styles using Douglas and Kenmore’s (2006) six leadership role descriptions: directive, visionary, affiliative, participative, pacesetting and coaching. Six thought they had both affiliative and coaching styles. They all reported that the administrative aspects of their roles had increased and they were concerned about the effect this had on their ability to lead their teams. An exercise was undertaken to establish whether this was the case, and this is described below. Administrative aspects To identify more detail about how heavy the administrative element of their roles was, an activity log was developed so that ward managers could break down how they spent a typical week. Tasks were divided into five categories, namely managerial, administrative, clinical, interruptions and other, and there was space for the managers to write comments in free text. Managers used the logs to record their activities and feed back to the group at the next meeting. The exercise highlighted that time spent on these tasks varied greatly among group members. For example, one manager spent all of his time over the course of the week in his office with no clinical contact. Managers who spent more time clinically felt anxious that administrative tasks were not completed. Some were able to maintain a balance that they thought was acceptable and the group found it helpful to have an opportunity to discuss how they achieved this, and to share tips and ideas, for example, about allocating tasks to ward clerks and junior staff. As a result of these discussions, some changes in practice were made to allow allocation of managerial tasks to junior staff in a supported way as part of their career development. Findings from the activity log exercise were shared with senior managers and consequently some administrative tasks, such as audits, were

Anecdotally, ward managers increasingly report feelings of burnout, and that they do not intend to stay long term May 2014 | Volume 21 | Number 2 27

Downloaded from RCNi.com by ${individualUser.displayName} on Nov 25, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.

Art & science | action learning handed to senior staff, which freed up time for the ward managers. More work is under way to examine how senior nurses can complement ward managers’ roles. Working environments Group members considered their workplace environments using the Working Environment Scale (WES-10) (Rossberg et al 2004), a ten-point questionnaire designed to evaluate workplace environments and job satisfaction for inpatient mental health staff. Evaluation is based on subscales related to ‘self-realisation, conflict, workload and nervousness’. The purpose of this exercise was to provide baseline data using a validated scale to help the managers consider whether the results supported the themes they had discussed in the earlier workshops. Positive findings were reported in relation to self-realisation, namely understanding the purpose of their roles and satisfaction that they knew how to undertake them, but less favourable findings were reported about conflict and workload. Qualitative discussion about responses from the WES-10 highlighted that group members were confident in their work with staff and that, although they sometimes felt tense and nervous when delivering direction and leadership with challenging staff, this was manageable. Group members had more difficulty in dealing with conflict and excessive workload demands than others. Supporting recovery-focused wards An exercise involving use of the Developing Recovery Enhancing Environments Measure (DREEM) tool (Ridgway and Press 2004) was undertaken to consider to what degree the managers’ wards were recovery focused. This tool is used to assess patients’ mental health recovery, and part of the assessment involves what they think of their care environment using a five-point Likert scale, from ‘strongly disagree’ to ‘strongly agree’. Managers used this part of the tool to evaluate how recovery focused they thought their wards to be: ■■ Nine out of ten agreed or strongly agreed that their ward promoted learning, thriving and growth. ■■ Nine agreed or strongly agreed that their ward was a hopeful one that promoted positive expectations. ■■ Eight agreed or strongly agreed that their service was inspiring and encouraging, and the other two said their services were neutral in this respect. ■■ Eight agreed or strongly agreed that staff on 28 May 2014 | Volume 21 | Number 2

their ward were caring and compassionate. ■■ Seven disagreed or were neutral about having enough resources to meet peoples’ needs. ■■ Nine agreed or strongly agreed that their ward provided meaningful participation and contribution. ■■ Eight agreed or strongly agreed that their service helped people to feel valued, respected and powerful. ■■ Five agreed or strongly agreed that their service helped people to feel connected to others in positive ways, three reported neutral responses, and two disagreed. ■■ With regards to the service being safe and attractive, six managers agreed and four were neutral.

