ORIGINAL RESEARCH

Nurse managers at a teaching hospital: training, responsibilities and challenges

Silvia Helena Henriques Camelo^I; Mirelle Inácio Soares^II; Lucieli Dias Pedreschi Chaves^III; Fernanda Ludmilla Rossi Rocha^IV; Vânea Lucia dos Santos Silva^V

^I Nurse. PhD in Nursing. Professor, Ribeirao Preto Nursing School, University of Sao Paulo. Ribeirao Preto, Sao Paulo, Brazil. E-mail: shcamelo@eerp.usp.br
^II Nurse. PhD Student in Nursing, Ribeirao Preto Nursing School, University of Sao Paulo. Ribeirao Preto, Sao Paulo, Brazil. E-mail: mirelleenfermagem@gmail.com
^III Nurse. PhD in Nursing. Professor, Ribeirao Preto Nursing School, University of Sao Paulo. Ribeirao Preto, Sao Paulo, Brazil. E-mail: dpchaves@eerp.usp.br
^IV Nurse. PhD in Nursing, Professor, Ribeirao Preto Nursing School, University of Sao Paulo. Ribeirao Preto, Sao Paulo, Brazil. E-mail: ferocha@eerp.usp.br
^V Nurse. Master in Nursing, Ribeirao Preto Nursing School, University of Sao Paulo. Ribeirao Preto, Sao Paulo, Brazil. E-mail: vanealucia@uol.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2016.11637

ABSTRACT

Objective: to ascertain the profile of hospital nurse managers by socio-demographic features and professional training, and to identify the challenges faced. Method: this quantitative and qualitative descriptive study was conducted in June 2014 at a public teaching hospital in São Paulo State. Participants were 15 nurse managers. Data from semi-structured interviews were subjected to thematic analysis, which produced the categories: Training for nurse manager duties; Becoming a nurse manager; and Challenges for management in nursing. Results: the challenges posed by working in management include performing functions interconnected with other areas and departments; gaining familiarity with administrative matters; and managing conflicts. Conclusion : hospital managers must invest in training their human resources, considering the reigning social, political, economic and health context.

Keywords: Nurses; management; hospitals; professional competence.

INTRODUCTION

The transformations that have been occurring in the modern world require from health services the constant update of their practices and professionals with differentiated profile aimed at excellence of quality of care.

In hospitals, the nurse is an essential part of the organizational structure, assuming tasks related to the management of physical, material, human and financial resources, being essential for the provision of quality nursing care.

The nurse manager of the nursing service takes the coordination of care and of the nursing staff ¹. In this context, the management as a care tool requires skills from professionals who faced technological changes and requirements of their clientele, which often causes changes in their work process².

Thus, the nurse manager must be sensitive to change, seeking alternatives and contributing to improve the management that affects the care of their internal and external customers³.

In addition, the labor market expects that the nurse manager has the ability to identify and address problems, proposing changes with strategies that contribute to the quality of care, approaching the team and the customer; it is expected that they have knowledge, skills and attitudes to meet the demands of services properly.

In this sense, the profile of nurse managers of hospital services must be a concerning issue for their managers and professionals related to teaching.

In this regard, in the health work process, by involving the management of the services/units, materials and management of nursing care itself, the development of managerial skills for nurses constitutes in effective strategies to improve the performance of an organization, producing potential and competent leaders who will meet the values proposed by the hospital organization⁴.

However, difficulties and challenges may be present in the management of hospitals, such as the tension between the patients and the prerogatives of the professionals, which must be solved by the manager.

In this direction, the following questions arise: who are the nurse managers of hospitals? How did they become managers? What are the challenges faced in their daily work?

About the relevance of this issue, the definition of the nurse manager profile may support professionals, managers and training centers in adopting strategies for the training of nurse managers, in order to meet the particularities of this position, culminating in professional and institutional growth.

