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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.45 no.4 São Paulo Aug. 2011
Communication conceptions in Hospital Nursing Management between head nurses in a University Hospital
Concepciones de comunicación en la Gerencia de Enfermería Hospitalaria entre enfermeros gerentes de un Hospital Universitario
José Luís Guedes dos SantosI; Adelina Giacomelli ProchnowII; Suzinara Beatriz Soares de LimaIII; Joséte Luzia LeiteIV; Alacoque Lorenzini ErdmannV
Ph.D. Student in Nursing, Graduate Nursing Program, Universidade Federal de
Santa Catarina. CAPES grantee. Florianópolis, SC, Brazil. firstname.lastname@example.org
IIRN. Ph.D. in Nursing. Faculty, Nursing Department, Universidade Federal de Santa Maria. Santa Maria, RS, Brazil. email@example.com
IIIRN. Ph.D. in Nursing. Faculty, Nursing Program, Universidade Federal de Santa and Centro de Educação Superior Norte de Palmeira das Missões. Palmeira das Missões, RS, Brazil. firstname.lastname@example.org
IVRN. Ph.D. in Nursing. Emeritus Full Professor, Universidade Federal do Estado do Rio de Janeiro. Faculty, Graduate Nursing Program, Escola de Enfermagem Anna Nery, Universidade Federal do Rio de Janeiro. Rio de Janeiro, RJ, Brazil. email@example.com
VRN. Ph.D. in Nursing Philosophy. Facult, Graduate Nursing Program, Universidade Federal de Santa Catarina. Florianópolis, SC, Brazi. firstname.lastname@example.org
The objective of the following study was to analyze the conceptions that head nurses of a university hospital have about nursing communication management. It is a descriptive-exploratory study with an interpretative qualitative approach. The set of data was produced between September and October 2007 through interviews with 19 head nurses in a university hospital in Southern Brazil and submitted to thematic analysis. The nurses recognize the relevance of communication in nursing management, but have different perceptions: part of the research group understands communication from its interactive and dialogical perspective; others understand formal communication, based on the transmission and maintenance of standards and hospital routines, with emphasis on written communication. Further discussion about the triad communication, management and dialogue is required in order to build more interactive forms of hospital nursing care management.
Descriptors: Communication; Management; Nursing, Supervisory; Nursing Service, HospitalNonono
Se objetivó analizar las concepciones de enfermeros gerentes de un hospital universitario sobre la comunicación en la gerencia de enfermería hospitalaria. Se trata de estudio exploratorio-descriptivo, de abordaje cualitativo e interpretativo. Datos generados entre setiembre y octubre de 2007 por viñetas y entrevistas con 19 enfermeros gerentes de hospital universitario de Sur de Brasil, sometidos a análisis temático. Los enfermeros reconocen la importancia de la comunicación en el gerenciamiento de enfermería, aunque la conciben de modos diferentes. Parte del grupo investigado destacó la comunicación en su perspectiva dialogal e interactiva; y otra, el entendimiento de la comunicación formal, pautada en la transmisión y mantenimiento de normas y rutinas hospitalarias, con énfasis en la comunicación escrita. Es importante ampliar las discusiones acerca de la tríada comunicación, gerencia y diálogo, apuntando a construir formas más interactivas de administrar el cuidado de enfermería hospitalaria.
Descriptores: Comunicación; Gerencia. ; Supervisión de Enfermería; Servicio de Enfermería en Hospital
In the hospital context, nurses have increasingly taken charge of personnel, team and process management, direct and or indirectly related with care, which involves coordinating and articulating activities different professional perform at hospitalization units(1-2). Thus, communication emerges as a strategic tool for nursing management.
Communication is an act inherent in human beings, involving the sharing and understanding of messages sent and received among two or more people, through which they relate, influence and can modify the reality they are inserted in. In this process, a range of materializations, which imply the representations of what one intends to say, are outlined and expressed in verbal and non-verbal forms, mainly through words, gestures and postures(3-5).
