Decision-making of the nursing team after the revitalization of a decentralized management model

La toma de decisiones del equipo de enfermería después de la revitalización del modelo de gestión descentralizada

Abstracts

This study's objective was to identify changes in decision-making arising from the revitalization of the participatory management model and how these changes impacted the daily work of the nursing staff, as well as to identify potential difficulties. This qualitative case study was conducted in a public hospital in the State of São Paulo, Brazil. Participant observation and semi-structured interviews were conducted with 23 nursing workers and the Health Technical Assistant. We used thematic content analysis for data analysis. The revitalization of the management model was not comprehensive because many professionals were oblivious to the process. Shared actions did not occur and adherence to the model was hampered because the workers were not fully informed of the assumptions concerning this management model. For the implementation of this model to be effective, teamwork and the inclusion of all the stakeholders should be reviewed in order to achieve more cooperative and qualified work.

Nursing, team; Organization and administration; Decision-making; Health management

Este estudio buscó identificar cambios en las decisiones derivadas de la revitalización del modelo de gestión compartida y la interferencia en el trabajo de la enfermería, así como identificar las dificultades encontradas. Estudio de caso cualitativo realizado en un hospital público en el estado de São Paulo por medio de observación participante y entrevistas semiestructuradas que fueron realizadas con 23 trabajadores de enfermería y el Asistente Técnico de Salud. Para el análisis de datos se optó por el análisis de contenido. La revitalización de la gestión no fue significativa, ya que muchos profesionales no tenían conocimiento del proceso. El acto compartido no se materializó y la adhesión al modelo fue insuficiente porque no había orientación de los supuestos del modelo. Para hacer posible la realización de este modelo de gestión, debe ser revisado el trabajo en equipo y la inclusión de todos los interesados con el fin de lograr un trabajo más articulado y calificado.

Grupo de enfermería; Organización y administración; Toma de decisiones; Gestión en salud

Objetivou-se identificar alterações ocorridas na tomada de decisão decorrentes da revitalização do modelo de gestão compartilhada e a interferência delas no cotidiano de trabalho da enfermagem, bem como identificar as dificuldades encontradas. Trata-se de estudo de caso com abordagem qualitativa, desenvolvido em hospital público do estado de São Paulo. Observação participante e entrevistas semiestruturadas foram realizadas com 23 trabalhadores da enfermagem e a Assistente Técnica de Saúde. Para a análise dos dados optou-se pela análise temática de conteúdo. A revitalização do modelo de gestão não ocorreu de forma expressiva, pois muitos profissionais desconheciam esse processo. O agir compartilhado não se efetivou e a adesão ao modelo foi prejudicada, pois foi incipiente a estratégia de orientação acerca dos pressupostos do modelo gerencial. Para que seja possível a efetivação deste modelo, deve ser revisto o trabalho em equipe e a inserção de todos os envolvidos buscando um trabalho mais articulado e qualificado.

Equipe de enfermagem; Organização e administração; Tomada de decisões; Gestão em saúde

INTRODUCTION

Nursing professionals face numerous situations in their clinical practice involving patients and different healthcare needs.¹ In this context, decision-making is a key instrument in the routine of this staff. The scope of shared decision-making, however, is not only related to nursing, but also depends on the establishment of bonds within the interdisciplinary team so that professionals feel they are supported to act and express their preferences and opinions.²

In the current context, the complexity of the hospital itself and the hospital routine, marked by conflicting interests, has indicated a need for a theoretical framework to aid thinking on hospital micro politics, such as experimenting news management strategies.³ Certain organizational structures imply certain management models, and consequently, new distribution of power, authority, communication and decision-making. Contemporary management models have indicated a need to intensify communication and to make both the decision-making process and the distribution of power more flexible.

