A discourse analysis of managerialism and trust amongst nursing professionals

During the 1990s, due to increasing conflicts with state and service users, healthcare organisations worldwide underwent public policy reform (Gilbert, 2005). Health service organisations adopted strategies involving privatisation, marketization and performance management (Hassard, et al., 2017). The changes within UK health care had dramatic consequences for the management of health care (Bresnen, et al., 2017; Hyde et al., 2016). Many organisations ‘downsized’ to achieve cost containment (Cope, et al., 2016). ‘Managerialist’ systems and structures, labelled ‘New Public Management’, were introduced to more effectively govern the public sector (Calnan and Gabe 2001; O’Reilly and Reed, 2010). These reforms took place within the context of financial crises, increasing healthcare demands, and an ageing nurse workforce (Hassard, et al., 2017; Buchan et al., 2013), with retention problems and skill shortages amongst existing nursing professionals (Jefferson et al., 2014).

A prime objective of NPM in the NHS involved the recruitment of professional managers (Hoyle, 2014), with a managerial but not necessarily a healthcare background (Hunter 2007; Townsend and Wilkinson, 2010; Yu and Levy 2010). However, many healthcare professionals expressed concerns that the new managers were more committed to general business management values such as entrepreneurship, innovation, competency, efficiency and financial management (De Vries and Nemec, 2013), with insufficient understanding of, and consideration for, patient care.

While NHS ‘managers’ had previously struggled with medical staff for power and legitimacy, ‘managerialism’ then became the dominant policy discourse of public service modernisation (Reed and O’Reilly, 2011). Over the last 10-15 years, the dominant discourse within the NHS moved away from ‘administration’ and ‘management’ to ‘leadership’ or ‘leaderism’ (Learmonth, 2017; Martin and Learmonth, 2012). The role of leader, rather than manager, was considered more legitimate and acceptable from a public perspective (Learmonth, 2017), and was used to build support and overcome professional resistance to general management responsibilities.

Over the same period, there has been a steady increase in work intensity and demands across the public sector (Granter et al., 2018). While certain aspects of health professionals’ work can be intrinsically intense, ‘organisational elements’ can make work intensity potentially hazardous. Work intensity is generally considered as workload versus time, involving a fast pace of work and long working hours (Felstead et al., 2013). This has contributed to labour turnover and declining numbers entering the nursing profession (Newman et al., 2002; Skinner, et al., 2004), now considered by many as a ‘stressful’ profession (Scudder, et al., 2011). Also, in trying to be viewed as effective “nurse managers”, many nurses abandoned their profession (Traynor 1999). With increasing managerialism, the profession has become ‘unrecognisable as something nurses or patients wish to engage with’ (Carter, 2007: 270).

Managerialism is defined as:

Gilbert (2005) suggests that ‘managerialism’ represents a clearly defined set of concepts, practices and discourses. Associated discourses such as ‘performance management’, ‘flexibility’, ‘quality’ and ‘customer service’ have initiated debates about the nature of nursing and healthcare provision (Gilbert, 2005; Nordgren, 2008).

Academic nursing discourse is conceptually fluid and open to other discourses, in particular managerial discourses (McNamara, 2009). The vocational focus traditionally associated with the nursing profession has now been informed by emerging academic nursing theories that have largely abandoned ‘front-line illness care’ and ‘bedside nursing work’ (Clarke 2006:177). Allen (2004:271) proposed an empirical reformulation of the nursing mandate to that of ‘healthcare mediator’, where the traditional concepts of individual nurse-patient contact linked to holistic care have been substituted with managerial and medical discourses (Latimer, 2000). Tensions amongst managers, professionals and service users have been observed on three levels: communication, discourses and values (Gilbert, 2005). Traditional notions of professional autonomy (Reed, 2002), self-regulation (MacDonald, 1995) and judgements around professional standards have been replaced with values such as transparency, accountability (Reinders, 2008) and performance management with controls on outputs and results (Tummers et al., 2009). Reinders (2008) suggests that increasing involvement of professionals with management responsibilities, combined with managers’ desire for a strong chain of command and the professional autonomy of clinicians, has contributed to ‘low trust’ and tensions between clinical staff and healthcare managers (Brown et al., 2011).

