Leadership in nursing : from teaching to practice in a hospital environment

Objective: To analyze the knowledge of nurses on teaching of leadership in the undergraduate and its exercise in a hospital environment. Method: Qualitative, descriptive and exploratory study. There were interviewed 37 nurses working in a public hospital in the state of Rio Grande do Sul, Brazil. Data were collected through semi-structured interviews and it was categorized according the Thematic Analysis method, using the NVivo software. Results: The nurses recognize leadership as professional competence and mentioned positive aspects related to the leadership formation in graduation, which was obtained from significant theoretical contribution, provided by nursing professors. The institution lacks investments to offer theoretical and practical leadership support. Final thoughts: Teaching leadership during graduation requires transversal approach, as well as strategies of permanent education that potentiate the exercise of leadership in a hospital environment.


INTRODUCTION
Leadership is a skill absolutely necessary in the nursing practice; this ability will enable nurses to influence the staff in order to provide care focused on health needs of users and their families. 13][4][5][6] In this sense, it is important to emphasize the nurse's role in the management of health care, people and health services.However, there are challenges experienced by nurses in the current context, which are related to population aging, since health care has to do with chronic conditions of population; this situation increases demands of care and nurses with necessary skills to provide a quality care. 5Such process occurs in the same way throughout the national context.Thus, it is necessary to change the training of health workers, especially of nurses; they need to obtain competencies with the purpose of assuming new responsibilities.Emphasis is given to the importance of performance in: health care; decision making; establishing horizontal communication processes; exercise of leadership and services management; and continuing education for healthcare professionals.The mentioned competencies do not have a differentiated perspective on the teaching-learning process, from the point of view of students as well as from teachers and managers.
A research study points out that it is necessary to invest in leadership formation; this activity must be integrated to the Nursing Curriculum.Therefore, educational institutions should encourage the development of leadership programs and seek greater integration among health services to promote improvements in practice and organizational culture.
In the national scenario, regarding the formation of leaders in nursing there are actions in the academic field that seek to develop transversal leadership during graduation.However, there are still weaknesses related to the teaching of this competence.In hospital environments, it is frequent to find work overload, lack of autonomy and managers' shortage of incentives to develop permanently professionals, all of that interferes negatively in the exercise of leadership. 7t is emphasized the importance of stimulating the exercise of leadership during graduation and after finishing it, moment when the professional enters the job market.The participation of teachers and administrators can help strengthen the leadership, since it relates to professional relationships competency.
Leadership when stimulated, during the teaching-learning process of nursing students, contributes to obtain professionals with the following characteristics: politicized; critical thinking; reflective; capable of make decisions to resolve conflicts; and capable of potentiating the care given to health services users. 7he development of leaders in nursing is of great importance in academic training and in health services.Therefore, it is proposed the following guiding question for this research: "What is the understanding of nurses on teaching leadership in undergraduate and its practice in a hospital environment?"Thus, the aim of this study was to analyze the nurses understanding on leadership teaching during under-graduation and its exercise within the hospital context.

METHOD
This is a qualitative, descriptive and exploratory study; it was carried out in a public hospital, located in the state of Rio Grande do Sul, in Brazil, which is a standard for the municipalities in the region.
A total of 58 nurses worked in that institution.To define the participants, the following inclusion criterion was adopted: have worked in the hospital at least six months.As exclusion criterion: not been working for any reason (example: health leave, maternity and others) throughout the period of data collection.The number of participants was defined by progressive inclusion, using a saturation criterion, it means, when the answer attended the objective of study and the nurses' opinion on the matter began to be the same and repeat itself regularly.Based on the criteria above mentioned, the study comprised 37 nurses.Participants had the following characteristics: 31 were female and six male; age ranged from 22 to 67 years; and training time from one to 32 years.Out of 37 participants, three had only undergraduate degree, 34 had specialization (seven completed a master degree and three PhD).There were representatives from all hospital units.Data were collected, from January to March 2014, through semi-structured and individual interviews, performed at the study site, with a pre-established date and time.Participants were questioned about the understanding of leadership and their perceptions on teaching leadership in undergraduate and improvements that can be made in that ability in the hospital context.
It was decided to categorize data using the Nvivo software, version 10.0 ® .To analyze the results, it was performed the coded interpretation, using the Thematic Analysis modality (performing pre-analysis, material exploration, treatment of the results obtained and interpretation). 8he study was approved by the Research Ethics Committee of Santa Casa de Misericórdia Hospital, in the city of Pelotas, in Brazil, protocol number 200/2013.It should be noted that, in the research development were observed the ethical principles established by Resolution no.466/12 9 of the National Health Council, which refers to research involving human beings.In order to ensure anonymity, the participants were identified by the letter E (nurse) followed by an ordinal number referring the order of interviews.