Thus, this study aimed to know the profile of the nurse manager according to the sociodemographic and training aspects, by identifying the challenges faced.

LITERATURE REVIEW

The constant changes and advancements in the health practices scenarios, especially in hospitals, have affected how teams are organized to provide health care. This requires that professionals, especially nurses, have specialized knowledge in management, as well as experience in administration⁵.

The management of nursing care promotes actions in relationships, interactions and associations among people as complex human beings, consisting of nursing and health teams with their own managerial competencies/skills/powers or inherent to the professional activities of nurses⁶.

Thus, the nursing work process is complex and involves, besides the administrative-managerial, educational and investigative functions, the care itself. Therefore, in this work process, there are not several dimensions, but instead, a multitude of activities in the practice of this professional, reflecting directly on the excellence of quality of care. In this context, the management and care functions are part of the nurse's responsibilities, with a view to carrying out care and articulating these functions in a constant adaptation, since while the patient is at the core of their actions, they need to use tools that assist in the management of their work, aiming at improvements in care⁷.

Thus, nurses often face undefined management models, with problems of human, physical and financial resources, which makes that their actions are directed to immediate solving of problems, which may not always result in effective work. In view of this, the work of nurses in the management of services should have a broader approach, that goes beyond actions directed at immediate problems, and that has a transformative potential of the practice of in the context in which they work.

METHODOLOGY

This is a descriptive, quantitative and qualitative study with methodological design based on a single case study, considered an empirical research method that investigates a phenomenon within a real context ⁸.

This research was conducted in June 2014 in a public teaching hospital located in Ribeirao Preto in Sao Paulo State, a reference in the Unified Health System (SUS) at municipal, state and national levels for patient care that require high complexity. The participants consisted of 15 nurse managers called by the institution as service directors that are responsible for one or more inpatient units.

For data collection, researchers used two sources of evidence: direct, structured and non-participant observation and semi-structured interviews. The observation took place during the visits to the fields for interviews and data were recorded in a diary. The observation and the interviews were conducted by the researcher and occurred individually during working hours, according to the availability of participants. For the interviews, authors used a script with guiding questions, which were later recorded and transcribed.

The data analysis of this study was focused on thematic analysis using the operative proposal of Minayo. In this type of analysis, it is sought the meaning core of a communication, whose presence or frequency means something to the object of analysis⁹. The final analysis of the material collected in interviews and observations gave rise to thematic categories.

In this sense, considering the qualitative nature of this study, the discussions of the categories were based on the identification of the nurse manager profile, their responsibilities and challenges.

It should be emphasized that the participants were identified by the letter N for nurse, and received a number in sequential Arabic numerals, guaranteeing thus the anonymity of speeches; they were referenced from N1 to N15.

The analysis of the interviews presented reflections on their perceptions regarding training and challenges related to nursing management in hospitals, which allowed identifying three categories: Training for nurse manager assignments; Becoming a nurse manager and Challenges for nursing management.

The study was approved by the Ethics Committee of the Ribeirao Preto Nursing School, from University of Sao Paulo (EERP-USP), under Protocol No. 05059312.5.0000.5393. Participants signed the Informed Consent Form, according to Resolution No. 466/2012 of the National Health Council.

RESULTS AND DISCUSSION

Profile of nurse managers

This is a predominantly female population (93.3%), which corroborates the historical and social aspects of the profession, demonstrating that the female population is the majority among nursing professionals¹⁰.

The data showed a profile of nurse managers with an average age of 46 years, ranging between 27 and 60 years. In this sense, researchers understand that a longer time of hospital nursing care provides to the nurse professional maturity due to improving their skills, promoting agility and expanded critical view on the situations imposed by the professional practice¹¹.

Regarding professional experience, nurse managers had between 12 and 25 years of employment relationship with the institution and from two to 15 years in management, having worked in other positions previously, which indicates a preference for experienced professionals, as well as the possibility to rise in professional career inside the organization.

