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Rev. Latino-Am. Enfermagem vol.13 no.4 Ribeirão Preto July/Aug. 2005
Management and leadership: analysis of nurse manager's knowledge1
Gestión y liderazgo: análisis del conocimiento de enfermeros gerentes
Maria Regina LourençoI; Gilberto Tadeu ShinyashikiII; Maria Auxiliadora TrevizanIII
INurse, PhD Student, Graduate Program In Fundamental Nursing, University of São Paulo at Ribeirão Preto College of Nursing, e-mail: email@example.com
IIPsychologist, Professor, University of São Paulo At Ribeirão Preto School of Economics, Business Administration and Accountancy, Brazil, e-mail: firstname.lastname@example.org
IIINurse, Full Professor, University of São Paulo at Ribeirão Preto College of Nursing, Brazil, WHO Collaborating Centre for Nursing Research Development, e-mail: email@example.com
Nurses have assumed management positions in many health institutions. To properly accomplish the demands of this role, it is important that they be competent in both management and leadership. For appropriate performance, knowledge of management and supervision styles is a priority. Therefore, the goal of this investigation is to identify the nurse manager's knowledge regarding management and leadership. A structured questionnaire containing twenty-seven questions was applied to twelve Brazilian nurse managers of primary care center called "Family Basic Health Units". Data analysis suggested that the nurse manager lower knowledge in management and leadership is related to visionary leadership, management and leadership conceptual differences, leader's behavior, and situational leadership. And, nurse manager greater knowledge is related to power; team work, and coherence between values and attitudes.
Descriptors: leadership; nursing; administration; nurse
Los enfermeros han asumido cargos gerenciales en diversas instituciones de salud. Para que ejerzan su cargo de forma adecuada, deben desarrollar competencias de gestión y liderazgo. Eso requiere conocimiento. La finalidad de esta investigación fue identificar el conocimiento de los enfermeros/gerentes sobre gestión y liderazgo. Aplicamos un cuestionario estructurado con veintisiete cuestiones a doce enfermeros/gerentes de las Unidades Básicas de Salud y de Unidades de Salud de la Familia. El análisis de los datos mostró que los enfermeros/gerentes poseían menos conocimientos respecto a liderazgo visionario; diferencias conceptuales de gestión y liderazgo; comportamiento del líder y liderazgo situacional. Los mayores conocimientos estaban relacionados con el poder; trabajo en equipo y coherencia entre valores y actitudes.
Descriptores: liderazgo; enfermería; administración; enfermero
The Brazilian collective health system has been making great efforts to reorganize and redirect its Single Health System (SHS) - "Sistema Único de Saúde (SUS)" based on decentralization. This decentralization approach is applied through regional distribution of resources and development of local management capacity.
We are facing rapid and intense technological, social, cultural and behavioral modifications, which have led to profound changes in the philosophy and form of business management. Organizational changes arise from the need for a new strategic directions, modifications, or transformations which may lead to differences in terms of organizational culture or structure(1). In view of these changes, managers need to acquire new knowledge and skills. The development of these skills requires knowledge about the differences between management and leadership and between their component elements.
We believe that a managers' role as a change agent is subject to the development of leadership skills. Although the current view of leadership is not focused on one single individual, it is this kind of leader who is frequently called upon to conduct the process of organizational change. New demands and needs may require managers to be able to act both as managers and leaders. Organizations have to be managed, but in view of current perspectives on the world and life, they are in much greater need of leadership(2).
The terms manager, leader and administrator are mixed up in literature, due to the variety of ways in which authors use them. Therefore, a clear distinction between these three terms is essential to understand the role each plays in an organization. Manager denotes a position in the organizational structure and refers to a person vested with formal authority; leader indicates a personal attitude, a competency in relationships aimed at achieving results; an administrator occupies a superior hierarchical post, works with an organization's functional processes, allocates resources, and uses staff in the best possible way(3).
Leading and administering predispose to the performance of different but complementary roles. An organization can have managers who administer as well as managers who efficiently act as leaders(3). To exercise leadership, managers have to understand the differences between leading and managing in an attempt to develop the necessary abilities to act as leaders. Managers must possess a view of the future and what scenarios need to be constructed. They must work in teams to build the organization and be equipped to conduct the change process. They must also be creative, able to handle ambiguities and conflicts, assume ethical commitments, and know how to listen and communicate(1).
