Representation of nurse’s managerial practice in inpatient units: nursing staff perspective

ABSTRACT

Objective

To understand the meanings that nursing staff gives to nurse’s managerial practice in the inpatient unit.

Methods

This is an exploratory and descriptive research with qualitative approach, conducted in a general hospital in a Southern city of Minas Gerais State. We used the Theory of Social Representations as theoretical framework. The study sample were composed by 23 nursing technicians and five nursing assistants. Data collection was conducted through semi-structured interviews, from December 2011 to January 2012. For data analysis we used the discourse analysis, according to social psychology framework.

Results

The meanings attributed to management occurred from the closeness/distance to staff and to patients` care actions.

Conclusions

The managerial nurse, perceived as a process apart from care, is classified as non familiar practice, of hard understanding and valuation.

Management; Nursing; Nursing staff, hospital; Qualitative research

RESUMO

Objetivo

Compreender os significados que a equipe de enfermagem atribui à prática gerencial do enfermeiro nas unidades de internação.

Métodos

Pesquisa exploratória, descritiva, de abordagem qualitativa, desenvolvida em um hospital geral de uma cidade do Sul de Minas Gerais. Utilizou-se a Teoria das Representações Sociais como referencial teórico. A amostra foi composta por 23 técnicos e cinco auxiliares de enfermagem. Os dados foram coletados por um roteiro de entrevista semiestruturada no período de dezembro de 2011 a janeiro de 2012. Para análise dos dados utilizou-se a análise do discurso, na concepção da psicologia social.

Resultados

Os significados atribuídos à gerência são elaborados a partir da relação de proximidade/distanciamento da equipe e das ações de cuidado aos pacientes.

Conclusões

A gerência, apreendida como processo aparte do cuidado, é qualificada como prática não familiar, de difícil compreensão e valoração.

Gerência; Enfermagem; Recursos humanos de enfermagem no hospital; Pesquisa qualitativa

RESUMEN

Objetivo

Comprender los significados dados por la equipo de enfermería a la gestión del enfermero en unidad de internación.

Métodos

Investigación exploratoria y descriptiva con enfoque cualitativo, desarrollada en un hospital general en una ciudad en el sur de Minas Gerais. Se utilizó la Teoría de las Representaciones Sociales como referencial teórico. La muestra fue 23 técnicos y cinco auxiliares de enfermería. Los datos fueron recogidos a través de entrevistas semi-estructuradas, de diciembre 2011 a enero 2012. Para el análisis de los datos se usó el análisis del discurso, en la concepción de la psicología social.

Resultados

Los significados de la gestión son elaborados a partir de la relación del proximidad/separación de la equipo e de las acciones de cuidado a los pacientes.

Conclusiones

La gestión, percibida como un proceso aparte de la atención, está clasificada como práctica não familiar, de difícil comprensión y valoración.

Gerencia; Enfermería; Personal de enfermería en hospital; Investigación qualitativa

INTRODUCTION

The Nursing work has as basic dimensions: care, management and education(¹). The Nursing management has object, objective, purpose, instruments and own means(²), it also occurs in the interrelationship of multiple agents of the Nursing and multidisciplinary team. In this process, the nurse is responsible for joint knowledge development of best care practices in healthcare and nursing services(³), which leads to maintenance of high levels of professionalism with regard to nursing care and management of resources and relationships(⁴).

However, this management, marked by technical and social division of work in a capitalist context, influenced by the model proposed by Florence Nightingale in the nineteenth century, during the profession institutionalization process, and the assumptions of management theories, it has been permeated by the dichotomy care/management(³), which outlines a work process in which the agent who designs and plans care is not the same as the one who applies it(⁵).

In this context, the Nursing work, fragmented among nurses, nursing technicians and assistants, may not be in favor of establishing horizontal relations and the symbolic power disputes may hinder the integration of professional, and fragment knowledge, negatively influencing the consolidation of a model that approximates Nurses to care(⁶).

Moreover, the Brazilian reality, characterized by the high proportion of vocational professional training compared to higher education level, has lead nurses to supervisory and managerial activities. Allied to this, most hospitals in the country are driven by capitalism assumptions and the culture of classical administration(⁶), therefore, they are not predisposed for the solidification of a professional profile able to articulate the managerial and care dimensions. This panorama can contribute so that nurses are primarily devoted to management demands(⁷).

In this sense, the dichotomy care/management has prevailed in the nurses discourse(³,⁸), considering that they have the perception that there is no articulation between the two dimensions, they consider that managerial activities will lead to patient distance, which may result in conflicts with the rest of the nursing staff(⁹-¹⁰).

Thus, a dilemma is created, the nurse work market requires them to be responsible for a series of activities related to indirect processes of care, through administrative activities and, paradoxically, academic and pre-professional experiences prioritize the individualized care education(³).