Communication efficacy involves a continuous and complex process divided in six elements: source, coder, message, channel, decoder and receiver. The communication source corresponds to one or more persons who intend to communicate, expressed in the form of a message and conducted to a receiver through a channel. To answer the message and complete the communication, the receiver needs a set of sensory skills: the decoder(3-4,6).
In administrative processes and work relations, communication is fundamental to exchange information, ideas, orders and facts, permitting the accomplishment of coordinated actions, minimizing differences and approximating people towards common goals. Messages can be transmitted formal and informally. Formal communication is official and mainly in writing, like in the case of file notes and the elaboration of reports and standards. Informal communication constantly takes place in daily contact among people, independently of their job or function, and is related or not to professional activities. In terms of sense, communication can also be classified as upward (subordinate-management) and downward (management-subordinate)(3).
In nursing management, communication is based on interactions nurses establish when performing management functions in the nursing work context, i.e. human care, and in the hospital context as a whole. Some activities head nurses commonly accomplish are elaboration and orientation regarding standards and routines, performance assessment of nursing team members, writing memoranda, elaboration of work scales and so many other forms of fine-tuning with people through face-to-face, written, telephone and computerized messages(7).
Communication in nursing management is not always successful though. A study about communication between nursing leaders and subordinates identified the following main conflicts in the communication process: lack of compliments from immediate superior to nurses, lack of honesty in interpersonal relations, lack of constructive criticism on nurses' professional performance, communication problems with other areas, non-welcoming of nurses' opinions and lack of acknowledgement of nursing work(8). Another problem refers to the centralization of the decision process in nursing management, which obstructs the communication flow and delays the decision process, causes information distortions, hampering agility and the work process in practice(9).
In that sense, it should be highlighted that successful communication as an interpersonal process is directly related with speakers' clarity and objectiveness about what should be communicated, basic communication knowledge and awareness of the bodily and symbolic manifestations that permeate nurses' human relations and management practice(10-11).
Despite the importance of and challenges involved in communication processes in health and nursing management, research on this theme is still incipient. In Brazil, knowledge production on nursing management is still concentrated on the instrumental dimension of management practices, which points towards the importance of strengthening competencies in the ethical-political dimensions of the profession's relational level(7,12).
To advance on and/or strengthen these ethical-political articulation competencies among people in nursing management work, it is considered fundamental to explore communication conceptions in nursing management for these professionals who are the subjects and protagonists of management practice. Thus, the question is: how do head nurses at a university hospital conceive communication in nursing management?
To answer the abovementioned guiding question, this study aimed to analyze the conceptions of head nurses at a university hospital on communication in hospital nursing management.
An exploratory and descriptive study with a qualitative, interpretative design was carried out.
The research context was a university hospital, located in the interior of Rio Grande do Sul. Its mission covers health care, teaching and research promotion, playing its role as a citizen in society, turning into a public reference point to see to the population's health needs.
The organizational structure comprises one consultant entity, the Board of Administrators; and one Executive Directory, with standardizing and deliberating functions, including a General Directory, Clinical Directory, Administrative Directory, Nursing Directory and Teaching, Research and Extension Directory. The Nursing Directory consists of five coordinators: maternal-infant, medical clinic, surgical clinic, outpatient nursing and psychiatric nursing. Each of these coordinators sees to specific services in the area, such as hospitalization units, intensive care, emergency and outpatient care.
At the time of data collection, between September and October 2007, five area coordinators and twenty service heads worked at the institution. Area coordinators are nurses working eight-hour shifts per day, besides periods on duty to complete their weekly hour load, except Saturdays and Sundays, when they are on leave. Nurses responsible for service units - head nurses or unit heads - work in administration and direct care, performing corresponding activities concomitantly. Most heads work mornings, but sometimes also afternoons or nights, in accordance with personal preferences or staff needs.
Study participants were 19 head nurses (three area coordinators and 16 service head nurses). An intentional sample of service heads or area coordinators was used, based on the data saturation criterion.
Data were collected through two techniques: vignette and semistructured interview. The vignette is a short and compact description of a real or imaginary situation, used to call attention, transmit a message, produce feelings and detect the respondents' attitude, opinion and knowledge about the research phenomenon(13). The interview allows the interviewee to discuss a proposed theme, without preset answers or conditions(14).
