Contributions of Paulo Freire to understanding the dialogic leadership exercise of nurses in the hospital setting^a

ABSTRACT

Objective

To know the understanding of nurses regarding the exercise of dialogic leadership in the hospital setting, and the challenges of leadership.

Methods

Qualitative and exploratory-descriptive study Thirty-five nurses of a mid-sized hospital in the city of Pelotas/RS participated in this study. Data were collected by means of semi-structured interviews, subsequently analysed using the operative proposal of Minayo.

Results

The results led to the following categories: exercise of dialogic leadership and challenges in the exercise of dialogic leadership. Dialogic leadership is understood as being the nurses’ ability to coordinate and organise the nursing team in horizontally-oriented relationships guided by dialogue. Regarding the challenges, the nurses stressed the lack of professional experience, and relationships of hierarchy and power.

Final considerations

Leadership based on dialogue can facilitate the management of care, of the nursing team, and of health services.

Nursing; Leadership; Health services

RESUMO

Objetivo

Conhecer o entendimento de enfermeiros sobre o exercício da liderança dialógica no ambiente hospitalar, bem como os desafios enfrentados para exercer a liderança.

Métodos

Estudo qualitativo do tipo descritivo e exploratório no qual participaram 35 enfermeiros que trabalham em um hospital de médio porte na cidade de Pelotas/RS. Para a coleta dos dados, foram realizadas entrevistas semiestruturadas, sendo que os dados foram analisados por meio da proposta operativa de Minayo.

Resultados

Formaram-se as seguintes categorias: exercício da liderança dialógica e desafios no exercício da liderança dialógica. Observou-se que a liderança dialógica é entendida como a capacidade do enfermeiro de coordenar e de organizar a equipe de enfermagem a partir de relações horizontalizadas, norteadas pelo diálogo. Quanto aos desafios, destacaram-se a falta de experiência profissional, as relações hierárquicas e de poder.

Considerações finais

A liderança a partir do diálogo poderá facilitar o gerenciamento do cuidado, da equipe de enfermagem e dos serviços de saúde.

Enfermagem; Liderança; Serviços de saúde

RESUMEN

Objetivo

Conocer el entendimiento de los enfermeros sobre el ejercicio del liderazgo dialógico en el medio hospitalario, bien como los retos enfrentados para liderar.

Métodos

estudio cualitativo del tipo descriptivo y exploratorio. Participaron del estudio, 35 enfermeros de un hospital de tamaño mediano de la ciudad de Pelotas/RS. Para recoger los datos, se realizaron entrevistas semiestructuradas y se los analizó a través de la propuesta operativa de Minayo.

Resultados

se formaron las siguientes categorías: ejercicio de liderazgo dialógico y desafíos en el ejercicio del liderazgo dialógico. Se observó que el liderazgo dialógico se entiende como la capacidad del enfermero de coordinar y de organizar el equipo de enfermería a partir de relaciones más planas, guiados por el diálogo. Cuanto a los desafíos, destacaron la falta de experiencia profesional, las relaciones jerárquicas y de poder.

Consideraciones finales

el liderazgo a partir del diálogo puede facilitar el gerenciamiento del cuidado, del equipo de enfermería y de los servicios de salud.

Enfermería; Liderazgo; Servicios de salud

INTRODUCTION

Leadership is characterised as the leader’s capacity to coordinate a group and encourage the team to reach collective goals, with the main objective of satisfying the needs of patients and their family members¹-³. The role of leader nurses essentially guarantees the quality of the provided care and the performance of nursing teams.

However, nurse leaders must face several challenges in the daily routine of their professional practice. Staff turnover, confrontations with others, interpersonal relationships, and lack of commitment and autonomy are some of these challenges². For newly graduated nurses, acceptance of the team, lack of interpersonal skills or continued education, scarcity of resources, and factors related to inexperience are the most common obstacles found in literature⁴.

In routine nursing work, nurses are faced with several difficulties that can be mitigated with strategic tools. One of the resources used by nurse leaders is communication, which is an essential element of leadership. Relationships based on dialogue can help nurses resolve conflicts more productively, with immediate benefits for teamwork¹. In addition, horizontal communication brings healthcare professionals and patients and their families closer, and facilitates the construction of therapeutic relationships.