Experiences built in the teaching profession in the hospital area have reaffirmed that the role of the nurse does not suit well to the ways of thinking of this teamwork. Given the need to rethink the training of Nursing staff, new reflections emerged that are revealed by the following question: What are the meanings elaborated by nursing technicians and assistants about the nursing management function?

To provide answers to this question, this research aimed to understand the meanings that nursing technicians and assistants give to managerial practice of nurses in inpatients hospital units.

METODOLOGY

This research belongs to a greater project of a masters’ dissertation entitled “Nursing Management in the hospital context: the Nurse’s and her/his team`s discourse”(¹⁰). Qualitative approach research, descriptive and exploratory, developed in a general hospital of a Southern city of Minas Gerais (MG). In this hospital, nurses are assigned to managerial activities of care, controlling the physical and material resources of the units, preparation of daily scale, supervision of technicians and nursing assistants, among others.

We used the Social Representation Theory(¹¹) as a theoretical framework. This theoretical framework can contribute to understanding the process of preparing and sharing the common sense knowledge in the sphere of collective productions located at the interface between the individual and the social level. The social representations are assumed as practical and oriented knowledge to understand the world, produced by social subjects on socially valued objects(¹²).

It is understood that the guidance and reorientation of practices are influenced by the ways in which subjects see, think, know, feel and interpret their way of life and their way of living in the world. Thus, the study of representations allows access to the meanings attributed by the subjects, individual or collective, and promotes understanding of how the articulation of interests of social actors occurs and how they are used(¹³).

We interviewed 28 professionals, of which 23 were nursing technicians and five were nursing assistants, they were selected as a convenience sampling. As interviewers proceeded to interviews, they asked participants to indicate co-workers who might be interested in joining the research. The number of participants was delimited by the data saturation criterion.

Data collection was conducted through semi-structured interviews, scheduled and recorded individually, in the work unit, from December 2011 to January 2012. Before the interview, participants were informed about the study’s objectives and they signed the Consent Form (CF). The interview script included the following questions: How do you perceive the role of the Nurse in managing the inpatient unit? How do you think the Nurse work should be in managing the unit?

To organize and analyze the data we used the discourse analysis in the perspective of Social psychology through Mind Maps (MM). The use of this methodological approach is in favor of investigations focused in drafting and sharing social representations(¹²).

The steps followed were: transcript of the interview, which was performed by the leading researcher, floating reading associated with listening to the audio and the discourse mapping through the significant issues identified, these themes are understood as elements of a representation. In this mapping, the interviews were transcribed in full, organized in columns, respecting the order of the discourse in each of the topics and encouraged the understanding of their relationship and analysis of the range of ideas and images presented(¹²).

The study was approved by the Research Ethics Committee of the Universidade Federal de Alfenas - Minas Gerais (UNIFAL-MG) (Protocol 207/2011). To guarantee privacy and anonymity, participants were identified by the letter T for nursing technicians, and A for nursing assistant, followed by an arabic number.

RESULTS AND DISCUSSION

Data analysis resulted in a map composed of the axis “Nurses performance as a manager in the inpatient unit: nursing technician’s and assistant’s point of view” permeated by three sub-themes: “Know-how dimension: closeness and distance of the staff and patients”, “Interpersonal relationship dimension: the nurse who is close versus the nurse who is distant” and “Desired profile dimension: the participant nurse”.

Know-how dimension: closeness and distance of the staff and patients

The managerial practice in inpatient units is given meaning by nursing technicians and assistants, predominantly as a distant practice of direct care, described as bureaucracy and handling of papers. However, dialectically, representations related to the direct care reported to patients’ approach, operational procedures and participation in the work process of the nursing team were found.

[...] sometimes you feel that the nurse should work directly with patients [...], some nurses really work. It is really surprising! For others, when someone says will the nurse work with patients doing everything? - Oh, she/he does! - But nurses do not do that! [...] (T3).

[...] because there are many nurses who just want to come here and work writing medical records [...] they do not help, remain seated studying the chart (T4).

[nurses] do not take responsibility for that role - well I am a nurse so I do not put my hands on it, I do not do that - [...] So, since I started working, they help you, if there is something to be done, they will do it [...] (T5).

[...] There are nurses who I knew that go from room to room talking to everyone, they don`t only look at papers [chart] [...] (A18).

[...] And generally most do not do it, there are few who do it, there are only a few who really put their hands on it, there are people who do not do it [...] (T20).

There are two management practice profiles coexisting, represented as antagonistic, whose framework is closeness/proximity or distance toward direct patient care. There has been opposition aspects between the nurse leader, the one who writes and handles charts and the nurse who cares for and helps the team.

[...] There are nurses who just work with papers [...](T2.)

[...] because many seem to like to write more [...] they do not seem to care much (A6).