The decision-making process has different characteristics depending on the management model adopted. The decision-making process of management models based on the classical approach is, for the most part, restricted to upper management. In this model, the employees do not participate in the decision-making process and passively receive the orders of superiors. Thus, the preferences of those with greater power within the institution not only influence the decisions of the less powerful members, but are also capable of inhibiting their preferences.⁴

In the case of a participatory, democratic, decentralized or shared management model, decision-making is shared among the different members of the multidisciplinary staff, as is power and authority. Making decisions requires information and in an organization in which decision-making is shared, an equivalent supply of information for all is necessary; that is, access to information should be facilitated. ^{5 - 6}

Participatory management recommends the decentralization of decision-making and the proximity of staff members who provide healthcare, in which workers have their participation ensured and are entitled to take part in discussions concerning the decision-making process. Therefore, healthcare organizations begin considering the importance of participatory management as a learning strategy due to the assertive event of training and qualifying workers. In this model, management promotes the workers' creative and innovative potential, appropriate to establishing new knowledge and expertise.⁷

To enable this management model, one should consider restructuring the top-down and rigid organizational charts that predominate in impersonal relationships and decision-making processes that are centralized in the hands of a few who retain formal power. The decentralized and participatory model is based on a condition of equitable decision-making facilitated by lateral communication and by de-layering the organizational chart so that all the workers are at the same level. Moreover, all workers would have a voice and opinions would be valued without any having preference over another.^{5 - 6}

Along with participatory management, team learning emerges in a new configuration capable of enabling the participation of the collective in decision-making. Working in a participatory model requires organization from both the leader and those under his/her leadership to promote environments conducive to the growth of the group, capable of valuing the individuals' potential, motivating these individuals and enabling them to commit to the collective work.⁸

Decisions made by a group are more fully informed and present a diversity of experiences and perspectives. Additionally, the different professionals and specialties increase the quantity and diversity of information, generating a larger number of alternatives. Other advantages include greater legitimacy, because joint and democratic decision-making lead to greater acceptance among the group, the members of which feel committed and share accountability for either the success or failure of actions to be implemented.⁹

From this perspective, we understand there to be an urgent need to change the managerial paradigm in regard to decision-making, for both the institution and professionals, including the nursing staff.

We chose this topic because it is essential to assess how decision-making took place after management was changed and also to verify whether there were improvements and how these were accomplished. The motivation to perform this study derives from the results found in a study performed in 2009 in the same institution, the objective of which was to identify changes in decision-making after the implementation of the shared management model and also to identify difficulties faced in the process from the perspective of the nursing staff. The conclusion at the time was that the nursing staff was not taking part in decisions, as suggested in this modern management model, which was formally implemented in the hospital facility currently under study. In reality, a traditional management model, based on the classical approach, was in place.

This study was necessary considering that there was, in 2010, mobilization to revitalize the shared management model with the possibility to make it real, as something formally described, to make it an active process where the intensification of communication and decentralization of power and decision-making would be a reality.

Therefore, the purpose was to present and discuss an organizational experience, the focus of which is the patient and the democratization of organizational life through management that is decentralized at all levels, seeking to ensure the participation of the hospital workers in the decision-making process and their commitment to quality of care.

This study's objective was to identify the changes that took place in the decision-making process accruing from the revitalization of the decentralized or shared model and the interference of these changes in the routine of the nursing staff, as well as the difficulties faced in the decision-making process.

METHOD

An organizational history case study with qualitative approach was used because it enables grasping the phenomenon more deeply.¹⁰ Qualitative research seeks a unique understanding of the phenomenon under study, working with the universe of meanings based on detailed descriptions, where the perceptions, emotions and interpretations of the individual inserted in the context can be captured.¹¹

This study was conducted in a medium-size public hospital facility, founded in 1956 and located in the interior of the state of São Paulo, Brazil. The board of directors, who took office in 1999, desired to change the hospital management system, then centered on the classical approach, which had been the case for the previous 30 years of organizational life. ¹² In 1999, the administrative structure became decentralized after the participatory management model with multidisciplinary representativeness was implemented.¹³ In 2010, the institution went through a revitalization of the managerial model and this is the reason we chose to conduct this study, because the change resulting from this revitalization may be an example for other institutions.