As for education, 70% had completed graduation for over 20 years, 60% had post-graduation in Management and 40% had Master of Business Administration (MBA). In Brazil, the post-graduation allows the graduate to specialize in their area of expertise, and the MBA is aimed at training executives in business management. In the group studied, only one nurse had academic master degree.

Training for nurse manager assignments

The management is one of the assignments of the nurse. Thus, in order to work as manager of a nursing service, knowledge, skills and attitudes are basic requirements, since we live in the era of information and knowledge, in which professionals are always seeking to achieve the best results. Thus, this professional must have initiative and willingness to develop their functions efficiently and effectively.

Focusing on the organizational issues of the work of nurse managers of hospitals, specifically those related to primary responsibilities of these professionals, the speech of the nurse N1 evidenced the lack of academic background and previous training to take over the position in which he is.

Nevertheless, professionals recognize the need for constant search for learning and reveal that the daily experience can be considered a learning factor that complements the deficiency of their training.

If, on the one hand, experience in social assistance contributes to nurses be able to manage, according to the needs of practice, on the other, it shows that one way for the nurse the rise in health organizations has been the shift to a managerial career path¹².

Healthcare organizations, as well as training centers, have an essential role in the training of nurses, representing an essential sphere in the construction of future professionals. Moreover, ethical issues permeate personal experiences and the experiences in educational and work scenarios, encompassing the doubts and conflicts arising from the training formation process¹³.

However, hospitals are home to significant number of nurses working in different areas. Each area has its technical, managerial and care specificity, and the deepening of professional training, in most cases, occurs concomitantly to work, depending from grants of the institution, motivation and personal availability¹⁴.

From this perspective, we must remember the responsibility of the institutions in the training of its employees, by providing tools to deal with technical, social and emotional issues.

In nursing, the responsibility of training is directly linked to the Continuing Education service, which is the co-responsible sector for training employees to properly perform their duties¹⁴. Therefore, there is need for a detailed planning of staff training proposals that encompass knowledge in management. In this context, the in-service Continuing Education is key to an awareness of the need for systematic training.

It is worth noting that nurse managers should also assume the role of articulating, guiding and thus preparing their team continually, motivating it, sensitizing it in relation to the pursuit of knowledge and professional growth.

However, in-service educational processes should be in line with the interests of all involved, meeting the expectations and needs of those who will attend the objectives of the institution and, in the case of nursing, the purpose of work, which is improving nursing care.

Becoming a nurse manager

By analyzing the study data, it is clear that the participants of the study became managers by nomination or invitation of their directors, which reveals an informal manner to rise in the position.

In the constant pursuit to take responsibility for the management of nursing and people care, the nurse manager may face situations of conflict and lack of experience in the field. Therefore, one of the criteria for choosing the professional for this function may be related to their ability to manage these situations.

In this perspective, nursing has experienced a period of transformation in matters involving the world of work. In this scenario, the management of services has experienced changes in strategies aimed at improving the quality of nursing care, which requires that the nurse manager knows their team and is able to face adverse situations that may emerge from work process of their team.

In this sense, the relational functions require skills and attitudes to manage the team by combining the interests of the organization, management and workers. However, it is part of the manager role the ability to negotiate with the different professional categories, articulating the demands of the institutional policy, managing conflict situations, as well as negotiating the oppositions and forwarding assertive resolutions¹⁵.

Given this premise, basing their decisions on professional experience and experience in conflict situations can be a source of support in management actions. For this, the good relationship in the workplace must be guaranteed in order to reduce dissatisfaction in the employment context¹⁶.

Thus, the nurse working in the management articulates with senior management and the front line directors. The head position in a health unit deals with bitter relations of tension between the categories and departments working in the same context. Thus, the nurse's performance in the management of a service can hinder or facilitate the progress of activities¹⁵. In this sense, participants perceive the fact of taking the position of manager in the hospital context as a complex assignment and that requires professional knowledge and experience in the area.