RESULTS AND DISCUSSION
From data analysis emerged two categories: Nurses' perception on leadership being taught in undergraduate courses and Exercising leadership in a hospital environment.These categories will be presented below.
Leadership in nursing: from teaching to practice Amestoy SC, Trindade LL, Silva GTR, Santos BP, Reis VRSS, Ferreira VB

Nurses' perception on leadership being taught in undergraduate courses
Regarding leadership being taught during university education, the nurses highlighted the following relevant aspects: how teachers theoretically address to: role of nurses (their position and posture); ethical aspects; attitudes; and ways of leading the nursing team.The following testimonies were obtained.
I think we're well prepared.Of course, day by day you are exposed to realities that are different from academic reality, in which you have to use what is taught inside the academy.Then, face reality and try to make a middle ground of it all, try to fit it in your reality (E4).

Yes, the university certainly helped. In fact, the base of my training for my thinking in this way was the internship time, when I met several teams that worked in several different ways. It is during the training that you decide the type of professional that you want to be (E5).
I thought it was pretty good.When we see theory is one thing, but in practice we see that some are bosses and others are leaders.But, college for me was great, no complaints (E15).

During college, we had a lot of support in that part, talked a lot. In theory, we see what we have to do, the ethical aspects that we cannot forget and that, at times, many people after graduation forget. But, the training gave us a good foundation on leadership (E19).
The testimonies point out positive aspects related to leadership formation during graduation, which had a significant theoretical contribution provided by the nursing professors.It can be seen that the program content provides support for students to approach the topic of leadership.In this way, leadership formation can assist the nurse to exercise this ability in practice, through the given theoretical support.Besides that, in this sense it stands out the importance of integration between teaching and assistance, which aims reducing the distance that exist between the academy and the services.
To facilitate the teaching of leadership, it is advocated education based on dialogue and autonomy which seeks to awaken in the student, regardless of their reality, a critical posture and the capacity of intervening in the world being conscious of her/his power of transformation. 7For this purpose, it is necessary to make changes in the academic field that allow an innovative didactic-pedagogical restructuration, 10,11 in which the teacher will have a fundamental role in the learning process.
In this sense, we must ensure that future nurses must be able to understand the leadership in nursing, in a clear and coherent way, making reference to the services needed by users.In addition, nurses must be capable of critically and reflectively analyze all kind of aspects to promote social changes and make interventions in the health care attention. 10,12Thus, this constitutes a central challenge to the teaching of nursing worldwide.
Besides that, it should be mentioned that leadership is one of the general competencies established by the National Curriculum Guidelines for undergraduate nursing courses, which signals the need for a consistent academic approach and adherence by teachers of horizontal pedagogical practices.This is coherent with the current dynamism of teaching and it should strengthen leadership formation and critical thinking of students; this will enable nurses to act resolutely in health demands of population: in maintenance of a Unified Health System and on struggles in favor of professional categories.
In this study, the respondents stated that they did not consider themselves ready to lead due to fear, insecurity, lack of preparation, and/or knowledge.The youth of nurses was also related to difficulties of becoming a leader.The participants recognized that time of experience and practice is an aspect that enhances the capacity of teamwork and the exercise of leadership.It is emphasized, that sometimes, these capabilities are closely related.

I think it is not. I think I've been learning slowly. You do not leave college and say "because I graduated, I'm a nurse and now I'm going to lead". There are a lot of people who do not know how to lead. There are a lot of newly graduated people who makes many mistakes, fight with employees, got stress for anything or wants to give many commands. In fact, sometimes don't even know where they are working (E9).
Not really, because I think we learn it afterwards, working day by day.Because in the practices, you are a student, but it is not the same thing when you later act as a nurse.

