Meanings of hierarchies in hospital work in Brazilian public hospitals from empirical studies

Abstracts

OBJETIVO: Compreender como as estruturas hierárquicas presentes na cultura organizacional de hospitais públicos brasileiros significam no trabalho hospitalar. MÉTODOS: O corpus da pesquisa originou-se em quatro teses e seis dissertações e foi organizado, analisado e interpretado sob a perspectiva da antropologia simbólica-interpretativa. RESULTADOS: Hospitais estão calcados na burocracia profissional e mecanicista, e as hierarquias, decorrentes dessas estruturas, produzem significados que interpretados indicam fragmentação das relações, disputas profissionais e distanciamentos, bem como conflitos e comportamentos subversivos no trabalho, respectivamente. CONCLUSÃO: As hierarquias em cada uma das burocracias encaminham diferentes enfrentamentos que desestabilizam os trabalhadores e seus processos de trabalho. Estratégias de reorientação e conscientização dos limites hierárquicos devem ser equacionadas, para que o trabalho seja otimizado.

Hospitais públicos; Cultura organizacional; Administração de recursos humanos em hospitais; Recursos humanos de enfermagem no hospital

OBJETIVO: Comprender que significan, en el trabajo hospitalario, las estructuras jerárquicas presentes en la cultura organizacional de hospitales públicos brasileños. MÉTODOS: El corpus de la investigación se originó en cuatro tesis y seis disertaciones y fue organizado, analizado y interpretado bajo la perspectiva de la antropología simbólica interpretativa. RESULTADOS: Los Hospitales copian la burocracia profesional y mecanicista, y las jerarquías, provenientes de esas estructuras, producen significados que indican una fragmentación de las relaciones, disputas profesionales y distanciamientos, así como conflictos y comportamientos subversivos en el trabajo. CONCLUSIÓN: Las jerarquías en cada una de las burocracias crean diferentes enfrentamientos que desestabilizan a los trabajadores y a sus procesos de trabajo. Estrategias de reorientación y concientización de los límites jerárquicos deben ser estudiadas, para que el trabajo sea optimizado.

Hospitales públicos; Cultura organizacional; Administración de personal en hospitales; Personal de enfermería en hospital

ORIGINAL ARTICLE

Meanings of hierarchies in hospital work in brazilian public hospitals from empirical studies^*

Helena Heidtmann Vaghetti^I; Maria Itayra Coelho de Souza Padilha^II; Wilson Danilo Lunardi Filho^I; Valéria Lerch Lunardi^I; Cesar Francisco Silva da Costa^I

^IUniversidade Federal do Rio Grande - FURG - Rio Grande (RS), Brazil

^IIUniversidade Federal de Santa Catarina - UFSC - Florianópolis (SC), Brazil

^{Corresponding author}

ABSTRACT

OBJECTIVE: Understand the meaning, in hospital work, of hierarchical structures present in the organizational culture of Brazilian public hospitals.

METHODS: The corpus of research was originated in four theses and six dissertations, and was organized, analyzed and interpreted from the perspective of symbolic anthropology interpretation.

RESULTS: Hospitals copied the professional mechanistic bureaucracy and hierarchies, from these structures, produce meanings that indicate a fragmentation of relationships, professional disputes and separations, as well as conflicts and subversive behavior at work.

CONCLUSION: The hierarchies in each of the bureaucracies created several clashes that disrupt the workers and their work processes. Reorientation strategies and awareness of the hierarchical boundaries should be studied so that the work is optimized.

Descriptors: Hospitals, public; Organizational culture; Personnel administration, hospital; Nursing staff, hospital

INTRODUCTION

Based on empirical studies, the investigations such as theses and dissertations have led to significant enhancements in the knowledge about the area of nursing/health, especially when trying to understand certain phenomena on multiple views and different realities. This is even more important for the reality of hospitals, which are the most important and most expensive part of the health system⁽¹⁾ with a culture that is unique and intriguing.