It is clear, therefore, the insertion of a professional with higher density of knowledge and attitudes associated with management, able to raise discussions.

Challenges for nursing management

The management that nurses play in health services should encompass the care, pedagogical, scientific-technical and political aspects, as well as those that relate to interpersonal relationships, in order to aim for the planning and organization of their work to provide a holistic care to the patient¹⁷.

In this sense, nurses reported that one of the challenges is to know the whole service, the tasks associated with the position, the institutional mission, once they understand that the absence of this hinders the effective management.

Given these notes, nurse managers need to deepen their knowledge about the organizational universe. Moreover, there is need to uncover the activities of the nurse manager for the team to feel co-participant of the process, so that they can support the manager's performance.

Thus, the current work environment has undergone changes in paradigms that require multifunctional workers and integrated to a team and to the institution, in which the nurse as manager should be a professional that goes beyond the task of proving care directly. This requires that the professional also takes over the duty of managing interpersonal relations and not only of supervising the execution of procedures¹⁸.

In this sense, the attitudes and behaviors of the demands of the nurse manager should be related not only to the technical training but also to the way they deal with the relational aspects in the workplace.

Nevertheless, the testimony of the participants corroborate the research that shows that nurses in management work as mediators of conflict situations experienced by the nursing staff, constantly being called to solve these situations. However, in health organizations, conflicts are present all the time, hence the importance of the nurse always be studying and discussing how to manage conflicts, as these are necessary for the development and growth of any organization¹⁹.

According to the last statement, there are many obstacles that are present on the daily routine of nurses' work, including the disagreements, the differences regarding ideas, values, personalities or feelings; the failure in communication (misunderstandings), aggressive behavior; stress/emotional and physical fatigue; disrespect; the limit or space invasion; the high turnover; the lack of trust and the leadership style¹⁹.

Therefore, the nurse managers, before conflict situations and with real possibility of bringing up in their work process, showed willingness to remedy these difficulties with the team. Thus, besides empowering health professionals with specialized expertise, it is necessary to develop people committed to the management process, which requires attributes such as creativity, innovation, intuition, ability to relate and manage conflicts, always keeping oneself updated.

CONCLUSION

In a move of comings and goings, the hospital work environment puts the nurse manager at the challenge of exercising interconnected functions so that they can make the dialogue with other departments and with their own work unit to guarantee the functioning of the service.

In this sense, the discussion on the profile of nurse managers of hospitals allows analyzing relevant aspects of their training, with regard to the characteristics that are specific to this function.

In this sense, regarding the category Training for the nursing manager assignments, there is need of much more than technical and scientific knowledge; it is necessary that nurses are qualified and want to be and to do, and also that they develop skills to do their work with quality.

Thus, in the category Becoming a nurse manager, ideal behaviors and attitudes should be recognized in the multiple dimensions involved in this interdisciplinary level of care.

Finally, in the category Challenges for nursing management, it was observed that nurses face in their work process various barriers, such as knowledge of the unit and the tasks, approach with administrative issues, dealing with people and managing conflicts. The professional experience can be a facilitator in the management, although the study participants had identified difficulties in meeting the different dimensions that this function requires.

However, hospital directors must invest in the training of human resources, considering the current health and socio-political-economic context.

In conclusion, this study has a limitation with regard to the professional category and setting, since the study chose to address only nurse managers of a single hospital. Thus, authors recommended extending the research to nurses from other institutions of various legal natures in order to obtain a broader view of reality.

REFERENCES

1.Torres E, Christovam BP, Fuly PCS, Silvino ZR, Andrade M. Sistematização da assistência de enfermagem como ferramenta da gerência do cuidado: estudo de caso. Esc Anna Nery. 2011; 15: 730-6.

2.Silva VLS, Camelo SHH. A competência da liderança em enfermagem: conceitos, atributos essenciais e o papel do enfermeiro líder. Rev enferm UERJ. 2013; 21: 533-9.

