Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.46 no.1 São Paulo Feb. 2012
The scientific production regarding leadership in the context of nursing*
Producción científica sobre liderazgo en el contexto de la enfermería
Simone Coelho AmestoyI; Vânia Marli Schubert BackesII; Letícia de Lima TrindadeIII; Bruna Pedroso CaneverIV
student, Federal University of Santa Catarina, Nursing Graduate Program. CNPq
scholarship. Member of the Nursing Education Research Group. Florianópolis,
SC, Brazil. email@example.com
IIPhD in Nursing. Associate professor, Federal University of Santa Catarina. CNPq scholarship of Research productivity. Leader of the Nursing Education Research Group. Florianópolis, SC, Brazil. firstname.lastname@example.org
IIIDoctoral student, Federal University of Santa Catarina, Graduate Program. Member of the Praxis Research Group. Florianópolis, SC, Brazil. email@example.com
IVRN, Federal University of Santa Catarina. Member of the Nursing Education Research Group. Florianópolis, SC, Brazil. firstname.lastname@example.org
The objective of this study is to identify the scientific production in the context of nursing produced in the last decade (1999-2008). This literature review was performed using the LILACS database and included studies published as articles, theses, dissertations, editorials and presentations in events. Studies were written in Portuguese, English, or Spanish with the electronic full-text version available. A form was developed to register the data regarding the production, which included: reference, source of the manuscript, year, category, objective, methodology and theoretical framework. A total of 57 publications were found; most were original, descriptive articles performed in the hospital environment, and very few studies were founded on the Leadership Theory. It is necessary to adopt leadership development programs and permanent education projects within health services, with the purpose of preparing nurses to work as leaders.
Descriptors: Nursing; Leadership; Health Services
Estudio que objetiva identificar la producción científica sobre liderazgo contextualizado en enfermería generada en los últimos diez años (1999-2008). Se trata de una revisión bibliográfica en base de datos LILACS, en la que se incluyeron trabajos publicados como artículos, tesis, disertaciones, editoriales, presentaciones de trabajos en eventos; en portugués, inglés o español; disponibles íntegramente en formato digital. Se optó por construir un formulario para registrar los datos de los trabajos, entre ellos: referencia, procedencia del manuscrito, año, categoría, objetivos, metodologías y referencial teórico. Se encontraron 57 publicaciones, predominando artículos originales de tipo descriptivo, en ámbito hospitalario, y la escasa utilización de Teorías de Liderazgo fundamentando los estudios. La investigación determina la necesidad de adoptar programas de desarrollo de líderes y proyectos de educación permanente en servicios de salud, a efectos de aplicar el Liderazgo en enfermería.
Descriptores: Enfermería; Liderazgo; Servicios de Salud
Given numerous changes in the world that originated in economic, sociology, political theory, ethics and philosophy, which characterize the complexity of current times, the need for greater flexibility and a broader view concerning knowledge emerged, which requires the qualification of professionals with new competencies and skills, among them leadership.
Leadership began to be scientifically studied at the beginning of the 20th century and consists of the process of influencing people to work in an ethical-professional manner. It requires the establishment of ties of trust to work collectively, aiming to achieve common objectives(1). Some authors from the field of Nursing consider it a phenomenon of group influence, in which it is necessary to aggregate individual efforts in order to achieve goals shared by the group(2-4). Hence, we observe that the exercise of leadership in the current context is included in a nurse's actions because nurses have, with increasing frequency, occupied prominent functions in health services related to the management of care.
In order to provide a better understanding of the topic, it is necessary to clarify that the learning-teaching process of nurses suffered many changes over the years and resulted in important changes in different historical contexts, changing the profile of nurses, as well(5). It is worth noting that new guidelines for a competence-based Undergraduate Nursing Curriculum were established in 2001, which include health care, decision-making, communication, administration and management, continuing education and leadership(6).
Nurses stand out in the field of health given the multiplicity of tasks they perform in addition to intellectual work, coordination of the nursing team's actions in relation to the work schedule, tasks, assignment of personnel as well as the organization and implementation of care(7). Given the previous discussion, mastering knowledge of leadership permits nurse-leaders to aid in the construction and change of the structure of the work of their teams and institutions, influencing administration, education, research, decision-making, improvement and autonomy of collaborators to provide quality care(8).
In addition to strengthening care, leadership can help nurses to construct a satisfying work environment through the establishment of healthy professional bonds and effective dialogical processes among nurses and the remaining members of the nursing team and the multidisciplinary team.
The education of leaders still remains a challenge in the learning-teaching process, not only for the educational process, but also for health services and nurses. Leadership is an essential condition, which enables one to visualize a future with new perspectives and possibilities of work, and to become able to contribute to a greater visibility and valorization of the profession(2).
