Leadership and empowering behavior: understandings of nurse managers in Primary Health Care

Abstract

Objective

To understand the empowering behavior of nurses in their management practice in the Primary Health Care context.

Methods

Exploratory qualitative study of nurse managers working in Basic Health Centers in a city in the state of São Paulo, Brazil. Semi-structured interviews were conducted for data collection and the content of interviews was fully transcribed. Data collection was ended after reaching theoretical data saturation in the seventh participant. The content analysis framework guided the organization of the qualitative corpus into themes and sub-themes.

Results

As leaders, nurse managers use empowering behavior to interpret their perceptions and attitudes in order to positively influence teamwork and mediate conflicts. Staff sizing and difficulties in holding team meetings and sharing decision-making processes generate challenges that create tension in the implementation of empowering behavior.

Conclusion

Aspects related to the management work of nurse leaders in Basic Health Centers are understood as empowering behavior and the challenges for its implementation are related to the organization and planning of the work process in Primary Health Care.

Leadership; Nurses; Empowerment; Primary health care; Health service administration

Resumo

Objetivo

Conhecer o comportamento empoderador do enfermeiro em sua prática gerencial no contexto da Atenção Primária à Saúde.

Métodos

Pesquisa exploratória de caráter qualitativo realizada com enfermeiros-gerentes que atuam em Unidades Básicas de Saúde em um município do estado de São Paulo, Brasil. Foram conduzidas entrevistas semiestruturadas para coleta de dados e o conteúdo das entrevistas foi transcrito na íntegra. Utilizou-se a saturação teórica de dados para o encerramento da coleta que se deu no sétimo participante. O referencial da análise de conteúdo guiou a organização do corpus qualitativo em temas e subtemas.

Resultados

O enfermeiro-gerente como líder utiliza do comportamento empoderador para interpretar suas percepções e suas atitudes, para influenciar positivamente o trabalho em equipe e mediar conflitos. Dimensionamento de pessoal e dificuldades em realizar reuniões de equipe e em compartilhar os processos decisórios geram desafios que tensionam a efetivação do comportamento empoderador.

Conclusão

Aspectos relacionados ao trabalho gerencial do enfermeiro-líder nas Unidades Básicas de Saúde são compreendidos como comportamento empoderador e os desafios para sua efetivação relacionaram-se à organização e ao planejamento do processo de trabalho da Atenção Primária à Saúde.

Liderança; Enfermeiros e enfermeiras; Empoderamento; Atenção Primária à Saúde; Administração de serviços de saúde

Resumen

Objetivo

Conocer el comportamiento empoderador de los enfermeros en su práctica gerencial en el contexto de la Atención Primaria de Salud.

Métodos

Estudio exploratorio de carácter cualitativo realizado con enfermeros-gerentes que trabajan en Unidades Básicas de Salud en un municipio del estado de São Paulo, Brasil. Para la recopilación de datos, se realizaron entrevistas semiestructuradas y se transcribió su contenido completamente. Para finalizar la recopilación, se utilizó la saturación teórica de datos, que sucedió con el séptimo participante. El marco referencial del análisis de contenido guio la organización del corpus cualitativo en temas y subtemas.

Resultados

Los enfermeros-gerentes como líderes utilizan el comportamiento empoderador para interpretar sus percepciones y sus actitudes, para influir positivamente el trabajo en equipo y para mediar conflictos. El dimensionamiento del personal y las dificultades para realizar reuniones de equipo y compartir los procesos decisorios generan desafíos que tensionan la materialización del comportamiento empoderador.

Conclusión

Los aspectos relacionados con el trabajo gerencial del enfermero líder en las Unidades Básicas de Salud son percibidos como un comportamiento empoderador, y los desafíos para su materialización se relacionan con la organización y la planificación del proceso de trabajo de la Atención Primaria de Salud.

Liderazgo; Enfermeras y enfermeiros; Empoderamiento; Atención primaria de salud; Administración de los servicios de salud

Introduction

In the National Health Service (Brazilian SUS), Primary Health Care (PHC) acts as the coordinator and organizer of care in the logic of Health Care Networks, being resolving and the basis of the system. This PHC has several models, such as Family Health Units (FHU), traditional Basic Health Centers, as well as mixed Basic Health Centers, which integrate work processes of the Family Health Strategy (FHS) with the traditional model for the same population.( ¹ )The FHS model, which is a priority in Brazilian health policy, focuses on comprehensive care for the registered population in an attempt to break with the hegemonic model.

