Nurses' managerial knowledge in the hospital setting

ABSTRACT

Objective:

to analyze nurses' managerial skills in the hospital setting, their perception of their own education and the relevance of training for their professional practice.

Method:

qualitative study based on the dialectical hermeneutics framework. Thirty-two nurses from three hospitals in the Brazilian state of Minas Gerais contributed to the study by taking part in six focus groups. Records were transcribed and three categories emerged from content analysis.

Results:

results evidenced the following managerial skills: supervision, leadership, decision making, planning and organization, as well as the relevance of education centers for their improvement and the continuing development of the nurses' managerial skills.

Conclusion:

the authors believe this investigation will contribute for the improvement of nurses' necessary managerial skills and also to identify gaps in this area of their education.

Descriptors:
Hospitals; Nurses; Professional Competence; Management; Universities

RESUMO

Objetivo:

analisar os saberes gerenciais do enfermeiro no contexto hospitalar, a percepção de sua formação acadêmica e a relevância da capacitação para atuar na práxis profissional.

Método:

estudo qualitativo, fundamentado na Hermenêutica-Dialética. Participaram 32 enfermeiros de três hospitais de Minas Gerais utilizando seis grupos focais. O material foi transcrito e por meio de análise de conteúdo foram extraídas três categorias.

Resultados:

os resultados mostraram saberes gerenciais do enfermeiro, tais como: supervisão, liderança, tomada de decisão, planejamento e organização, bem como a relevância dos centros formadores nos seus aprimoramentos e a capacitação contínua desses profissionais no que diz respeito às práticas gerenciais.

Conclusão:

acredita-se que essa investigação contribuirá para clarificar saberes gerenciais necessários ao enfermeiro, como também identificará lacunas desse conhecimento na sua formação.

Descritores:
Hospitais; Enfermeiros; Competência Profissional; Gerência; Universidades

RESUMEN

Objetivo:

analizar los conocimientos gerenciales del enfermero en el ámbito hospitalario, la percepción de su formación académica y la relevancia de la capacitación para actuar en la práctica profesional. Método: estudio cualitativo, fundamentado en la Hermenéutica-Dialéctica. Participaron 32 enfermeros de tres hospitales de Minas Gerais, divididos en seis grupos focales. El material fue transcripto y, mediante análisis de contenido, fueron determinadas tres categorías.

Resultados:

los resultados mostraron conocimientos gerenciales del enfermero, tales como: supervisión, liderazgo, toma de decisiones, planeamiento y organización, así como la relevancia de los centros de formación en su mejoramiento y la capacitación permanente de estos profesionales en lo referente a las prácticas gerenciales.

Conclusión:

se considera que esta investigación contribuirá en el esclarecimiento de los conocimientos gerenciales necesarios para el enfermero, así como también identificará la carencia de tales conocimientos en su formación.

Descriptores:
Hospitales; Enfermeros; Competencia Profesional; Gerencia; Universidades

INTRODUCTION

Constant changes and advancements in all health practice scenarios, especially in the hospital setting, have affected how teams are organized to offer health care. This situation requires specialized managerial knowledge from professionals, especially nurses, and experience in administration⁽¹⁾.

Nursing care management mobilizes actions in relationships, interactions and associations among people as complex human beings, constituted of nursing and health teams with managerial competences/abilities/powers inherent to the nurses' professional activities⁽²⁾. With this in mind, nursing knowledge has increased in the management dimension because of new management models based on participative planning, which progressively affects demand for readjustments in the educational process⁽³⁾.

The objects of the nurses' managerial work are the organization of nursing work and nursing human resources. A range of managerial knowledge is employed to carry out this process. Some of them include: planning, allotment, selection and recruitment of nursing staff, permanent and continuing education, performance supervision and assessment. Other means and instruments are also employed, such as work force, materials, equipment and facility⁽⁴⁾.

Recommendations for better managerial practices focus on the educational process of future nurses and point to the need for providing opportunities for students to understand the theory and visualize and experience at first hand the possibilities of coordination between management and care in professional practice⁽⁵⁾.

Thus, universities have the role of preparing professionals who are able to master theoretical knowledge and practice to support human aspects of the care offered to patients⁽⁶⁾. In this sense, considering that one of the nurses' work processes is management and that these professionals have historically occupied management positions in health services, defining and developing managerial knowledge becomes relevant for institutions, including educational institutions⁽⁷⁾.