3.Ruthes RM, Cunha ICKO. Contribuições para o conhecimento em gerenciamento de enfermagem sobre gestão por competência. Rev Gaúcha de Enferm. (Online). 2007; 28: 570-5.

4. Pihlainen V, Kivinen T, Lammintakanen J. Management and leadership competence in hospitals: a systematic literature review. Leadersh Serv Saúde (Bradf Engl). 2016; 29: 95-110.

5. Souza LPS, Souza AMV, Pereira KG, Figueiredo T, Bretas TCS, Mendes MAF, Santana JMF, Mota EC, Silva CSO. Matriz Swot como ferramenta de gestão para melhoria da assistência de enfermagem: estudo de caso em um hospital de ensino. Rev Eletrônica Gest Saúde. 2013; 4: 1911-921.

6.Erdmann AL, Backes DS, Minuzzi H. Care management in nursing under the complexity view. Online Braz J Nurs. 2008; 7(1).

7.Jacondino MB, Martins CL, Nunes NJS, Thofehrn MB. Processo de trabalho em enfermagem: competências gerenciais. In: Thofehrn MB, organizadora. Enfermagem: manual de gerenciamento. Porto Alegre: Moriá Editora; 2016. p. 13-26.

8.Yin RK. Estudo de caso: planejamento e métodos. 5ª ed. Porto Alegre (RS): Bookman; 2015.

9.Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 12ª ed. São Paulo: Hucitec; 2012.

10.Santos EI, Gomes AMT, Marques SC. Acidentes ocupacionais biológicos e práticas protetoras evidenciados nas representações sociais de enfermeiros sobre sua vulnerabilidade. Rev Baiana Enferm. 2015; 29: 391-399.

11.Trigueiro EV, Leite JEL, Dantas DNA, Coura AS, Enders BC. Profile and positioning of the nurse manager regarding to the nursing process. Esc Anna Nery. 2014; 18: 343-9.

12.Furukawa PO, Cunha ICKO. Perfil e competências de gerentes de enfermagem de hospitais acreditados. Rev Latino-Am Enfermagem. 2011; 19: 106-114.

13.Ramos FRS, Brehmer LCF, Vargas MAO, Shneider DG, Drago LC. A ética que se constrói no processo de formação de enfermeiros: concepções, espaços e estratégias. Rev Latino-Am Enfermagem. 2013; 21: [09 telas].

14.Ferreira JCOAF, Kurcgant P. Capacitação profissional do enfermeiro de um complexo hospitalar de ensino na visão de seus gestores. Acta Paul Enferm. 2009; 22: 31-6.

15.Barbieri AR, Hortale VA. Desempenho gerencial em serviços públicos de saúde: estudo de caso em Mato Grosso do Sul, Brasil. Cad Saúde Pública. 2005; 21: 1345-56.

16.Oliveira EB, Silva AV, Perez Junior EF, Costa HF, Nascimento LP, Souza LAM. Fatores de risco psicossocial em terapia intensiva neonatal: repercussões para a saúde do enfermeiro. Rev enferm UERJ. 2014; 21: 490-5.

17.Almeida ML, Segui MLH, Maftum MA, Labronici LM, Peres AM. Instrumentos gerenciais utilizados na tomada de decisão do enfermeiro no contexto hospitalar. Texto contexto-enferm. 2011; 20: 131-7.

18.Spagnol CA, L'Abbate S. Conflito organizacional: considerações teóricas para subsidiar o gerenciamento em enfermagem. Ciênc Cuid Saúde. 2010; 9: 822-7.

19.Ciampone MHT, Kurcgant P. Gerenciamento de conflitos e negociação. In: Kurcgant P, organizadora. Gerenciamento em enfermagem. Rio de Janeiro: Guanabara/Koogan; 2010. p. 35-50.