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Revista Brasileira de Enfermagem

Print version ISSN 0034-7167On-line version ISSN 1984-0446

Rev. Bras. Enferm. vol.70 no.5 Brasília Sept./Oct. 2017

http://dx.doi.org/10.1590/0034-7167-2016-0491 

REFLECTION

Nursing supervision for care comprehensiveness

Supervisión de enfermería para la integralidad del cuidado

Lucieli Dias Pedreschi ChavesI 

Vivian Aline MininelII 

Jaqueline Alcântara Marcelino da SilvaII 

Larissa Roberta AlvesI 

Maria Ferreira da SilvaIII 

Silvia Helena Henriques CameloI 

IUniversidade de São Paulo, Ribeirão Preto College of Nursing. Ribeirão Preto, São Paulo, Brazil.

IIUniversidade Federal de São Carlos, Nursing Department. São Carlos, São Paulo, Brazil.

IIIUniversidade Federal de São Carlos, Postgraduate Program in Nursing. São Carlos, São Paulo, Brazil.

ABSTRACT

Objective:

To reflect on nursing supervision as a management tool for care comprehensiveness by nurses, considering its potential and limits in the current scenario.

Method:

A reflective study based on discourse about nursing supervision, presenting theoretical and practical concepts and approaches.

Results:

Limits on the exercise of supervision are related to the organization of healthcare services based on the functional and clinical model of care, in addition to possible gaps in the nurse training process and work overload. Regarding the potential, researchers emphasize that supervision is a tool for coordinating care and management actions, which may favor care comprehensiveness, and stimulate positive attitudes toward cooperation and contribution within teams, co-responsibility, and educational development at work.

Final considerations:

Nursing supervision may help enhance care comprehensiveness by implying continuous reflection on including the dynamics of the healthcare work process and user needs in care networks.

Descriptors: Nursing Supervisory; Organization and Administration; Nursing; Nursing Team; Nursing Services

RESUMEN

Objetivo:

Reflexionar sobre supervisión de enfermería como instrumento gerencial del enfermero para integralidad del cuidando, considerando sus potencialidades y limitaciones del escenario actual.

Método:

Estudio reflexivo basado en formulación discursiva sobre supervisión de enfermería, presentando conceptos y enfoques teóricos y/o prácticos.

Resultados:

Las limitaciones del ejercicio supervisional están relacionadas a organización de servicios de salud fundamentada en modelo funcional y clínico de atención, en posibles carencias del proceso formativo del enfermero y sobrecarga laboral. Respecto a potencialidades, se destaca la supervisión como instrumento articulador de acciones de atención y gerenciales, que favorecerían integralidad de atención, estimular actitudes cooperativas y colaboración en equipo, además de corresposabilización y promoción de la educación en el trabajo.

Consideraciones finales:

La supervisión de enfermería contribuye al fortalecimiento de la integralidad del cuidado, presuponiendo reflexión continua, para contemplar el dinamismo del proceso de trabajo en salud y necesidades de pacientes en las redes de atención.

Descriptores: Supervisión de Enfermería; Organización y Administración; Enfermería; Grupo de Enfermería; Servicios de Enfermería

THEME CONTEXT

The historical evolution of nursing has been accompanied by increasing concern with healthcare demands and complexity of services, which have been objects of study over the years to better support the best practices for complete care. There is a perceptible need for development and organization of nursing work in order to overcome obsolete management models, which were created to supply the demand of a particular era but are still practiced today(1-2).

Nurses’ performance is part of the clinical model of the biological approach to care, which values the knowledge of specialties and fragmented care. These situations imply underrating of general practitioners in the healthcare area, in addition to privileging the inclusion of high-technological density that results in high costs in the production of health care. The above-mentioned model of care is connected to the function-based way of organizing work, whose approach is piecemeal and task-centered(1-2).

However, care practices have emerged in Brazil with an extended, complete, and articulated clinical approach. Such practices are not only consistent with the Comprehensive Health System (CHS) and its principles, but are also aligned with current Healthcare Networks (HN) policies. This is reflected in care and management issues and more dynamic and participative arrangements for organizing work in health services(2).