Data collection took place between October 2011 and January 2012 and was conducted with professionals from the nursing staff of the Coronary Care Unit and the Intensive Care Unit: five nurses, one nursing technician, 16 nursing auxiliaries, and the hospital's Health Technical Assistant, totaling 24 interviewees. The number of participants was defined by theoretical saturation of data, which is the point appropriate to cease the collection of information from a group or one individual, regarding the discussion pertaining to a given subject.¹⁴ Theoretical saturation is verified by continuously analyzing data from the beginning of the process of data collection.¹⁵

Inclusion criteria were: being at the hospital at the time of data collection and having been hired in 2009 or before that year. This last inclusion criterion is important because the professional had to have experienced the period of revitalization concerning this model.

The data collection instrument was submitted to apparent and content validation by five judges from the field of hospital management. The guiding questions addressed: the change of nursing management after the shared management model was revitalized; changes in the decision-making process; difficulties faced after the revitalization of the model in regard to decision-making; and the participation of the staff in problem-solving.

Participant observation was used. The observation occurred through direct, frequent and prolonged contact between the researcher and the social actors in their cultural contexts, while the researcher him/herself is an instrument of research. This enables the understanding of facts and interactions among the subjects under observation in their context.¹⁶

Observation took place from two to three hours a day, from Monday to Friday, in order to interact with the team in the two units under study, ensuring an active involvement in the process. In addition to observation, semi-structured interviews were conducted, which provide distinct advantages in many situations. Usually, interviews are very useful to researchers when a new field is being explored.¹⁷ In these situations, this method enables researchers to explore basic problems or issues, to verify how sensitive or controversial a topic is, to determine how people conceptualize the problems or talk about them, and to discern the range of existing opinions or behaviors that are relevant to the issue under study.

The researcher conducted and recorded the interviews after approval was obtained by the Institutional Review Board (Process No. 1314/2011), in accordance with the requirements of Resolution 196/96, National Council of Health.

Thematic content analysis as described by Bardin was used to analyze the data. The phases of this method are organized into: pre-analysis; exploration of material; treatment of the results; and interpretation. After intensive reading of the interviews' reports, data were classified in record units to reach the core or meaning of the text, after which three categories of analysis were created. To improve understanding, the subcategories were arranged into two major categories because they gathered similar themes.¹⁸

RESULTS

Based on data analysis, the following subcategories were created: "Measures to revitalize the management model", "Management model after revitalization", and "Decision-Making". These categories were grouped into two categories: "The process of revitalization of the decentralized management model", which portrays the perception of the actors in regard to the revitalization, and "The participation of the nursing staff in the decision-making process", which concerns the facilities and difficulties faced in order to produce collective decisions.

The process of revitalizing the decentralized management model

From the time in which the institution's ideal is the decentralized management model, we understand that all those involved in the process need to adopt and acknowledge this proposal. Therefore, it is essential that all its aspects be extensively discussed with the entire staff. The revitalization of the management model, however, was poorly disseminated, as some of the professionals did not even realize there was a process going on, despite the informational actions that were implemented.

I didn't even know about the revitalization. I thought you were talking about the difference between the management here and that of the campus, but I didn't even know about this change (NT1)

.

The revitalization process came about with some speeches, there was a meeting with the leader and some employees because it happened during the day shift, and the intranet was used, too. There was some dissemination, but we have no idea of how much was disseminated, how many people were informed. (N4).

People don't have proper knowledge yet; even though they received information, they haven't yet being able to put it into practice (HTA).

The information that was provided did clarify some issues for some professionals, enabling them to acquire greater understanding and to share responsibility for the model, consequently improving communication, participation in meetings and in decision-making. Those who were not aware of the model's revitalization, however, highlight a lack of understanding and lack of participation in discussions, a fact observed by the researchers.