Nursing is a driving force within this context both because it is the largest workforce and because of nurses’ resoluteness based on their technical-scientific competence.( ² , ³ )Management, care and education activities are among nurses’ attributes, and these are inseparable from their routine.( ⁴ )The fact that most Health Centers are managed by nurses is also noteworthy.( ⁵ )Despite the importance of empowerment in nursing management practices, there are still few studies in the context of PHC both in the national and international literature.( ⁶ , ⁷ )

The essential competence to manage a health center is leadership, since the management of health services is expected to be participatory.( ⁵ )Despite the weaknesses identified in its conceptual aspect, for example, through different definitions, styles and theoretical contributions, leadership appears as a transversal and fundamental element in nurses’ work.( ⁸ )

Transformational leadership is a style related to the development of skills of leaders and their teams. It broadly relates to nursing by inspiring and empowering those led from the collective and the mutual trust established between the entire team towards the achievement of goals and objectives by supporting institutions in the reach of results.( ⁹ )

Thus, empowerment theories have been associated with strategies that enable leaders to achieve results in their work context( ¹⁰ , ¹¹ )and arouse nursing’s interest in articulating these theoretical frameworks in the management practice.

The leader’s empowering behavior has been the subject of research in the field of Nursing for approximately four decades. The construct was developed from the need to investigate the practice of empowering subordinates as a component in the process of leadership and management of organizations.( ¹² )

In a study completed in 2017, the Leader Empowering Behavior (Likert scale type) was adapted and validated to Brazilian Portuguese. It has 21 items distributed in four domains: meaningful work; participatory decision making; employee trust; facilitating the achievement of goals. This instrument makes it possible to know the behavior of the leader in order to empower the team, showing the association between the leading style with the efficiency of results presented by followers, a healthy work environment and patient safety.( ¹² )

Empowerment related to organization of the service can be conceptualized from structural and psychological dimensions. Structural empowerment concerns the mobilization of resources and achievement of goals by nurses, based on access to information, support, resources and opportunities. In short, access to information refers to knowledge focused on the profession and position; access to support is the support obtained from staff and superiors; access to resources is related to the ability to obtain material resources; and finally the opportunity, which involves moments that provide learning and development to workers. Psychological empowerment, on the other hand, is linked to working conditions, that if appropriate, bring appreciation, motivation and professional satisfaction.( ¹³ )

Lack of management support, overload of activities due to the accumulation of care and management, appreciation of the volume of care to the detriment of the quality of care offered, and interpersonal conflicts are difficulties and challenges that cross the work of nurses in PHC and reflect the structural and psychological dimensions of empowerment.( ¹² , ¹⁴ )In addition, the low retention of medical professionals, work processes with vertical interference by the coordination, absence of systematic spaces for continuing education, and lack of career plans and professional incentives.( ¹⁵ )

In the international context, contributions of the leader’s empowering behavior are observed in management processes such as job satisfaction,( ¹⁶ )professional commitment,( ¹⁷ )creativity and a favorable environment.( ¹⁸ )Its application has been explored in the training of nurse-leaders by enabling self-assessment of the performance of empowering behavior and the reflexes in the teams.( ¹⁹ )

Therefore, since PHC is the main level of care in the Brazilian SUS and must be resolute for most of the population’s health needs, studies involving the empowerment of nurses in management practice are essential, since they contribute to professional satisfaction and the quality of care.( ⁶ , ⁷ , ²⁰ )

Studies focusing on the empowering behavior of the leader associated with the current interest of leadership in management processes of nurses working in the context of PHC are scarce in the national territory. In order to guide this study, we proposed to answer the research question: how do nurse managers of Basic Health Centers understand the empowering behavior for the exercise of leadership?

Aiming to understand the empowering behavior of nurses in their management practice in the context of Primary Health Care, we expect this questioning will contribute to knowledge about the role of the empowering behavior of the nurse leader in the management context of PHC services, advancing in the incorporation of this construct in processes of initial and continuing education, as well as in the critical reflection about leadership in Nursing.

