RESEARCH ARTICLES

Nursing leadership competence: concepts, essencial attributes and the role of the nurse leader

Vânea Lucia dos Santos Silva^I; Silvia Helena Henriques Camelo^II

^I RN. Master's Student at the Fundamental Nursing Program of University of Sao Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, São Paulo, Brazil. E-mail: vanealucia@usp.br
^II RN. Ph.D. in Nursing, Professor at the General and Specialized Nursing Department of University of Sao Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, São Paulo, Brazil. E-mail: shcamelo@eerp.usp.br

ABSTRACT

This study aimed to examine concepts of leadership in nursing, their attributes and the role of the nurse leader. It is an integrative review and the search strategy was to consult the electronic databases in february and march 2011. The analysis of the 14 selected articles revealed three categories of articles: conceptualizing nursing leadership, essential attributes for nursing leadership and the role of the nurse leader. Leadership is the ability to influence people to act in an ethical and professional in order to achieve common goals. Effective performance of the nurse leader requires the development of personal and professional skills, as well as commitment, responsibility, making decision, effective communication and management qualifying the service and meeting the expectations of the organization. The nurse leader can provide performance efficiency of the team, promoting satisfaction for the customer, professional and institution.

Keywords: Nurses, male; leadership; hospital administration; management.

INTRODUCTION

The transformations taking place in the modern world have demanded a constant update in the practices of the health services, requiring different profiles of professionals to adjust to the new technologies and to the work that is increasingly shared, aimed at quality care.

It is unquestionable that hospitals still play an extremely important role in providing health care, considering the scope of activities offered in these institutions, either with respect to their greater integration to the service network, or in terms of how to manage them with the emergence of new hospital management models.¹

The singularity of hospital organizations has been highlighted due to the care of patients in increasingly critical health situations, requiring complex and individual responses to their health needs. Thus, hospital work requires new skills from professionals who are faced with changes in technology and demands on the part of their patients causing, quite often, changes in their work process.

Nursing has been expanding its space in the health area, which allows its essential characteristics to remain in light of technological changes. However, researchers reveal that nursing practices include health planning, the resolvability of services and extramural activities, in search for comprehensive care².

During the development of nursing care, it is the nurse's duty to manage the care provided to patients, to perform administrative, educational and research activities, in order to improve professional practice³. Hence, the nurse stands out in his/her team because of the multiplicity of activities developed, which includes intellectual work, the coordination of the nursing staff's actions, as well as the organization and implementation of care. ⁴

In light of this context, it is essential to highlight leadership as a management tool in the nursing work process, assisting nurses in team management, decision making and coping with conflicts that may emerge in the work environment⁵. Leadership is considered a phenomenon of group influence, in which it is essential to join efforts in order to reach the goals shared by the group.⁶

Leadership is defined as the ability to influence a group in order to pursue and achieve common goals. This influence may be either formal, such as that conferred by a high position in the organization or may come up naturally from inside a group.⁷

The exercise of leadership demands preparation, creativity and determination. In this sense, it is understood that the capacity to lead needs to be built and improved, daily⁸. Nevertheless, in order to exercise leadership, in the hospital setting, the nurse must understand its meaning and importance as a professional competence, recognizing the essential attributes for its development.

Based on this, the study guiding question was: 'What are the meanings and concepts of leadership as a professional competence of the nurse in the hospital?'; 'What are the key attributes for leadership in nursing?' and 'What is the role of the nurse leader?'.

Understanding the concept of leadership in nursing, its attributes and the nurse's role as a leader contribute to the process of reflection of future nurses regarding how the competence of leadership is associated with the performance of their duties, as well as enable educational institutions to reflect on their role in the preparation of this professional.

The objective of this study is to identify and analyze the meanings of the term leadership in nursing, its essential attributes and the role of the nurse leader.

METHODOLOGY

The integrative review method was chosen to achieve the objectives proposed, since it is the broadest methodological approach regarding reviews, allowing the inclusion of experimental and non-experimental studies to understand the phenomenon analyzed better. It combines data from theoretical and empirical literature, and incorporates a broad range of purposes: definition of concepts, theories and evidence review, and analysis of methodological problems of a particular topic⁹.