According to a systematic review study that sought to analyse the relationship between nursing leadership practices and patient care, it is important to strengthen the leadership role of nurses in healthcare. Leadership can be achieved through programmes that address this subject and focus on extending the experience of leading, constant professional development, training, and encouraging the appropriate skills for the nursing environment⁵.

It is also possible to improve the skills and capabilities that nurses need to lead by ensuring easy access to teaching and learning through contemporary educational programmes based on scientific evidence related to clinical and managerial aspects⁶-⁷. The impact of leadership on care is notorious since it directly affects the organisational culture, personal satisfaction, and the quality of healthcare⁷. However, nationwide investments in the education of nurse leaders are still scarce, which highlights the importance of studies that investigate the subject of this paper.

To promote thought on nursing leadership, this study was anchored in the perspective proposed by Paulo Freire on dialogicity since the precepts he advocated are important for the foundation of leadership and its direct relationship with the construction of nurse leaders. Dialogue from the perspective of Freire has a meaning because the dialogic subjects not only retain their identity, they defend it and grow with one another. Consequently, the dialogue does not level, it does not generate reductionism; on the contrary, it drives respect between the engaged individuals⁸. By extending the scope of nursing training to the professional exercise, the authenticity of dialogue facilitates interpersonal relationships by making the subjects feel valued and aware of the importance of their social role and in the transformation of reality.

The study is relevant because it seeks to instigate nurses working in hospitals to reflect on dialogic leadership based on efficient communication to stimulate their autonomy, co-responsibility and appreciation for colleagues and users of hospital services, as well as to support decision-making, planning and the implementation care practices⁹.

In light of these observations, we sought to answer the following question: what is the understanding of nurses of the exercise of leadership in hospitals? Based on this question, the aim was to know the understanding of nurses on the exercise of dialogic leadership in hospitals, and the challenges that leaders must face.

METHODS

This is a qualitative, descriptive and exploratory study conducted in a philanthropic hospital in Pelotas, a centre of reference for cardiac and vascular surgery in the entire southern region of Brazil. This study is part of macro research conducted in the municipality.

During the data collection period (April to June 2014), 43 nurses worked at the institution and they were all invited to participate in the study. The criterion for inclusion was nurses who worked exclusively in the healthcare setting. The criterion for exclusion was nurses on leave from work for any reason and/or involved with the research. Of the nurses at the institution, 35 agreed to participate (one nurse was involved with the study and the others refused to participate in the study).

Data were collected through individual and scheduled semi-structured interview conducted at the study location. The interviews lasted 40 minutes on average. First, we used a sociodemographic questionnaire to characterise the profile of the participants. A script was used to guide the interviews and collect the data. The interviews were recorded and transcribed shortly after they were completed.

The data were analysed using the operational proposal of Minayo¹⁰, characterised by two operational moments. The first moment involves the fundamental determinations of the research and mapping in the exploratory stage of the investigation. The second moment was considered interpretative because it consists of the start and finish points of the investigation and represents the empirical facts. In the interpretative stage, we ordered the data from the interview transcripts and reread the material. The data were then classified by means of horizontal and comprehensive reading to capture the relevant structures and ideas. During the cross-sectional reading, the data were divided into units of meaning. In the classification process, we identified the categories and joined similar parts to understand the connections, and stored them in codes. In the final analysis, the data were confronted with the theoretical framework of Paulo Freire.

To ensure the participants received feedback of the results, a copy of the final report of the survey was submitted to the hospital’s nursing manager.

The study was reviewed and approved by the Research Ethics Committee of the Hospital Santa Casa de Misericordia de Pelotas, under the protocol number 200/2013. The study followed the ethical precepts of resolution No. 466, December 12, 2012¹¹. All participants signed an informed consent statement. The statements were identified with the letter N (nurse) and the ordinal number according to the order of the interviews (N1, N2, ..., N35).

