Introduction
A recent revival in policy implementation has brought street-level practice to the forefront of the policy debate (Evans, Reference Evans2010; Van Berkel and Van der Aa, Reference Van Berkel and Van der Aa2012). The practice of nursing has been inextricably linked to changes in health and policy (McMahon, Reference McMahon, Roe and Webb1998; Bergen and While, Reference Bergen and While2005; Hoyle, Reference Hoyle2011), and the delivery of care is set against a context of constant social and political change. Drawing on the works of Michael Lipsky (Reference Lipsky1980, Reference Lipsky2010), who linked policy, organisational structures, resources and individual practitioners (street-level bureaucrats) as influencing the implementation of policy, this article explores the extent to which hospital nurses can be seen as street-level bureaucrats and can shape the implementation of policy.Footnote 1 More specifically, it examines how nurses interpret policy and how this influences decision-making and the use of discretion within the ward setting. Furthermore, it will demonstrate the importance of discretion within the day-to-day work and decisions of front-line nursing staff.
Lipsky defines street-level bureaucrats as ‘public service workers who interact directly with citizens in the course of their jobs, and who have substantial discretion in the execution of their work’ (Lipsky, Reference Lipsky2010: 3). The core argument is that discretion is not only unavoidable but is also necessary within welfare bureaucracies. Those individuals directly involved in delivering policy at street-level will exercise their discretion in how policies are carried out. Durose (Reference Durose2011: 980) views discretion as a ‘choice or judgement within recognised boundaries’ taken by front-line workers. According to Tummers and Bekkers (Reference Tummers and Bekkers2012), it is the freedom in which street-level bureaucrats make choices concerning the provision, quantity and quality of resources, alongside the sanctions or rewards available to the public. When implementing a policy, role conflicts can arise when professionals perceive the demands to implement policy to be incompatible with their professional experience (Lipsky, Reference Lipsky1980; Ham, Reference Ham2009; Tummers et al., Reference Tummers, Vermeeren, Steijn and Bekkers2012). According to Taylor and Kelly (Reference Taylor and Kelly2006: 631), three types of discretion can be identified within street-level bureaucracies: (1) rule discretion, which is bounded by legal, fiscal or organisation constraints; (2) value discretion, which may be determined by notions of fairness or justice and can involve professional and organisational codes of conduct and ethics; and (3) task discretion, the ability to carry out prescribed tasks which involve working with clients.
In the study of public bureaucracy, there is an inherent tension regarding the role of politicians and public bodies in relation to the freedom the latter possess in implementing policy; and there is also tension between organisational administration and front-line workers concerning policy implementation. There have been many studies which apply the work of Lipsky for analytical purposes, although these have mainly been in public sector areas such as employment services and social work services. To date, very little has been written which draws upon Lipsky's (Reference Lipsky1980) classic study of street-level bureaucracy in relation to the use of discretion by allied health professionals, including nurses (Hoyle, Reference Hoyle2011).
This article draws upon data from a single case study site where thirty-one qualitative interviews with qualified nursing staff were carried out. Firstly, it will discuss the continued relevance of Lipsky's (Reference Lipsky1980) work for ground-level bureaucrats before examining how nurses can be defined as street-level bureaucrats. Secondly, an overview of the research methodology will be provided. Thirdly, the findings will focus specifically on nurses’ interpretation of policy and the conflicting goals of managers and professionals. Finally, the forms of discretion that are used by nurses as part of their nursing role and the influence this can have on patient care will be considered.
The continued relevance of Lipsky?
There has been a debate over the continued relevance of Lipsky's approach for today's ground-level practice in health and social welfare (cf. Howe, Reference Howe and Davies1991; Cheetham, Reference Cheetham, Page and Baldock1993), given that Lipsky (Reference Lipsky1980) wrote his book in the late 1970s prior to the rise of neo-liberalism and New Public Management (NPM). Through the 1980s in the UK, the National Health Service (NHS) was seen by some as inefficient and unresponsive to consumer demands, a drain on the public resources and part of a dependency culture which prevented the success and growth of the organisation (Lapsley, Reference Lapsley1994). In response, the government introduced organisational changes into the NHS and adopted ideas such as efficiency and value for money within policy guidelines (Hudson, Reference Hudson and Hill1997; Harvey, Reference Harvey2005; Evans, Reference Evans, Harris and White2009). This led to fundamental changes to structures, cultures and practices of public sector organisations (Exworthy and Halford, Reference Exworthy, Halford, Exworthy and Halford1999).