Healthcare Networks policies consist of a strategy to overcome fragmentation of care in the CHS, with systemic integration of action, services, and care management qualification of current sanitary challenges, which reveal the insufficiency of the hegemonic care model(2). This requires a change in the current pervading logic, having care comprehensiveness as its object with resulting horizontal professional relations and actions, implementation of collaborative inter-professional practice within legal and technical abilities, and focus on care that is targeted to user healthcare needs.

The polysemic concept of completeness encompasses meanings related to the production of care centered on user needs, aspects of structuring and managing healthcare services, and professional knowledge within a central and extended vision of human beings(2).

Regarding health care from the perspective of completeness, it depends on an inter-subjective, dialogic practice that entails the coordination of health promotion, prevention, and recovery actions, considering the uniqueness of each user. This qualified care is under a construction process and implies the incorporation of inter-professional collaborative practice, adding the expertise of professionals who are dedicated to care, and considers users to be co-responsible for their own health, within a logic of coordinating available healthcare resources and services.

However, changes in patterns that are historically and culturally rooted occur gradually, considering the challenges and difficulties that are intrinsic to the transition process and changes in context. A strategy to enhance the change process has to do with increasing the participation of involved citizens. From the perspective of care comprehensiveness, it is essential in the healthcare scenario to mobilize nursing professionals for the development of new care and management paradigms that are focused on users.

In this context, supervision emerges as a management instrument that may allow for optimum planning, implementation, and assessment of complete care for users, as well as guidance for the work of nursing teams.

The task of supervising nursing teams is traditionally and legally assigned to nurses, who answer to the management of nursing services before professional regulatory agencies. Nurses play the role of supervisors in their daily practice. They cannot do so in a way that is not related to the professional, institutional, and social analysis of their countries and the world, because of the globalization process. If they do so, they will be functioning in a way that is limited in terms of a general understanding of healthcare problems and interventions.

It is important to highlight the scarcity of studies in the literature that address nursing supervision from the perspective of care comprehensiveness, education, coordination of care, and management. A search conducted in the LILACS database for the period 2010 to 2016 using the descriptor “nursing supervision” and considering studies conducted in Brazil resulted in 20 publications, of which only five addressed the issue of nursing supervision. Of these, three had been developed from the perspective of primary care and two from the perspective of hospital care; none considered the context of HNs in the CHS. This situation may reflect underrating of this tool, even though it is an attribution of nurses, who enable the coordination of the care, management, and educational dimensions of nursing work in the scenario of care networks.

It is possible to observe how essential it is to reflect on the characteristics of nursing supervision in the context of the current healthcare scenario when one considers the following: the set of Brazilian national political guidelines concerning the organization of HNs, which are reflected in health services and nurses’ work; the complexity of care and management nursing actions that directly reflect on care provided to users; the understanding of nursing supervision as a powerful tool to boost change processes in order to achieve care comprehensiveness and coordination of healthcare actions from the HN perspective; and the on potential, limits, and challenges for nursing supervision in coordinating work from an educational perspective on complete care

The goal of the present study was to reflect on nursing supervision as a management tool that nurses can use for care comprehensiveness, considering its potential and limits in the current scenario and its ability to present theoretical and practical concepts and approaches. The authors understand that these reflections can help clarify the nuances involved in nursing supervision applied to the production of health care.

METHOD

This is a reflective study of discourses about nursing supervision, based on current references, analogies, and various theoretical and practical perspectives.

This article is organized into the following sections: context of the theme of study; nursing supervision in the context of care comprehensiveness; reflections on the limits and potential of nursing supervision; and final considerations.

Therefore, based on the premises of the HN organization, the complexity of nursing care and management actions that directly reflect on care of users, the understanding of nursing supervision as a powerful instrument to boost the change process to achieve care comprehensiveness, the researchers addressed the theme of this study from the perspective of the potential and limits of nursing supervision for coordinating nursing work with an educational, complete care focus.