Like other organizations, health services have been trying to keep up with this new tendency of management advances, in order to give an adequate response to current developments. Difficulties have been met to implant the SHS. Mainly, decentralization has occurred, because this model presupposes municipal authorities to assume greater autonomy and responsibility in health service management. This process has collided with the health teams' lack of preparation to assume management and leadership functions. The function of a municipal manager is relatively new. In the centralized model that existed before the SHS, decisions were made at the federal level and merely put into practice in the municipal context.
In Brazil, the decentralization and administrative reform process, in place since the 1980's, has revealed the debate on health management technologies; highlighting the need for management changes at all levels of health organizations(4).The health sector reform in Brazil has been going through already provokes organizational changes that affect the entire health system(1). In this context, nurses have assumed management positions at Basic Health Units (BHU) and need to develop management and leadership skills that allow them to act as change agents. A study of nurses active in BHU management revealed that, in performing a management role, these professionals hold an idealist and disciplinarian view and get frustrated when they see that things do not happen as they expected, turning into a source of constant tension(4).
When assuming a management function, nurses must have a clear view of changes in society and how they affect organizations, as well as the fact that they need to act differently. Choosing to go beyond established paradigms is a conditio sine qua non for them to develop their function. The traditional nursing administration model does not fit here anymore; people change and nurses are facing difficulties to assimilate this process. Changes happen, and if we lose the opportunity of transformation they offer, they knock us down. To incorporate the necessary changes into the health sectors, aimed at offering comprehensive, equitable and efficient care, efforts are being made to implant new care and management models. Therefore, the goal of this investigation is to identify nurse managers' knowledge regarding management and leadership.
A quantitative methodology was used. This exploratory study was done in the interior of São Paulo, Brazil, and involved twelve nurse managers at Basic Health Units and Family Basic Health Units, who agreed to participate and signed the Free and Informed Consent Form. A structured questionnaire containing twenty-seven questions was used to verify the subjects' knowledge on management and leadership. Ethical approval was obtained from the Research Ethics Committee at the University of São Paulo at Ribeirão Preto College of Nursing.
RESULTS AND DISCUSSION
Characterization of study participants: As shown in Table 1, six (50%) participants are between 25 and 30 years old; four (33.3%) are between 30 and 40 years old and two (16.66%) are over 40; eleven (91.66%) are women; seven (58.33%) graduated seven or less years ago; and nine (75%) participants have occupied this management function for two years.
Ten (83.33%) participants do not have any previous management experience and assumed this function for the first time under the current municipal government; ten (83.33%) possess a specialist degree, nine (75%) of whom took a Specialization Course in Collective Health; all (100%) participants are taking the GERUS program, and nine (75%) have never participated in any specific course on leadership (Table 2).
NURSE MANAGERS' KNOWLEDGE ABOUT MANAGEMENT AND LEADERSHIP
A structured questionnaire with 27 multiple choice and true-false questions was used to evaluate knowledge about management and leadership. The following aspects were considered: conceptual differences between management and leadership; types of power; leadership theories; situational leadership; visionary leadership; teamwork; values and attitudes of a leader; vision; and transformational leadership. We have limited our analysis to those items on which the participants revealed to possess the greatest or smallest knowledge.
The group answered approximately (62%) or 17 questions correctly. All participants gave the right answer to questions 3; 15; 21; 22; and 24. Question 3 refers to the power attached to the position. One of the characteristics of leadership is that leaders exercise power(5). Power is the capacity to influence another person or group's behavior so as to make them do something they would not do otherwise. Power is the ability to induce or influence behaviors(6). The difference between leadership and power is that leadership is simply any attempt to exert influence, while leaders' power is their potential to influence. Thus, power allows a leader to influence other persons or get them to submit themselves. Position power is also called legitimate power and represents the power a person receives as a result of his/her position in the organization's formal hierarchy(5).
Various studies have attempted to classify power bases. We have identified five: coercion, competence, legitimacy, reference, and reward power(6). Question number 15 focuses on the team. Teams appear when the result is a matter of collective responsibility. Leadership increasingly occurs in the context of teams. This is a great challenge for leaders nowadays. Team leaders need to develop abilities like: instructing; conflict solving; listening; giving feedback; and using oral persuasion. They need to learn how to share authority and results(5).