Although methods for conducting integrative reviews vary, there are patterns to be followed. In the operation of this review, the following steps were taken: selection of the thematic question, establishment of criteria for sample selection, representation of the characteristics of the original study, data analysis, interpretation of results and presentation of the review. ¹⁰

Search was performed by means of consulting the electronic databases of Latin American and Caribbean Literature in Health Sciences (LILACS), Scientific Electronic Library Online (SciELO) and Nursing Database (BDENF).

Due to the specific characteristics of access to the selected databases, the strategies used to locate the articles were adapted to each of them, and guided by the study questions and inclusion criteria, avoiding errors in the selection of articles.

Thus, the survey of articles was performed using the Descriptors in Health Sciences (DeCS): nurses, nursing leadership, hospital administration and hospitals; as well as the keyword: leadership in nursing. The descriptors and keywords selected were combined, according to the database.

The criteria used for sample selection were: articles published in Portuguese, English and Spanish over the last five years, available in their full version, and addressing the studied theme.

The results and discussion were structured as it follows: characteristics of the studies, conception of leadership in nursing; essential attributes for leadership in nursing and the role of the nurse leader.

RESULTS AND DISCUSSION

Characteristics of the studies

The literature review was conducted between February and March of 2011; the articles found and selected were written in Portuguese, totaling 14 publications ^{6, 8, 11-22}, as shown in Figure 1.

FIGURE 1: Characteristics of the studies analyzed. Period of publication 2006-2010.

The articles were published in national magazines, some of international circulation, predominantly journals linked to public universities. The descriptors in health sciences most used by the authors were: leadership, nursing, hospital administration, nursing staff and management.

The journals selected presented the study objectives clearly, i.e., they allowed the easy understanding by the reader. The objective constitutes the proposed action to answer the question of the study and is fundamental to understand the article published ²³.

When analyzing the most common research outlines in our sample, two articles used the quantitative methodological approach^{6, 11,12} and the qualitative approach^{8 0.12-22}. Regarding the studies using the qualitative methodological approach, the most common method were: descriptive and exploratory.^{8,13-15,17,22} The quantitative studies were descriptive.^6,11 In this regard, the research object under analysis may be studied by different methodological outlines.

The analysis of the selected studies, as per the descriptors set, enabled the grouping of data into three categories which are described below, using a qualitative approach.

Conception of leadership in nursing

This category represents the various meanings of nursing leadership found in 14 publications selected for this study.

The concept of leadership is a topic that has been addressed from several perspectives. Its study in the organizations refers to the leader's effort to get cooperation for a common task.¹¹

Leadership is the ability to influence people to act in an ethical and professional manner in order to achieve common goals through collective commitment. ^{24, 25} It can also be defined as the ability to get things done through people, and the work with people will always present two dynamics at stake: task and relationship.¹²

The plurality of senses regarding the meaning of leadership attests that some authors consider leadership as supervision; others refer to it as a synonym for management and there are still those who bind leadership only to the informal aspects of the organization.¹³

It is known, therefore, that supervision is a management function, which calls for a legal delegation of authority to someone to be able to act as needed. Leadership, as opposed to management, can be identified in its formal structure, and also in informal work groups. The theme of leadership meaning quite often generates reactions such as laughter, fear and restlessness, on the part of professionals, proving to be a complicated matter and difficult to be defined. ¹⁴

Regarding the meanings they attribute to leadership, nurses described it as fundamental to the organization of rules and routines, since it is associated with the performance of activities of team coordination and articulation of the work of nursing professionals⁸. Some nurses explain leadership as something innate to the individual, believing in an initial potential that, if developed, can make the individual capable of exercising this function. Others define it as an action to influence people, linked to a team process with a goal to be reached¹⁴.

Nevertheless, researchers note that nurses have difficulty understanding the meaning of leadership, despite considering it important in their daily life; they confuse the concept of leadership with that of management, in addition to showing that the understanding of leadership is not consistent with the concepts presented in the literature consulted; that is, there is a deficit of knowledge regarding this theme.⁸

In agreement with some authors, we believe that leadership assists the nurse in achieving the care objectives, including the delivery of quality care to patients, permeated by the ability of this professional to influence their collaborators ⁸. Hence, leadership can be considered one of the major competences to be developed by the nurse,²⁶ since in teamwork this professional must be qualified to take over the leading position.