Since the publication of Lipsky's Street-Level Bureaucracy, there have been numerous developments within the public sector. However, the view that Lipsky is no longer applicable is disputed (Baldwin, Reference Baldwin, Gould and Baldwin2004; Evans, Reference Evans2010). Within social work literature, there has been a sustained interest in Lipsky's ideas on resources and discretion (Lewis and Glennerster, Reference Lewis and Glennerster1996; O'Sullivan, Reference O'Sullivan2011). For example, the use of discretion by practitioners has been found to still exist in social services bureaucracies in the UK (cf. Ellis et al., Reference Ellis, Davis and Rummery1999; Baldwin, Reference Baldwin2000; Evans, Reference Evans2010), as well as employment and welfare services (cf. Fletcher, Reference Fletcher2011). However, other authors argue that due to the rise of NPM, discretion has been limited and work has become increasingly more regulated (Harris, Reference Harris1998; Jones, Reference Jones, Exworthy and Halford1999, Reference Jones2001). Frenkel et al. (Reference Frenkel, Tam, Korczynski and Shire1998) and Kinnie et al. (Reference Kinnie, Hutchinson and Purcell2000) have argued that managerial approaches which incorporate individualising strategies have severely reduced any form of resistance within the workplace as the degree of autonomy held by workers is limited (Frenkel et al., Reference Frenkel, Tam, Korczynski and Shire1998; Mulholland, Reference Mulholland2004). Despite this, Van den Broek (Reference Van den Broek2004) asserts that these managerial imperatives have not been successful in causing increased individualisation. Numerous studies have shown that discretion continues to be used by street-level bureaucrats and plays an important role in their day-to-day work (Scott, Reference Scott1997; Wells, Reference Wells1997; Baldwin, Reference Baldwin2000; Wright, Reference Wright and Millar2003; Evans and Harris, Reference Evans and Harris2004, Reference Evans and Harris2007; Evans, Reference Evans2010; Johansson, Reference Johansson2011; Grant, Reference Grant2013). Lipsky's approach has also recently been extended to non-traditional areas such as cultural services (McCall, Reference McCall2009). Lipsky drew upon findings from research in the 1970s, which was undertaken at a time of financial constraints, and references to financial crises and cuts are common through the text. Governments were arguing for dramatic reductions in spending and taxation to stimulate growth. The echoes to today are clear, where there is much talk of austerity, and government policies are aimed at cuts in public spending and improving the economy following the economic crisis within the UK (HM Treasury, Reference Treasury2010).
Lipsky's (Reference Lipsky1980) work showed a variety of problems which street-level bureaucrats can encounter. For example, excessive rules and regulation which impose goals could conflict with professional norms (Lipsky, Reference Lipsky2010: 29), meaning there can be a conflict for nurses who prioritise patient care over organisational goals. Newman and Clarke (Reference Newman, Clarke, Clark, Cochrane and McLaughlin1994: 22) define bureau-professionalism as a ‘combination of professional expertise coupled with the regulatory principles of rational administration as the means of accomplishing social welfare’. Nurses can be seen as street-level bureau-professionals because their role involves both professional and administrative functions, and, as such, the debate regarding policy implementation and discretion at ground level for nurses must be considered similar to other professional arenas, such as social work, employment and welfare. This article applies Lipsky's concepts within a contemporary managerialist context and demonstrates that nurses use their own discretion within their work (in terms of rule, value and task discretion): strategies are being employed to circumvent policies which are not agreed with, and coping mechanisms are developed to help overcome difficulties such as financial constraints. This is about the actions nurses take and their own use of discretion during their day-to-day work, which in turn influences the way in which policies are implemented at the front-line.
