Services on Demand
Print version ISSN 0104-1169
Rev. Latino-Am. Enfermagem vol.14 no.3 Ribeirão Preto May/June 2006
Nurses' management in the clinical practice: problems and challenges in search of competence1
Maria Auxiliadora TrevizanI; Isabel Amélia Costa MendesI; Gilberto Tadeu ShinyashikiII; Genevieve GrayIII
IRN, Full Professor, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Brazil, CNPq Researcher 1A, e-mail: firstname.lastname@example.org, email@example.com
IIPsychologist, Faculty, University of São Paulo at Ribeirão Preto School of Economics, Business Administration and Accountancy
IIIRN, Faculty, Faculty of Nursing, University of Alberta, Edmonton, Canada.
With the purpose to enable reflections concerning nurses' managerial performance in hospitalization units, three studies conducted in three different decades, in the same university hospital, were analyzed. From this analysis, it was observed that nurses' managerial practice has been mainly characterized by the accentuated compliance to pre-established norms, thus showing a reiterative praxis. Understanding the fragility of this managerial situation in terms of involvement with and commitment to clients and service givers, an alternative managerial conduct, which is based on the creative praxis, is presented to nurses.
Descriptors: management, nurse, managing nurse, competence, clinical nursing
With the development of hospital organizations and their transformation into bureaucratic institutions, the nurse's role has changed, particularly as a result of physicians' expectations, since they believed that they were professionals with an administrative capacity. Physicians' willingness to transfer to nurses the administrative functions that they did not want to carry out is related to the support in the process of patient's treatment in which these professionals become involved, mainly as a result of formal organization. Therefore, nurses began to assume the responsibility for the unit's maintenance, for the provision and control of drugs and necessary materials as well as for the organization and coordination of the care activities that are processed by different professionals conjointly with the curing activities performed by physicians in the hospitalization unit.
In this context, nurses' management in the clinical practice has been founded on the organization's bureaucratic and formal needs, thus privileging and becoming much more committed to organizational objectives in detriment of attaining workers' and patients' individual goals, thus bringing about the existence of an imbalance that has caused tension, discouragement and even disbelief at work.
Of the investigations concerning nursing bureaucratization in our milieu, the studies conducted by Trevizan(1,2) and Fernandes(3), which were developed in the same university hospital in the last three decades of the 20th century, are emphasized. The analysis of these studies has the purpose to enable reflections on nurses' managerial performance in the hospitalization unit and, then, present considerations in order to guide and enable managerial actions that are more directed and committed to the human capital involved in the work context by locating and replacing professional values and clients' needs on a higher threshold.
This study presents a reflection on the results obtained from three studies developed at a large public hospital. The first study, developed by Trevizan(1) in 1978, analyzes the activities of nurse heads at hospitalization units; the second, by the same author(2), one decade later, addressed aspects of nursing administration and bureaucracy at the hospital; finally, the third study, carried out by Fernandes(3) in 2000, also discusses nurses' functions at the same institution, replicating the first study(1).
THE STUDIES UNDER ANALYSIS
When investigating nurses' activities - heads of the hospitalization units in the above-mentioned hospital in two time periods: - 1973 and 1976, Trevizan(1) observed the development of administrative activities as well as of those involving direct patient care, teaching collaboration and research, which must be assigned to the auxiliary personnel and performed by other services, including private service givers. In relation to the administrative activities, it was observed that, in 1973, the mean period of time spent on such activities was 38.90% and in 1976, 53.15%. In her conclusions, that author points out that most of the activities performed by head nurses were not in accordance with what the profession expects from such professionals, since most of the time spent on their attributions was related to administrative activities, particularly to those of a bureaucratic character.
From the diagnostic made by Trevizan(1), it was understood that nurses did not make efforts in order to value the profession's intentions and that they were underused and restricted in their potential as professionals and citizens. It was also understood that their performance had the purpose to meet the requirements of the organizational power and the expectation arising from physicians, to which they were submitted.
Many reflections, questions and studies emerged as a result of this behavior from nurses. The literature regarding that issue continued to show that the managing nurse's practice had not changed.
With the conviction that nurses privileged the administrative activities, Trevizan(2) analyzed the functions performed by them in the light of a typology of bureaucratic and non-bureaucratic administrative functions. The author found that 74% of the administrative functions had a bureaucratic character. In face of the impositions of hospital organizational processes, she states that the nurse should assume and perform managerial functions, but emphasizes that the content and form of such urgency must focus on clients' care(2). Thus, by combining management and care, nurses would have a new spirit to redirect and reactivate their professional potential.
In the 1990s, Fernandes(3) elaborated a replica of the study conducted by Trevizan(1) in the same hospital. With the purpose to identify the activities performed by nurses and evaluate their development. The results of both studies were compared and it was then concluded that, although more than 20 years have passed, most of the activities performed were centered on bureaucratic management (43.4%). When investigated(3) as to what activities took most of their time, nurses, once again reported, among others, those with an administrative and bureaucratic nature. The author expresses her concern about that situation and states that a lot of hesitations and uncertainty still persist in nurses' daily conduct; that the problems pointed out in the past still exist at present. Finally, she asserts that we "still experience the old dilemmas of our profession".
Based on the information above, we believe that it has been possible to configure the management performed by clinical nurses until now. Therefore, it can be understood that such management has been mainly characterized by the accentuated compliance with to pre-established norms in agreement with a reiterative praxis.