In Brazil, the hospital network is highly stratified, with hospitals that are worldwide excellence centers and others that are below a reasonable standard of quality in care. However, different from other countries, the Brazilian hospital system is highly pluralistic with many and different structural arrangements to manage, finance and own it, both in the public and private sector, giving it a unique feature⁽²⁾.

Until the 80's, the Brazilian hospitals had a hegemonic technical care that was medical and hospital centered which made them centers solely for healing and rehabilitation. With the introduction of the Single Health System (SUS), the Brazilian public hospitals created a new design that, in addition to the technological part common to all organizations, offers another framework with impact on the management and structural issues of these spaces. These hospitals are searching for strategies to practice the principles of universality and equality and the SUS guidelines to decentralize, to provide integral care with social participation, using management models that maximize productivity, reduce costs, and optimize the quality of care provided.

An example of this strategy is connected with the start of the Brazilian Program of Hospital Accreditation by the Ministry of Health in 1998, which proposes that hospitals adopt management processes to achieve continuous improvement, so that the quality of these units is achieved and, then they are certified through a total assessment⁽³⁾. Thus, Total Quality in its essence or with adjustments, has been widely used not only to achieve quality of care, but also as a tool to pursuit a mission, the objectives and goals that are part of the Brazilian public hospitals. Other means of management have been fully or partially implemented in the Brazilian hospitals, such as Strategic Planning Technologies, Situational Strategic Planning, and Goal Oriented Planning. In spite of these innovative management tools, some Brazilian public hospitals are bureaucratic organizations, whose socially defined hierarchical structure has outcomes in the organization and in the production of the work performed there.

This set of hierarchies/work production and organization drew scholars attention as early as in the beginning of the 20th century, when classic management, represented by Henri Fayol, aimed to meet the practical problems of the organizations, and the sociological management, based on Max Weber's Bureaucracy, dealt with the hierarchical models that were present, especially in the bureaucracies, to increase the productivity in these places. Currently, the Toyota Production System, which has been introduced in many Brazilian hospitals, also assesses the influence of hierarchical lines in cost and error reduction in these places. We believe that a study that treats hierarchies in hospitals with the bias of the organizational culture may help understand the complex relations that are established in hospitals and that influence the work that is carried out.

Thus, we have resorted to PhD thesis and Master dissertations that focus directly or indirectly on the organizational culture of public hospitals. From then on, we have assessed the authors' interpretation on the meanings expressed by workers, who were the subjects of these studies, in their work.

Thorough the study, we aimed to answer the questions that guided the present study: -What is the meaning of these hierarchies in the organizational culture of the Brazilian public hospitals? - What is the result of these meanings in the hospital work?

There is the expectation that the expression of these workers on the hierarchies is a collective statement of their feelings and perceptions, because we know individuals build and share meanings, socially and historically, that indicate how they perceive, feel, think, judge and act in their life, and in their work⁽⁴⁾. The hierarchies, among other structural and philosophical components of the bureaucratic organizations, play an interpretative role, because, "they work as primary points of reference for the way people think and give meaning to the context in which they work" and work in the understanding of the realities⁽⁴⁾.

In the present investigation, the organizational culture had the concept of culture based on symbolic anthropology, and the concept of organization in the theory of organizational symbolism. Symbolic anthropology, comes from cultural anthropology, it has an interpretative or hermeneutical line. The theory of organizational symbolism is also fed by the symbolic interpretative anthropological paradigm⁽⁵⁾.

Thus, the present study aimed to understand the meaning, in the hospital work, of the hierarchical structures that are present in the organizational culture of Brazilian public hospitals. It was supported by the subjective perspective of the symbolic-interpretive anthropology and is also associated with ideas of several authors of the fields of health, management, anthropology, sociology, psychology and the professional experiences of the authors.