Most of the time no, I don't take part in problem solving, because, like, I don't know how it works here. There's the manager group, there's the meeting of the manager group and everybody is summoned, but I have never participated (NA1).

There is a lack of understanding on the part of the workers and also insufficient participation from them in the meetings, which makes us wonder whether the inclusion of the institutional actors was efficient.

Another problem observed is that the staff working the night shift remained oblivious to the activities proposed within the shared management model, including the election of the managers.

I didn't even take part in the election of the managers because these things don't even take place on the night shift. They happen during the daytime. They organize everything for the voting but not for the night shift (NA13).

The participation of the nursing staff in the decision-making process

Participating in problem-solving within the unit is a right of individuals when they are included in a decentralized management. When problems are not resolved or when people are not included in the solution of problems, they no longer feel they are part of the team and experience a lack of motivation.

There are meetings once a month but there are no results and people feel a lack of motivation. So nowadays, they don't even go anymore; the employees are not attending the meetings anymore (NA6).

Despite the difficulties reported, greater autonomy was observed in one of the functional units in regard to internal decisions, allowing greater participation in the changes implemented in the work routine, improving care delivery.

The auxiliaries have more voice, are listened to in some issues, such as in the case of humidifiers. The nurse in management listened to our suggestions, found them interesting, sought and discussed with CCIH and changed some things (NA11).

Opinions are important in these meetings; our opinion is not decisive but I guess that we have an important role [...] I need to change equipment, so I request it, it's something urgent, it's justifiable, so the hospital manages to arrange a urgent buy and brings it and replaces the material in record time, considering it to be a public service [...] (N2).

Note that the decentralization of the intra-unit decision-making process, as well as greater proximity of the manager to the functional units, improved the motivation of workers.

I believe that because we are closer to the problems, these are informed to us in a more accurate form and I realized that, as people are entitled to claim something and be listened to, they have more reason to be motivated and develop their work (N3).

Observation and interviews showed that most of the workers lacked increased access to information and did not even participate in the decision-making process.

Nursing management still seems a little centralized. The nurses have participated, but some decisions take place without the consent or consultation of everyone. One practical example, the CCU will be renewed, there is a project, a floor plan, but the workers haven't seen anything yet [...] So, I believe that people should become more involved in the process, because after it's done, there'll be no more opportunities. Greater involvement is important to value professionals and make them feel part of the process. It would value the staff, make the group work as a team (N4).

Another aspect reported and also observed involves the employees working on the night shift. The effective participation of the professionals working on this shift is inhibited because they are not involved in discussions and decision-making, since these events occur during the daytime.

Information is transmitted to those working during the daytime but for us working at night, we just get things, it's new and you have to do it. We don't know how, why; often we figure it out or because we mimic or see others doing it, or we learn about things during the shift changes and ask how things are supposed to be. It's easier during the day, the immediate supervisor is there, the managers are there, everything is less complicated (NA11).

Coupled with the non-participation of the workers from the night shift is the fact that decisions are not shared by the entire group, by representatives of all professions.

Participant observation showed that the involvement of the nursing technicians in problem-solving is limited. These workers are no longer interested in participating in meetings; they became disappointed with the lack of information provided by the representatives concerning decisions.

Our participation in decision-making is zero. For us, nursing auxiliaries, orders come and we comply (NA13).

Decisions are more centered on nurses, participation of technicians or auxiliaries is very small, we don't exert much influence anyway; even if we give our opinion in whatever we manage to participate, the opinion of nurses usually prevails (NA14).

The employees feel discredited and report that nurses make most decisions.

DISCUSSION

The use of strategies to revitalize the management model, such as speeches, contributed to disseminate information to some of the workers, however, did not effectively reach all those involved as the model recommends. When the participation and adherence of everyone to a democratic management model is expected, information should be shared and understanding concerning the model should reach all the stakeholders. Nonetheless, no strategies were used during the period of observation to minimize this lack of information.