[...] Puff! I do not quite know what their function is because most of them only give order and take notes [...] we do not know well what he must do (T26).

[nurse] is not assigned to changing diapers, to prepare medicines, [...] he is assigned to the ward management [...] I do not even know what they have to do, in detail [...] we know that through guessing, as a general idea [...] (T13).

The objectified management as the action of just handling papers appears in the discourse with short adjectives, permeated by hesitations and silences.

The management unrelated from direct care emerges as a function of difficult anchorage in the imaginary universe. Maybe we can understand how, in this representational scheme, management cannot be valued by other Nursing professionals, considering that its purpose is not understood, perhaps because it is not shared. In this management format, the fragmentation between the work design and execution can be repeated(⁵).

The design of how the team thinks regarding management functions of the nurse may refer the difficulty in the identification of their role in care management with the team, despite the fact that care and management are complementary objects of the same work process(⁸)

The paradigm, based on scientific, classical and bureaucratic conceptions of management, prioritizes work fragmentation and seems to subsidize the reciprocal distance between nurses and their team. Not least because the work organization, based on the vertical integration of processes, it is able to generate alienation and worker weakened relations(¹⁴).

The breakdown of theoretical/practical knowledge seems to prevail in the understanding of nursing technicians and assistants on the nursing management practice.

[...] they have to know the practice of the job, there are nurses who do not know it [...] vein puncture, electro, on the procedure part[...] (T9).

[...] They know the theory, so sometimes it is a bit difficult [...] the newcomers have a lot of theory [...], but only theory [laughs]. [...] They come to manage and have never seen certain things that happen. [...] So I think it’s kind of weird. Because you know the importance of practice (T19).

Nursing technicians and assistants claim their role as legitimate of practical knowledge, which refers to the first of the nursing knowledge, regarding technical and procedural decisions(¹⁵).

It is possible that the participants situated technique as a central element in organizing the representation of management because it is from it, operationalized in direct care, that they are able to objectify the know-how of nursing and contrast it to other elements of professional practice.

The foundations of this notion are anchored by the early days of nursing as a profession, in which nursing tasks which predominated were derived from medical prescriptions and performed by assistants’ personnel, and the management tasks required for specialized medical care, performed by nurses. From there, the knowledge of health could be divided into medical knowledge and nursing knowledge, and thus set up by fragmented knowledge, hierarchical and endowed with different complexities(¹⁶).

This scenario provides a fertile ground for conflicts and disputes between staff.

[...] I think everything the higher education nurse does, we do, even if I can’t, I do not even know why, but call to schedule a test, call a doctor to say that his patient is hospitalized here, call and request an ambulance, I think anyone can do this, not only those with higher education [...] What can they do that I cannot? What do they know that I do not know? In fact [...] in theory they know a lot, but in practice ... [...] we know much more (T26).

[...] Sometimes we work as a nurse [...] because nurses have to do electro [...] they have to deal with the infusion pump [...] they have to do a blood transfusion, they do not do it, nursing technicians are doing these things[...] (T13).

Researchers reflect that nursing technicians and assistants have difficulty in accepting the difference in Nurse’s status(¹⁶), as well as the understanding and appreciation of the management exercised by them(⁹).

The positioning of the participants seems to indicate one of the possible ways to resignify the knowledge and practice of the nurse, the path of rapprochement towards direct care through a role of close relationship with the care work process.

[...]Sometimes there are nurses who see this part, keep doing things, for example - Well! let me go there and do the dressing for you! - Sometimes you have a losing vein here and there - Oh, you can go puncture here, I go there and I will puncture it for you (T14).

[...] yes, some of them help [...] we have their support in this regard to puncture a vein, [...] they don`t only play the role of leader and give orders [laughs] [...] (A17).

Interpersonal relationship dimension: the nurse who is close versus the nurse who is distant

We draw attention on the periphery of discourse, the fact of the deponents explain the managing function, associating how the nurse stands in the relationship with the team.

Interpersonal relationships are represented and shaped by the Taylorism and Fordism management styles, settled in a rigid vertical integration and in hierarchy, which impairs collective participation and enhances the fragmentation of work(⁵,¹⁷), and at times, they seem to point to more participatory management approaches(¹⁷).

[...] [There are nurses] who come in and tell you - I cannot do this, Can you help me? - Wow! I think it is great, but if [...] they talk like that - I know!- if you know that they do not know, then a barrier will be created [...]nursing technicians and assistants won’t help (T23).

[...] until now I did not find a mistreating nurse, but I’m already aware that there are some like that... (T16).

[...] Sometimes the nurse is so nice, friendly. They do not give orders, they know how to ask, [you] will never refuse to do something, but they will decline something because it is imposed (T7).