Question 21 is related to the coherence between values and attitudes that influence behavior. Leaders' behavior has to be strictly in accordance with their discourse. The values they adopt in theory and practice have to be coherent. Leadership is a relation based on credibility and trust(7).
Question 22 refers to the power of reference, which is partially maintained through good interpersonal abilities. This power is based on personal charisma, on the way leaders speak or act(8). The power of reference is adopted by truly productive leaders. They are efficient because of their followers' admiration and identification with the leader as a person and the cause (s) he defends. This kind of power naturally involves its followers(3).
Question 24, also related to power, affirms that leaders lose power when they delegate a decision to their collaborators. All participants classified this statement as false.The answers to questions 3, 21, and 24 reveal that, although nursing history displays a more directive leadership, this has been changing. We believe that undergraduate programs have stimulated reflections for nurses to adopt more participatory models, delegate power to collaborators, be coherent in team coordination, and know how to use their position power.
Study participants revealed the smallest knowledge in questions 2; 7; 10; 17; 19; 25. Question 2 refers to visionary leadership. Leaders possess a clear sense of the future and what it takes to get where they want; in other words, leaders have a vision. Question 7 looks for knowledge about the difference between leadership and management. Answers revealed that most participants inverted these concepts. Leadership is different from management. The former constitutes the basic force behind any successful change. Management implies maintaining the current system functioning through planning, budgeting, organization and control. Leadership works through people and culture, it is flexible and warm. Management, on the other hand, acts through the hierarchy and is more rigid and cold. Leadership and management serve different purposes(9).
Question 10 describes the most frequent behaviors in leadership research, such as: task performance, group maintenance; and decision making. In this respect, it stands out that, in their answers, participants continue indicating research on styles, such as autocratic, democratic and laissez-faire leaders. Question 17 states that "task-oriented leaders are worried about guaranteeing high performance levels for the organization".
Studies on behavioral theories in leadership have tried to identify which characteristics of leaders' behavior could be related to efficient performance and reach two dimensions: task-oriented behavior or people-oriented behavior. These studies concluded that employee-oriented behavior is more associated with satisfaction and productivity than task-oriented behavior. We know from contingency theories, which included situational factors, that there is no ideal behavior for all situations.
Question 19 deals with contingency theories of leadership, more specifically the theory of situational leadership(6). In this approach, the authors conclude that the process of leading is a function of the leader, the subordinate and situational variables.
In research on nurses' leadership style in the context of situational leadership, the authors affirm that, when nurses enter the labor market, it is very difficult for them to exercise leadership, and they usually do not have a reference framework to guide them in this process(10). The participants' answers to these questions reveal that they do not know this reference framework.
Question 25 affirms that all leaders have a vision. We know that not all leaders are visionaries. In leadership studies, vision comes up as a characteristic of the charismatic leader. These leaders are willing to take risks because of their vision, but it is in visionary leadership studies that the vision gets stronger. It is different from all other forms of guidance. A vision is accompanied by a clear and instigating image that offers an innovative form of improvement. It uses people's energy and emotions. A vision's essential characteristics seem to be the inspiring possibilities that are feasible and value-focused. It is capable of offering a clear and better image of the future, and has to be perceived as challenging and possible(5). Participants made most mistakes on questions related to visionary leadership; to a conceptual understanding of management and leadership; to leaders' behavior; and to situational leadership.The highest number of correct answers went to questions related to: power; teamwork; and coherence between values and attitudes.
We believe that undergraduate nursing programs should stimulate the development of management and leadership competencies, as these are required by the labor market. The same is true for the institutions where nurses have skills as managers. But, in assuming management functions, nurses need to search for knowledge and develop the necessary competencies to be able to act as a manager and a leader, in accordance with the new paradigm.
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Recebido em: 11.11.2004
Aprovado em: 30.6.2005
1 Article extracted from Doctoral Thesis, Graduate Program in Fundamental Nursing, University of São Paulo at Ribeirão Preto College of Nursing, Brazil, WHO Collaborating Centre for Nursing Research Development