Nurses as street-level bureaucrats
Nursing has transformed itself into a profession, having gained professional status in 1992 in the UK (Warren and Harris, Reference Warren, Harris and Anderson1998; Greener, Reference Greener2009; Kirkpatrick et al., Reference Kirkpatrick, Dent and Kragh Jespersen2011; Noordegraaf, Reference Noordegraaf2011), and has moved away from a traditional hierarchical structure (Hunter, Reference Hunter and Hunter2007). This means that nurses have become increasingly responsible and accountable for their actions. The current nursing priorities within Scotland are around: caring and compassionate staff and services; clear communication and explanation about conditions and treatment; effective collaboration between clinicians, patients and others; clean and safe care environments; continuity of care; and clinical excellence (Scottish Government, 2010). However, nurses face many constraints in their work; these have arisen due to the influence of marketisation. There is continued emphasis on targets, audits and value for money imposed by the government, and within the current economic climate rather than more qualified nurses being employed there has actually been a reduction of registered nurses, meaning that workloads are growing (Buchan and Seccombe, Reference Buchan and Seecombe2012).
In Lipsky's analysis, the characteristics shared by street-level bureaucracies include: a need to ‘process workloads expeditiously’ (Lipsky, Reference Lipsky2010: 18), conditions of work that include inadequate resources (including financial, personnel and time), a demand that exceeds supply, ambiguous and multiple objectives, difficulties in defining or measuring good performance, a requirement for rapid decision-making and ‘non-voluntary’ clients (Lipsky, Reference Lipsky2010: 56). Street-level bureaucrats will have substantial autonomy in their individual interactions with clients and an interest in ensuring and furthering that autonomy (Lipsky, Reference Lipsky2010: 56). However, according to Maynard-Moody and Musheno (Reference Maynard-Moody and Musheno2000, Reference Maynard-Moody and Musheno2003), Lipsky views public sector staff as agents of the state, whereas Maynard-Moody and Musheno believe the term ‘citizen-agent’ would be better. This is because the ‘citizen-agent’ allows front-line workers to be defined by their relations with citizens and other street-level workers, rather than by terms such as hierarchy, legitimacy, implementation and discretion which are inherent within the term ‘state-agent’. The term ‘citizen-agent’ perhaps more accurately reflects the way in which street-level workers (such as nurses) negotiate their role and make pragmatic decisions and use discretion in their work.
Lipsky argues that policy-making can take place as much at street-level as it does via the more traditional top-down approach (Hill, Reference Hill1997). The position of nurses in implementing policy is a unique one which can be very influential (Loyens and Maesschalck, Reference Loyens and Maesschalck2010) and they can be thought of as ‘agents of social control’ (Lipsky, Reference Lipsky2010: 4). Nurses working within the NHS interact with citizens on a daily basis, and can influence the treatment and experience of these citizens by using their discretion, thus influencing and producing policy, despite being in the lower layers of a hierarchy (Meyers and Vorsanger, Reference Meyers, Vorsanger, Peters and Pierre2007; Loyens and Maesschalck, Reference Loyens and Maesschalck2010).
Methods
The research project reported here was a qualitative interpretivist (cf. Atkinson et al., Reference Atkinson, Delamont and Hammersley1988; Denzin and Lincoln, Reference Denzin, Lincoln, Denzin and Lincoln2000; Crotty, Reference Crotty2005) study grounded in the methodology of adaptive theory. A case study approach (cf. Yin, Reference Yin1994; Cresswell, Reference Cresswell1998; Robson, Reference Robson2002) was taken in order to understand how managerial practices shaped working relationships in an acute hospital setting. During a three month period, from June to August 2010, semi-structured interviews were undertaken with thirty-one front-line nursing staff based in accident and emergency department (five participants), medical assessment and surgical receiving units (six participants), medical wards (nine participants) and surgical wards (eleven participants) within a large inner-city hospital in Scotland. Further details about the study site are not given to maintain the anonymity of the study site. For this study, ethical approval was obtained from the NHS ethics service and the appropriate research and development department.
Participant recruitment
A flexible approach was used for gaining access to and recruiting participants. This meant some participants were recruited by the researcher approaching individuals on the wards and asking for participation. In other areas, the Ward Manager disseminated information sheets and then provided the researcher with the details of those willing to participate. Interviews were undertaken with registered nursing staff who were between Band 5 and Band 7 who met the inclusion criteria (Table 1). These bands were chosen as it is these grades that generally work in the ward areas. Newly qualified nurses are eligible to work in Band 5 roles. Nurses can then progress onto Band 6 and then onto Band 7 and above. As staff progress, they will be required to take on more responsibilities and managerial type roles (at Band 7, staff tend to be in a position of management such as a Ward Manager). The mean length of the interviews was forty-five minutes, but they varied from twenty minutes to sixty minutes.