METHODS

This study has a qualitative approach and the methods were based on some of Geertz's conceptions^(6-8). The search for thesis and dissertations occurred from January and December 2008 in virtual libraries from several Brazilian universities with post graduation programs and in the Medline, Lilacs Express system, at SciELO (through the key words "organizational culture" and "hospitals"), in the Portal of journals (Capes) and in the bibliographic references that were present in the studies on the subject.

The thesis and dissertations that were not available online were obtained through the request of authors and/or tutors and direct contact with the post graduation programs involved, or with the libraries where the studies were stored, to be sent by mail or email. Other studies were obtained from private libraries.

We have catalogued 14 thesis and dissertations produced and published from 1996 to 2008. Four have been excluded because they did not meet the requirement of having public hospitals integrated with the network of health care of the SUS as the research field. This was a condition because we believed we would have greater adherence to the reality demonstrated, and thus empirical base to assess and discuss the findings since we have worked in public hospitals for several years.

Finally, four thesis^(9-12) and six dissertations^(13-18) have been selected and were later organized according to the year of publication, theoretical reference used, objectives and focus of the investigation and exhaustively read.

The study corpus was formed by the collection of text extracts which, according to our view, had meanings on the hierarchies of the culture of hospitals, expressed by the authors of the studies based on the meaning produced by the subjects of their investigation.

The text extracts/fragments led to several thinking units that named the ideas that emerged during the readings. From then on, these extracts have been grouped and encoded according to the corresponding thinking unit, study type (thesis or dissertation), authorship and page number where the fragment was. Afterwards, the extracts were typed (those that were not available in word file and those that were only available on "paper"), copied and pasted (in those we could do that), with a total of about 800 fragments.

The thinking units with their text fragments were grouped according to relations and connections that could be established among them, outlining some "significant structures" or "structures of meaning"⁽⁶⁾.

Thus, the structure of meaning, "The hierarchies in the professional bureaucratic and mechanistic structures of Brazilian public hospitals", resulting from the previous exercise was developed into two analytical axis "Hospital hierarchies and professional dispute" and "Hospital hierarchy and work subversion", both showed meanings resulting from each bureaucratic structure - the professional and the mechanistic -, expressed by health workers about the hierarchies in each hospital culture.

The analysis of the corpus was to interpret what the authors of thesis and dissertations have interpreted about the informers of the aspects of their cultural reality, and it was what Geertz⁽⁶⁾ calls third, second and first order interpretation respectively. For the author, the anthropological texts are "themselves interpretations and, actually, second and third order interpretations. (By definition, only a "native" makes first order ones: it's his culture)"⁽⁶⁾.

His proposal, based on hermeneutics, use the interpretation of reports "to draw some conclusions on the expression, power, identity, or justice" that can be "far away from the standard styles of demonstration". When we interpret, "we use deviations, we enter through parallel streets", because, according to the words of Wittgenstein, (...), we see the straight highway before us, but of course we cannot use it, because it is permanently closed"⁽⁸⁾.

Therefore, the analysis was carried out through the "guessing at meanings, assessing the guesses, and drawing explanatory conclusions from the better guesses (...)"(6), and the interpretation "enlightening"⁽⁸⁾ the meanings of hierarchies in hospitals.

Thus, the dialogical movement established between the interpretations and the theoretical references proposed by several authors of anthropology, administration and sociology, among other subjects, provided the views that will be exposed now on the meanings of hierarchies in the culture of Brazilian hospitals.

RESULTS

When we were searching for the meaning of hierarchies in studies focusing the organizational culture of hospitals, we saw that the realities in which the investigations occurred were both professional and mechanistic bureaucracies and so the meanings to the hierarchy were different. Thus, we had first to understand this event so that we could interpret the meanings of the hierarchies under the two prisms: that of professional bureaucracy and of mechanistic bureaucracy.

All organizations, understood as hierarchically defined social structures, present a certain level of bureaucratization characterized by more or less hierarchical structures of authority, rules and lines of specialization that are used essentially to organize people, so that they produce goods and services efficiently⁽¹⁹⁾.