NURSING SUPERVISION IN THE CONTEXT OF CARE COMPREHENSIVENESS

Supervision is a management work tool that emerged as a specific knowledge and practice field in the context of administration in the nineteenth century. The theories of Taylor and Fayol, characterized by their emphasis on the rationality of tasks and structures, were reflected in the adoption of supervision to guarantee production(3).

The creation of modern nursing was ordered from the organization of care, with the systematization of technical procedures, organization of the therapeutic environment, adoption of cleanliness and hygiene measures, and organization of agents through disciplinary mechanisms and staff qualification – all aligned with the social and technical division of work(4). As far as administration is concerned, nursing has historically adopted management models derived from other productive sectors, incorporating Taylorist principles that emphasize the division of work, which assigns particular tasks to workers(1,5).

Thus, the work process in nursing, which was influenced by the principles that guide administration and management under the capitalist paradigm, still has the aura of an activity that is characterized by the social and technical division of work, with a supervision model based on the distribution of tasks and fragmented actions to ensure productivity, whereby nurses take the responsibility for the organization and results of their work. It is necessary to highlight the importance of refocusing supervision in order to achieve complete health care, whose central aspect lies in interaction of nursing workers and healthcare teams with users to favor resolute interventions.

When nurses who are mobilized to reorganize health care practices that focus on care perform supervision work, they need to contemplate completeness at an individual level, connecting it with user healthcare needs and from a collective perspective of organizing the work of nursing teams and healthcare services(6).

The promotion of care comprehensiveness strengthened by supervision may also become effective through the process of coordinating the care nurses provide by nurses in health services with that of care teams and workers from various professional categories and teams, like in HNs, from the challenging investment in practicing reference and counter-reference of users for the continuity of care within the care network.

This coordination of care depends on one of the indispensable features of supervision: communication. It must occur with a particular focus on understanding and empathy, which may be reflect in the various directions encompassed in the exercise of supervision. Researchers emphasize the relevance of horizontal communication as a powerful tool to promote shared decisions that favor effective teamwork, which are essential elements of complete care(7).

The scientific production on supervision points to three main directions for its development: control, education, and political articulation(6,8). It is essential to underscore the importance of overcoming the negative connotations of the term ‘control,’ which must be understood as the possibility of monitoring and following up on the work process, emphasizing the instrumental actions of nursing teams in order to favor the adjustment of technical and scientific rules to clinical practice. Thus, supervision has the potential of being a tool to rethink work and facilitate management and care performance that is related to developing the abilities of nursing teams (8).

Regarding the educational perspective on supervision, it does not express its predominant sense. After all, the educational process places more emphasis on controlling and regulating actions, giving less importance to investment in the possibilities of collective construction of work interventions through continuous education of workers (8). It is worth asking why nursing faces difficulties and limits in incorporating this educational vision of the tool of supervision, because beginning in the 1980s, the Brazilian Ministry of Health was already issuing publications pointing to the educational and guiding nature of nursing supervision.

Finally, the sense of political articulation pervades all supervision actions, including those related to the monitoring of the work process and education: these actions lead to taking ethical and political stands(5).

The exercise of supervision requires a broad vision of work management and creates a diligent, efficient, effective, and continuous process that values education. This supervision also plays a motivational, guiding, and supportive role in the management of the human, material and organizational assets of the nursing work process(9).

Researchers understand that the role of supervision is to direct, guide, and modify the types of service that will achieve high-quality results when it motivates teams to pursue strategies for solving problems and carrying out the educational process(9). This enhances the importance of nurses appropriating the idea of supervision in their daily work. This tool has the potential to reflect on the care, management, and educational dimensions of work, in addition to giving rise to a more comprehensive view of problems, plans, and goals.

When supervision is used in an educational, collaborative way, it can favor assessment of results and qualification of care, in addition to fostering integration in various social and political relations(9). In this process, researchers emphasize the use of technical, management, and relational skills in understanding people and teams, combining sensitivity and strength in actions. It is also relevant to take into account the aspect of reciprocity in supervision, because it is a type of relationship that depends on the interaction abilities and mutual influence among nursing workers and other professional categories.