Health organizations, as well as education centers, perform a crucial role in the development of nurses, representing an essential part in the construction of future professionals. Also, ethical issues permeate personal experiences, the realities of education and work, touching on doubts and conflicts that are part of the education process. In this context, instructors are the professionals responsible for creating spaces and building strategies to facilitate the understanding of managerial knowledge for nursing students at all times during their education, in addition to promoting these individuals' critical analysis with practical problems⁽⁸⁾.

In this context, academic development can positively or negatively interfere in the construction of managerial knowledge that is necessary for their professional practice. Therefore, health managers, who are responsible for the management of hospital services, must reassess strategies to qualify these professionals with the goal of meeting patients' demands more effectively.

Hence, this study was based on the following questions: What are managerial practices or knowledge developed by nurses in their professional practice? Do education centers ensure that professional nurses have managerial knowledge for their practice? How do these professionals perceive their own ability to practice in a hospital scenario?

The development of this study is necessary given the relevance of this subject, and with the aim of contributing to the critical analysis of nurses, managers and education centers regarding the needs of professionals who are apt for managerial roles, who are autonomous and who seek their own path when employing their knowledge in trying to break the dichotomy between what is recommended and what is actually practiced in the nursing routine. It also collaborates for the planning and organization of management and care practices.

Thus, the objective of this study was to analyze nurses' managerial knowledge in a hospital setting, the nurses' perception of their own academic development and the relevance of training for professional practice.

METHOD

This study has an exploratory design, with a qualitative approach, based on the theoretical methodological framework of dialectics hermeneutics, which is considered an empirical research method. This shows a belief in the moving process that permanently happens in society, and in the historical construct and the capacity of transforming and overcoming contradictions through practice⁽⁹⁾.

This investigation was carried out in the practice scenario of nurses from three hospitals in a city in southern Minas Gerais, one public hospital, one public teaching hospital, and a private institution. Eighty-five nurses from these institutions were invited by letter, telephone and electronically. From those, 32 nurses participated in the study.

For empirical data collection, the authors chose the focus group technique. According to each hospital's nurse allotment, six meetings were organized, with a focus group with four nurses in the private hospital, two focus groups in the public hospital, both composed of seven nurses, and three focus groups in the public teaching hospital, composed of five, four and five nurses, respectively.

Digital recorders were used to record the participants' speeches addressing our research questions regarding managerial practices and knowledge, these professionals' academic development and the role of organizations in nursing training.

It is worth noting that the focus groups were conducted in each required hospital institution. Because of that, they were organized according to work shifts namely, morning, afternoon and night shifts, as well as according to the availability of each nurse to participate in the focus groups. Participants were identified by the letter "N" and received a sequential number, thus ensuring the anonymity of their speeches. Therefore, they were labeled from N1 to N32.

After a detailed transcription of speeches and an exhaustive reading of each interview, the material obtained was subjected to technical content analysis, as proposed by Minayo⁽¹⁰⁾, which consists of three phases: pre-analysis, exploration of resources and treatment of results.

The study was conducted according to the requirements of Resolution CNS 466/12 of the National Health Council⁽¹¹⁾. The Research Ethics Committee of the Federal University of Alfenas (UNIFAL - MG) approved the research proposal.

RESULTS

Participants' details

The participants of the study were nurses responsible for units in sectors of low, medium and high complexity. Among them, there was a predominance of women (81.25%), which confirms the social historical aspects of the profession. Age ranged from 23 to 45 years, showing a young population occupying managerial roles in the institutions. From the 32 participating nurses, 10 had been nursing technicians before finishing their undergraduate nursing courses (31.25%); two nurses graduated over 20 years ago (6.25%); seven graduated over 10 years ago (21.875%); and the remaining 23 have been graduated for one to 10 years (71.875%).

As for education, data showed that the professionals possessed some form of lato sensu graduate education (100%) and only one nurse had a stricto sensu graduate degree (3.125%), in other words, an academic master's degree.

Analysis of the subjects' speeches enabled reflections on their perception of nursing managerial knowledge for practicing in hospital contexts. This enabled the identification of three categories: "Nurses' managerial knowledge for practicing in hospital contexts; education centers and nurses' managerial practices; nursing training for managerial practices".

Category 1: Nurses' managerial knowledge for practicing in hospital contexts

The nurses' speeches showed that their practice in hospital contexts is directly related to the use of managerial strategies and/or tools that encourage and appreciate the team's participation in the decision-making process.

[...]We have a good rapport with the nursing team, who are our direct subordinates [...] interaction is very linear. They trust us, we decide together, it is very multidisciplinary, very participative. I feel we have a very collaborative multi-professional team interaction. (N1)

[...] they are not in doubt about anything. They talk to me about everything. If they detect some anomaly, they ask if they can carry out some procedure that differs from what is prescribed. I authorize it if it is inside nursing standards and if it makes sense to me. (N30)

Thus, knowing how to lead teams democratically and horizontally, and how to communicate and supervise is crucial managerial knowledge noticed by nurses when conducting the teams.