Table 1 Participant criteria
A semi-structured interview guide was developed and used during the face-to-face individual interviews. The questions were structured around key themes; these being the role of nursing and relationships with management, financial accountability, efficiency, the impact of targets and monitoring, policies, working conditions and consumerism. For example, with regard to policy, participants were simply asked ‘What does the term policy mean to you?’ The themes explored within this article were not asked about specifically, but rather emerged from the data during analysis.
The interviews were either audio recorded or notes were taken at the time of interview if consent for recording was not given (as occurred in three interviews). The transcriptions were analysed using QSR NVivo 8 software. Once fieldwork had been completed, a set of thematic categories (cf. Ritchie et al., Reference Ritchie, Spencer, O'Conner, Ritchie and Lewis2008) was developed. Further themes were also identified throughout the analysis process. This research study has been an exploration for understanding and has not been about achieving quantifiable results. The interpretive approach taken within this study does not seek to make claims of generalisability, but rather to offer a narrative from the front-line.
Findings
Nurses’ interpretation of policy – use of discretion
Policy can have a variety of interpretations, but generally it can be seen to be a statement of intent. According to the Oxford English Dictionary (2006: 1109), the term policy means ‘a course or principle of action adopted or proposed by an organisation or individual’. Within the discussions there was often ambiguity and confusion as to what was actually meant by the term policy. Targets, audits, guidelines, codes of conducts, procedure guidance, and memoranda from managers were all spoken of as types of policy. There were those staff who viewed policy as:
a written rule or regulation or procedure regarding an aspect of nursing or medicine or whatever it is. Something that's been printed and is to be adhered to and followed. (Female, Staff Nurse (SN), 2–3 years)
This was in comparison to those who view policy more flexibly as:
essentially as a set of guidelines to achieve an end result. (Male, Ward Manager (WM)/Charge Nurse (CN), 15+ years)
This shows that the term policy, according to staff, can encompass anything that the institution or managers use to help shape behaviours, actions and practices within the workplace. These differing understandings of policy meant that nurses would use differing levels of discretion when interpreting and following what they perceived as policy, and this would vary for each individual nurse.
Those who viewed policies more in terms of rules and regulations demonstrated an increased concern regarding the potential for blame:
nursing management are not responsible, it's the individual. (Female, SN, 15+ years)
along with the lack of support from management:
If you do something wrong and it comes back to you, the management will say ‘well it's your own fault because there was policies there for you to read’ so they've got the policies there to cover themselves. (Female, SN, 6–10 years)
Mulgan (Reference Mulgan2000) and Khatri et al. (Reference Khatri, Brown and Hicks2009) both suggest that there has been a growth in accountability and responsiblisation within the professions, which has led towards a culture of assigning blame. The blame culture can develop within an organisation where there is a fear of criticism or management admonishment (Khatri et al., Reference Khatri, Brown and Hicks2009; Gorini et al., Reference Gorini, Miglioretti and Pravettoni2012) and this can then lead to defensive practice by staff. This has caused raised levels of anxiety, as the majority of staff declared that it was unrealistic to assume that staff would always adhere to regulations:
there's a policy for everything, isn't there and you can't – with the best will in the world, you'll not know every single one. (Female Ward Manager (WM)/Sister(S) 15+ years)
The front-line nurses developed ways to cope with an unmanageable quantity of information. This often meant that many of the policies were not implemented or not fully adhered to, if they were felt to be irrelevant:
the policies that do fall by the wayside are policies which some of the nurses regard as a bit daft, like some of the health and safety policies. (Female, SN, 2–3 years)
I think some of the policies that come in, don't really apply to, or can't apply to us. . . and sometimes you look at them and think ‘how can you possibly work by that, because it just doesn't make sense for a department like this’. (Female, SN, 3–5 years)
It was not a case that they were not co-operating with the regulatory mechanisms of the organisation, rather they were more selective when they accessed and engaged with policies that controlled their working practice:
I mean, obviously you're using your discretion. (Female, SN, 6–10 years)
This means policies were not being implemented as was perhaps intended, and the implementation varied from nurse to nurse. The values of the front-line nursing staff were prioritised over perceived management values in the application of policy. Due to the nature of the type of work, nurses were undoubtedly influenced by their own moral judgements, for example whether the patient was seen as ‘deserving’ or not:
some people are just genuinely daft and just don't know how to behave, don't know how to act . . . you get to see the twenty year old drunk ‘NED’Footnote 2 who can be so demanding, then you get to see the eighty year old wee wifey with a broken hip who will not ask for pain relief, purely because she doesn't want to hassle you. (Male, SN, 6–10 years)
Although all patients were entitled to treatment, nurses were willing to make extra allowances for those individuals who they felt were deserving or whose behaviour they chose to overlook. This, however, was not explicitly highlighted by responses. Discretion allowed the front-line staff to intervene on behalf of clients and also to discriminate amongst them, allowing some individuals to be prioritised over others (which is needed within the medical area: some individuals will require quicker or more extensive treatment than others).