Communication is one of the principles of participatory management that guides democratization so that workers should meet periodically to rethink the work environment and suggest new directions for the organization. This way, in addition to dialogical communication, the workers exercise decision-making and shared leadership.^{6 , 19}

Participatory governance supports a flat organizational structure. In this process, managerial and functional roles become connected and form a partnership that favors shared decision-making. Opportunities to take note of clinical professionals become regular and communication improves both formally and informally.²⁰ In this sense, the effective participation of the entire group, including workers from the night shift, should be ensured. Otherwise, professionals become passive elements in the process.

For the effective participation of the interdisciplinary team in the health facility, these individuals should develop closer bonds with the groups in order to gradually move from the condition of passive participants to active and engaged actors.

It is necessary to allow the members' opinions to be expressed and enable integration in order to develop actions to empower the group. Overcoming conflicts and promoting continuous group-learning favor the building of a participatory environment.²¹

Paradoxically, leaders in hierarchical structures usually govern in isolation from those doing the work within the organization. Not having a point of connection between the layers hinders acknowledging the potential of workers.^{20 , 22} This distance is not permitted in the participatory model and the time of choosing the manager should be an opportunity to strengthen the organization, to encourage participation, autonomy, and communication. Being committed to this process guides the team to less hierarchical and more participatory models.²³ The choice of the managers, however, did not occur in accordance with the assumptions of the management model, since the workers from the night shift remained oblivious to the process.

From this perspective, the modern managerial model was not incorporated by the entire staff. We believe that to achieve the ideal of this managerial model, each member of the collective needs to have a desire to participate, abdicating the individual role to become a "team member", that is, enable accountability. For that, however, these individuals need to manifest interest in the change and, more importantly, need to absorb the assumptions that guide this model,^{3 , 6 , 23} a fact that did not occur after revitalization in the institution under study.

One of the assumptions refers to decision-making, which implies making choices, from the simplest to the most complex.²⁴ Like any field of health, it is convenient in the hospital context that nursing workers make the highest number of significant decisions. Since the decisions of these professionals can be fatal, however, it would be more prudent if decisions were collective, including workers from different professions.

The shared management model predicates that decisions, the governance of which can be achieved within the work unit, should be made by the collective of workers themselves. In addition to decision-making shared among the different workers that compose the committee, the participatory management model assumes lateral communication. We understand the communication process to be a key factor to ensuring that activities are both efficient and efficacious, and should be continuous to promote information and understanding necessary to the performance of tasks, and, more importantly, to the motivation, cooperation, and satisfactions of the workers in their functions.²⁵

We certify that, in the participatory management model, the decision-making process is diluted among the different members of the multidisciplinary team because it should be a group process in order to present more complete information from a greater diversity of experiences and perspectives. Additionally, intense communication among representatives of different professions increases the quantity and diversity of information, generating a larger number of alternatives. Other advantages include increased legitimacy, since joint and democratic decision-making leads to increased acceptance within the group, which feel more committed and share responsibility for the success or failure of the actions implemented.

Observation also revealed that the participation of workers in the manager groups was on an individual basis, and sometimes restricted to the unit and not extended to the organization as a whole, that is, did not cause a global impact. One study conducted in a community acute care hospital in Louisville, KY, USA, showed that the nursing leaders employed the transformational leadership style, empowering the team members, but these members did not influence the organization. Therefore, the team's decisions did not reach macro-management and were restricted to the scope of the unit. Soon the professionals became reluctant to participate in projects that went beyond the direct care of patients.²⁶

In this context, we note that disengagement and alienation of some of the team members increases the likelihood of failure. As previously mentioned, the night shift workers were not included in the new structure because changes would take place during daytime and these changes were sometimes communicated to the workers on the night shift, but other times were not.