Not really, very little. Usually we will get that experience in every working day. In relation to the course, in this case, I think that the part of leadership we went acquiring experience in each day of work; it gave me more base, in my time; at least I think it was like that. I think it is my every day of work that made me gets this whole amount of experience (E14).
Nurses feel that leadership is strengthened over time and, for this reason, they mentioned difficulties in exercising leadership at the beginning of the profession.A study, carried out in South Africa, evidenced a similar result, which highlighted the lack of coordination and leadership among professional nurses.Based on the results, it was pointed out that there was a need for academic restructuring to enable nurses to be better trained through teaching and practices of quality. 13In addition to that, it was thought that the experiences mentioned by the interviewees is related to: time needed to understand the work process; time to get acquainted with the team members: and, time to master Leadership in nursing: from teaching to practice Amestoy SC, Trindade LL, Silva GTR, Santos BP, Reis VRSS, Ferreira VB technical and relationship skills, which will offer greater safety and knowledge allowing nurses to plan and intervene ethically and professionally.
A study carried out in Australia with nursing students pointed out the importance of leadership as strategy to strengthen and prepare future professionals, which makes imperative that they develop a clear understanding of leadership. 12rom this perspective, we recovered the possibility of including transversal teaching of leadership in the Curriculum that must be adopted during graduation.In addition, there is concern related to improvement of professionals and in bring them closer to reality of work process, which will improve assistance in the current scenario.Also, it is necessary to invest in strategies to facilitate the formation of nurse leaders. 7This aspect gains high importance in debating reformulation of Curricular Guidelines for nursing courses and also provokes reflections on how to implement a continuous teaching of leadership, in a problematizing and provocative way.
Based on Curricular Guidelines, one study 14 deals with advances in the nursing education field.It highlight advances in construction of training process related to population health needs; it is focused on: 1) interdisciplinary perspective and use of active methodologies centered on students (protagonists of the teaching-learning process) to reorganize the curricular components and strengthen the articulation between theory and practice; 2) inseparability of the triptych: research, teaching and extension; 3) diversification of learning scenarios that aims to integrate teaching and services; and 4) evaluation of formative capacity and training of generalist professionals that are capable of acting in various scenarios.It seeks to avoid fragmented visions of reality.
In front of this and considering the extension of possibilities to improve the student in its multidimensionality, it can be affirmed that those advances have a positive impact on the teaching of leadership.However, there is still a need to continually discuss the nursing education, with the aim of preserving and strengthening the advances already made and to face the new challenges that arise at any moment, in the current health care situation.
Another result found relates to interpersonal relationships in the work environment.One participant expressed that during her/his training, the teachers stimulated the distance between the nurse and the team, avoiding a more affective approach, which could impair the progress of the assistance.

I do not remember having much stimulation, I do not remember having much encouragement, but what was very striking in my discipline was not being friends with the people with whom you work with, don't allow approach, don't allow much, let's say, audacity or intimacy. This was what they taught. Not having much relationship. Then, you never sit down and have a coffee with the nursing technicians, this was not a nurse's behavior [...]. And I think today has changed, from what I've seen, it seems that changed (E1).
From the perspective of the current training of nurses, they should be encouraged to have ties and to approach team members, in this way they can feel valued and could facilitate the communication process of the team members. 15,16herefore, it is necessary that nurses improve their potential to develop necessary skills related to leadership, especially in the communication process and in developing organizational climate of support, favorable to the exercise of leadership. 17he leadership of nursing, in an institutional culture is reflected in engaging in dialogue and into creating an atmosphere of openness.Thus, it is up to this professional to support and promote attitudes to become an excellent caregiver, serving the users according to the best practices.The nurse, in the exercise of leadership, needs to consider values, norms, history of the organization, as well as individuals. 18

Exercising leadership in a hospital environment
This study also allowed discussing the technical/practical support on leadership and the permanent training offered by the hospital.These aspects make possible to understand how the process of continuing teaching and the exercise of leadership occurs.The following statements express what nurses understand about this subject.

