versão impressa ISSN 0080-6234
Rev. esc. enferm. USP vol.43 no.3 São Paulo set. 2009
A busca pelo comprometimento atitudinal: tendência da conduta ética do enfermeiro gerente
Maria Auxiliadora TrevizanI; Isabel Amélia Costa MendesII; Miyeko HayashidaIII; Simone de GodoyIV; Maria Suely NogueiraV
INurse. PhD. Free Lecturer. Associate
Professor at Nursing Department, Faculty of Medical Sciences, Campinas State
University. Campinas, SP, Brazil. email@example.com
IIRN. Full Professor at Nursing Department, Federal University of São Paulo. São Paulo, SP, Brazil. firstname.lastname@example.org
IIIPhysicist. Researcher at Medical Informatics Department, Medical School, University of São Paulo. São Paulo, SP, Brazil. email@example.com
Historically, nurses' management functions have evidenced that their conduct is compatible with programmatic commitments. This fact was observed in the analysis of 18 studies carried out in healthcare services located in different Brazilian regions. Since the 1990's, management experts have alerted that traits such as commitment, interdisciplinarity, risk, uncertainty, spirituality, and ethical involvement will frame the characteristics of the human capital of 21st century organizations. In this much more humane environment, people's integrity and their way of relating at work must be based on the dimension of BEING. In order to face the new century institutions' healthcare demands, nurses are now urged to present a conduct permeated by the ethics of the attitudinal commitment. Thus, this study aims to stimulate a critical reflection on this ethical trend of nurses and finally propose that this trend be an essential value in nursing management processes.
Key Words: Nursing. Personnel administration, hospital. Management. Ethics, nursing. Health manpower.
Historicamente, as funções gerenciais do enfermeiro evidenciam que sua conduta é compatível com o comprometimento programático. Esse fato foi constatado através da análise de 18 estudos realizados em serviços de saúde localizados em diferentes regiões do Brasil. Desde os anos 90, especialistas da área de gestão alertam que compromisso, interdisciplinaridade, risco, incerteza, espiritualidade e envolvimento ético constituirão características do capital humano inserido nas organizações do século XXI. Nesse ambiente muito mais humano, a integridade das pessoas e sua forma de relacionar-se no trabalho devem fundamentar-se na dimensão do SER. Para enfrentar a demanda das instituições de saúde no novo século, se começa a solicitar do enfermeiro uma conduta permeada pela ética do comprometimento atitudinal. Assim, nosso objetivo é propiciar reflexão crítica sobre essa tendência ética do enfermeiro e, em conclusão, propô-la como valor essencial na gerência exercida por ele.
Descritores: Enfermagem. Administração de recursos humanos em hospitais. Gerência. Ética de enfermagem. Recursos humanos em saúde.
A revolution in the health services has begun, aimed at investment in human capital in order to serve customers and to make a significant impact on the quality of the service provided and to transform it in a competitive resource.
Regarding the administration and provision of services, the authors consider the following ten lessons on these concepts as their main findings:
1. Services have a stronger economic impact and worse quality than we imagined; 2. Several service organizations assume a defensive posture towards quality; 3. The administration needs to see the impact of service on their profit in order to take it seriously; 4. The longer you work in a particular scope of activity, the greater the probability of your not understanding the customer; 5. A service is completely different from a material product; 6. Administrators do not control the product quality when the product is a service; 7. The improvement of service starts at the top of the organization administrators must follow through on what they say ; 8. Administrative practice must change from a production orientation to an orientation regarding the real moments, to face the demands of the competition; 9. Employees are their first market first, it is necessary to convince them about the idea of service, otherwise they will never be able to pass it on to their customers; 10. Systems are generally enemies of service(1).