Moreover, nursing supervision favors the interface between care given to users, teamwork within staff, and the context of the health services in which these relationships are inserted. In other words, it has the potential coordinate care and management from the perspectives of users, professionals, and healthcare services(3). It consists of a privileged space for achieving care comprehensiveness, as previously mentioned.

Supervision may orient services toward achieving desirable results, positively and satisfactorily affecting the organization. When nurses perform supervision they can enhance the quality of the services rendered and the pursuit of strategies to solve problems, in cooperation with the members of their teams, including educational and relational aspects(9). Good inter-professional relations and horizontal communication promote coordinated care, strengthening integrated actions and minimizing fragmentation of care.

Co-responsibility for health care requires a supervision process rooted in participative management that promotes integrated action planning and continuous education in health through the problematization of daily practices. Both participative management and continuous education enable the grounding of technical decisions and enhance worker autonomy(5).

On the basis of recognition of these requirements, nurses need to appropriate scientific knowledge about supervision methods, techniques, and tools, training themselves to carry out this task and excel in their performance. Researchers emphasize that health care and nursing practices still retain characteristics of the biological, mechanical, professional-centered medical model that values expertise to the detriment of health actions that can more effectively and inclusively apprehend the needs of users and their families, in a context of complete care(2). Thus, the need emerges for a supervision model that overcomes the sense of strict control and takes an educational approach, from the perspective of collaboration and care comprehensiveness, aligned with CHS public policies and best practices in health care, recognizing that working in networks and engagement between healthcare teams and users is indispensable.

REFLECTIONS ON THE LIMITS AND POTENTIAL OF NURSING SUPERVISION

The ideas presented above allow for a broadened conceptual vision of the theme addressed in the present study. However, in the scenario of healthcare services, different supervision strategies can be used depending on the characteristics of the context, which highlights the relevance of the participative and educational actions of nursing team. Thus, the present study aims to provide reflections on and show the possibilities of nursing supervision from the perspective of completeness, since it is not possible to choose an ideal supervision model that fits all scenarios and prescribes a particular standard for professional performance. Researchers wish to raise questions concerning the limits and potential of supervision as a management tool that can be continuously reassessed and reworked to represent the dynamics of nurses’ work process.

As far as limits are concerned, researchers refer to those connected with the organization of health services, based on the clinical model of care and the functional work method(1), that strengthen the piecemeal approach and strict control of supervision. These, in turn, translate into strictly hierarchical relations that make the interactions inherent to the supervision process more difficult and strengthen the idea of punishment that is erroneously connected with supervision. This context creates teams that must live with problems related to the quantitative and qualitative aspects of staff, low motivation, conflicts, and flaws in professional cooperation and collaboration. All of this makes it more difficult to carry out more dynamic and educational supervision practices(8).

It is necessary to consider that the limits on the exercise of supervision by nurses may be reflections of gaps in their training process regarding topics such as communication from a participative and dialogic perspective, interpersonal relationships, conflict management, and the exercise of supervision itself.

Another factor that plays a role in compromising health services supervision is the multiplicity of demands and attributions that are typical of the nurses’ work process. This can limit the focus of supervision, restricting it to monitoring and controlling work without going any further in terms of educational aspects and ethical and political articulation, which can help improve care and working conditions(5,8).

Despite the limits, researchers believe that the use of nursing supervision as a management tool, with a particular focus on its educational approach, has the potential to produce change. It is understood that it is necessary to direct efforts toward gradual and continuous changes in processes, with the aim of care comprehensiveness, focusing on users and greater participation by professionals(8).

Consequently, regarding the potential, researchers understand that supervision may favor care comprehensiveness when considering coordination of care and management, understanding the uniqueness of subjects in a broader concept of health that goes beyond the biological dimension. This will increase participation in care and monitoring its results, in addition to empowerment and satisfaction(8). This situation demands new organizational work arrangements focusing on flexible management models that are based on practices based on dialog and inter-professional teamwork(5).