It is believed that leadership can be earned and improved, however, this requires nurses to mobilize some characteristics to assist them in this role, making them exercise a comprehensive, coherent and ethical leadership; that is, a leader is not born ready; a leader is formed in the course of his/her development as a professional and human being.¹⁵

Key attributes for leadership in nursing

This category approaches relevant aspects or attributes that must be presented, or even developed in the nurse leader.

Attributes are characteristics inherent to the person, resulting in personal qualities that guide their actions, immeasurably important for the exercise of professional activities. Some attributes are rooted in personality (e.g.: integrity); others, in personal characteristics (flexibility) and others in individual skills (understanding of concepts) ²⁷.

Leadership enables the encounter of different people and professionals in teamwork, challenging nurses to develop listening skills, getting along well with their subordinates in order to have them as allies in the care process, thus winning their professional autonomy within the institution and expanding his/her performance area.¹⁶

In this sense, aspiring an effective performance of the nurse as a nursing team leader presupposes the constant search for behaviors, knowledge and development of essential skills for leadership, which involves personal qualities, interpersonal skills and knowledge of the organizational context ²⁸.

Technical, administrative and relational skills are sometimes the criteria for choosing a leader to manage an area. Technical skill presupposes critical thinking to evaluate clinical conditions and patient needs, in addition to preparing diagnoses and nursing interventions that lead to best health care outcomes. Knowledge of equipment and resources to develop care actions are also expected.¹⁷

The administrative ability involves the need to domain processes, unit structure and resources, required for the development of care actions. It is worth emphasizing the importance of the leader to have domain over administrative standards and rules, as well as a broader view of the whole institution and the interactions that occur at all levels, which affects the daily lives of the workplace. Finally, we agree with some researchers with respect to the leader's relationship skills being related to the ability of this professional to integrate technical and administrative knowledge in a concrete practice that combines the rational and human in each situation.¹⁷

Some researchers^{25, 29} emphasize that indispensable qualities of a leader include: commitment, communication, listening, responsibility, vision and talent to establish healthy interpersonal relationships.

In this context, we emphasize communication as one of the relevant factors in the process of nursing leadership because, through it, the reality is interpreted, priorities are defined and rules are established.²⁷ The manner in which a message is transmitted will interfere in the expected outcome. Communication is at the core of leadership, since it establishes an interpersonal relationship in which leaders influence people to change through a communication process.¹⁸

Communication in nursing performance is linked to managerial processes with interface in the exercise of leadership. There is no leadership without communication.¹⁹ The nurse leader needs to know how to communicate and manage communication, because the communication skill is fundamental to achieve more significant professional and personal relationships, with higher self-conscience and acceptance of the differences.²⁰

Other features that should be cultivated in the construction of the nurse leader are: persuasion, credibility, integrity, determination, dedication, recognition, intellectual capacity, common sense, self-knowledge and sense of humor.^{15, 27}.

Studies also highlighted flexibility and motivation as essential skills for leadership, being considered facilitators of this process¹⁴.

Flexible behaviors are a result of self-assurance, allowing the free expression of ideas, avoiding prior judgments and recognizing listening to be as important as speaking. Mental flexibility allows to imagine possibilities that surpass conventional categories, leveraging creativity and innovations. It allows laterality in order to develop growth and credibility in other values.²⁷ The changes that have been occurring in the health area demand from professional nurses a more flexible and adaptive profile in order to provide quality care.

Motivation is another prominent element in the attributes of a leader; it is the action performed by individuals in an attempt to meet unachieved needs, thus becoming a force that encourages them to act. This action, which determines the behavior, is originated in a set of psychological factors, conscious or not, interacting between themselves, encouraging different forms of behavior. Thus, motivation involves synergy between people using all their capacity, guiding them to individual and group achievements.²⁷

The figure of the leader is important for the development of motivation in the nursing staff, as this person must appreciate his/her staff considering them competent, creative and above all capable of developing quality work. Thus, the leader must help his/her employees develop their potentials.³⁰

Leadership is essential in the professional life of nurses, because being able to communicate clearly with the group, being able to identify solutions to conflicts and having initiative in decision-making are features that guarantee a satisfactory performance in the art of care.²¹

The role of the nurse leader

This category addresses studies approaching the role and responsibilities of the nurse as a team leader.