The vignette was constructed based on a hypothetical situation that projected the nurses to a work context in which the communication and understanding process floated freely among professionals and conflicts were used to problematize daily problems. Against this background, the intent was to discuss possible divergences and convergences between the "ideal" panorama presented and the reality they experienced as head nurses.
During the semistructured interview, initially, data were surveyed about the subjects' socio-demographic characteristics: age, gender, time of work in Nursing, time of work at the institution, time in current function, degree and management courses: next, the following guiding questions were asked: What do you consider as communication in nursing management? What is the importance of communication in your management practice? What is your opinion on communication in nursing service management at the institution?
Interviews totaled between 20 and 30 minutes and were previously scheduled with the research participants, who consented with audio recording for further transcription.
Thematic content analysis was adopted for data analysis, which comprises three steps: data ordering, classification and final analysis. In the ordering phase, the data collected through the vignettes and interviews were processed, the material was reread and reports were ordered. In data classification, the collected material was associated with the theoretical framework, based on exhaustive and repetitive reading of the texts, with a view to apprehending relevant structures. During final analysis, the empirical and theoretical material were articulated to obtaining an interpretation and abstraction of the underlying contents(14).
Approval of the project was obtained from the Institutional Review Board at the hospital (CAAE No 0098. 0.243.000-07). Study participants received information about the research problem and signed an Informed Consent Term to formalize their agreement to take part in the research, in compliance with National Health Council Resolution No 196/96. Subjects' anonymity was guaranteed through the use of codes to identify their testimonies (D1, D2,..., D19).
RESULTS AND DISCUSSION
Out of 19 study participants, all were female and between 31 and 69 years old. They had been working in Nursing for at least six years. Ten of them possessed between 20 and 30 years of professional experienced and had worked at the institution for at least 15 years.
As for the time on the job, 11 had been working in their current function for less than one year, as they had been elected during a vote held about one year before the time of data collection: only four had no previous management experience though.
Regarding professional qualification, 16 nurses held a graduate degree: two a Master's degree in Nursing and the remainder were specialists, six of whom in Health and Nursing Management. In addition, 11 managers reported specific management courses, during which communication had been addressed.
In the head nurses' statements, at least two distinct conceptions were identified about communication and the way it is processed in hospital nursing management: one is related to communication from a dialogical and interactive perspective, while the other is guided by the understanding of formalized communication, based on the transmission and maintenance of hospital standards and routines.
Part of the research group considers communication as a dialogue based on the exchange of ideas between a group of people or a person and a team, aiming for understanding between the send and the receiver(s). This conception confirms the communication concept based on the relationship and dialogical encounter between one or more people(3-5).
It is an exchange, a dialogue between two or more people, in which the persons need to understand each other, give feedback on what the person said or asked. Communication only exists when there is understanding among the parties involved (D 6).
It is the exchange of messages, exchange of ideas, knowing how to talk, listen, it is the relationship itself (D 16).
The interviewees expressed their understanding that communication is based on dialogue and interaction with the people they interact with and share hospital nursing management. Considered this way, communication can produce changes and new behaviors, as it allows people to grant meaning to the actions they are developing in their daily work. These results converge with the findings of a study on management communication among head nurses at a hospital unit in Manaus(7).
In the analysis of 11 study participants' statements, however, an association was verified between the act of communicating and that of passing on, recalling or transmitting information, requesting compliance with standards and task performance by the nursing team and/or other health professionals, that is, it was inferred that these head nurses understand communication as a synonym of information.
For me, communication is something you are saying, there's a standard, something that has to be communicated to someone as if he were the receiver and do that (D 3).
[...] it is a means to pass on information to the team (D 5).
It is correct transmission, that you see that you are passing on the information and people are also passing it on without distortions (D 11).
These testimonies remit to communication ruled by hierarchy, in a process in which who has access to certain information transmits it to others, expecting no changes in the initial message. This understanding, however, relativizes the complex symbolic and subjective sphere involved in communication processes among human beings. When receiving a message, each individual interprets it according to his/her values and conceptions, which is inherent in the human condition. The understanding and uniformity of the message depend on the receiver's response, confirming or clarifying the message with the sender, through the establishment of a dialogue.
