Human capital in the nursing management of hospitals*

Objective: To analyze how the components of human capital are used in the nursing management of hospital organizations. Method: This was an exploratory and qualitative study. Data collection took place between October 2014 and May 2015 using semi-structured interviews. The data were analyzed according to content analysis. Results: Twelve nurse managers participated. The components of human capital used by the nurses in personnel management were: during the hiring process, when requiring specialized education in the field and prior professional experience; when retaining talents with promotion strategies; in building capacities of professionals through support and training; and in collective work to construct processes and outcome assessment. Conclusion: The components of human capital need to be managed strategically with a focus on professional skills and development, with the aim of transforming individual and collective knowledge into new technology.


INTRODUCTION
The strategic use of Human Capital (HC) in nursing management contributes to increasing development and innovation of nursing work and the resulting economic and social value of hospital organizations. The knowledge, and management and decision-making skills of managers influence organizational outcomes and performance (1) .
Human capital is one of the components of intellectual capital and involves the capacities, skills, experiences and knowledge of all the processes involved in the work dynamics. These elements are developed through investments in education, training and experiences provided by companies with the objective of fostering creativity, innovation and organizational growth (2)(3) .
Nurse managers are responsible for balancing work relationships, disseminating the institutional philosophy, ensuring suitable conditions for implementing quality of care, promoting ongoing education and professional qualification, and facilitating and executing organizational changes in all work environments (4)(5)(6) .
With the experience and knowledge gained through participating in the strategic decision -and policymaking, it is believed that nurse managers should be able to use human capital components in management, whether implicitly or expressly. When strategically applied, these components add value to intangible hospital assets.
The nursing team contains the greatest number of professionals within hospitals. In addition to the complexity of the job, nurse managers also need to evaluate technological, organizational and human resources. These are necessary to knowledge creation and management, which includes identifying, using and incrementing strategies to develop HC within hospital organizations (4,7) .
Companies that do not adopt management policies aimed at valuing and developing its professionals face difficulties when competing and setting themselves apart in society, as personal development and satisfaction at work are positively correlated with productivity, given that workers transform the company's potential capability into actual capability.
The objective of this study was to analyze how human capital components are used in nursing management of hospital organizations, considering that the management process has been impacted by scientific and technological advances of a globalized world, requiring a focus on the potential and value of human beings and the development of their professional actions as an important strategy for organizational growth, better performance and achieving results when meeting the needs of clients.

METHOD
This article was extracted from a larger qualitative study called Capital Intelectual na Gestão das Enfermeiras em Organizações Hospitalares (Intellectual Capital in the Nursing Management of Hospital Organizations), which describes and interprets the experiences of nursing managers in nine hospitals in the city of Salvador, northeast Brazil.
Non-probabilistic or intentional nursing selection was used to select the sample, which consisted of 32 nurses in management positions in hospital organizations in Salvador at the time of data collection, which was between October 2014 and May 2015. After identifying and locating these managers, they received invitations by e-mail and social networking sites explaining the study's intent, objectives and importance of their participation. Of these nurses, 12 did not reply, two said they were not available to participate, two were on vacation, one on maternity leave, and three said they were waiting for permission from the hospital's research ethics committee, which never replied.
In light of the above, 12 nurses were interviewed: five from public hospitals, four from private hospitals and three from philanthropic hospitals, all of whom occupied positions in nursing management, including coordinators, managers, directors and advisors, and who had at least six months of experience in the position, considered by the researchers as enough time to be fully integrated into the organization and therefore more confident in the management process as they had created institutional policies. Mean time in management position ranged from 5.8 to 10 years. Managers on vacation or leaves of absence were excluded.
The interview consisted of the following question: Describe how you use the following five components of human capital in your management practice: talent retention; knowledge/skills/capacities; education level/development/investment in education; organizational environment/ interpersonal relationships; and innovation.
With the participants' consent, audio recordings were made of the interviews using the researcher's mobile phone in order to capture all verbal information. The interviews lasted an average of 30 minutes and participants were seemingly comfortable in reporting their experiences as managers in relation with the HC components. At the end of the interview, the participants were given the chance to listen to the recording before authorizing its transcription.
This study was approved under ruling no. 812.679 of September 30, 2014, and abided by the directives and norms that regulate research with human beings as per Resolution 466/2012 of the Brazilian National Health Council (8) . After receiving the necessary explanations, the participants signed free and informed consent forms in duplicate -one copy was given to the participant and one remained with the researcher. To preserve the identity of those interviewed, an alphanumeric system was used, with M for manager followed by a number corresponding to the order of the interview, from M1 to M12.
The data were analyzed using content analysis (9) in the three following stages: pre-analysis, exploration of the material, and data processing, which includes interpretation and inferences.