RESULTS AND DISCUSSION

Of the 35 nurses who participated in the study, 28 were women and seven were men. Their ages ranged from 22 to 59 years and their academic background ranged from one to 34 years. Eighteen nurses had completed a specialisation course and one had a master’s degree.

The results led to the following categories: exercise of dialogic leadership and challenges in the exercise of dialogic leadership.

Exercise of dialogic leadership

Regarding the nurses’ understanding of dialogic leadership, the participants associated this form of leadership with the ability to organise and coordinate to meet the needs of the service and the team.

I understand dialogic leadership as coordinating, organising, assessing the workplace needs, observing difficulties, trying to solve them and encouraging changes when needed (N3).

The ability to keep everything organised. I think this is the principal of leadership. In my case, working with a closed unit, the leadership has to be really firm because the situations are unexpected and you have to lead in the sense of knowing where all the equipment is. To know and be able to trust in my team. This is the main leadership (N18).

I think it’s “to command” the team and be able to organise the sector in a way that is homogeneous with the whole team (N5).

The statements reveal that leadership is related to the organisation and efficiency of the unit. As managers, hospital nurses need to be qualified and prepared to assume the role of leaders. This basic condition is critical to make any changes in the practice, ensure the quality of care provided to patients, and conciliate the organisational goals with the needs of the nursing staff¹².

According to Paulo Freire, committed people are courageous, decided and aware, and they are always ready to face challenges. These attitudes are expected of nurses who exercise leadership in health services¹³. However, relations of power are also associated with the exercise of leadership, as observed in the testimony of N5, who stated that leadership is “to command” the team. This result suffers the influence of leadership education since according to the academic background, some nurses were exposed to a more rigid teaching process that more emphatically addresses managerial skills in the last semesters in the disciplines of management/administration, as opposed to the current reality in which leadership is understood as a transversal skill.

According to Freire, the power relationship occurs proactively and respectfully⁸, in which the leader grows with the growth of the group, while maintaining the identity and uniqueness of everyone involved.

Hierarchical relationships and relationships of power also emerged in the study. The term hierarchy is understood as relations between leaders and employees, that is, the difficulty to do something or to guide, delegate and, above all, listen to the constituent members of a group. The following statements address this topic:

Hierarchy doesn’t mean you’re going to be a general and people have to salute to you, but many times, you assess a situation and you think it should be that way. Unfortunately, nowadays many technicians do not respect the hierarchy and do not accept what you’re saying (N22).

You have to know the right time to tell them off, but still I have a good relationship. Always with respect, you have to have a limit between friendship and the work that you’re going to do (N25).

To facilitate the understanding of power relations, we mentioned the thoughts of Freire, in which power permeates relations between the oppressor and the oppressed. According to this concept, the oppressed will only be able to free themselves of this situation by liberating themselves and not craving the position of the oppressed, which stresses the importance of reinventing power and allowing everyone to exercise it⁸.

This analysis resulted in statements associated with the need to avoid imposing rules and inflexible power relations in the hospital environment.

It’s not about you imposing anything. You have to be open with people, in this case with the staff, avoid imposing conditions, enforcing rules, but explain why and also try to understand and let them talk about their opinion and try to discuss certain situations and rules (N13).

For example, we can’t be boss, you can’t just get there and make them d something and they do it unwillingly, they don’t know why they’re doing it, they do it against their will. So being a leader is just that, it’s about explaining so they willingly do what you are asking (N14).

The statements clearly show that the nurses try to avoid the autocratic leadership model based on the centralisation of the leader’s decisions, the imposition of orders, and a tendency toward aggression, tension and frustration that prevents healthy interpersonal relationships among team members.

Freire stresses the importance of dialogue with the oppressed in any degree of struggle for liberation. The self-confidence of the oppressed occurs through the quest for freedom and autonomy⁸. From this perspective, autonomy is related to the act of deciding, considering that it is through decision-making that we learn to decide. Autonomy is reflected as a process of maturing, built through the experience gained from making decisions¹³. However, it is clear that the nurses seek to distance themselves from authoritarian and imposing conduct that undermines teamwork.