Conflicting goals – managers versus nurses
With regard to conforming to the formal structures of authority, Lipsky (Reference Lipsky2010: 16) indicates that workers for the most part accept the legitimacy of these structures, and are not in a position to disagree with them. However, if street-level bureaucrats (in this case nurses) did not agree with the organisational views and preferences of the managers, then their goals were not the same. This can lead to non-compliance by nurses and also to conflict between managers and nursing staff:
Because a lot of the time these people are only managers, they don't actually have background knowledge within a ward area, or how behind the scenes works in regards to the running of a ward, or, you know, they're not medically minded, they're management minded. (Female, SN, 6–10 years)
Discretion, as opposed to resistance or non-compliance, was used in coping with a large workload when working with fewer resources, including staff and time that were less than optimal, which means that short-cuts and simplifications are developed in order to cope:
If everybody else is a lot busier, then you've got less time to spend with patients or you're maybe doing your job a bit more quicker than you should, or trying to rush things through. (Male, SN, 3–5 years)
Such coping mechanisms were generally unsanctioned by the management. The priorities of staff nurses, compared to those of management, can lead to difficulties and potentially to conflict (Lipsky, Reference Lipsky2010: 18). It was felt that managers tended to be focused on performance and the cost of such performance:
Obviously budgets are the big issue and they're complaining about overspending, but they've not been in the wards to see that it's not suitable for them to run understaffed or without products that we need. (Female, SN, 6–10 years)
Managers were seen to be trying to restrict workers’ discretion to ensure results were achieved. Due to nurses expecting the right to exercise their clinical autonomy to make critical discretionary decisions, the restrictions imposed by managers on staff were often seen as illegitimate. There was a tension between having a professional status as a nurse and the need to comply with superiors’ directions:
It angers you a bit, but then I know there's nothing I can do. We can only do what we can, we can try; we see a lot of things change which we feel is for the worse, but it's out of our hands to change it. It's frustrating a lot of the time but you have to get on with it. (Male, SN, 3–5 years)
In order to cope with such tensions, Lipsky (Reference Lipsky2010: 21) argues that street-level bureaucrats will use the rules, regulations and administrative provisions to evade or change policies that will limit their discretion. In Lipsky's view, workers are aware of constraints and they ‘see themselves as fighting on the front-line of local conflict with little support and less appreciation by a general public whose dirty work they have to do’ (Lipsky, Reference Lipsky2010: 82). If they are working inadequately, then workers do not see it as their fault.
Identity within nursing – the case of the ward sister/charge nurse versus the ward manager
According to Lipsky (Reference Lipsky2010: 18–19), street-level bureaucrats will have different aims and goals to those of their managers. This view was often reflected by the participants when asked generally about managers; however Ward Managers were not seen to fulfil the role of a manager as viewed by Lipsky. Evans (Reference Evans2010) showed that street-level ideas of managers are more complicated than suggested by Lipsky's analysis, instead showing that managers who are also clinicians often have both the professional and sympathetic values shown by front-line staff. There was a difficulty in how staff classified Ward Managers; they were not perceived by the participants as a ‘manager’ in the way they viewed ‘other’ managers, but were seen as more akin to a member of the nursing staff. For Lipsky, managers and street-level bureaucrats worked in different ways, they had different priorities, values and commitments. Managers were focused on policy implementation whereas the workers attempted to make working conditions acceptable and tried to control the direction of their own work. However, there must be compromise between such managers and workers. Within nursing, this raises questions with regard to local managers (such as Ward Managers and lead nurses), as according to Lipsky these managers would be presented as obedient to the organisation.