Methods

This is an exploratory qualitative study( ²¹ )in which the empowering behavior in leadership performed by nurse managers in the context of PHC was the object of investigation. It was based on the items proposed by the Consolidated criteria for reporting qualitative research( ²² )to ensure methodological rigor.

The study took place in a medium-sized municipality in the hinterland of the state of São Paulo with approximately 195,000 inhabitants. Regarding PHC, approximately 58% of the population is covered by it, with 17 Basic Health Centers under management of a Social Health Organization responsible for hiring and supervising all professionals involved in PHC.

Each Basic Health Center has a nurse who acts as Technical Responsible and service manager. Based on intentional sampling,( ²³ )the 17 nurse managers were invited to participate in this study, but two of them refused due to lack of time. Thus, 15 nurses accepted and according to data saturation criteria, seven were included in the study.

Initially, a time was scheduled with each participant separately at their workplace for preliminary explanations about the study, clarification of doubts and obtention of participants’ verbal acceptance. Then, a date and time for the interview were agreed upon, according to participants’ convenience.

The data collection period lasted between March and May 2018. It was conducted by a female researcher graduated in Nursing and a master’s student who had no previous relationship with participants. The collection procedure began with the reading and signing of the Informed Consent form. Afterwards, the researcher asked the first questions of the data collection instrument addressing demographic (sex, age, self-declared color, marital status, number of children), occupational (workplace, weekly workload, working time in the institution) and academic (education and academic level) characteristics of participants.

At the end of this first part, in-depth interviews were conducted with orientation of open and guiding questions. Such questions were based on domains elucidated in the Leader Empowering Behavior scale and on resources used by the leader so that followers perceive the work developed as significant and the established goals are achieved.( ¹² )

All interviews were audio-recorded and fully transcribed, lasted an average of 30 minutes and took place in a private environment at the Basic Health Center where the participant was working. An alphanumeric code consisting of the letter “N” followed by a digit for presentation of excerpts from the interviews was assigned to ensure participants’ confidentiality.

Data from interviews were processed according to the methodological framework of content analysis proposed by Graneheim and Lundman, which involves reducing the text and preserving the nucleus of meaning and essence of discourses, called condensation. It comprises the following steps: Units of meaning; Unit of condensed meaning; Interpretation of the unit of meaning; Subthemes and themes.( ²⁴ )The phenomenon studied was interpreted in the light of the theoretical-conceptual framework of empowerment.( ¹⁰ , ¹³ )

In consideration to ethical precepts, the present study was approved by the Research Ethics Committee on 20/03/2018 under number 2.558.970 (Certificate of Presentation of Ethical Appreciation: 82299318.9.0000.5411). All participants were informed of the details of the study and consented to their participation by signing the Informed Consent form, respecting Resolution No. 466 of the National Health Council.( ²⁵ )

Results

Participants in the study were seven nurse managers aged between 28 and 46 years, six female and one male. Five participants declared themselves as white and two as mixed race, four had children, three were married, three were single and one was divorced. Regarding occupational aspects, all worked 40 hours per week in an institution. Three participants affirmed they had been working in PHC for 3-5 years, and four for 10 years. With regard to training, no participant reported having a postgraduate degree in management. The analysis of the qualitative corpus allowed the construction of two central themes related to the empowering behavior of the nurse manager in the context of PHC, as illustrated in figure 1 , which presents the clipping and grouping carried out from the content analysis used.

Figure 1
Presentation of themes and subthemes

The theme “ Nurses as leaders and their performance in the work process ” expresses the attitudes and actions of nurses in the performance of their leadership, as well as their influence on teamwork. From participants’ perspective, these elements have a significant and positive impact on their empowering behavior. Acting as a service manager leads to an accessible and flexible exercise of leadership, weighing opportunities of collective decision making with the team at times or of a more directive action at other times, so that activities are performed in services.

We have to be accessible, the leader has to be flexible, has to have empathy with the employee, he often has to put himself in their shoes, both in employees’ and users’. And has to be democratic! The thing cannot be rigid by setting rules and just being his way. (N3)

[...] there is a work process that cannot be changed and adapted. So, there are things we inform [impose] and others that we share to see what we’re able to implement. (N4)

The leader’s empowering behavior was identified as a facilitator for the achievement of goals and indicators by the team. To that end, the actions of coordination of the work process need to be planned and implemented in a way that allows professionals of the team to understand the coordination between objectives of the service and those of the institution. This way, tasks can be shared collectively, encouraging the participation of all those involved in the execution of proposed activities. By coordinating this process, the leader has the possibility to involve employees and make them co-responsible for the results achieved.