An imitative or reiterative praxis is based on a previously existing creative praxis, "from which it takes a ruling norm. It is a second-hand praxis which does not produce a new reality, does not produce a qualitative change in the present reality, does not transform creatively, although it may contribute to enlarge the area of what has already been created and, therefore, to quantitatively multiply a qualitative change that has already been produced. It does not create; does not cause a new human reality to emerge, and that is where its limits and inferiority in relation to the creative praxis lie"(4).
Next, we will present considerations that can provide a basis for the work of nurses articulated to the creative praxis.
NURSES' MANAGEMENT: DELINEATION ARTICULATED TO THE CREATIVE PRAXIS
With the invasion of post-modernity affecting sciences, technology, arts, thoughts, as well as social and individual spheres, a new environment and a new condition for man began to be configured. The post-modern environment expresses the power of electronic technology in everyday life through the saturation of information, entertainment and services.
In the economic context, it represents the personalized consumption, which seduces individuals to its hedonist moral, that is, seeks man's seduction through values based on the pleasures arising from using goods and services. The post-modern condition reflects individuals' difficulties to feel and represent to themselves the world in which they live as nothing has a definite identity(5).
Post-modernity is still obscure in our environment, but it has already invaded the developed societies that are fundamentally tied to this new age, the Age of Information, in which knowledge and information are the powerful sources to generate wealth.
These perspectives bring a change in the paradigm of organizations. As institutions that are representative of an Age, organizations in developed countries began to undergo transformation, that is, real revolutions that have been paved by globalization, by the power of information technology, by the collapse of the hierarchical structure, by downsizing and, now, by the attention to man's need to give a meaning to life, thus re-encountering humanity.
In the Brazilian case, institutional boundaries need to be more permeable so that organizations can become prepared and capable, aiming at the implementation of the changes required by the new world context and thus adapt to the new order which "is not a mere tendency, but rather the result of powerful and uncontrollable forces..."(6).
As an organization rendering health services, hospitals must also embrace this task if they are willing to commit to new expectations. In this case, our attention is focused on nurses' managerial behavior in the clinical practice.
Assuming that people are our most important asset, the importance of human capital, of the structural capital and of the client's capital has been emphasized. In integration, these constitute the assets of knowledge, that is, of an organization's intellectual capital. Human capital is the source of innovation and renovation; however, "intelligent individuals are not synonymous to intelligent companies"(6). In this way, the structural capital means the levering of knowledge, its sharing and transmission among people through structural intellectual assets, such as information systems, databases, good management, among others, which "transform individual know-how into a group's property"(6). The client's capital means the value of the relationships between an organization and its clients.
Nursing organizations represent a fertile field for their members to become workers of knowledge and managing nurses committed to the development of human capital, of the structural capital and of the client's capital, which potentially constitute the intellectual capital of such organizations.
In this sense, nurses' middle management position in hospital organizations places them at the center of learning and knowledge development processes that are essential for acquiring competencies with a view to the quality of patient care. Nurse managers act at the vertical and horizontal crossroads of information at the hospitalization unit, which turns them into a communication linkage between high administration and frontline workers(7).
Thus, there is a need to stimulate team work and other social forms of learning in order to develop human capital which then begins to share talent and knowledge. The best structures are those that present fewer obstacles and, therefore, easier transit, as well as those which allow, as far as possible, work directed to their clients(6). The result of this learning process favors changes in organizations' behavior.
By contemplating nurses' management articulated to the creative praxis, we understand that, in view of the expectations of contemporaneity, managing information and knowledge becomes their most important task, although to do so, they begin to depend on new abilities. The goals and strategies of this management include the search for optimal results, the development of interdependence awareness, the common view of the interest in the service's objectives, the valorization and implementation of creative decisions made by the team and the team's involvement with new knowledge. Such goals and strategies are reflected on the managerial proposals of the contemporary paradigm and on creative praxis, which is determinant, since it enables man to face new needs and new situations.
Finally and above all, the managerial practice that we aim at finds an essential dimension in human values.
1. Trevizan MA. Estudo das atividades dos enfermeiros-chefes de unidades de internação de um hospital-escola. [dissertação]. Ribeirão Preto: Escola de Enfermagem de Ribeirão Preto/USP; 1978. [ Links ]
2. Trevizan MA. Enfermagem hospitalar: administração & burocracia. Brasília: Ed. UnB; 1988. [ Links ]
3. Fernandes MS. A função do enfermeiro nos anos 90: réplica de um estudo. [dissertação]. Ribeirão Preto: Escola de Enfermagem de Ribeirão Preto/USP; 2000. [ Links ]
4. Vázquez AS. Filosofia da práxis. São Paulo: Paz e Terra; 1990. [ Links ]
5. Santos JF. O que é pós-moderno. São Paulo: Brasiliense; 1993. [ Links ]
6. Stewart TA. Capital intelectual. Rio de Janeiro: Campus; 1998. [ Links ]
7. Shinyashiki GT, Trevizan MA, Mendes IAC. Sobre a criação e a gestão do conhecimento organizacional. Rev Latino-am Enfermagem 2003 julho-agosto; 11(4):499-506. [ Links ]
Recebido em: 27.1.2005
Aprovado em: 24.11.2005
1 Study presented at the 4th Meeting of Regulatory Authorities from the Western Pacific and South East Asian Regions, Hong Kong, November 2002