Previously, nursing was regulated by professional associations (Hoyle, 2014), where nurses experienced a high degree of autonomy, with strong focus on patient welfare over economic considerations (Freidson, 2001). Changes in state and institutional attitudes towards professional groups led to a decline in professional autonomy (Reed, 2002) and self-regulation (MacDonald, 1995). Traynor (1999) notes how ‘managerialist’ rhetoric positioned itself in opposition to professional discourses, by putting systems of ‘managerial governance’ as a counterweight and check on ‘professional expertise’. Within professional organisations, managerial leadership is defined as transactional, concerned with day-to-day performance management, efficiency and achieving targets (Currie and Lockett, 2007). Despite the apparent dominance of managerial discourse, there is evidence of continuing dependence on the knowledge and professional expertise of healthcare professionals (Gilbert, 2005). Some researchers comment on the capacity of professional groups to resist ‘managerialism’, essentially by adopting strategies that allow them to maintain or increase their influence within their respective institutions (Carvalho, 2012).

In undertaking managerial roles, whilst at the same time retaining influence and leadership of their respective professional groups (Croft et al., 2015a; Marinetto 2011; Tummers et al., 2012), NPM converted ‘doctors’ and ‘nurses’ into managers (professional hybrids). Professional identity develops during education and training (McCabe and Garavan, 2008) and relates to ‘what you do’ (Pratt et al., 2006). Nurses who undertake hybrid roles often undergo a period of identity conflict (Ibarra and Barbulescu, 2010). Many nursing professionals adapted by expanding their professional boundaries to incorporate managerial roles and responsibilities (Carvalho, 2012). While some nurses embraced managerial discourses (Hallier and Forbes, 2004; Llewellyn, 2001; Kurunmaki, 2004), ‘blending’ managerial roles and responsibilities with their professional practice (Iedema et al., 2004), others experienced difficulty with the competing professional and managerial demands of hybrid roles (Croft et al., 2015a; Traynor, 1999), in particular the caring side of their role (Blomgren, 2003).

Hybrid managers were seen as increasing managerial control (Bejerot and Hasselbladh 2011; Ferlie et al., 2013; Martin and Learmonth, 2012) and as part of a strategy for overcoming professional resistance to organisational reform (Tummers et al., 2012). Croft et al. (2015a, p. 383) explore the concept of liminality in considering how professional hybrids manage identity conflict in constructing new identities. They conclude that the influence across numerous groups relies on creating an ‘a positive liminal space’ and suggest that nurse hybrids occupy a ‘perverse liminal space’. This can perpetuate identity conflict and prevent identity transition, which ultimately undermines their effectiveness as hybrids. When undertaking hybrid roles, Croft et al. (2015a, p. 381) suggest adopting an ‘individual-level approach’ in balancing professional and managerial responsibilities. This study seeks to further explore the challenges nursing professionals face when transitioning into hybrid manager roles (whether distant or local), and how this affects trust.

Newell and Swan (2000) define trust as comprising three elements: companionship, which is based on judgements, goodwill and friendship; competence, which is the ability to perform tasks and duties; and commitment, where parties fulfil their end of ‘the bargain’. Trust plays an important mediating role in the relationship between government, healthcare professionals and health service users (Gilbert 2005). Rydenfält et al. (2012) discuss how trust can be affected by the social and organisational context and note the importance of trust amongst professionals, when focused on a common purpose. Connell and Mannion (2006) discuss the crucial role played by trust in healthcare organisations involving professional multi-agency teams that work and cooperate interdependently across organisational and speciality boundaries (Gilson, 2003; Rowe and Calnan, 2006), within a secure working environment (Peter and Morgan, 2001). Gilson (2006) examines the role of trust in health care, exploring issues of equity, justice, policy and managerial priorities. Areas she identifies for policy and management actions in order to sustain trusting relationships include recruitment, training and institutional development. She also discusses the role of ‘distrust’ as useful in guarding against the abuse of power.

Having reviewed the literature, the next section details our research methods.