[...] She gives me freedom to reach her and say that I am in need of holidays and sometimes I do not need to say [...] she already realizes that because of my behavior[...] it seems that when the supervisor is good, participant, comprehensive [...] we can do a lot, the work flows well [...] (T10).

[...] [nurses] understand, listen to us, listen to our opinion, because sometimes they are not seeing what we’re seeing [...] (T4).

It is believed that hospital organizations, marked by rigidly hierarchical systems, authoritarian and centralized, determine the conditions of possibility of management exercised by the nurse. This traditional management model establishes barriers to communication as well as manifestation of subjectivity and creativity of workers(¹⁷).

The ability to relate empathetically, cooperatively and mutually is considered characteristic of managerial excellence and, on the other hand, the relational difficulties make them vulnerable to rejection, a negative effect interfering on his relationship with the team(¹⁸).

In addition, vertically integrated and hierarchical relationships, combined with the cultural approach that permeates the reporting relationships can influence the perception of workers about managers, culminating in discomfort or lesser involvement in interpersonal relationships(¹⁸).

Moreover, contemporary management approaches that emphasize the appreciation of the needs of workers and the humanization of interpersonal relationships, have been implemented in health care settings, in order to reduce fragmentation of care, strengthen teamwork and improve the quality of care(¹⁹).

In the sphere of common sense knowledge, workers with complete high school point out that the establishment of horizontal relations favors the working process and the vertical relations distance team members.

However, the fact that the two manager profiles coexist in the minds of interviewed may indicate some focal initiatives undertaken by nurses in an attempt to overcome the ambivalence of a disjointed management function by adopting other models with participatory processes(¹⁷) favoring not only care for the sick person, but mutual care among its agents, guided by symmetrical relations(³).

The desired profile dimension: the participant nurse

It is reincidence in the discourses, as qualifiers of the desired managerial approach by employees, the notes regarding help and the team know-how.

[...] He/she should be more participatory if I’m not doing well, then we should do it together [...] everyone tends to want to grow. [given some problems] Let’s solve it together [...] both of them together in my opinion [nurse and technician] (T1).

[...] He/she has to be participating [...] in contact with patients, because we, nursing technician, have contact [...] I think that has to be followed more [...] (T11).

[...] pay more attention to patients [...] I think it’s not only writing [...] they have to be more present with patients, more with nursing technicians [...] and assistants (A12).

[...] They shouldn`t just stand there, for example, managing the paperwork, let’s face it, these are only papers [...] they should support even more nursing technicians and assistants [...] they should be more present with us, with the patient (T15).

[...] So, I think they have to be more interactive [...] with the team, with those who are there caring, in the direct care for patient [...] (T22).

The team perceives as meaningful participant nurses, the ones who exercises direct care actions.

Thus, the nurse as a professional responsible for the management of nursing care, should be articulated to the nursing staff in the development of this activity, so that all elements are responsible for weaving a network of care, since they share the same work object: the therapeutic care and quality of care(²⁰).

From this perspective, it is understood that management must be organized in teamwork approaches(³) and consider the reduction of hierarchies, more flexible communication and co-responsibility of workers for the results(¹⁷).

A more participatory management approach can contribute to the establishment of bonds between professionals, and promote their appreciation, enabling them to be recognized as indispensable components to the success of activities(²⁰).

Thus, the nursing management that can meet these needs, perhaps, is one that subsidize the practice of the nurse care management of nursing actions(³,⁸), this can be carefully understood as part from the body of knowledge of procedural order, which enables technical success, but also as one which favors the practical success, taken as the value that the actions taken for individuals with a view in the social dimension(¹⁹).

In addition, the nurse is responsible for ensuring the quality and safety of care, therefore, the ability to share decisions and contribute to the development of the nursing staff must be developed, encouraging the members to reflect on their own work, as necessarily, new work process organization requires the engagement of all(¹⁷).

In this sense, management strategies are needed to value vocational training level nursing professionals and their know-how(¹⁷).

CONCLUSION

From the viewpoint of nursing technicians and nursing assistants in the context of the study, the managerial practice of nurses is represented as bureaucratic and distant mainly from care, assuming a nebulous purpose for the meaning of practice and of difficult anchorage in the imaginary universe.

In this universe, other theories coexist, referring to the approach of the nurse towards the working care process, affiliating it to the care management dimension and horizontalization of relations, favoring the overcoming of the dichotomy between care and management.

We point out as limits for this study the fact that it was conducted in one place at a time and setting historically dated moments. Noting the fact that the team considers the instrumental knowledge as central to nursing practice, it is necessary to investigate what possible management strategies and designs are able to reposition the nurse as a fundamental professional who is reference to Nursing know-how.

Given the above, we suggest the planning of researches guided in other methodological approaches, in order to contribute, facing this reality.

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Publication Dates

• Publication in this collection
  2016

History

• Received
  23 Mar 2015
• Accepted
  16 Dec 2015