Challenges in the exercise of dialogic leadership

One of the challenges that interfere in the exercise of dialogic leadership is lack of professional experience, as illustrated in the following statements:

I didn’t know what would come, what it was like to work with lots of people, also for being young and most of the team had been in the profession for a while, so it’s a little difficult. It’s you joining a team that has been here for years, being young, first job, so for me, it wasn’t very easy (N6).

Look, I have faced some challenges because I am new in the area (N19).

At first, when I came here, it was complicated. People don’t respect you because you are new here, both age-wise and for being new in the house [hospital], and I’m not a technician, everything is new. It was hard, I had to face a lot of obstacles here in the hospital (N20).

These statements reveal that the nurses feel they lack the experience and preparation to cope with the situations they face when exercising leadership. Since the leader is expected to guide the activities of the other team members, he or she must be trained and qualified to coordinate a work team and promote integration, in which respect, humility, and cooperation are the basis for a relationship of mutual trust.

Each professional is unique and essential to the work process, and the individual characteristics differ from those of the other professionals. Some of the statements below are associated with this concept:

Leading is not easy because you have to deal with various people, various personalities, various ways of thinking, people who are totally different from us, who think differently from us and have other interests to ours, and you have to lead them, keep them satisfied, that is also very difficult (N7).

Leading the team is a daily struggle, you have to be flexible. In my case, I have a team of 18 people, with different thoughts, different purposes and you’re there in the middle, you’ve got to do your best, try to please everyone, without discouraging anyone (N31).

The participants associate their difficulty in dealing with different personalities and the different ways of thinking of the members (values, beliefs, previous experiences). To tackle this issue, leaders have to be flexible, willing to listen and attend the requests of employees, whenever possible, for the end result of the work process to be positive.

The ability to conduce interpersonal relationships reflects the maturity and preparation of nurses in the exercise of leadership. Therefore, leadership must be guided by dialogue, in which relationships are horizontal and empowering, value team members, and support decision-making and the implementation of care practices¹⁴. As regards the current training of nurses, it is necessary to stimulate the construction of bonds and approximation between the members of the teams in order to promote the feeling of appreciation and facilitate communication¹⁵.

Also in the organizational context, the professionals take time to learn how to perform their duties within a team. Thus, it is important for professionals to remain in a given position for a certain period. Employee turnover is another of the challenges encountered in the exercise of leadership, as shown below.

The reality I am living today, the team of the sector where I’m working, it is constantly changing, so it’s complicated. Workers come from other sectors, who don’t know the routine, so we have to explain everything every day because every day we get a new one (N1).

The turnover rate affects the progress of work. When professionals become a part of a team, they create bonds and establish a harmonious relationship with the other members. This relationship will possibly enable greater engagement in the work routine since the employees are already aware of their roles within the team. However, it is believed that turnover can also hinder the building of bonds at work and the progress of work activities.

A similar results was found in a study with nurses working in hospitals in Florianópolis/SC that aimed to understand the main conflicts experienced by nurses-leaders in the hospital setting. Turnover was found to contribute to the appearance of conflicts since the constant relocation of workers impairs the formation of professional bonds, teamwork anchored in union, and the establishment of clear and common goals³.

In the statements of this study, some of the nurses mentioned they had difficulty in imposing limits in certain situations involving team members.

For me, it is still difficult. One of the difficulties that I still have is saying “no”. When you need to reach out and say, “I don’t want you to do that, that’s not how it goes”, that’s the part that I think is harder, that part of leadership (N29).

It is worth mentioning that the leader has autonomy over the team. When the leader sees a downside that can effect patient care or any inappropriate behaviour coming from the team members, he or she has the duty to engage in dialogue and to seek the best way to guide them. According to Freire, true dialogue does not diminish in any way the ability of subjects to exercise their right to disagree, to oppose, and to position themselves; on the contrary, it encourages the expansion of ideas¹³.