This disengagement and alienation accrues from a lack of effort on the part of the coordinators and management to transform the routine of these workers, valuing their potential, motivating them and including them as participatory members in the decision-making of the management model adopted. ^{6 , 19}

Shared governance in the participatory management model greatly benefits patients, professionals and health institutions. Through leadership, nurses are capable of making decisions that seek collective participation in the delivery of qualified care, moving toward participatory²³ management, which does not occur in this reality.²⁷

The desires, ideas and expressions of all the workers should be acknowledged and granted a hearing. In this case, however, despite mobilization to revitalize the shared management model, expropriation of decision power remains.

CONCLUSIONS

This study showed how difficult it is to effectively establish the assumptions of the shared management model in a public hospital facility. The extreme importance of involving the entire collective of workers in problem-solving is well known, as is also the case in the development of improvement proposals, as well as leading these individuals to share the responsibility for decisions so that it is possible to effectively establish the managerial model. Shared governance was not effectively established, however, because the night shift workers and most of the nursing technicians and auxiliaries did not take part in the decision-making process.

Adherence to the model was hampered in the facility under study because the strategy to qualify and guide the workers in regard to the assumptions of this model was incipient. Therefore, the inclusion of all the workers, as well as teamwork, seeking to establish more cooperative, communicative and qualified work should be reviewed. It will only be possible through an ample and intense communicative process. The effective decentralization of power will only be possible through acknowledging different ideas and positions, the persistence of professionals, continuity of proposals, use of educational strategies to effectively accomplish all the principles proposed by the decentralized management, and deepening knowledge concerning this subject so that there is greater support of its practice through theory and the accumulation of experiences on the part of those involved.

The development of this study in a single hospital facility, as well as the fact that only the members of the nursing staff and the Health Technical Assistant were interviewed, constitute limitations. There is a need to include more facilities, involving institutions with different legal arrangements, and also a need to expand observation and interviews to representatives of other professions, since the managerial model recommends the work of an interdisciplinary team.