The management knowledge that supports the development of leadership include: planning, organizational structure, personnel management, decision making, time management, conflict management and communication.²⁰

In the practice of nursing leadership, the nurse should provide a favorable environment for the implementation of activities in his/her daily work. This professional assumes the difficult task of coordinating the nursing staff, and therefore needs to develop skills that foster a balanced handling of a heterogeneous group, conveying safety in decision-making.²¹

In one of the selected studies, professionals in nursing have identified the leader as someone who listens, collaborates on routine, commands well. Thus, in the understanding of some professionals, leadership has a more affective and understanding role.²²

The leader must be involved by commitment, responsibility, empathy, ability to make decisions, and efficient and effective communication and management, qualifying the service and meeting the expectations of the organization.²⁷ The duty of a nursing leader is to overcome barriers so that the professionals in his/her team can deliver care to their patients.³¹

In the nursing staff, the hospital nurse is the most suitable professional to exercise leadership. The power of this professional derives from the hierarchical position he/she occupies in the team and his/her technical, scientific and ethical knowledge acquired during graduation, making him/her able to head the nursing team.³² The profile of the nurse leader and his/her professional behavior are closely related to the philosophy of the institution in which he/she acts.³³

The work of the nurse leader in health institutions aims at reaching the common goals of the institution, work teams and patient. In this case, nursing leadership, as a group phenomenon, will be understood by the leader as a challenge in order to share ideas and resources to satisfy patient and professionals.⁶

It is up to the nurse leader to develop his/her work and fulfill the proposed activities. The improvement of leadership skills, either through experience, innate characteristics or the search for qualification, makes the nurse able to influence a team and reach his/her goals and objectives.³⁴

The nurse leader wins and inspires the team, builds bonds of friendship and trust, and is also a promoter of change and motivation.⁵ From there, the leader who wishes to positively influence his/her team must, in the first place, set the example and use, coherently, action and speech.⁸

Currently, the desired leadership is one that not only manages people, budgets and time focused on the effectiveness of performance, but also one that is geared to meet needs and aspirations.²⁷

CONCLUSION

This integrative review study identified meanings of the term leadership in nursing, the essential attributes to professionals for their development and the role of the nurse leader. In conclusion, leadership is one of the core competencies of the nurse and should be earned and improved. Nevertheless, it is important to highlight the need to develop attributes such as responsibility, determination, humility, flexibility, organizational knowledge, integrity, persuasion, credibility, sense of humor, among others. The nurse leader can provide efficiency in the performance of the health team and nursing practice, generating a critical, reflective and participatory practice, further enabling patient, professional and institution satisfaction.

Given the constant changes occurring in the health labor market, which is increasingly competitive and requires professional preparation to assume various responsibilities, the qualification of nurses is fundamental in relation to leadership skills, so as to provide quality nursing actions.

In light of this, the authors believe that further studies should be conducted with nurses in order to promote a reflection regarding their role as leaders of a health team responsible for the health care of patients.

REFERENCES

1.Organização Pan-Americana de Saúde (OPAS). A transformação da gestão dos hospitais na América latina e Caribe. Brasília (DF): OPAS; 2004.

2.Sampaio DMN, Vilela ABA, Simões AV. Representações sociais e prática do enfermeiro: limites, avanços e perspectivas. Rev enferm UERJ. 2012; 20:481-7.

3.Galvão CM, Trevizan MA, Sawada NO. A liderança do enfermeiro no século XXI: algumas considerações. Rev esc enferm USP. 1998; 32:302-6.

4.Rodrigues FCP, Lima MADS. A multiplicidade de atividades realizadas pelo enfermeiro em unidades de internação. Rev Gaúcha Enferm. 2004; 25:314-22.

5.Amestoy SC. Liderança como instrumento no processo de trabalho da enfermagem [dissertação de mestrado]. Rio Grande (RS): Universidade Federal do Rio Grande; 2008.

6.Santos I, Castro CB. Estilos e dimensões da liderança: iniciativa e investigação no cotidiano do trabalho de enfermagem hospitalar. Texto contexto – enferm. 2008; 17:734-42.

7.Robbins SP. Comportamento organizacional. 9ª ed. São Paulo: Prentice Hall; 2002.

8.Amestoy SC, Cestari ME, Thofehrn MB, Backes VMS, Milbrath VM, Trindade LL. As percepções dos enfermeiros acerca da liderança. Rev Gaúcha Enferm. 2009; 30:617-24.

9.Whittemore R, Knalf K. The integrative review: update methodology. J adv nurs. 2005; 52:546-53.