The goals, we always work with protocols, using tools to illustrate those goals numerically, spreadsheets, lists so they visualize their goals, I think this way it is better for them to achieve such a goal. (N4)

We try to provide feedback and ask them how we are going to do it, for example, to reach the indicator of children aged 0-2 year, so I present them the problem and they give ideas, and then, we put them into practice as long as it does not deviate from what is standardized by the health department. (N6)

Understanding the purpose of assignments at work encompasses a skill performed intentionally by the nurse leader. This performance requires decentralization with concomitant sharing of work actions and, in particular, having the ability to deal with the initial challenges arising in the implementation of change processes. Over time, the benefits begin to be observed and those involved acquire a greater degree of autonomy and involvement to act in decision-making processes.

I gave each one an assignment, because it was all connected to the nurse. If the nurse wasn’t there, nobody did it, so I tried to give each one an activity. At first [...] I faced a little resistance, because they were used to really centralizing everything on the nurse, but then they started to like it, [...] then, they started to see they had the power to manage that activity. (N1)

Empowering behavior for leadership appears as a strategy for building resolutions and sharing responsibilities. In this context, the inherent communication in interactional processes is essential for nurses’ empowerment, as it is related to an individual’s ability to mediate, make and influence the decisions discussed in the team and the possible conflicts that may arise between members.

They usually bring me a lot of problems expecting a solution from me. I like to work in a way that they bring the problem, but I also make them try to bring the solution. Not me coming up with the solution for them, because this makes it easier for them. (N2)

Here, the resolution of conflict we first try to seek in the conversation, I think it is important to always listen to both parts, and in a second moment, put the parts to talk together. (N4)

In addition to the role of direct mediator in conflicts arising between team members in the work process, the team meeting space is remembered as a potential for the planning and organization of the work process, and for empowering employees to perceive themselves as part of an organized collective.

[...] We try to make a democracy, we sit down, I set the goals we have to achieve and we sit together in meetings to see the best way to achieve the goals, the indicators. So, we all talk together to find the best solution to the problem [...] (N3)

I bring the indicators and in a team meeting, we discuss how we are going to improve. (N6)

The empowering behavior of leadership is presented as a strategy that enables positive teamwork environments, reflecting on the importance of team professionals working collaboratively. The leadership performed by the nurse is conducted with a focus on the goals of work and the organization, and on the way the steps of the process are coordinated for delivery in a co-responsible, relational process with a collective purpose.

The second theme “Barriers related to the organization of the work process ”, covers the way the nurse leader manages the existing obstacles to execute the activities planned and how these exert influence in their empowering behavior. Some obstacles are considered as justification for not achieving the idealized results, whether only by the nurse or by the entire team. Among them is the coordination of the work overload arising from sizing of Nursing personnel below the necessary and recommended.

As I have very few employees, I cannot get them out of the department and divide the team to sit and talk. (N5)

This overload is general for nurses. I feel here is one of the only units where the nurse can do only what the nurse is responsible for. This is possible because of the reduced number of patients. It’s a very difficult thing, because when the flow is too big you cannot stop, because if you stop the service, the patient cannot wait ten minutes either. Patients already complain... it is hard to stop. (N7)

Obstacles and challenges have an impact on job satisfaction and as a consequence, affect nurses’ empowering behavior. With reduced staff and care demands, it is necessary to prioritize the execution of daily activities, communication becomes more difficult and interpersonal conflicts become more frequent.

The moments of team meetings were remembered as powerful for the planning and organization of the work process and empowerment of employees so that they perceive themselves as part of an organized collective. However, they identified difficulties in holding team meetings with all team members and maintaining the service open to the population, which makes spaces for employees’ expression of opinions incipient.