Similarly, a study on nurses' cultural and bodily manifestations in management practice also evidenced the paradoxical use of communication. Among team members, there is greater room for dialogue and more direct conversation; communication, however, can become perverse when it is used to recall and alert on compliance with hierarchical orders(11).
In that sense, it is important to highlight that communication and information are interdependent concepts in nursing management, but whose essence differs. Information is formal, impersonal, and is not influenced by emotions, expectations and perceptions; and communication, on the other hand, involves feeling and can represent shared experiences(15).
Thus, head nurses are responsible for much more than transmitting information on themes related with service management. As senders, nurses should seek a closer relation with their team members as, when communicating, they enhance the social interaction process, which can mobilize and approximate people with a view to cooperation and integration in daily work.
Therefore, one of the main phases to put in practice the communication process is feedback, which comprises the message receiver's response to the message sender(6). The understanding of the importance of feedback for a successful communication process with the people they manage or interact with, however, was limited to those head nurses who understand communication as a dialogue.
[...] there needs to be a return to the person, indicating that I understood the message she transmitted (D 7).
[...] if I manage to communicate, then the staff can give feedback (D 14).
The few allusions made to the importance of feedback to the message among the informants may be associated with the connotation they grant to communication. Many study participants consider that communication means informing or transmitting information and the main concern of who perceives communication as such are the techniques to send their messages, instead of the understanding or actions they should produce(5).
Despite the dual conceptions on communication, study participants unanimously affirmed that it is fundamental for nursing management:
Importance of communication? It is fundamental! If you do not communicate, you do not have a cohesive team, it is through communication that you manage to bring people closer, express your needs (D 1).
Communication is the direction of nursing management (D 9).
For me, communication is everything, it is the car key (D 13).
According to the head nurses, communication is one of their main work instruments, constituting an act inherent in their management practice, in the process of influencing and approximating nursing team and other health professionals' actions in the attempt to plan and achieve common goals. This result confirms research findings on the opinions of nurses responsible for hospital services on communication in nursing management(7,16).
Regarding the communication types nurses use in nursing management, emphasis on written communication was found in study participants' interactive processes. This type of communication is often used to formalize and commit the interlocutor to what is verbally addressed.
Making things as clearly as possible and easy to understand, and even better if it's written, because writing continues and whatever communication that arrives I ask people, when they read it, to undersign and put the date, because then I know as the head who read and who didn't read the information (D 2).
You cannot let things get too informal, when it's important you have to formalize it and use writing for that, so that things flow and happen better (D 8).
The largest part of communication is written, mainly meeting proceedings and memoranda (D 16).
Although records are important in view of the information complexity and quantity nurses are faced with in management practice, the emphasis on written communication may be related with the influence the premises of classical administration exert, according to which nursing work was historically constituted. Literature records, for example, that despite efforts to construct more interactive and dialogical forms of nursing management, remnants of this model are still present in nursing management processes(2,17).
The use of oral communication was mentioned as a strategy when one aims from rapid message transmission, like when a problem needs to be solved for example.
[...] there's nothing like face to face, of course there's much that needs to be communicated in writing, but verbal expression, face to face is very important for me (D 11).
If there is some problem, if you have to talk to a person about something, it's much better to say things delicately than, you know, dumbly, I think that, delicately, you manage everything, not everything, but it helps [laughs] (D 15).
Based on the analysis of testimonies, it can be inferred that, to persuade and convince the other, head nurses adopt an educated and well-mannered approach as a strategy, without going straight to the point, as talking personally allows interlocutors to benefit from other sensory information, which can enhance the communicative process(18). Persuasion, that is, the sender's ability to make the receiver accept his viewpoint as true, is one of the main communication goals and demands creativity and skill to formulate good arguments, which does not mean manipulating and/or suppressing the interlocutor's freedom of expression(6).
The study participants mentioned Internet and e-mail communication as an alternative to speed up communication and information exchange processes, mainly among large groups of people. It is used in an isolated way though, as not all units have structural conditions that facilitate computer access and as many nurses do not master the use of these communication tools.