Because nurses have the responsibility to coordinate the nursing team and manage hospital units and facilities, they are seen as professionals people look to for guidance, information and referrals. For this reason, continuous updating is required and one cannot solely rely on learning acquired during an undergraduate program(9). Nurses also multiply knowledge, which needs to be shared with the team so everyone is constantly improving.
However, educational institutions and health facilities need to be sensitive to the importance of teaching and learning leadership to contribute to the education of professionals apt to take on positions of leadership on nursing teams and being capable of adopting conscious attitudes and becoming agents of transformation(10). The education of politically-minded nurses is expected to be able to meet the needs of individuals and collectivities. For that, one needs to rethink the existing gap between teaching and the requirements of the job market to provide nurses with tools to be used in the leadership of their work place and contribute to the construction of dialogical spaces based on participative, autonomous, and critical management in the health services.
Given the benefits and importance of leadership, we seek to explore this professional competence and, consequently, the need to verify the scientific production in the field has emerged. In this context, this study aimed to identify the publication of studies addressing leadership in the context of nursing indexed in the Latin American and Caribbean Health Sciences (LILACS) database from 1999 to 2008. The study also permitted the identification of the main theories in leadership and enumerates them in the Latin-American publications as well as contributes to critical reflection regarding the development of research in the topic and emphasizes its importance in the health context.
This bibliographic study follows the assumptions of bibliographic reviews, which recovers published studies, systematizes them, analyzes, discusses and draws conclusions concerning a topic of interest aiming to increase the reliability and depth of reviews(11).
To perform this review, we followed the following stages: selection of the theme and key words; definition of databases for search; establishment of criteria for sampling selection; identification of the general panorama of results of a search; construction of a form to record the collected data; analysis of data and interpretation of results(12).
A search in the LILACS database was initiated for studies addressing leadership in the context of nursing published between 1999 and 2008 using the descriptors: Liderança, Leadership, Liderazgo and Enfermagem, Nursing, Enfermería, that is, respectively written in Portuguese, English and Spanish.
The period of time was chosen given the constant updating of knowledge and information and also because it includes 2001, the year when the new curricular guidelines were established emphasizing and disseminating the concept of leadership as a professional competence for nurses.
Inclusion criteria were: studies published in the format of papers, theses and dissertations, editorials, presentation in events; written in Portuguese, English or Spanish; and have the full text available in electronic format. Another three researchers replicated the search to ensure the correct application of search procedures and inclusion criteria. The following stage consisted of reading, organizing results, and categorizing information extracted from the papers. A form was used to record the references of the studies, the year and origin, field of knowledge, type of study and details of the study's methodology. The objectives, final considerations, and leadership framework used in the studies were also considered.
Data were collected between September and October 2009. Afterwards, the full texts of all the studies were read followed by the systematization and categorization of the findings.
RESULTS AND DISCUSSION
A total of 481 studies were found in LILACS using the descriptor Liderança, Leadership, Liderazgo. After it was combined with Nursing, a large number of studies were found (154 studies). After exclusion criteria were applied, original papers from the state of São Paulo and those published in 2005 predominated.
The publications were mainly descriptive studies, though neither qualitative nor quantitative designs were predominant; diversified techniques of data collection were also used. Even though these studies addressed leadership in the context of nursing, just a few used Leadership Theories to ground the studies. A total of 154 studies were selected with 91 studies published between 1999 and 2008. A total of 57 studies were found in the full text version freely available on line.
The most significant exclusion criterion (30.7% of the studies were excluded) was not being published during the predetermined period of study (1999 to 2008). A total of 63 papers out of 154 were excluded after this criterion was applied. Another relevant criterion was related to the availability of papers online and free of charge; 34 papers were excluded given this last criterion resulting in 57 studies (37% of the total studies) in the format of scientific papers, dissertations and theses.
The analysis of the 57 studies revealed a greater number of studies published in 2005. Table 1 presents the years and number of studies.
Most studies (34/52.6%) originated in the state of São Paulo, which is one of the main academic regions in Brazil and has a considerable impact in the scientific production in the field of nursing; ten (17.5%) studies were from Rio de Janeiro, Brazil. Two studies originated in each of the Brazilian states of Paraná, Santa Catarina and Ceará, while Rio Grande do Sul, Goiás, and Minas Gerais had one study each. One study was published in Brazil but originated from a discussion among nurses from various countries such as the United States, Canada, Columbia, Ecuador, Argentina, Peru, Mexico and Brazil. Another three studies published in Brazil had Mexican, American and Canadian origins. Hence, a predominance of Brazilian studies addressing the topic in the investigated period was observed.