REFERENCES

• ¹
  Campos DCF, Graveto JMGN. Papel do enfermeiro e envolvimento do cliente no processo de tomada de decisão clínica. Rev Latino-Am Enferm. 2009 Nov-Dez; 17(6):1065-70.
• ²
  Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012 Out; 27(10):1361-7.
• ³
  Bernardes A, Cecílio LCO, Nakao JRS, Évora YDM. Os ruídos encontrados na construção de um modelo democrático e participativo de gestão hospitalar. Cienc Saude Colet. 2007 Jul-Ago; 12(4):861-70.
• ⁴
  Marquis BL, Huston CJ. Administração e liderança em enfermagem: teoria e prática. Porto Alegre (RS): Artmed; 2010.
• ⁵
  Motta PR. Gestão contemporânea: a ciência e a arte de ser dirigente. 13ª ed. Rio de Janeiro (RJ): Record; 2002.
• ⁶
  Bernardes A; Cecílio LCO; Évora YDM; Gabriel CS, Carvalho MB. Collective and decentralized management model in public hospitals: perspective of the nursing team. Rev Latino-Am Enferm. 2011 Jul-Ago; 19(4):1003-10.
• ⁷
  Medeiros AC, Pereira QLC, Siqueira HCH, Cecagno D, Moraes CL. Gestão participativa na educação permanente em saúde: olhar das enfermeiras. Rev Bras Enferm. 2010 Jan-Fev; 63(1):38-42.
• ⁸
  Moura GMSS, Magalhães AMM, Dall'Agnol CM, Hoffmeister LV. A face oculta de um processo participativo para escolha de chefias de enfermagem. Texto Contexto Enferm. 2012 Jul-Set; 21(3):528-34.
• ⁹
  Robbins SP, Decenzo DA. Fundamentos de administração: conceitos essenciais e aplicações. São Paulo (SP): Prentice Hall; 2004.
• ¹⁰
  Triviños ANS. Introdução à pesquisa em ciências sociais: a pesquisa qualitativa em educação. São Paulo (SP): Atlas; 1987. 175 p.
• ¹¹
  Minayo MCS, Deslandes SF, Neto OC, Gomes R, organizadores. Pesquisa social: teoria, método e criatividade. Rio de Janeiro (RJ): Vozes; 2010.
• ¹²
  Ferraz CA. Ensaio sobre reforma político-administrativa hospitalar: análise sociológica da transição de modelos de gestão [Tese Livre Docência]. Ribeirão Preto (SP): Escola de Enfermagem de Ribeirão Preto da Universidade de São Paulo; Programa de Pós-Graduação em Enfermagem; 2002.
• ¹³
  Santos JS, Scarpelini S, Brasileiro SLL, Ferraz CA, Dallora MELV, Sá MFS. Avaliação do modelo de organização da unidade de emergência do HCFMRP-USP, adotando, como referência, as políticas nacionais de atenção às urgências e de humanização. Medicina. 2003 Abr-Dez; 36:498-515.
• ¹⁴
  Strauss A, Corbin J. Pesquisa Qualitativa: técnicas e procedimentos para o desenvolvimento de teoria fundamentada. 2ª ed. Porto Alegre (RS): Artmed; 2008.
• ¹⁵
  Fontanella BJB, Ricas J, Turato ER. Amostragem por saturação em pesquisas qualitativas em saúde: contribuições teóricas. Cad Saúde Pública. 2008 Jan; 24(1):17-27.
• ¹⁶
  Correia MCB. A observação participante enquanto técnica de investigação. Pensar Enferm. 2009 Jul-Dez; 13(2):30-6.
• ¹⁷
  Polit DF, Beck CT, Hungler BP. Fundamentos de pesquisa em enfermagem. 5º ed. Porto Alegre (RS): Artes Médicas; 2004.
• ¹⁸
  Bardin L. Análise de conteúdo. 70ª ed. Lisboa (PT): Persona; 2007.
• ¹⁹
  Bernardes A, Cummings G, Évora YDM, Gabriel CS. Contextualização das dificuldades resultantes da implementação do Modelo de Gestão Participativa em um hospital público. Rev Latino-Am Enferm. 2012 Nov-Dez; 20(6):1142-51.
• ²⁰
  Beglinger JE, Hauge B, Krause S, Ziebarth L. Shaping future nurse leaders through shared governance. Nurs Clin North Am. 2011 Mar; 46(1):129-35.
• ²¹
  Moura GMSS, Magalhães AMM, Dall'Agnol CM, Juchem BC, Marona DS. Liderança em enfermagem: análise do processo de escolha das chefias. Rev Latino-Am Enferm. 2010 Nov-Dez; 18(6):1099-106.
• ²²
  Hammett P. The paradox of gifted leadership: developing the generation of leaders. Ind Commerc Train. 2008; 40(1):3-9.
• ²³
  Bernardes A, Évora YDM, Nakao JRS. Gestão Colegiada na visão dos técnicos e auxiliares de enfermagem em um hospital público brasileiro. Cienc Enferm. 2008 Set; 14(2):65-74.
• ²⁴
  Ciampone MHT, Melleiro MM. O planejamento e o processo decisório como instrumento do processo de trabalho gerencial. In: Kurcgant P, organizador. Gerenciamento em enfermagem. Rio de Janeiro (RJ): Guanabara Koogan; 2010. p.37-53.
• ²⁵
  Santos MC; Bernardes A. Comunicação da equipe de enfermagem e a relação com a gerência nas instituições de saúde. Rev Gaúcha Enferm. 2010 Jun; 31(2):359-66.
• ²⁶
  Newman KP. Transforming organizational culture through nursing shared governance. Nurs Clin North Am. 2011 Mar; 46(1):45-58.
• ²⁷
  Kramer M, Maguire P, Brewer BB. Clinical nurses in Magnet hospitals confirm productive, healthy unit work environments. J Nurs Manage. 2011 Jan; 19(1):5-17.

Publication Dates

• Publication in this collection
  Apr-Jun 2014

History

• Received
  Apr 2013
• Accepted
  07 Apr 2014