As health professionals internationally continue to face challenges, with increasing job demands within a resource-constrained context, the continued relevance of understanding factors influencing trust in key relationships within health service organisations is underlined. Given the importance of trust in an increasingly NPM healthcare context, our aim was to explore how ‘managerialism’ and ‘trust’ were talked about amongst nursing professionals in two British healthcare organisations, and to examine how they affect managerial and professional nursing relationships. The study involved analysing qualitative interview data from nurses and nurse ward managers. The original data, collected in 2000-2002, were re-analysed from a discourse analysis perspective. With ongoing changes within the British NHS, and a growing emphasis on policies and practices associated with managerialism, we re-interrogated the original data to address two new research questions:

Semi-structured interviews were considered the most effective method to capture perceptions of managerialism and trust. To gain their collective interpretations, and since managers have key interpretational roles (Bennis and Nanus, 1985; Smircich and Morgan, 1982), we sought the views of both nurses and nurse managers. This re-analysis of the interview texts focuses on the language and discourses used by nursing professionals, in relation to managerialism and trust and the connection both phenomena have with the professional identities of nurses and nurse managers (Potter and Wetherell, 1987).

Two NHS organisations were selected: an acute hospital and a community hospital. The participants were informed about the study through their line-manager and selected through a process of random sampling (n=39). The sample reflected a variety of age, grade, ward and tenure/length of service – time working within the NHS. They included nurse ward managers and nurses at various stages of their career, with tenure ranging from 3 to 34 years. Twenty-eight nurses and 11 ward nurse ward managers were interviewed, with 20 from the acute hospital and 19 from the community hospital. The first author briefly explained the purpose of the study and participants consented on a voluntary basis, with confidentiality assured. Sample details are provided in Table 1 below.

The interview schedule, informed by a review of literature, contained open-ended questions regarding managerialism and trust, and was piloted amongst four nurses. While each interview contained the same broad topics, we maintained flexibility to explore areas of significance to participants. The interviews, conducted at participants’ workplace facilities, lasted approximately 45 minutes to one hour. They were recorded through note taking and audio cassette and transcribed in full text format. Access to participants was negotiated and approved by HR, who acted as the initial point of contact between the interviewer (first author) and interviewees. Approval was granted through the ethics committees of both organisations.

A critical discourse approach can be useful in exploring power relations between nursing professionals and managers. Social phenomena, such as trust and managerialism, are created through language, symbols and words, of which discourses are a part (Sambrook, 2000; Stewart and Sambrook, 2007). The interviews explored professional nursing and management discourses around managerialism and trust, and how these phenomena affect the practice of nursing. The context in which discourses occur is central (Crowe, 2005). Discourse analysis focuses on both the macro and micro levels of discourse use (Fairclough and Wodak, 1997).

The original data were collected between 2000 and 2002, when NPM and managerial discourses were nascent in the NHS. Participants took the lead in discussing management, trust and nursing identity. Given increasing managerialism and its impact on trust in the NHS, we sought to examine, retrospectively, how this was talked about then. Thus, we have re-analysed the data from a discourse analysis perspective. Our analysis reveals that nurses and nurse ward managers were already both recognising and resisting emerging managerialist practices and associated discourses. The themes that emerged from our re-analysis of the qualitative data were based on frequency and the extent to which they were discussed and explored by the participants.

Many commentators have criticised approaches to discourse analysis for lacking sufficient rigour (Kvale, 1996). To address this, careful attention was paid to the transcription/analysis of the interview tapes and discussion of emerging themes. The interview transcripts were analysed line by line, using an inductive theory-building approach, where emerging themes were developed from rigorous analysis of the qualitative interview data. We compared the responses of participants in both organisations, as well as those of nurses and nurse managers, noting any particular discursive resources (Sambrook 2001). Our re-analysis and emerging themes are supported by and extend contemporary research findings. We argue that this research remains timely, offering new perspectives that are still relevant in the current healthcare context.

Here, we address our first research question. We summarise our findings on the effect of managerialism on professional nurse identity, nurse manager relationships, and the extent to which nursing professionals accommodated or resisted managerial identities and discourses.