It is not offered. Because I work in two [hospitals], here, at the hospital, you have almost nothing (E6).
Little or nothing.Because there is no continuing education.Today, there is a sector in the hospital, but I still think it is developing; it may be that it improves.Many times, nurses are not released to go out to take courses.I believe it still needs very much improvement (E8).
Look, we've had some lectures, not many, two at the most about it, but they were very superficial.Already had two or three chapters of a course; they lasted during a six months period and spoke some things about nursing.Some were very specific to a higher level; they explained something about the difference of leadership, but nothing very specific (E18).
Look, I think that sometimes there is a conference, but there is not a permanent education.I think that continuing education has a schedule that should be followed (E20).
Leadership in nursing: from teaching to practice Amestoy SC, Trindade LL, Silva GTR, Santos BP, Reis VRSS, Ferreira VB Based on the statements, it can be affirmed that all the participants consider that the institution has weaknesses regarding incentives for permanent development of professionals.In the testimonies, there are important obstacles that impair continuing education of the workers.
It's worth mentioning that permanent education has been considered an important instrument for development of workers; this teaching tool stimulates the critical thinking of nurses and guides their actions through knowledge that is in constant transformation.
In this way, permanent education considers the needs of work environment and it is developed contemplating the daily problems identified in the current reality.This type of education seeks to contribute to the world of work by transforming it and at the same time transforming the worker.However, even with the creation of National Policy for Permanent Education, more than ten years ago, there are still difficulties to implement it in health services; 19 it can be verified that its greatest legacy is not in operating or implementing strategies for permanent education (inside different health scenarios in the complex and diversified Brazilian territory) but in the reflections on theoretical structures that incentives the formation of Brazilian health professionals.
Even considering the weaknesses highlighted, some participants believe that nursing administration has mobilized resources to invest in permanent education of Brazilian professionals; although, nurses are aware that those investments are an incipient proposal.
About leadership, we are in another process, which is to bring a little more updating and innovations into our work process.I believe that, currently, the institution with new direction and with aspects even about nursing management is looking for possibilities to discuss a little more with the nurses about those issues (E10).
Recently a permanent education project was implemented here in the hospital.Management wants to insert working professionals as instructors of permanent education.A professional who wants to present some subject, some relevant topic and shows interest in it, should contact the communication sector and schedule a presentation [...].Now we are having some more support, but this is a recent event, it happened after the change of the hospital administration (E28).
The hospital has been changing a little bit with new management.It has been investing more in professional training.When I joined the hospital, management did not invest much in professional training; now they offer courses.We have now the management closer to the team.Today, it's already starting, in a very slow way, but it's already starting to prepare professional for day-to-day situations.Then, this is not ideal, but it has already improved a lot (E32).
The way managers understand and conduct the process of permanent education can encourage or prevent its implementation.One study carried out in Japan highlights that managers have understood the importance of intellectual stimulation in health services.This incentive, at last, allows increasing affective commitment of nurses with the team and to distribute tasks among them equally; the effects of improving personal satisfaction of workers and the services they offer to users are reflected in better provision of health services. 6or this reason, the importance of including permanent education in health services is reinforced through sensitization of managers and professionals; besides that, permanent education stimulates the participation of educational institutions in developing postgraduate courses and in creating strategies of social control.With the understanding that workers are agents that can transform reality and in order to increase quality care, it is necessary to offer professional improvements and promote spaces for professional growth. 7Besides that, permanent education can open new forms of dialogue and interaction within the team; it can also fill in voids in processes of training and sharing knowledge; thus, adding new perspectives for leadership and to provide health care.
With the intention of guaranteeing development of skills necessary for leadership, nurses need to have easy access to education through contemporary high-quality educational programs that strengthen clinical and management skills. 3,4,20herefore, it is necessary to provide a safe, effective and encouraging working environment, in which it could be recognized the importance of leaders with positive behaviors that accept the leadership responsibilities. 21Due to the dynamic and the modern environment that are intertwined with the profession, the identification and developing of nursing leaders has huge value. 22n this study it was evidenced that it is necessary to have leadership in all levels of nursing.This ability has been associated with better work culture, personal satisfaction and, above all, more quality in the health care given to users.One study highlights the importance of adopting programs to develop leadership with emphasis on clinical practice.The impact on clinical leadership is essential, since it affects personal satisfaction and quality of health care. 23esides that, nurses who are leaders and have clinical knowledge are essential to succeed in health care initiatives, since good leaders help to produce good health care.On the other hand, professionals with difficulties to lead will provide poor services; this aspect is also observed in the academic, political and nursing administration fields.With identification, support and appropriated development, future nursing leaders will be empowered to collaborate in achieving important nursing goals: excellence in the profession and nursing care centered in the person. 22eadership in nursing: from teaching to practice Amestoy SC, Trindade LL, Silva GTR, Santos BP, Reis VRSS, Ferreira VB

FINAL CONSIDERATIONS
This study sought to analyze nurses understanding on the teaching of leadership in undergraduate and its practice in hospital context.Regarding the academic education, participants mentioned positive aspects related to leadership formation in undergraduate studies by means of significant theoretical contribution provided by nursing professors.It is important to consider that programmatic contents given in teachinglearning processes, provides assistance by approaching the leadership theme to students; as a consequence, they can help professionals to exercise this ability in practice.
However, it was found that development of leadership is strengthened with experiences lived in the daily work of nurses.The experiences mentioned by participants may be related to: time needed to better understand the work process; team-based approach; mastering technology and relational skills; improve security; and knowledge acquisition, which allow nurses to plan and intervene in health services.It was evidenced that hospitals offer few investments destined to theoretical and practical support on leadership and to permanent education promotion of professionals; generally, the investments limited to specific activities and without periodicity.
Continuing education could be thought of as strategies in favor of processes to build leadership and to qualify the care given by nurses.However, hospitals need to encourage the process of permanent education, since it enhances the teamwork qualification and makes healthcare practices more efficient.These institutions should also engage in implementation and development of leadership programs.
In this research the adoption of interviews as the only technique of data collection could be considered as a study limitation.In addition, it is suggested to carry out additional studies to observe in practice the exercise of leadership by nurses or also the use of group techniques; with the obtained information will be possible to contribute more to idealize strategies that could help developing leadership in nursing.
It should be emphasized that the results of this study have implications in the professional practice of nurses.In this research was analyzed the nurses leadership and the aspects that need to be improved during formation and training of nurses; aspects that are intended to strengthen the development of leading.The teaching of leadership should begin in under-graduation and continuing after finishing studies, moment in which professionals enter the labor market.These results deserve closer examination in academic settings and in health care services.