[...]I think it makes a difference. I think that the nurses' role, for me to know how to guide my practice, my team, I have to know how each member of the team is working, if they are working according to what is right, what is correct. (N22)

Any small thing they detect, they call me so we decide what should be done, which direction to take, how we should behave; and whatever we, as nurses, can solve, we solve together [...]. (N29)

Moreover, the nurses perceive their responsibility in managing human, material and physical resources, according to the speeches below.

[...]equipment acquisition is our responsibility. They usually let us try out the whole equipment and they respect our opinion and there is also the issue of materials, so I think that is positive for us, because if we think that something is not adequate and we report it, the person who is responsible for that can stop its acquisition. (N4)

[...]we did it [...] we resized the team, how many workers were part of it [...]before, we used to have five workers in a sector with thirty patients; today, we have eleven workers; so, they care for four patients, five at most, each [...]. (N20)

Nurses are the professionals who are technically responsible for their teams, being considered points of reference by the whole team.

Here I notice this very well. It is very clear that nursing technicians consider us points of reference, both technically and administratively [...] the nurses' role is almost essential, because technicians trust us more than they trust the physicians. (N1)

[...] We are points of reference and they report most stuff, almost everything, to us [...] so much so that we are the ones called upon for these care processes, we are always involved, most of the times, in our tasks. (N3)

Thus, nurses must have a comprehensive view of the whole work processes, plan, execute and assess care and management activities, identifying priorities in nursing care.

[...] I puncture veins, I apply bandages and when nurses have this perception of planning, focusing on executing a task, I believe that there are quicker results [...]. (N1)

[...] we organize service and normally prioritize what is more important at a given time. The basic work is first assessing the patients and finding what actually needs to be done. (N12)

[...] some of them appreciate it. Some workers appreciate it when you ask the patients "can I help you?". At that moment, you assess the patient, you check potential ulcers, you check catheter infections, you check bandages, and you check how they are caring for that patient [...]. (N32)

Category 2: Education centers and the nurses' managerial practices

Nurses in this study reported that managerial knowledge was partially acquired during their academic training.

[...] with our knowledge, academic knowledge, we trained for this, there are various foundations for the care we offer nowadays, which are the theories of nursing. So, when I plan, when I perform my tasks, I have in mind what guides me, which is concrete nursing theory, the academic foundations we learned to become caregivers. (N1)

[...] everything I am today I owe to my academic training. Of course, there are also graduate programs [...] a complement, but the basis was very important. It taught me the definition of things, where everything is based upon, so I could attend a number of graduate courses. However, the basis, the cradle, is eternal. (N28)

The planning of nursing actions, care knowledge and activities were emphasized as acquired knowledge, based upon disciplines learned during academic training.

We plan while observing theoretical guidelines that were studied, that are proven and that have scientific and academic bases. So, I think what makes our services different is this academic basis. So, our uniqueness comes from that. (N1)

[...] I finished the program focused on caregiving, because I would do really well with care [...] if I take a patient, I take great care of them observing the techniques, what has to be done. [...]. (N19)

Category 3: Nursing training for managerial practices

Continuing education is mentioned as a strategy to implement nursing training.

I think a nice way to do that is to have the nursing staff on continuing education, repeatedly using the skills. I don't know if everybody has this difficulty I have [...] if you don't use it, you end up forgetting it. (N12)

[...] you cannot stop, because if you stop, how are you going to practice? [...] evolution is fast, and if you don't study, you cannot keep up with that. Continuing education really has to exist. (N14)

Training can also happen through courses or other activities, as long as workers are interested and there is encouragement and incentive from the organization.

[...] our own training, if we are interested in a course, we are encouraged to do that course [...] we are always invited to courses, we are encouraged to participate and that is important for us. We have our own internal program; we have periodical trainings, when hired and after changing positions. (N4)

In this study, considering this training context, nurses seem to be aware of the need for constant improvement.

[...] if you don't keep learning, you can't take it. You have to follow the evolution on a daily basis. What would we do if we stopped? We can't. (N14)

[...] we have an obligation to study, because that's how we become nurses. There's no way around, it is impossible to not study [...]. (N20)

Not stopping [...] always learning. I think that college... it gives you the basis and you take over from that. (N22)

DISCUSSION

Nurses in the hospital context carry out activities that range from offering direct care to patients to managerial activities, which puts them in a unique position, giving them more autonomy and the ability to influence the organization's decision making⁽¹²⁾. When working with teams, these professionals possess the highest ability to handle conflicts and challenges, as well as to manage activities in environments of trust and satisfaction.