RESULTS
The participating nurse managers used HC components within the hospital context, identified in the category of personnel management. From this category, four subcategories emerged, namely: the hiring process, talent retention, professional training, and collective work.
www.ee.usp.br/reeusp Rev Esc Enferm USP · 2017;51:e03232 The hiring process The managers declared using the following criteria when hiring nursing professionals: mandatory specialized education in the desired field and previous professional experience, particularly in specialized care units. They align professional profile with the vacant position and conduct employee training in the form of courses, following standard organizational programs. These courses present basic content on topics related to the type of service to be provided, such as: hospital-acquired infections, patient safety, ethics, organizational norms, and protocols:

TalenT reTenTion
The managers also use promotion strategies to retain talents by offering management positions, designating professionals to work in areas of interest and maintaining a favorable work environment. They also reported losing talents due to salary problems, job stability and shorter workdays, as shown in the following excerpts: When I identify talents, I pair up with the management area to find them a management position, to occupy a management vacancy, based on knowledge, technical skills and relationship skills (M8).
People end up choosing to stay here because they understand that the work environment is a healthier environment than that of other institutions (...) (M2).

professional Training
The managers revealed that they promote professional training among the organizations' nursing staff when they conduct training sessions and support professional selfdevelopment, considering the service's specialties and necessities, as well as occupied positions. Formal training predominated, with lecture classes and group discussions conducted by coordinating, head or reference nurses. Some examples are shown in the excerpts below: We provide on-the-job training (...) every two months we conduct training sessions with 100% of the team (...) we have forums (...) to discuss a given topic (...) employees are trained by the reference nurse (M4).
Group studies with coordinators every two weeks, every Wednesday afternoon we have study groups, to improve knowledge (...

collecTive work
The managers coordinated collective work by involving professionals in planning, in the construction of work processes and assessment of performance results. This strategy contributed to an efficient and effective organizational environment that took interpersonal relationships into account. All the changes we made, we always made as a group, we even had a pilot project, a pilot unit, implementing decisions and assessing them before expanding (...). I can't work by myself, and I think the work needs to be done as a group, with feedback (M8).
We are very focused on interpersonal relationships; we have a great training session that addresses interpersonal relationships, teamwork; nothing technical, just the relationships between people (M4).