In the structural setting of the organizations, the bureaucracy can be considered mechanistic and professional. Professional bureaucracy is found in hospitals and universities and hierarchy and power are based on workers' competences and knowledge, that is, in the professional nature and in specialization. The mechanistic bureaucracy is present in those organizations where the work processes are repetitive and standardized and the hierarchy is dictated by the position or function in the hierarchical chain⁽¹⁹⁾.

However, we have observed in the thesis and dissertations studied, aspects of both bureaucracies living together which can be a hybrid movement characteristic of the public hospital organizations that were the focus of the investigations. This may be modeled by the nature of the hospitals studied, with an identity characterized by "health" and by "public". At the same time, the activities of hospital workers are geared to face the death and life phenomenon and for the production of services that promote physical, mental, and social well being of users⁽²⁰⁾, without the objective of profit.

Thus, the "public" can determine the mechanistic bureaucracy and the fold "health" can lead to professional bureaucracy in these places. Under these two prisms, the developments of this structure of meaning have been organized in "Hospital hierarchies and professional disputes" and "Hospital hierarchies and work subversion" each showing a type of bureaucracy and producing different meanings that imply the work in Brazilian public hospitals.

DISCUSSION

Hospital hierarchies and professional dispute

In professional bureaucracies, including hospitals, there are two parallel hierarchical lines, one for professionals, in an ascending and democratic order, and another for support positions, in a descending order, with a mechanistic bureaucracy nature. These two lines are in opposite fields and can lead to conflicts in the organizations⁽¹⁹⁾.

In the studies investigated, we have found traces that strengthen this idea. Public hospital management and the more technical professionals, especially those in health area have different views on the management of these organizations; one is geared to management, and the other to care problems. The meanings of this conflict lead to a culture of detachment among workers, conditioned by the different understandings on the purpose and final product of the work in hospitals, leading to severe breaks in the work process, even though all people involved want to optimize hospital care. The following text extracts demonstrate this:

Physicians mainly do not have a planning view, they don't have a macro vision[...]. The obstacle is that, sometimes, the purposes are twisted when professionals at the end do not have a view of the whole [...]⁽⁹⁾.

Additionally to the different interfaces "technical/care" and "management/administrative", a detachment was observed among professionals performing end activities at the care end and the management of the Institute [...]⁽¹⁵⁾.

Physicians have a different logic in the work orientation, they tend to value the technical aspects referring to their areas⁽¹¹⁾.

In the United States, the reflection "Hospital-medical staff culture clash: is it inevitable or preventable?" points out that there are historical tensions between the medical staff and the hospital administrators. Both groups of professionals are united by a desire to offer patients optimal care but these intentions are hindered by conflicts resulting from different positions that are connected with deep cultural divisions, regarding the autonomy of physicians and the control performed by managers⁽²¹⁾. Likewise, the article called "Desafios do administrador hospitalar - Challenges of the hospital administrator" provides administrator's view about hospital management. Authors, who are graduated managers, refer that physicians and nurses, when they manage a hospital, make it based on the daily practice and their management skills are poorer than their technical quality, since they "don't like or understand management activities"⁽²²⁾.

These studies, even though they were carried out in two different realities, reinforce the findings on the thesis and dissertations, demonstrating the presence of professional conflicts caused by the fight between technicians and administrators since each segment is supported by its own professional logic to perform hospital work. This leads to a measure of forces that, according to some text extracts, is usually won by administrators who, most of the times, in the name of expense reduction, justify some reductions in the budget for consumables and personnel. On the other hand, when physicians, nurses and other professionals get into a conflict with administrators, looking for more and better instrumentals, they do it for users, and many times this conflict is to make administrators responsible for the possible problems that can result for not meeting their needs.

Another focus found in the studies concerns to the professional dispute between physicians and nurses caused by hierarchies. Despite the hospital chart, most times, there were no hierarchical lines of power and authority between the two professions, the historical submission of nursing to medicine is still present in some hospitals.