Therefore, leadership supports nurses in building a satisfactory work environment through the establishment of healthy professional relationships and effective dialogical processes between the nursing team and the members of a multi-professional team⁽¹³⁾.

It is worth to emphasize that through leadership nurses bring together the aims of the organization and the nursing team, with the objective of improving professional practice and the quality of care that is offered. Thus, nurses are defined as facilitating elements for the teams' work⁽¹⁴⁾.

Leadership, communication, teamwork and personal interaction are important competences for nurses' managerial practices, as is the case of conflict management, since these professionals are daily demanded to handle various situations that require decision making, flexibility, problem solving, team coordination, planning and entrepreneurship with the aim of achieving the organization and the patients' goals⁽¹⁵⁾.

In addition to being leaders and the central figures of the nursing team, it is the nurses' role to manage physical, material, human and information resources. This requires knowledge so that work is developed with an ethical-political attitude⁽¹⁶⁾. For that end, each organization has unique characteristics and, for such, nurses must solve problems, allocate resources, plan their use, develop strategies, perform situational analyses, and guarantee the performance of the nursing staff, among other activities⁽¹⁷⁾.

These professionals are legally authorized to provide direct care to patients, as well as to manage the health facility and the nursing team by delegating specific roles to workers. However, knowledge, skills and attitudes related to decision making are necessary, as well as planning for the execution and assessment of care plans⁽¹⁸⁾.

Thus, nurses coordinate the teams and, because of that, they are the professionals who must be prepared to act appropriately along with other professionals, supporting them in the various actions that are necessary for patient care in the hospital context, as regulated by the professional practice law.

In this view, it is very important for nursing to maintain knowledge production regarding planning and organization of actions, so that turning this knowledge into professional instructions make it possible to train the team to constantly contribute to the population's health levels⁽¹⁹⁾.

However, there is a need to prioritize care, to plan nursing activities and assess the offered care. Yet, supervision is a technique that came to help nurses, being considered a management instrument that has been in use since the beginning of business administration as a specific field of knowledge and practice in the end of the 19^th and start of the 20^th century⁽²⁰⁾.

Therefore, the complexities of the hospital context and the amount of activities that fall upon the shoulders of nurses make it necessary to seek new knowledge in various areas to demystify bureaucratic and centralizing models by enforcing the network of connections that are necessary for human care, which is wide, dynamic, multifaceted and complex⁽¹⁴⁾.

Nevertheless, it is not always possible to put managerial knowledge to practice. The workplace, gaps in training, professional experience or ignorance of managerial practices can be factors that cause insecurity in nurses trying to apply their knowledge to management. Thus, it is believed that nurses responsible for managerial processes must be sensitive to notice emerging demands, entrepreneurship skills, the ability to encourage innovative actions and flexibility to adapt to multiple situations⁽¹⁴⁾.

However, in the current scenario, changes in the modern world require health services to be constantly developing, which demands from professionals a unique set of skills, so they can adapt to new technologies and shared work. As such, hospital work demands new competences from professionals, who face technological changes and demands from the clients, which frequently cause transformations in the work processes.

In this perspective, nursing education has been defined by the constant discussion of pedagogical proposals and implementation of changes in the syllabus. The curriculums of undergraduate courses in nursing must train professionals to be capable of transforming what they learn into behaviors that employ the profession's knowledge, as well as reflecting about their actions and the practice of their tasks in daily work⁽²¹⁾.

It is worth noting that it is still common for nursing schools to emphasize the training of nurses who are highly prepared to offer individualized, science-based care. However, the role that is expected from these professionals in reality is, mostly, of service management, which, not uncommonly, is limited to the management of materials and staff instead of care⁽⁵⁾.

As a consequence, the use of managerial knowledge is based on the education of nurses. Thus, health work management must be a central axis of these professionals' training so that they can put their managerial knowledge to use⁽¹⁹⁾.

In nursing, managerial knowledge involves many paths to approach activities that are part of the learning process. Action planning and organization as a managerial skill is one of the technical tools used in the work process to support decision making. It consists of creating strategies to reach defined objectives⁽²²⁾.

Action planning and organization was observed in our study as a crucial managerial skill for the daily practice of nurses and which can be acquired during undergraduate studies. Furthermore, the contribution of undergraduate studies and professional practice for the development of competences happen in different ways in service management and care. Generally speaking, curriculum disciplines address basic concepts and underwrite guidelines for procedures.