In relation to the methodology, descriptive studies predominated (28 studies/49.1%). There were 26 (45.61%) original studies, 11 (19.29%) reflective studies, seven (12.28%) bibliographic reviews, five (8.77%) historical studies, two theses, two editorials, one dissertation, one experience report, one testimony and one round table. There is a greater interest in and more space is available in scientific publications for field research, which in part explains the larger number of original studies. Despite the large number of Latin-American studies addressing the subject, the number of theses and dissertations addressing the topic in the context of nursing is small, indicating the importance of greater academic investment in the topic.
In relation to the studies' designs, seven (12.28%) studies were qualitative and six (10.52%) were quantitative. One study combined qualitative and quantitative approaches. This result shows that there was not a considerable difference between the use of qualitative or quantitative research in Latin-American studies addressing leadership in the context of nursing between 1999 and 2008.
The techniques used to collect data were diversified including non-participant observation, workshops, questionnaires, semi-structured interviews, international instruments, bibliographic review and scales. The use of different techniques shows the subject allows for many forms of investigation.
In relation to the studies' settings, 27 studies were conducted in hospital facilities. Ten (17.54%) of these were conducted in university hospitals, eight (14.03%) in private hospitals, five (8.77%) in public hospitals, three (5.26%) in philanthropic hospitals and one study was carried out in a hospital facility that was not characterized. One of the studies was carried out in three hospital facilities and another in two facilities concomitantly. Only two studies were conduced in primary health care units, which shows the great interest of researchers in developing studies in hospital facilities. Researchers state that hospital facilities are seen as places conducive for professional development and are considered complex systems that absorb a large number of health workers with positions for diverse workers such as in administration, hygiene, and maintenance, among others(13). Additionally, this environment is, historically and culturally, a space where complex relationships are developed, permeated with unique experiences of health workers and users.
Some studies assert that the nurse-leader has an essential role within a health facility, whether in a hospital or primary health care unit. For this reason, during the exercise of leadership, this professional has to promote a favorable environment to perform care, assuming the difficult task of coordinating the nursing team. For that, nurses need to develop and improve skills and competencies that favor the balanced leadership of a group, among which are: the constant search for knowledge, efficient communication, problem-solving capacity, and good interpersonal relationships, among others(9,10,14).
Another objective was to identify the main Theories of Leadership used in the studies. The Managerial Grid Model was identified in seven studies(15), four studies adopted the Situational Leadership Theory(16) and one used Behavioral Theories(17).
The Managerial Grid Model consists of a behavioral theory created by Blake and Mouton, researchers of the Ohio State University(15), in which each manager is, to a greater or lesser extent, oriented toward production, people or power. The scores composing the Managerial Grid are: (9.1) the manager aims to maximize production through the exercise of power and authority; (1.9) the manager seeks to promote good relationships among colleagues and subordinates; (1.1) does what is necessary to remain in the organization; (5.5) the manager's intention is to reach halfway, which results in conformity with reality; (9.9) production-orientation is combined with people-orientation. The latter may be seen as team management in which the manager seeks, in addition to guide toward goals, to reach excellent results of great quantity through participation, commitment and the resolution of conflict(15). Some researchers investigate the use of the Management Grid Model to identify the styles dominant among nurses in the hospital routine. The studies highlight that nurses aim to adopt style Grid 9.9 in which management of the team is permeated by an open communicational process, permitting mutual understanding, satisfaction, consensus, creativity and innovation in the work place(4,18-19). Based on these findings, we also highlight that the behavior of the leader reflects on the team's performance, since its members mirror the model they believe or perceive as necessary to perform their practice in delivering care to patients in health services. One can infer the nurse-leader's leadership style by analyzing the behavior of the group given the nursing work routine, which determines the right moment for the leader to adhere to behavior and diverse attitudes, aiming to involve collaborators(4). From this perspective, we observe the valorization of communicational processes in the exercise of leadership, which is indicated as a preponderant aspect in the construction of good interpersonal relationships at work.
The Situational Leadership Theory of Hersey and Blanchard focuses on the inter-relationship between the amount of guidance and direction provided, also called task behavior. The amount of socio-emotional support (relationship behavior) provided by the leader and the level of maturity of those being led in performing a task(16). This model was developed to help people to become leaders, regardless of their role or position, because it offers a greater understanding of the relationship between an efficient leadership style and the level of readiness of those being led.