Now for example, we created an Internet group to communicate, exchange new, because we found that was the easiest way to communicate. But it's not general at the hospital. That's one thing that got worse over time [...], today I see a backlash, in the age of informatics that could be easier, right? (D 6).
When asked about the quality of communication at the hospital institution, study participants consider it faulty and fragmented. They manifest their dissatisfaction with the nursing management's hierarchization, which segments and hampers the communication process.
There are many cuts, because it goes to the head, from the head it goes to the coordinator and then to the directory, I don't think that is very good and I believe things should work, should be more open. There were times that we communicated better (D 7).
Communication is not effective. It may be somewhere. But I don't know where it stops. It does leave the source, but I don't know how it gets to us. [...] it goes through different parts and gets lost in the middle (D 17).
Based on the testimonies, it is perceived that an intense division in hierarchical levels characterizes nursing service organization at the institution, which interferes negatively in communication processes. The communication process, interspersed with hierarchical relations, in a vertical and authoritarian way, was also evidenced in a study on nursing management actions regarding nursing workers' health-disease process(19).
In this analysis, the results of a study on work relations and health work organization in the hospital context should be highlighted, according to which relations based on authentic communication, respect for other people and their knowledge, sustained by cooperation and interaction/articulation between professional knowledge and action, enhance the accomplishment of changes, benefiting both users and workers(20). In addition, communication, work coordination and relational skills with health team professionals are fundamental to improve care processes nurses manage(21).
Regarding the interference of hierarchical relations in communication processes, the role the head nurses in this study play with a view to more effective communication at the institution demands reflection. Hence, it is asked: Is the fact that many head nurses associated communication with information transmission and exchange not complicating communication at the institution? In their management practice, do nurses feel able to formulate arguments, take a stand and dialogue with their interlocutors, in search of a consensus that covers patient, nursing team and institutional goals?
As the research participants occupy a strategic position in the hospital context, granted by a function inserted in the institution's organogram, it can be inferred that their communication conceptions hamper more interactive and dialogical activities. Thus, the head nurses feel they are impaired by a hierarchy they may be reproducing themselves in their communicative and management practices.
This study addressed head nurses' conceptions on communication in hospital nursing management and evidenced two main empirical categories: communication from its dialogical and interactive perspective and formalized communication, based on the transmission and maintenance of hospital standards and routines.
The group of nurses who served as the research sample possessed a relative level of life experience, professional maturity and nursing management practice in the hospital context. Based on the testimonies, it was confirmed that other studies had already appointed the importance of communication as a work instrument in nursing management, as these professionals play an articulatory and mediating role of professional activities related to care delivery to human beings hospitalized in the context of health and nursing work organizations.
Despite this importance, a communication process was evidenced that included not very well defined mediations between sender, received and feedback. Part of the study group sees communication as a relationship of dialogue and message sharing: the other, however, relates communication with information transmission and seems to be more concerned with the sending of its messages than with the effect and/or action they are expected to trigger. These dual conceptions may be hampering communication and the information flow at the nursing service of the research institution.
As for the communication types nurses use in nursing management, emphasis on written communication was found in head nurses' interactive processes, and use of oral communication when rapid message transmission is the goal, like the need to solve a problem.
In this sense, the research demonstrates nurses' trend to use formal and written communication in nursing management practice, with a view to informing or transmitting information about what is happening, minimizing the importance of interactions and social relations at work. Thus, it becomes imperative to broaden discussions about the communication, management and dialogue triad in nursing, with a view to the construction of more dialogical forms of nursing care management. Effective communication centered on dialogue, interaction and sharing of ideas among head nurses and their team can contribute to personal satisfaction, professional accomplishment and, consequently, entail a positive impact on nursing care quality for hospital patients.
Thus, communication is a fundamental tool for nursing management as a social practice based on information production, circulation and exchange, involving work processes in the hospital context. Hence, it is important for nurses to develop further theoretical knowledge of the constituent elements of the communication process, as well as to understand the importance of interpersonal relationship for successful management communication in nursing.
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