DISCUSSION
Currently, personnel management policies and practice tend to focus on human potential, an important strategy for organizational development, performance enhancement and good outcomes when meeting the needs of clients.
Personnel management focuses on the development of an organization's professionals and involves capacity building, training, and strategies to involve workers in the production process. This management activity favors honing talents through processes that develop and care for an organization's human capital (10) . Thus, it includes the recognition of workers by the organization and employee professionalism to achieve higher levels of production and performance.
The managers in this study used HC components in personnel management when conducting the hiring process, retaining talent, training professionals, and developing collective work with professionals geared towards organizational performance.
The hiring process used by the managers includes selecting and training employees. The managers of private hospitals conducted the selection process based on pre-defined criteria for available positions, such as: specialized education in the area, time of experience, professional profile, and the selection of nurses with internship experiences in nursing services. The nurse managers in public hospitals only selected personnel when hiring temporary professionals and used the same criteria as managers in private hospitals.
Nurse managers must ensure that professionals have the necessary knowledge and skills associated with client care, whether patients are in critical conditions or not (11) .
In the hiring process, one of the important elements of human capital, managers have the opportunity to select talents based on criteria that identify them. During this phase, the process of constructing the foundation of HC starts.
Specialization programs help professionals study and acquire important and consolidated knowledge in a given area, but they do not ensure the acquisition of the expertise needed to conduct their practice with competence. Many of these courses provide degrees but do not qualify professionals, as they do not provide practical experiences in real work environments. Thus, holding a degree is not enough; the candidates must be tested on the knowledge required to effectively exercise the activities assigned to the position.
Regarding the requirement of previous experience in open units, such as hospital wards, and clinical and surgical units, the managers tended to require three to six months' experience; these units do not care for clients in critical health conditions, and the care provided uses light-hard technology. Specialized knowledge, which originates from professional experience, is essential to understand how nurses construct their thinking about technology. Care provided by non-qualified professionals can result in oversights or under-use of such care technology, and the unfounded use of such technology can harm the health of clients whose vital functions are susceptible to instability (11) .
Developing HC requires retaining and strengthening talents, a process that begins with identifying professionals with expertise, and then requires planning and the implementation of strategies to retain them in the organization. Thus, talented professionals must possess knowledge, experience, power of innovation, values, skills, culture, and incorporate the organization's philosophy, coupled with work capability.
It is understood that in nursing, management, and care positions in areas considered critical require greater time of experience in the position, so that professionals can act with autonomy and safety, a period that may exceed six months. Studies have shown that nurses with experience in caring for clients, and who use technological devices, tend to exhibit more confident practice, while those with less experience find it hard to coordinate the use of technology, well-grounded use, with patient care (11) .
Employee training is a resource that aims to adapt new professionals to the organization and teach them care regulations, routines, procedures and directives. Even though it is a laborious process, it results in significant gain both for professionals and for clients and the organization (12)(13) .
The participants mentioned healthy work environments as key to retaining professionals. The organizational environment is influenced by people's way of being and behaving, thus, negative environments harm cooperative focus and group integration, hindering the progress and motivation of professionals. When the environment is positive, however, it fosters exchanges, participation and collaboration (14) .
A positive work environment represents an important motivational factor for professionals to better develop themselves in their work using proactivity. Coupled with learning, innovation and graduate programs, such environments function as a retention strategy that should be part of organizational development and commitment plans (15)(16) .
Nurse managers lacked autonomy to raise wages among their teams, and this was seen as a critical point that was out of their sphere of action. Low wages negatively impact talent retention, and therefore, issues related to wages and limited management powers were recognized as important elements determining the effectiveness of the talent retention process.
It is recommended that talented professionals be rewarded financially, as this is highly valued by many professionals. However, this strategy only serves as encouragement, not a motivation, as it represents a temporary stimulus that loses strength over time. Financial rewards do not take into account social context, which needs to meet the new demands that emerge in the lives of these professionals over time.
Thus, there are many ways for managers to reward talented professionals, such as keeping an open relationship between management and team members. This allows for professional autonomy, room for growth, dialogue, and participation in all organizational decisions, and job satisfaction. Furthermore, professionals can assist in workload maintenance and establishing adequate workdays.
Private organizations lose significant talents to public hospitals when they hold civil servant entry exams, as public organizations require lower workweeks and provide job stability. Loss of talent and the consequent higher rate of turnover must be avoided in organizations, due to the high costs of selection processes, investment costs to train new employees, and loss of human capital, represented by the professional expertise. When workers leave an organization and no longer contribute with their talents to organizational development, continuity of care is lost, affecting quality of care.
A study on turnover costs among a teaching hospital nursing team showed that the financial impact of lost employees was three times the mean nursing wage, indicating the need for improving personnel policies aimed at nurse retention (17) .
For decades, nursing personnel management has employed active employee training, a low-cost practice for organizations, in that it makes use of already existing facilities and teams. Training activities include: lectures, seminars, videoconferences, audioconferences, courses, and scientific events. Uniform and mechanistic practices should be avoided, and workers should be encouraged to actively participate and reflect on their actions. Quality indicators of organizational training include the amount expended and the number of workers trained (18) .
Training strategies must be applied 70% on the job, 20% through coaching and mentoring actions, and 10% through formal training (16) . As shown in this study, the managers opted to support self-development and making work schedules/shifts flexible; to negotiate openings in courses with educational institutions, and encourage professionals to attend these courses. A study showed that investments www.ee.usp.br/reeusp Rev Esc Enferm USP · 2017;51:e03232 in professional knowledge are important to productivity of services in organizations, and their benefits far outweigh the resources invested, positively impacting care outcomes (19) . Organizations must focus on the quality of professional education and training and avoid dispersing the necessary information to develop knowledge and compromising the quality of HC. A study confirmed that organizations that invest in professional development present higher levels of nursing HC, associated with higher levels of quality of client care (20) .
The managers defined collective work as work that involves the participation of professionals to construct and re-construct work processes, in which decisions are debated with and receive feedback from all of the staff. Shared work creates situations in which professionals are summoned to make decisions about their own practice and also favors the performance and quality of nursing services.
Effective communication and the maintenance of good interpersonal relationships positively impact the organizational climate and foster the development of shared nursing work. Knowing how to develop collective work is an important and essential pre-requisite for nursing professionals, a skill that is learned through experience and managerial conduction (21) .
To develop HC management strategies, managers must be aware of which competencies and resources are essential to developing collective work, and how to obtain and retain them. Furthermore, they must know the type of environment needed to favor a network among professionals in which information and knowledge is shared. Above all, nurse managers must identify how to develop effective relationships with clients, such as by measuring the outcomes of implemented processes and projects and how to reward professionals (22)(23) .
A harmonious work environment promotes a constructive behavior, which contributes to increased productivity and quality of life of employees. This is especially true in the field of nursing, in which tasks are primarily collective. It is essential that relationships be based on dialogue, and that professionals understand that interpersonal conflict interferes with continuity of care, leading to inadequate conduct and negligence (24)(25) .
The nurse managers in this study displayed commitment to staff participation, capacity building, and HC engagement and development, despite the limitations of the organizational policies to which they were bound.

CONCLUSION
The human capital components used by the managers in personnel management were: talent retention, knowledge/ skills/capacities, education level/development/investment in education, organizational environment/interpersonal relationships and innovation. These were used when developing activities related to the hiring process, talent retention, professional training, and collective work.
However, for these actions to be effective in developing HC in nursing, managers must strategically manage team knowledge, focusing on professional competencies and development to transform individual and collective knowledge into technological innovations. In so doing, they can meet organizational objectives and promote the nursing profession by increasing the visibility of its work product.
Limitations of this study include the impossibility of generalizing it to the universe of hospital organizations.
This study contributes to the development of nursing professionals involved with personnel management, by focusing on human potential and value in organizational growth as a relevant strategy for improving performance and achieving good results.