However, it is necessary to create a new educational model that seeks to change how knowledge is acquired, how technical abilities are developed, and to enable the practice of social capabilities for critical and ethical acts that drive the revision of paradigms, placing them in the context of contemporary society⁽²³⁾.

The dissemination of nursing education has been encouraged due to the conclusion that the profession simply solidifies a science-based body of information. Accordingly, the discussion about the inclusion of content, disciplines and strategies that foster education in universities is very important⁽²⁴⁾.

In the decade of 1990, nurses were responsible for the curriculum review that sought to define, beyond the profession's profile, its general and specific competences. The new configurations for these professionals' training, indicated in the Brazilian National Curriculum Guidelines for undergraduate nursing courses are not limited, since technical issues related to training content are based on the adoption of a theoretical pedagogical framework that supports meaningful learning, which transforms emerging social and professional demands⁽²⁵⁾.

In this perspective, the challenge for higher education institutions focused on nursing training must be to prepare nurses who are technically and politically competent, as social individuals with knowledge and logical thinking for life and society issues. This can be done by training them to act in complex contexts of uncertainty, such as hospitals.

Changes in the competence profile of nurses aim to meet health demands, requiring them to be able to act upon, mobilize and transfer knowledge to solve practical situations, constantly learn and to engage in response to the requirements and demands of organizations. Management and the adoption of strategies to change the professional competence profile of nurses must be carried out by those who conduct work processes, which demands professionals who can lead these changes while observing standards of quality and productivity⁽²⁶⁾.

The need for learning and development comes from the increase in demand by users of the Brazilian Unified Health System, which caused the institutions to take on the mission of improving the managerial knowledge of professionals focused on health promotion⁽²⁷⁾. In this context, continuing education is an essential tool to improve professional performance and to enable the development of managerial practices for acquiring knowledge, skills and practices in order to interact with and act upon reality, in addition to help in minimizing problems that result from training gaps⁽²⁸⁾.

Thus, nurses emphasize that, in order to make any knowledge real, it is necessary to put it to practice; and continuing education is an ally in this challenge. Institutions must reconsider their strategies for professional training, with workers motivating themselves to participate in courses and events.

Hence, the administration of the unit and/or hospital health services has been incorporated to the nurses' professional practice. Therefore, as managers of units or teams, nurses are responsible for making decisions that guarantee care quality. For that end, these professionals must constantly develop their knowledge, with the aim of practicing more successfully.

At the sphere of national health policies, continuous professional development must be a proposal that contributes for the transformation of training processes. In this sense, continuing education must continuously meet the demands of the professionals during their development process, since it occupies a unique position that makes it different from other educational interventions. Thus, there is an expectation for the democratization of workspaces, for the development of learning and teaching capabilities of everyone involved, for finding creative ways to solve emerging problems and for permanent improvement of health care quality⁽²⁹⁾.

However, it is crucial to emphasize that this study is limited when it comes to the professional category it investigated, since the authors opted to address only hospital nurses, believing that only these professionals could have an opinion about managerial knowledge, which left out other professionals in the team.

FINAL CONSIDERATIONS

Management in the context of hospitals is a competence of nurses that is directly related to the search for care quality. For that end, it can be observed that nurses act in the performance of care by managing human and material resources, in leadership, in planning and in the organization of care, in supervision, in the work of the nursing team, in the coordination of care and in the assessment of nursing actions.

The authors showed that nurses in the studied institution have used their managerial knowledge when planning and organizing their work processes, as well as to manage the demands of their professional practice.

Thus, education centers have the role of qualifying future professionals for the development of this knowledge while reconsidering their teaching strategies and priorities with the aim of effectively meeting the population's health demands.

Although there were disciplines that led to nurses learning managerial knowledge, the authors notice that there is a need for training to become closer to practical problems through the creation of situations in which there is effective development of skills required for nursing practice.

However, institutions must reconsider their professionals' competences by implementing strategies that more effectively deliver excellent quality care.

The authors believe that this investigation contributes to clarify the nurses' managerial knowledge and their ability in regards to continuing education and training in service. Nonetheless, other studies are necessary to enhance this understanding and to give higher visibility for the nurses' practice, since there would be a need for improvement proposals coming from education centers and hospital institutions to implement continuing education strategies for nurses. By building and rebuilding their knowledge, these professionals will be capable of transforming their own professional practice through continuous learning.

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Publication Dates

• Publication in this collection
  Jul-Aug 2016

History

• Received
  30 May 2015
• Accepted
  23 Mar 2016