This fact can be closer to the statement that nursing professionals are placed in a situation of subordination in the division of the medical work, because the nursing work is defined from the nature of the medical work, and the functional position of their tasks is determined from the centrality of medical tasks^(23-24).

The extract below exemplifies how this theme has been approached in the hospitals that were part of the study, demonstrating that hierarchy can be an invisible line, translated into a culture of power established by the historical formation of both medicine and nursing:

[...] even though they know the job market is subordinated to the process of capital valuation, the participants (nurses) serve the prevailing ideology, admitting their work as subordinate to the medical power, still hegemonic, compared to the other health professionals⁽¹²⁾.

This statement can be partially denied from the idea that hospital coordination is actually with the nursing, even though there is a paradox situation since those coordinating care are dominated in this situation⁽²⁵⁾. However, the study "Relationship between nurses and physicians in terms of organizational culture: who is responsible for subordination of nurses?" also reinforces the meanings presented in thesis and dissertations since interviewed nurses in this investigation mention that the physicians tend to control them and feel superior, encouraging hierarchical relations that do not promote communication between the members of the group⁽²⁶⁾. The study called "A saúde do trabalhador de enfermagem sob a ótica da gerência: obstáculos e possibilidades - The health of nursing workers under the view of management: obstacles and possibilities"⁽²⁷⁾, also indicate that the nursing work is a mean activity, subordinated to the medical work technically and administratively.

Apart from these indications mentioned above, some meanings seen in the text extracts of the selected thesis and dissertations show that nurses dispute the leading role in care actions to users, even when they see their work as dependent on the medical work. This is demonstrated when, in the reality of hospitals, medical care is commonly criticized by nurses because it is not holistic, nor it is developed full time or in an individualized fashion.

Hospital hierarchies and work subversion

In the mechanistic bureaucracy there is a clearly defined hierarchical line in which the command unit is carefully maintained by the hierarchical nature and there is a clear distinction between the operational and functional levels⁽¹⁹⁾. In the Brazilian society, this exposed sense of hierarchy and subordination is based on the traditional military force and in the rational-legal power to establish and maintain the authority⁽²⁸⁾.

The lines of authority which are part of the hospital hierarchical structures, especially in the organization of nursing work, are possible source of detachment and conflicts between workers, which may lead to subversion in the work in hospitals. Some fragments found in the thesis and dissertations express these cultural evidences that are interpreted next:

But there are some managers that are not well integrated with their subordinates, with a detachment created by the hierarchical culture that is still present in some cases⁽¹⁴⁾.

Regarding the network of power, there must be a formal hierarchy between the members of the nursing team, where some individuals from inferior levels demonstrate a certain level of dissatisfaction⁽¹⁶⁾.

Thus, the position brings to light a threat, including also the other participants of the category, this perception leads to internal conflicts in nurses in the work context⁽¹²⁾.

The social division of nursing work has always been a reason for detachment and conflicts, because the profession has been historically organized in functional extracts, characterized by different categories and, consequently, different competences. Thus, some nursing assistants and technicians find it hard to accept that nurses have a different status in the team, greater prestige and authority, as well as a higher salary. Likewise, when they are on the top of the hierarchical chain of the team, nurses can have an extreme domination on their subordinates, leading to feelings of anger and indignation with outcomes in the work, causing dissatisfaction about the work, the rules and the routines established by nurses.

So, in this situation where power is unequal, individuals can become alienated, with low motivation and thus they can be passive, with no initiative in the work, leading to situation of latent conflicts⁽²⁸⁾. This, in the worker/work relation, results in dissatisfaction and suffering that can also affect the relationship among workers. Pathogenic suffering at work, because of the relationship that is established and the management models occurs when people face "fixed, strict pressures that cannot be controlled, leading to repetition and frustration, boredom, fear or feeling of powerlessness", which cause mental or psychosomatic decompensation and diseases⁽²⁹⁾.