10.Ganong LH. Integrative reviews of nursing research. Res nurs health. 1987; 10:1-11.

11.García García I, Santa-Bárbara ES. Relação entre estilos de liderança e bases de poder das enfermeiras. Rev Latino-Am Enfermagem. 2009; 17:295-301.

12.Sousa LB, Barroso MGT. Reflexão sobre o cuidado como essência da liderança em enfermagem. Esc Anna Nery. 2009; 13:181-7.

13.Souza FM, Soares E. A visão administrativa do enfermeiro no macrossistema hospitalar: um estudo reflexivo. Rev Bras Enferm. 2006; 59:620-5.

14.Strapasson MR, Medeiros CRG. Liderança transformacional na enfermagem. Rev Bras Enferm. 2009; 62:228-33.

15.Amestoy SC, Cestari ME, Thofehrn MB, Milbrath VM. Características que interferem na construção do enfermeiro-líder. Acta Paul Enferm. 2009; 22:673-8.

16.Santos I, Oliveira SRM, Castro CB. Gerência do processo de trabalho em enfermagem: liderança da enfermeira em unidades hospitalares. Texto contexto – enferm. 2006; 15:393-400.

17.Moura GMSS, Magalhães AMM, Dall´agnol CM, Juchem BC, Marona DS. Liderança em enfermagem: análise do processo de escolha das chefias. Rev Latino-Am Enfermagem. 2010; 18:1099-106.

18.Balsanelli AP, Cunha ICKO. Liderança no contexto da enfermagem. Rev esc enferm USP. 2006; 40:117-22.

19.Spagnuolo RS, Pereira MLT. Práticas de saúde em enfermagem e comunicação: um estudo de revisão da literatura. Ciênc saúde coletiva. 2007; 12:1603-10.

20.Peres AM, Ciampone MHT. Gerência e competências gerais do enfermeiro. Texto contexto – enferm. 2006; 15:492-9.

21.Ribeiro M, Santos SL, Meira TGBM. Refletindo sobre liderança em enfermagem. Esc Anna Nery. 2006; 10:109-15.

22.Vendemiatti M, Siqueira ES, Filardi F, Binotto E, Simioni FJ. Conflito na gestão hospitalar: o papel da liderança. Ciênc saúde coletiva. 2010; 15(Supl.):1301-14.

23.Burns N, Grove SK. The practice of nursing research: conduct, critique and utilization. 4ª ed. Philadelphia (PA): WB Saunders; 2001.

24.Chiavenato I. Gerenciando com pessoas: transformando o executivo em um gestor de pessoas: um guia para o executivo aprender a lidar com a sua equipe de trabalho. Rio de Janeiro: Elsevier; 2005.

25. 14.Maxwell JC. O livro de ouro da liderança. Rio de Janeiro: Thomas Nelson Brasil; 2008.

26.Camelo SHH. Competência profissional do enfermeiro para atuar em unidades de terapia intensiva: uma revisão integrativa. Rev Latino-Am Enfermagem. 2012; 20:192-200.

27.Marx LC. Competências da enfermagem: sedimentadas no sistema primary nursing. Petrópolis (RJ): EPUB; 2006.

28.Simões ALA, Fávero N. O desafio da liderança para o enfermeiro. Rev Latino-Am Enfermagem. 2003; 11:567-73.

29.Gómez E. Liderança ética: um desafio do nosso tempo. São Paulo: Planeta Brasil; 2008.

30.Fernandes MS, Spagnol CA, Trevisan MA, Hayashida M. A conduta gerencial da enfermeira: um estudo fundamentado nas teorias gerais da administração. Rev Latino-Am Enfermagem. 2003; 11:161-7.

31.Hunter JC. O monge e o executivo: uma história sobre a essência da liderança. Rio de Janeiro: Sextante; 2004.

32.Vilela PF, Souza AC. Liderança: um desafio para o enfermeiro recém-formado. Rev enferm UERJ. 2010; 18:591-7.

33.Lanzoni GMM, Meirelles BHS. Liderança do enfermeiro: uma revisão integrativa da literatura. Rev Latino-Am Enfermagem. 2011; 19:651-8.

34.Souza e Souza LP, Ferreira Cordeiro AL, Nunes de Aguiar R, Veloso Dias O, Vieira M, Ramos LH. A liderança na visão de enfermeiros líderes. Enferm glob. 2013; 30:281-93.