Discussion A number of themes emerged from the work undertaken in this project, and some activity and further work was generated in response to these. The project confirmed that ward managers’ roles are complex, difficult to define and that they vary according to individual perspectives and personalities. To some extent, they also vary depending on the type of ward that is managed and the staff group working on the ward, which supports Alimo-Metcalfe et al’s (2007) assertion that the link between contextual factors and successful leadership cannot be overestimated. In the workshops, group members were unclear about their roles’ priorities and whether they should be the ward’s clinical lead. This was compounded by the differing views of more senior managers on whether the role priority was managerial or clinical, which supports Cleary et al’s (2011) findings that nurses want recovery-focused leadership. As the sessions progressed, group members agreed they wanted to be clinical leads, but felt unable to allocate enough time for this aspect of their role. The activity log broke down their time simply, and enabled them to reflect on their time, identify what they viewed as priorities, and share suggestions with each other, which they found helpful. Looking at working environments and job satisfaction using the WES 10 (Rossberg et al 2004) offered ward managers a helpful breakdown of the managers’ feelings of satisfaction and conflict in their workplaces. The encouraging findings, related to job satisfaction and fulfillment in some aspects of their roles, were counterbalanced with perceived workload demands and the difficulties they had in managing conflict. Further exploration of this in the context of staff burnout is required, and work NURSING MANAGEMENT

Downloaded from RCNi.com by ${individualUser.displayName} on Nov 25, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.

has been developed recently to enhance patient experience and staff communication. Based on their use of the DREEM tool, the managers reported that their wards do provide recovery-focused environments, and it is heartening that they regard their wards in this way despite the pressures of their roles. The DREEM tool was also completed by some of the ward staff to supplement the managers’ evaluations and, although detailed findings are not reported here, staff also thought their wards were recovery focused. These findings need to be explored in more depth; the tool was not completed by patients or other members of the multidisciplinary team, whose responses may have been different.

Conclusion Although this project was undertaken with a small cohort of ward managers in one NHS trust, the work supports the view that trying to carry out managerial administrative tasks while being a clinical lead on the ‘shop floor’ is fraught with

difficulties and tensions, and a wider exploration of these tensions is needed. Finding a balance between managing administrative tasks and acting as a clinical role model is difficult at times, but taking time to reflect on the role was helpful for this group of managers. Doing so enabled them to identify their strengths and articulate that their wards were recovery focused. The managers used peer support to help them define and refine different approaches to finding a balance between the different elements of their roles and the project enabled them to share their frustrations in response to which actions were taken at ward and organisational levels. The sessions were positively evaluated by group members, who welcomed the opportunity to reflect with their peers and to be able to agree about areas on which to focus during the course of the project. It is essential that ward managers access this kind of support to help them maintain a reasonable balance between the wide and varied demands made of them.

Online archive For related information, visit our online archive and search using the keywords

Conflict of interest None declared

References Alimo-Metcalfe B, Alban-Metcalfe J, Samele C et al (2007) The Impact of Leadership Factors in Implementing Change in Complex Health and Social Care Environments. tinyurl. com/kormbz2 (Last accessed: March 28 2014.) Cleary M, Horsfall J, Deacon M et al (2011) Leadership and mental health nursing. Issues in Mental Health Nursing. 32, 10, 632-639.

Cummings J, Bennett V (2012) Compassion in Practice: Nursing, Midwifery and Care Staff Our Vision and Strategy. tinyurl.com/c5lc4n2 (Last accessed: March 28 2014.)

Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. www.midstaffspublicinquiry.com/report (Last accessed: April 1 2014.)

Douglas B, Kenmore P (2006) Nursing Leadership: Being Nice Is Not Enough. tinyurl.com/lr87veg (Last accessed: March 28 2014.)

Nicolson P, Rowland E, Lokman P et al (2011) Leadership and Better Patient Care: Managing in the NHS. tinyurl.com/mnrr82f (Last accessed: March 28 2014.) Ridgway P, Press A (2004) Assessing the Recovery-Commitment of your Mental Health Service: A User’s Guide for the

NURSING MANAGEMENT

Developing Recovery Enhancing Environments Measure (DREEM). UK Version 1. University of Kansas School of Welfare Office of Mental Health Research and Training, Lawrence KS. Rossberg J, Eireing O, Friis S (2004) Work environment and job satisfaction: a psychometric evaluation of the Working Environment Scale-10. Social Psychiatry and Psychiatric Epidemiology. 39, 576-580.

May 2014 | Volume 21 | Number 2 29

Downloaded from RCNi.com by ${individualUser.displayName} on Nov 25, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.

Leadership support for ward managers in acute mental health inpatient settings.

This article shares findings of work undertaken with a group of mental health ward managers to consider their roles through workshops using an action ...
201KB Sizes 2 Downloads 3 Views