One managerial role discussed in some detail was that of the Ward Manager. This position has seen considerable change over the past decade and has been influenced by the ideology of NPM. Traditionally, these individuals would have been known as ‘Sister’ or ‘Charge Nurse’, which has little connotation with manager or management within the names, and more recently these individuals have been re-named as ‘Ward Manager’:
I'm soon not going to be a Sister, I'm going to be a Ward Manager. (Female, S/WM, 15+ years)
and as such, has led to a change in their role:
The Ward Sister is a very different job now from when I qualified . . . there wasn't anything like as much management involved in the day-to-day running of the ward, it was more . . . you were more clinical based, you were more looking after your staff rather than all the other . . . the budgetary responsibilities and all that that we have now, Ward Sisters didn't have that initially. (Female, S/WM, 6–10 years)
This means that Ward Managers continue to have a case load of patients and are responsible for the running of the ward area, but the Ward Manager's role also includes budgetary and other managerial responsibilities (Pope et al., Reference Pope, Royen and Baker2002; Wong, Reference Wong2004). This can lead to conflict as it will restrain their autonomy to make clinical decisions that are best for the patient, given that they will be balancing any clinical decision with those of costs and resources (Som, Reference Som2009), leading to tension between the ‘professional ethos of patients welfare and the managerial perspective of efficiency’ (Som, Reference Som2009: 305). Such significant changes in working practices for senior staff means that there was discontent with the managerialist approach (Brunnetto, Reference Brunnetto2002; Townsend and Wilkinson, Reference Townsend and Wilkinson2010; Hutchison and Purcell, Reference Hutchison and Purcell2010). This leads to demoralised staff (not just Ward Managers), who feel vulnerable and suspicious of change (Maddock and Morgan, Reference Maddock and Morgan1998).
The Ward Manager role has different responsibilities and connotations when compared with the previous roles associated with Sister/Charge Nurse titles, and several of the respondents remarked that the increased managerial role was not what they became a nurse for:
I don't think I personally came into nursing to be a Manager. I came into nursing to look after people. And I took the role on not realising there was probably a bit of management in it as well, I thought it would be more . . . the same as what my colleague before me had done, and then I took her job, and then that changed. (Female, S/WM, 15+years)
This echoes findings from Bolton (Reference Bolton2000: 6) who stated that: ‘nurses are keen to dissociate themselves from the title of mangers and see their role as that of mediating the excesses of NPM’. Historically, Ward Sisters have undertaken line management responsibilities in the form of training, organising and the monitoring of junior nurses work (Bolton, Reference Bolton2003). But, as highlighted by Brunnetto (Reference Brunnetto2002), the cost cutting aim of NPM means that those professionals acting in a position of management (such as Ward Managers) are being forced to adopt bureaucratic strategies in order to ration and limit resources, which conflicts with their professional ethics:
I feel sometimes that it's a lot more kind of politics now within the ward area. From basic things to the budget, I mean, even when I was doing my auxiliary many years ago, the nurses would use things and it wouldn't even cross their mind how much it was. But now we're constantly being reminded that if there's an alternative we can use that's cheaper . . . Our stock levels aren't great now as well because we're trying to cut down on our budget and we tend to run out of dressings, and it's a surgical ward. I feel I just didn't see that happen in the past before, so I feel that's kind of – but I understand that they're concentrating on the budget and trying to find ways to cut down on that. But sometimes it is affecting patient care because we don't have the appropriate dressings or tablets that have been ordered up. (Female, SN, 3–5 years)
This leads to resistance to change, for example, staff who referred to themselves as ‘Sisters’ or ‘Charge Nurses’ compared to those who referred to themselves as ‘Ward Managers’. Resistance can indicate a lack of communication, the way changes were imposed on staff, a clash of values, and a cultural clash with differing perspectives on what was important or necessary.