We still do separate meetings by category. Every 15 days we split nurses, assistants, reception, community agents, general service assistant, pharmacy. We still don’t get a day to stop the service and gather [...] the entire unit. (N2)

We used to do it by sectors. Always in parts, never a meeting with everyone. (N7)

Attitudinal aspects of team members were identified as challenges for the performance of empowering behavior. Weaknesses in proactivity and being apathetic in fulfilling professional attributions were some examples, sometimes maintained even with support from participants, encouraging them to take the initiative to express their work-related opinions.

They lack initiative. Sometimes because of the rush, or lack of motivation or even the person’s own personality, like this: I stay in my corner, I have no idea, I don’t bring initiative to the position, I just do what I’m asked to. (N2)

What I sometimes observe is that they even give opinions and bring different ideas that end up contributing, at other times, we see that no matter how much we talk, we think it’s better to keep the proposals of the process that comes [from municipal management]. (N4)

Weaknesses in the coherence between positioning and behaviors were also observed in the attitudes of those being led and have a negative impact on trust between team members and on participation in the decision-making process.

Today, I notice there are many complaints, they want to feel more educated, more participatory in decision-making, including meetings, although in practice I see little initiative from the team as a whole. (N5)

Some professionals, we see that [...] are not so dependent on the figure of the manager, the nurse, or the immediate superior. Others don’t, they are more dependent. Sometimes they are looking for backup from someone [...] I think some do not believe they can come up with good ideas and thus change the routine of the service. (N4)

Another factor understood as a justification for distancing from decision-making by some team members lies in the lack of knowledge about the principles and guidelines of PHC.

Most of them do not know what the family health strategy is, don’t know its importance or its reason. Many people see it just as a job, but they don’t know what indicators are, what is the purpose of working in the family health strategy, then, there are some employees who understand, so the dialogue is easier when there is a demand from the secretary, while with others we already have more difficulty because there was no basis regarding the importance of primary care. (N6)

In this context, nurses’ behavior can facilitate the team access to information and opportunities for learning and growth through permanent education actions, with a view to creating empowering environments for work.

The second theme explains that the coordination of empowering behavior in the leadership of nurse managers in the context of PHC depends on the organizational dimension of the work process and the training of team workers, and these obstacles have a negative impact on interpersonal relationships and satisfaction in health work.

Discussion

The results show the characteristics of leaders’ empowering behavior from the perspective of nurses working in PHC. Such analysis evidences a complex intentionality expressed in actions focused on the objective, coordinating and explaining its steps through the co-responsible and relational exercise with peers.

The perspectives elaborated and shared by participants demonstrate how much the leadership model adopted by leaders, their perceptions and attitudes reverberate in the leader-led relationship and in the development of environments of greater empowerment, improving communication, enabling those led to perform teamwork collaboratively with all members of the health team, thus favoring quality patient care.( ⁹ )

The involvement of work organization and its resources in leadership is discussed in the PHC work context.( ²⁶ )These aspects are understood through leaders’ empowering behavior as part of the structural empowerment in accessing resources and in the ability to mobilize them towards meeting organizational objectives.( ⁸ )

Four elements are common in the conceptual framework of leadership in organizations: having the characteristic of a process, implying in influence, being exercised in the context of a group and implementing objectives that reflect a common vision.( ²⁷ )The latter is related to the first subtheme that expresses participants’ perceptions and attitudes around empowering behavior. In summary, the understanding was observed in the focus of organizational objectives and in the planning of team work tasks.

Interpersonal relationships can be considered the central dimension for both structural empowerment and authentic leadership.( ²⁸ )According to participants’ understanding, empowering behavior was linked to the relational dimension of work positively observed in peer relationships. However, this same dimension brought challenging elements to empowering behavior: interpersonal conflicts, non-implicated posture and attitudinal inconsistency. It is important to emphasize and understand that there are different intensities of implication among those led over time; it represents opening a space for flexibility in the relational dimension.

When there is less contact and interaction between individuals, the communication process and interpersonal relationships become more difficult hence, the nurse-leader role as a conflict mediator becomes essential. As exemplified by the nursing team, the existence of many tasks to be accomplished and the lack of sufficient human and material resources to provide better quality care lead them to live in an unfavorable context to interactions and communication acts.( ²⁹ )

Staff sizing bears a close relationship and positively or negatively affects the teamwork process and the care provided.( ³⁰ )Particularly in PHC, the specifics of this tool were instituted a few years ago, a situation that may reflect on services that need to have their dimensioning reviewed, dealing with fewer professionals in the Nursing team than expected for the performance of the work.( ³⁰ , ³¹ )

The empowering behavior from the perspective of leadership in the PHC context has an interdependent relationship with the organization of health work. The weaknesses that crossed the team meeting device as a common attribution make it possible to infer a loss of a space conducive to integration and articulation between professionals working in the team. Consequently, negative implications arise for the planning and organization of the work process,( ³² )weakening the establishment of empowering behavior.