This disintegration of and at work in the hospitals where studies were carried out produces meanings whose interpretation demonstrates neglect, lack of commitment, indifference, complaints and insubordination of workers, it also causes them great suffering, and controverts the order pleasure at work, that should be natural.

Thus, what has been demonstrated can cause a value crisis, leading to several ethical distortions, with outcomes in the work of these health professionals that become accommodated or give up because of the daily operational problems. They "let themselves be carried away by an avalanche of subterfuge and casuistry that increase bureaucracy and decrease the final quality of health care" and they start "to practice (consciously or unconsciously) principles that are not compatible with the values that they previously believed as correct to the just human living"⁽³⁰⁾. This phenomenon was found in some hospitals were studies were carried out, when it was observed that when nursing workers who were examples of responsibility, commitment and dedication had problems with head of departments, usually caused by uprising against the hierarchies, they started to present a behavior of being against to what was established by nurses, going against their previous behavior. The explanation that comes is based on the idea that when a position is determined in the chart, people are reduced to positions of power, establishing a disciplinary order of the spaces/limits that are allowed⁽³¹⁾, making the representation of power cause discomfort, both in those that are exercising it and those that are subjected to it.

FINAL REMARKS

The search to understand the meaning of the hierarchical structures of the organizational culture of Brazilian public hospitals in the hospital work, made it possible for a partial comprehension of this phenomenon in the routine of organizations studied in thesis and dissertations that approached the theme. We say that this reading is partial because not all meanings are perceived in the investigations, due to their diversity and complexity, since this ambition would extrapolate the limits of the current investigation.

Some Brazilian hospitals are based both in the mechanistic and in the professional bureaucracy where hierarchical levels operate and have impact on the meanings health workers build on this phenomenon. This is translated into a culture where the stiffness of hierarchical lines affect the development of the work in the realities that were studied, in the sense that they fragment the relations and cause professional conflicts, they also cause detachment and conflicts, leading to subversive behavior at work.

According to our findings, there is a great need to encourage strategies in public hospitals that foster discussions on the hierarchical structures with the participation of workers, managers, and the government, so that these structures are no longer obstacles to the proper development of the work. In this sense, debates can also ensure the understanding that the power ensured by the hierarchical chain in the hospital institutions is not only the result of the evolvement of some professions, but rather, a way to facilitate the management process. On the other hand, the exercise of power of nurses in the hierarchical chain of the nursing team should be revised, both in the hospital practice, and in the process of academic education, so that new strategies for nursing work are created and introduced.

We also understand that hierarchical models that produce positive relationship between health workers, overall, can have results in the care provided in hospitals and in the production and satisfactory organization of the work of the several professions that are routinely living with this reality.

The translation of the set of meanings of hierarchies in Brazilian public hospitals, based on the thesis and dissertations that include in their scope the organizational culture, expressed a profile of the culture of these spaces which will help build paths that will lead to the comprehension of these organizations and their complex connections. It can also make researchers committed with the knowledge of the process of hospital management instigated and concerned, it may become a reason for criticism but, especially, a reason to reflect on these realities.

However, as the present study used third order interpretations, as referred by Geertz, in a restricted sample of empirical studies submitted to its intrinsic criteria, it may be impossible for generalizations to be made, and they are often necessary to complete scientific studies. On the other hand, the interpretations that have been produced on the meanings given by the individuals researched to hierarchies, according to the authors of the thesis and dissertations can subsidize other studies, using the organizational culture as a starting point to allow for several other study views on hospital organizations.

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Received article 23/11/2009 and accepted 05/09/2010

*

Study carried out at Universidade Federal de Santa Catarina - UFSC e Universidade Federal do Rio Grande-FURG.

Publication Dates

• Publication in this collection
  15 Mar 2011
• Date of issue
  2011

History

• Received
  23 Nov 2009
• Accepted
  05 Sept 2010