Conclusions
If street-level bureaucracy is an ‘inescapable feature of the modern (welfare) state’ (Rowe, Reference Rowe2012: 15), then the need to understand how street-level bureaucrats respond to policy, management and financial constraints, along with their interactions with the public is essential. As has been seen in this article, nurses are street-level bureaucrats who can influence the implementation of policy via their use of discretion in their work.
Within Lipsky's analysis of street-level bureaucrats, there are many reasons why workers will resist management policies. If the traditional view of nursing being a hierarchical model of governance is considered, it would be expected that nurses would follow policies, and be unlikely to deviate from them. However, as street-level bureaucrats, nurses have considerable discretion in determining the nature, amount and quality of benefits and sanctions provided by their organisation, despite policy which dictates that discrimination will not occur within the NHS.
Nurses held differing views as to what the term policy meant, and this influenced their use of discretion when enacting a policy and decision-making. Nursing staff developed strategies in order to cope with the influence of policy decisions and the interactions which occur between themselves, managers and the public. The staff reported feelings of powerlessness, but due to their status as street-level bureaucrats, they were actually in a position to influence the implementation of policy. If the nurses did not view a policy as legitimate and in the best interest of patients or their working conditions, then they were able to use limited strategies to adapt, change and resist policy at the implementation stage.
There were often conflicting goals between management and front-line staff. This again has led to the use of discretion and resistance by nursing staff in the application of policies. Nursing staff would question the legitimacy of management to make decisions and this could often lead to conflict. It should be noted that Lipsky largely discounted the existence of value-based discretion (Lipsky, Reference Lipsky2010: 71). However, within this research it was found that although all patients would have been entitled to treatment, nurses were willing to make extra allowances for those individuals who they felt were deserving or whose behaviour they chose to overlook. Using Lipsky (Reference Lipsky1980, Reference Lipsky2010) as a way of analysing the use of discretion within the nursing workforce, it can be seen that staff employed several methods in order to resist or to alter management policies.
The changing role of Sister/Charge Nurse to Ward Manager has been explored in this article and can be seen as a clear example of staff attempting to resist to managerial policies. This role change can be seen to have created conflict for these individuals as they tried to reconcile a managerial role with a clinical role, when they found that both had differing priorities which could not be reconciled. Lipsky (Reference Lipsky2010: 19) characterises managers as a unique group which, cast in a particular role, is seeking to control practice and limit discretion. But according to Evans’ (Reference Evans2010: 165) findings, which focus on managers (as opposed to Lipsky's 1980s study, which focused on practitioners), managers are ‘using their discretion to adapt, change and subvert policies’ in similar ways to practitioners. Lipsky portrays local managers and street-level bureaucrats as having fundamentally different orientations, but this may not always be the case. For example, Ward Managers who remain clinical will find themselves torn between management priorities and the goals of ward level patient care.
The ever-changing health policy environment which characterises nursing has given rise to a challenge within the profession, where responding to sometimes ambiguous government demands can conflict with maintaining a professional ethos. Lipsky's concept of street-level bureaucracy has been used in this article to offer some explanation as to how nurses interpret and implement (or do not implement) policy at ward level. The role of nurses as policy implementers has been largely overlooked in comparison to studies within other allied health professionals and medical counterparts. Furthermore, the influence of NPM in shaping the working practices of nurses has also been overlooked. This is perhaps due to nursing having been viewed as retaining a hierarchical structure. In this article, however, nurses have been shown to be affected by managerialism, and it is clear that they are not just practitioners who follow policy, but also are active, resourceful and credible agents within policy implementation, and as such have much influence at the ground level. The use of discretion (in terms of rule, value and task discretion) by front-line nursing staff is important for them to be able to continue to provide effective patient care.
This article has offered insight from a small scale piece of research, but has clearly demonstrated the conflict that arises between the goals of managers compared to those of front-line staff and thus leading to the use of discretion when implementing policy. The way in which front-line nursing staff interpret and enact policy will clearly influence the care that patients receive whilst in hospital. This needs to be studied further to see how the use of discretion can impact on the quality of a service.