As previously mentioned, the revolution in services has only begun, but several organizations are not yet involved in this change. Nowadays, the companies that provide services are classified in five levels according to their commitment to the quality of the provided service, in other words: a) some companies are closed, because they are too distant from their customers; b) there are companies that obstinately try to achieve mediocrity, that it, they try to survive but the quality of their service is not consistent with their goals; c) some companies that are present and in well-known location have an innate consideration for the most elementary things in the provision of services, and quality is not important in their strategy; d) other companies are trying hard to turn service into a competitive instrument and are also advancing, taking risks and innovating; the administration of services corresponds to the leading idea of the organization; e) finally, there are organizations that carry out the service as some kind of art, due to their tireless commitment to the doctrine of the maximum positive impact towards the customer at all levels(1).
In several western countries, the perception about the service quality is negative; evidence indicates that services need to improve considerably. Most of the questions related to the low quality in the provision of services come from organizational systems that are based on the ethics of hierarchy. In this kind of organization, people who have authority determine what must be done and the employees obey the orders, carrying out what has been established through tasks. In this process, the intermediate administrator must, among other duties, guide the staff and provide information to the upper levels about the events and problems related to the service and the execution of tasks. The intermediate administrator feels confident in his position and transmits to the employees a feeling of stability, guaranteeing that his service servitude is an important promotion factor. Therefore, the established administrative ritual and organizational structure contributes to the adaptation and maintenance of staff and management in their comfort zones; in other words, they feel supported in this insane environment and any sign of change is a reason for concern and insecurity. The strategy accepted and incorporated by these companies is limited to the repetition of the known performance and the projection of future growth, without anticipating any significant change in the administrative model(2).
Another characteristic of traditional organizations is the absence of an integrated view, so that individuals do not perceive the meaning of their work relative to the whole, generating low levels of personal and professional commitment, and making it impossible for them to offer their best contribution.
The commitment of the employee to this organization is based on the need to continue there. He cannot leave, because he hopes to receive benefits, for instance retirement benefits, and these plans are non-transferable. The problem of poor résumés, which is evidence of their lack of experience in some areas, is also a factor that prevents this employee from finding a position at another organization. Under these circumstances, the programmatic commitment is what ties this subject to her work.
People who adopt only this kind of commitment are physically present, but they do not invest their human capital to the service of the organization and stay with the system without any emotional bond - the reason for this is that the price of leaving is too high(3).
The administrative methods and premises applied to the production of goods in the Industrial Age are still in force in several nursing services in our area. Besides being oriented to the resources of the production of goods, nurses from these services have based their administrative actions on models that have already been useful.
In this context, the purpose of this study is to encourage critical reflection led by the authors and based on 18 studies about the nurse's administrative functions.
ADMINISTRATIVE FUNCTIONS OF THE NURSE
After analyzing 18 studies conducted over the last four decades of the 20th century that analyzed health services from different regions of Brazil, it was evident that the administration executed by the nurse has been limited to activities of provision, maintenance and control of material resources; to the distribution of tasks to the personnel, according to their attributions; to the supervision, evaluation and control of actions and results; to the interpretation of medical indications so that employees implement them, comprising the elaboration of work routines, programs and guidelines. These activities aim at the operation of the sector, which has already been organized by the bureaucracy. It is possible to state that the nurse dedicates most of her time to the execution of these activities, based on the programmatic commitment, which results in low self esteem (4-16).
In the 70's, authors(17-19) wrote about the nurse's administrative function, oriented to service and the patient, associating the approaches of the sector administration to those of patient care administration.
At the end of the 80's, through the operationalization of the typology of administrative functions established by the author(20), there was evidence that nurses still dedicated most of their time to bureaucratic activities, with the objective to respond to medical and administrative expectations of the hospital. The author warns that the way nurses have behaved is restricting their space to what other professionals attribute to them, without searching for their own space or trying to go beyond pre-established expectations. The author considers that the professional must execute administrative functions, but the exercise must be done differently from the way it is currently done.
The same scenario described(20) has already been found(21), indicating that the task executed as a routine, the fragmented care, the impersonal care, as well as the excessive and authoritarian rigor of the scientific administration, which limits the horizons of the human being, must give place to a sensitive administration. This administration is compatible with the behavioral commitment.