Professional identity, involving a commitment to professional nursing values, emerged as the most dominant theme throughout the discourse analysis. This was articulated in terms of professional pride and autonomy, identity, direct patient contact, holistic care and good nursing practice:

The participants talked about belonging to a ‘humanistic’, ‘people-orientated’ profession with a strong interest in patient care and welfare. These features were considered key sources of job satisfaction and motivation amongst nursing professionals. Linked to, and supporting, this were training, development and progression, which also involved professional nursing care standards, ‘evidence-based’, best-practice approaches to nursing:

Most participants associated NPM with resource management, which they strongly felt curtailed, and often compromised, professional nursing-care standards. Rather than focusing on the quality of care provided, they felt that the ‘performance management criteria’ emphasised ‘cost’ as the basis for measuring ‘performance’. The participants talked about prioritising and rationing care across the health service, saying that they delivered the best care they could, in the context of a ‘resource-constrained’ environment:

The participants viewed the introduction of budgetary principles, more commonly associated with the private sector, as responsible for fewer resources available for quality care, training and development, as well their terms and conditions of employment:

If you want to get in the league tables you have to push more patients through.

(Male, age 37, 13 years in NHS, Ward Manager, Anaesthetics, Acute)

They also discussed greater use of unqualified and agency nurses, and fewer resources available for professional training and development, as well as quality patient care.

In terms of accommodating managerial identities and discourses some participants were pragmatic. They adopted a flexible approach towards the issue of resource management and managed their own expectations in relation to the resources available for patient care and their own professional training and development. Many, however, talked of ‘deskilling’, the ‘replacement’ of qualified with unqualified nurses, and an increased emphasis on ‘patient throughput’ and work intensification.

The participants also discussed how this impacted on their level of job satisfaction, particularly in relation to the principle of ‘direct’ and ‘holistic’ patient care;

While the main issue in relation to training and development concerned the resources available, many respondents felt that their current training and development had moved them away from ‘bedside care’ and had become more ‘academic’ in nature. They also felt that the new career progression structures were more managerial in nature, which moved them further away from their ‘traditional’ professional nurse duties, roles and responsibilities:

Participants discussed how senior nursing roles had been redesigned to include greater ‘managerial’ duties and responsibilities and felt that the promotions available to them were more managerial than professional. They said that they no longer had the freedom of movement or the possibility for promotion within their profession.

Addressing the second research question, we now consider how nursing professionals ‘talked’ about the influence of ‘managerialism’ on trust between manager-nurse relationships and amongst nursing professionals themselves. We also examine factors that can support or erode trust, and how high trust relationships can be built between nursing professionals and managers.

The participants conceptualised trust in terms of their immediate ward environment, their line-manager and peers – local, as opposed to distant colleagues and managers. Participants discussed ‘camaraderie’ and ‘peer support’ amongst their colleagues and manager at ward level as the basis for establishing trust:

Nurse-managers at ward level play a significant role in either positively or negatively influencing trust levels both within the ward level and with management outside the ward and the wider organisational environment. The respondents expressed a preference for ‘visible’, ‘hands-on’ and ‘involved’ managers, available for support and guidance.

The participants were less trusting of managers outside their immediate ward environment – those they viewed as more ‘removed’, ‘distant’ and less understanding of the pressures they were under. Some of the comments suggested frustration with managerial decisions being taken above ward level, by managers with very little understanding of the impact their decisions had at ward level:

Staff lower within the organisation were less likely to trust senior management, who were generally viewed as non-nursing. They felt that there was a tendency amongst senior managers to view nurses simply in terms of ‘numbers’. They generally considered senior management as ‘distant’ and ‘removed’ and did not feel valued by them:

Most participants said that high trust levels resulted in positive work environment and patient care outcomes. They described the reciprocal nature of trust, suggesting that it needed to be exchanged between the participants concerned. They said that trust took time to build up and was based on previous experiences. They discussed individuals’ willingness to reciprocate as being influenced by several factors, including personality, experience, work history, training, profession and staff association, union membership, political views and psychological contract issues:

Participants discussed the influence of previous experiences on the development of trust, and the necessity of ‘reciprocating’ – ‘demonstrating’ trust through openness and good communication:

They said that some people were more trusting than others:

They suggested that trust both enhanced communication and openness, but also said that mistrust did the opposite.

Participants felt that some nurses were more proactive in ‘constructively engaging’ with management. They discussed the importance of feeling that they were ‘trusted’ by management and given sufficient autonomy to ‘get on with’ their work in an environment that was free of excessive monitoring and oversight. They felt that proactive engagement, whether or not it was characterised by conflict, communication and reciprocal gestures of goodwill, was linked to the development of trust:

Poor communication and uncertainty were discussed as factors contributing to mistrust. The participants from the community sector organisation were particularly critical of their management in this regard.