Previous chapters have explored the clinical role of the nurse and mapped working relationships between doctors and nurses through exposition of developments in clinical working environments. The clinical domain is but one arena in which nursing and medical staff interact. This chapter explores another area within which medicine and nursing operates, that of the service domain of health care practice. The term 'service domain' is used to describe any area relating to the management of clinical units, and of the clinical service. Such activity occurs not at the micro patient interface level, but at middle management level or the clinical unit-trust interface. At its most influential, this area can then extend to involvement in executive and national policy level decisions. It requires nurses, doctors and health service managers to make operational and strategic decisions about the delivery of the service, rather than be directly involved with patient management. This, therefore, offers a comparative area to explore the working relationships between doctors and nurses, who both work with managers in order to deliver the clinical service.
In order to understand the nursing role in the service domain, I begin this chapter with a review of the introduction of management structures into the NHS. I particularly focus on service changes that have occurred since the 1970s. This chapter simply descr ibes the impact of the health policy initiatives and the resultant management structure changes on the nursing role. I do not set out to explore, nor to ignore, the presence of management discourses that can be located within nursing, nor the clinical values that underpin the principles of managers (Traynor 1999).
The introduction of general management principles into the health service has raised important issues about health care professionals working within a managerial structure. This area is explored through discussion of working relationships between managers and health care professionals at local clinical unit level. The consequences of the NHS re-organisations at this level are explored, and the implications for those involved in health care management are examined. Through this, I will demonstrate that the ways that clinical management teams have developed, and the evolution of roles within these teams, have similar tensions to the clinical practice domain.