Authors define readiness as the ability and willingness of individuals to take responsibility for their own behavior. Leadership represents the process of influencing activities or individuals or groups, in the attempt to achieve the objectives established in a given situation. There is no single manner to exert influence in the Situational Leadership because it depends on the level of readiness of the members of the group the leader wishes to influence(16). One study highlights that the choice of one leadership model over another depends on the work team. Hence, the behavior of the group members indicates which actions are relevant. The importance of the interaction between the nurse and the team is highlighted in this process, as well as the way such interpersonal relationships are established among the involved actors(20). In relation to the application of this theory, it is worth noting that a study performed in an emergency unit aimed to identify how consistent were the opinions of nurses and nursing auxiliaries concerning the leadership style used by nurses and the style nurses should adopt in relation to the level of maturity of the team members given the care activities developed. The results showed that the style most used by nurses was E3 (sharing) while they should adopt style E4 (delegating), given the level of maturity of the auxiliary personnel, which suggests the team presented a high level of maturity (M4)(21). A similar result was obtained in a study conducted in surgical centers in which E3 also predominated among the studied nurses. Style E3 encourages the team to participate in the decision-making process. Hence, the communication of the leader in this style is bilateral, that is, the nurse encourages and supports the team members in the development of the required task(22).
Likert's system 4 was also used. It influences the formation of work teams, collaborating in the establishment of ties of trust and loyalty between team members and supervisors. Interpersonal relationship skills and problem-solving capacity are considered relevant in this model. Therefore, the effective participation of the group in determining organizational objectives is encouraged, highly motivating them to achieve such objectives. The communication process is efficient and effective, with a reciprocal flow of information and a technically competent leadership capable of achieving a high level of performance(17). Communication represents a strategy that facilitates the performance of the nurse-leader and is present in a large portion of the selected studies(10,14,20,23-24). Because the benefits of communication are recognized, a new way of thinking about leadership in nursing is proposed through the use of dialog, which consists of a human phenomenon that cannot be reduced to simply 'depositing' ideas of one individual into another. Rather, it refers to the meeting of individuals to discuss problems and situations aiming to transform reality(25). Dialogical leadership emerges as the ability of a leader to influence his/her collaborators to act critically and reflectively upon their practice through the establishment of an efficient communication process, and can contribute and encourage changes in micro and macro spaces where the nursing team acts, as well as encouraging autonomy, co-responsibility, and valorization of workers and users of health services(26).
Another study highlights leadership as a strategy to favor the implementation of the evidence-based practice in nursing, encouraging nurses to seek scientific knowledge whether through the development of studies or use and application of the results obtained during professional practice. Through this approach, nurses can become agents of change, incorporating innovations in their daily practice through the integration and incorporation of evidence originating in scientific knowledge in humane and ethical care provided by the nursing team(27).
The analysis of the theories used in the studies showed that research in nursing is seldom based on Theories of Leadership because only 12 (21.05%) out the 57 studies used such theories as a point of reference. This lack of theoretical framework observed in nurses in relation to leadership may be directly related to the limited number of tools provided to these professionals to exert leadership in their work place and also to the low valorization of leadership during the education of these professionals. A similar result as found in another study developed with clinical nurses who worked in a philanthropic hospital in Pelotas, RS, Brazil(10).
Being prepared is a prime condition for nurse-leaders to implement changes in their work place, aiming to improve quality of care while reconciling organizational objectives with the needs of the nursing team. Given the previous discussion, we identify the need for nurses to adopt a reference to guide their professional practice to enhance care and its planning, as well as the expected results.
The analysis of the results revealed a large number of studies in which original and descriptive papers predominated, in addition to several techniques of data collection approaching leadership in the context of nursing. However, studies addressing the topic in the LILACS database are still scarce. The studies were mainly Brazilian; this topic is seldom investigated in the international scope.
The hospital facility was the prevalent study setting and we believe this result may be associated with the concern of researchers in relation to the difficulties found by some nurses to exert leadership in this environment.
Even though the concept of leadership was highlighted by the new curricular guidelines as a desirable professional competency for nurses, we perceive, given the development of research, that Leadership Theories are seldom used in the analyzed studies, which may hinder the availability and use of tools by nurses in relation to the application of leadership in the health services. We note that this is an essential tool for professionals to develop and take leadership positions aiming to qualify care provided to individuals and the collectivity, meet the social health needs and promote humanized care.
Each theory represents potentialities that can guide the exercise of leadership. These theories have as a convergent aspect the search for ways to deal with the needs of the current job market, which increasingly requires unique, creative, and productive individuals. Dialog is the thread that conducts interpersonal relationships within the work environment, especially in health services, given the marked contact of caregivers and patients with finitude and disease, which weakens them both. Therefore, based on the studies' findings, we believe that leadership can help to overcome fragmented and inflexible practices experienced in various contexts of health services, through the encouragement of new propositions of work based on dialog and in evidence-based practices, which tend to positively influence the quality of care delivery.
There is also a need to adopt programs to develop leaders and projects of continuing education in health services to prepare individuals to apply leadership based on the establishment of an efficient communication process in order to encourage autonomy, co-responsibility, and the valorization of the leader and his/her collaborators, aiming to meet the health needs of the population.
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