It is necessary to take into account the ethical and political aspects that are part of the supervision process and of the relationships established by critical and reflexive practice that results from knowledge. This scenario has the power to improve the working conditions, qualification, and power of professionals(5).

Still in the realm of the potential, supervision can foster cooperative attitudes, the creation of partnerships, team collaboration, co-responsibility, promotion of education at work, and motivation and guidance in human resource management. It is also an important tool for qualification and legal records of complete care provided to users, enabling monitoring of the nursing care provided. It also benefits an approach that endorses and documents the professional exercise, including the accounting of expenditures and audits in health care(5).

It is worth to highlighting that supervision is an important tool for qualification and legal records of complete care provided to users, enabling monitoring of the nursing care provided. It also benefits an approach that endorses and documents the professional exercise, including the accounting of expenditures and audits in health care.

It is highly relevant that continuous education strategies need to include developing skills to ensure that future nurses are prepared to take leadership and supervision responsibilities(10).

In summary, it is necessary to advance toward reflection and action to understand that care comprehensiveness entails an approach that includes dimensions that pervade both care and management. There are challenges to and potential for understanding and performing nursing supervision to coordinate care and management actions, from a perspective that is indissociable from care and management, overcoming mistakes in the exercise of management of care.

FINAL CONSIDERATIONS

The reflections offered in the present study point toward the limits and potential of nursing supervision, considering care comprehensiveness in HNs. Researchers highlight that in the still-hegemonic clinical model of health care, supervision is considered a tool for adjusting the dynamics of healthcare actions to meet organizational goals, inasmuch it pursues strict control of workers and the work developed. Therefore, it consists of elements that reflect the goals and interests of the hegemonic class, aiming at maintaining and perfecting the current system.

However, the insufficiency of this model of care and work organization vis-a-vis health care of users and needs of workers is a sign of the urgency of changing the work reality by incorporating approaches based on completeness and more flexible management models. Nursing supervision, which is influenced by management and healthcare models, also needs to be rethought in light of care comprehensiveness and inter-professional teamwork.

Supervision makes up an important part of the nursing work process; it is shaped by activities that are developed in collective and interdependent ways among the various nursing agents, and between them and other healthcare professionals.

The exercise of this activity demands constant analysis of organizational contexts and their relationships with healthcare policies; follow up of interventions and their results, in both quantitative and qualitative terms; improvement and qualification of workers through the development of participative and democratic teaching and learning processes; and political articulation that enables mediation between different organizational spheres and among workers themselves, creating spaces for the negotiation of interests, desires, powers, and values rooted in ethical aspects that favor quality of care.

At this time, the challenge is to understand supervision as a structured tool that is embedded in the work process in health and nursing. It must be considered a strategic space for subjects, who can reinterpret and transform ways of thinking and acting in achieving care comprehensiveness.

There is a clear need for changing and overcoming the current care and supervision models for work that is done collectively. The ultimate goal must always be cooperation and encouragement to improve the care given to users. The success of this transformation lies in the implementation of continuous education actions that boost supervision in a participative approach, aiming at education instead of punishment.

The supervision style is a consequence of the current philosophies and goals of organizations and the dominating ideology. Therefore, the challenge is to advance beyond the current context, which is seen as outdated and exclusionary, from the perspective of building an approach that emphasizes participation, education, care comprehensiveness, and the central role of users.

Nurses are expected to be the protagonists in the exercise of supervision, acquiring the necessary tools to implement it and empowering themselves to occupy spaces of mediation between institutional policies and coordination of various management spheres. The expectation is that, in addition to the technical skills for supervision, nurses will seek to understand people and recognize the importance of work relations within their teams, so that this activity is a qualifying tool for their nursing practice. Ultimately, this may result in better care provided to healthcare service users.

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Received: September 01, 2016; Accepted: February 20, 2017

CORRESPONDING AUTHOR: Lucieli Dias Pedreschi Chaves. E-mail: dpchaves@eerp.usp.br

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