In the sphere of structural empowerment, the development of self-awareness in subordinates precedes the self-regulation of behaviors and in a certain way, maintains a relationship of dependence with access to opportunities, such as the development of advanced skills and abilities at work and access to a system of recognition and reward.( ⁸ )According to the aforementioned model, any form of impediment to access the opportunity explains a weakness in the development of self-regulation of behaviors that ultimately culminates in elements understood as challenges for the empowering behavior.( ²⁸ )

Thus, fostering participation in decision-making requires an effort from leaders in terms of requesting employee input in the decision-making process. This participation facilitates the achievement of objectives and provides autonomy and freedom from bureaucratic restrictions, allowing the best use of talents and resources employed to obtain the best possible work performance results.( ³³ )

The multiple actions performed by leaders in the PHC context were the limits found for implementation of effectiveness of their empowering behavior. The multiplicity of activities performed by these professionals, ranging from coordination of nursing team actions to the service and tasks schedule, staffing, organization and implementation of care to performance of intellectual work, constitute weaknesses for empowerment of the nurse before their team.( ³⁴ )In addition, because leadership permeates the actions of nurses due to their increasingly frequent occupation in prominent positions in health services related to people management and care management.( ³⁵ , ³⁶ )

This challenge is also present in joining efforts to educate and train professionals with critical-reflexive thinking, capable of promoting social changes and meeting the real health needs of the population.

Educational interventions implemented through active teaching methodologies since graduation are effective in developing leadership practices and the empowering behavior of the nurse leader.( ³⁷ )Information as an element of structural empowerment also makes the continuing education process a powerful and essential resource in health institutions for providing opportunities to prepare nurses so they can bet on changes in their work environment, with a view to improve the quality of care and collaboration between team members, reconciling organizational objectives with the needs of nursing staff and patients.( ³⁵ , ³⁶ )

Limitations of the study are the theoretical saturation reached in the seventh participant and the study location. However, the results of this investigation contribute to in-depth understanding of the management exercise in its dimensions of leadership and empowering behavior. It implies that the coordination and organization of PHC consider the dialogue and negotiation with nurses managers of their services in order to achieve quality and safe care. The exploratory model of the study, its themes and subthemes contribute to establish theoretical models to advance in the production of knowledge on the theme of leadership and empowering behavior in Nursing.

Conclusion

Qualitatively analyzing the empowering behavior from the perspective of the leadership of nurse managers in the context of PHC allowed us to understand the strengths, such as perceptions and attitudes in leadership performance, contributions to teamwork and conflict mediation. These results are obtained from the training process that advances in the development of the leadership profile in services of the Brazilian SUS, and are achievements of Nursing related to their work in PHC.

It brought to light central challenges aimed at the empowerment of nurses, difficulties in staff sizing, in the team meeting device and in the shared participation in decision-making. Although the importance of these challenges is discussed in scientific productions and in the job world, the search for ways of constantly instituting these means of work is still necessary, given the fundamental condition in the work process and consequently, in PHC leadership. This context calls a reflection by workers, managers and scholars about the spaces for negotiation and agreement, in which there is listening of the needs of nurses managing Basic Health centers focused on their empowering behaviors for the exercise of leadership. The development of new studies on the theme in other scenarios and contexts from different data collection instruments is recommended. We also suggest the application of the Leader Empowering Behaviour Scale validated for Portuguese in order to assess the behavior of nurse leaders in Brazil.

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Edited by

Associate Editor (Peer review process): Alexandre Pazetto Balsanelli ( https://orcid.org/0000-0003-3757-1061 ) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, SP, Brazil.

Publication Dates

• Publication in this collection
  06 Feb 2023
• Date of issue
  2023

History

• Received
  12 Jan 2022
• Accepted
  20 June 2022