ETHICAL BEHAVIOR OF THE NURSE IN THE ADMINISTRATION: BEHAVIORAL COMMITMENT
Recent world changes that derive from globalization are penetrating all aspects of life. The interrelation, the mutual dependence and the influence existing between populations have affected the field of work of health organizations.
In its process of alignment to external changes, the hospital tends to reorient its administrative methods, mainly focusing on human resources. In the past, however, provided with the contribution of certain authors(22-23), hospitals were structured in hierarchical levels with defined responsibilities and competences; nowadays, in order to adapt to changes, these health organizations must develop strategic abilities and flexibility regarding what really matters - the customer's care. Therefore, the activities of people who interact with customers constitute the strategic point of the hospital system and, in this context, must flow from administrative behaviors committed to the quality of the care provided(24).
Considering the categorization of organizations that provide services, according to their level of commitment to quality, it is possible to infer that most Brazilian nursing services are present and at a well-known location, since they show respect for the most elementary aspects of the provision of services, but quality still does not have an important position in their strategy. These organizations use what marketing theoreticians call natural participation of market, in other words, the participation over which they have rights simply because they exist(1).
Fortunately, some of our nursing services are trying hard, and are making an effort to transform the service into a competitive resource. Their administration put a lot of effort in this idea, which represents the leading idea of the system; taking risks, innovating and investing in people.
Nevertheless, service excellence is found in those organizations that view service as an art. This is the goal of Brazilian nursing. Nurses are aware that in order to achieve this, they need to provide the maximum level of service quality in the opinion of the customer. In this context, people provide the organization with the availability of their personal human capital, individual capacity, commitment, knowledge and experience. Personal behaviors, professional know-how and the network of contacts are components that constitute the core of a person's capacity, which may be developed through experience and qualification.
The way these components are applied in practice depends on the attitudes and personal values of the person. The human capital of the organization exceeds the individual competence, including the way people work in groups and the internal and external relations to the organization(25).
Values and attitudes shape the behavior of people. Attitudes are closely related to values and refer to the way people see their world, which is called by some people as mind components or mind maps(23). This author believes attitudes can be changed. The values of the profession include up-to-date knowledge and the professional's autonomy in order to provide, with competence and through administrative action, qualified care to the human being, in philosophical and practical terms. This professional must try to enhance the welfare of the human being, through action and through integrating ethical questions into her performance(26). In other words, it is necessary to open spaces and legitimize the possibility of acting differently, which may be shared, co-responsible and decentralized(27).
In Brazilian nursing care, the behavior of the nurse in the administration of care to the customer needs to change from the ethics supported by programmatic commitment to the ethics of behavioral commitment, bearing in mind not only the demands of health institutions, but also the full satisfaction and fulfillment of the professional. Since the beginning of the 90's, specialists have indicated that behavioral commitment, interdisciplinarity, risk, uncertainty, and spirituality, among others, are characteristics that will be appreciated in organizations of the 21st century.
The nurse's behavioral commitment is characterized by identification and involvement with service, demonstrating dedication and enthusiasm, which indicate deep bonds between the professional and her work. Because she feels motivated, she invests her human capital and enjoys working in the organization because she values her interests and goals(3).
There is a dimension of the behavioral commitment that refers to internalization. According to thisinternalization, the administration executed by the nurse is based on recognition of her own inner reality and depends on the acceptance of the other, on comprehension, generosity and compassion. These attitudes allow the nurse to feel what happens to the other in a certain situation(28), developing her empathy. Intuition, convictions, creations, customized communication, quality of life and personal commitment are some other internalization aspects that support the behavioral commitment of the nurse with her internal and external customers.
In this human environment, the care provided, the quality service and the way caregivers relate to their job go beyond doing and reach the dimension of being.
The search for behavioral commitment is a tendency of ethical behavior of the nurse-administrator, who tries to build a more human environment nowadays, in which the integrity of the people and the way they relate to their work support the dimension of BEING. In order to face the demands of health institutions in this new century, the nurse is expected to demonstrate behavior permeated by the ethics of behavioral commitment.
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