Dialogue is considered a way of resolving conflicts and facilitating the management of care and the nursing staff to improve the progress of work. This understanding was revealed in the following statements:

I mainly tried to engage in dialogue with them. Sometimes there is a problem in the team or even with a family member or patient, I tried to talk to them and guide them as best I could (N17).

When I see that something is not coming out as expected, I like to sit and talk with all of them, the kind of open dialogue. I ask for their opinion, ask them how it’s working, accept new ideas and try to show them the things I need to change, why and how favourable it will be for the team and especially for the patient (N19).

Always with dialogue with all the team members together, identifying faults, pointing out the solutions that need correcting, praising their performances, motivating, educating and learning. Seeking a good work relationship with me and the other members, cheering them on, motivating (N30).

Dialogue is a human phenomenon that cannot be reduced to the simple dumping of ideas from one subject to another; it is a meeting between people to discuss situations and transform reality. It can also be assimilated as a horizontal relationship between A and B that is nourished with love, humility, hope, and faith. For this reason, only the dialogue communicates, through the establishment of an emphatic relationship⁸, ¹⁶.

The authenticity of the dialogue facilitates interpersonal relationships and makes people feel appreciated and aware of the importance of their social role. Therefore, the dialogue is understood as a strategy that can facilitate the exercise of leadership and the professional nurse practice, taking into account the multiple actions, duties and responsibilities of this practice³.

Dialogic leadership emerges as a political act that nurse leaders can use as a strategy in their workplace. It also serves as a guide for the leadership style; when people are considered a relational and singular being, they set themselves apart from others by defending their convictions in their social context. Furthermore, it can support new ways of practicing healthcare based on more democratic, human and ethical attitudes that promote the freedom of expression rather than power relations based on authoritarianism and oppression¹⁷.

Institutions should overcome the lack of investments in nursing leadership education by stimulating leadership programmes and pursue greater integration between teaching-service to promote improvements in the practice and the organizational culture¹⁸. It is also essential to promote a safe, effective, and supportive work environment, and recognise the importance of nurses with positive conducts that assume the responsibilities of leadership¹⁹. Nurse leaders should also be trained to learn from everyday situations and best adapt their practices to the needs of the team, the users, and the institution.

The exercise of leadership requires the application of critical thinking to decision making, conflict resolution, and the management of care with high standards of quality. Leadership as a human ability strengthens management and enables nurses and their teams to reach healthcare goals²⁰. In this sense, dialogue is the key to the success of good relationships because it allows members to know the needs, desires, thoughts, and feelings of the other team members.

FINAL CONSIDERATIONS

This study used the theoretical framework of Paul Freire to show how nurses understand the exercise of dialogic leadership in hospitals, and the challenges they face as leaders.

The perspective of Paulo Freire supports reflection on dialogue and autonomy, and helps us understand the power relationships that interfere with dialectic interpersonal relationships, namely the dialectic relationship between nurses and the nursing staff.

According to the data obtained, organisation in the exercise of dialogic leadership is essential for decision-making and conflict resolution. Concerns with hierarchical relationships were also reported. For the nurses, hierarchical or autocratic leadership is embedded in the hospital context; however, they also believe that if this form of leadership is used cohesively, it can facilitate workplace relationships, which can be contradictory since nurses tend to avoid the autocratic management model because they believe it causes physical and mental burnout, and affects the social lives of employees.

Regarding the challenges they face when exercising leadership, they mentioned the lack of professional experience, having to deal with different personalities in a team, and difficulties in imposing limits.

The limitation of this study was the low adherence of the hospital nurses, which can suggest their difficulty in or apprehension about discussing this subject with their peers even after we guaranteed their anonymity and freedom to stop the research or not answer all the questions. Moreover, the use of other data collection techniques, such as observation, and new ways of addressing this subject with the employees can increase of the possibility of better understanding the object of this study.

We hope that this study will contribute to the development of further scientific studies since the subject of leadership is of utmost importance to the exercise of the nurse leader’s function. Furthermore, this broad subject is constantly changing to meet the needs of the labour market, especially hospital institutions.

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Publication Dates

• Publication in this collection
  2017

History

• Received
  30 May 2016
• Accepted
  04 Dec 2016