Best leadership practices of nurses in hospital risk management: case study

Mejores prácticas de liderazgo de enfermeras en la gestión de riesgos hospitalarios: estudio de caso

ABSTRACT

Objective:

To highlight the best leadership practices of nurses who contribute to hospital risk management.

Method:

Single case study with two integrated units of analysis, with a qualitative approach. Data collected from April to November 2018, through focused interviews with nurse managers, non-participant observation and documentary research. Analysis using the analytical technique to the explanation construction.

Results:

Three thematic categories were evidenced, demonstrating that the best leadership practices involve technical and non-technical competencies anchored in behavioral development, scientific knowledge, guidelines for quality and patient safety and participatory management of the health team.

Conclusion:

The best leadership practices of nurses who contribute to hospital risk management pervade technical skills and/or formal positions, valuing each team professional in a unique way and emphasizing the importance of scientific knowledge and the professional reference model that the nurse exercises in hospitals.

Keywords:
Nursing; Leadership; Patient safety; Security management

RESUMEN

Objetivo:

Destacar las mejores prácticas de liderazgo de las enfermeras que contribuyen a la gestión de riesgos hospitalarios.

Método:

Estudio de caso único con dos unidades integradas de análisis, con un enfoque cualitativo. Datos recopilados de abril a noviembre de 2018, a través de entrevistas enfocadas con gerentes de enfermería, observación no participante e investigación documental. Análisis utilizando la técnica analítica para construir la explicación.

Resultados:

Se evidenciaron tres categorías temáticas demostrando que las mejores prácticas de liderazgo involucran habilidades técnicas y no técnicas ancladas en el desarrollo conductual, conocimiento científico, lineamientos para la calidad y seguridad del paciente y gestión participativa del equipo de salud.

Conclusión:

Las mejores prácticas de liderazgo de las enfermeras que contribuyen a la gestión de riesgos hospitalarios impregnan las habilidades técnicas y/o los cargos formales, valoran a cada miembro del equipo de una manera única y enfatizan la importancia del conocimiento científico y el modelo de referencia profesional que ejercen las enfermeras. en hospitales.

Palabras clave:
Enfermería; Liderazgo; Seguridad del paciente; Administración de la seguridad

RESUMO

Objetivo:

Evidenciar as melhores práticas de liderança dos enfermeiros que contribuem para gestão de risco hospitalar.

Método:

Estudo de caso único com duas unidades integradas de análise, de abordagem qualitativa. Dados coletados de abril a novembro de 2018, por entrevistas focadas com enfermeiros gestores, observação não participante e pesquisa documental. Análise por meio da técnica analítica para construção da explanação.

Resultados:

Evidenciaram-se três categorias temáticas demonstrando que as melhores práticas de liderança envolvem competências técnicas e não técnicas ancoradas em desenvolvimento comportamental, conhecimento científico, diretrizes de qualidade e segurança do paciente e gestão participativa da equipe de saúde.

Conclusão:

As melhores práticas de liderança dos enfermeiros que contribuem para a gestão do risco hospitalar perpassam habilidades técnicas e/ou cargos formais, valorizando cada profissional da equipe de forma singular e enfatizando a importância do saber científico e do modelo de referência profissional que o enfermeiro exerce nos hospitais.

Palavras-chave:
Enfermagem; Liderança; Segurança do paciente; Gestão de segurança

INTRODUCTION

The growing expansion of access to information, technological innovations, cultural and political changes has directly affected the organization of work in the health field, since the care process is daily transformed and requires professionals to increasingly search for improvement. Due to the complexity of the work, health environments are recognized as high risk and a safety culture has an influence on patient results1.

Risk management has been a practice emphasized in this scenario because it is an approach to the risks to which the patient is submitted in health services, allowing the identification and assessment of these risks, as well as the development of strategies to face them. In this context, prevention and control activities and those aimed at reducing its impact are included2. Thus, it is clear that, for the qualification of the hospital assistance service, there is a concern to adopt safety and risk management practices, since avoiding adverse events requires a systemic and multiprofessional approach1.

Data on the occurrence of adverse events and their cost to the health system are still alarming, even in developed countries2. Furthermore, the search for scientific evidence that qualifies the realized actions is increasingly valued within the academic and professional environment, so that the adoption of criteria arising from studies of Evidence-Based Practice (EBP) has become a highlight in the discussion of the organization of work processes. Because it is based on scientific studies results, added to the development of professional skill and respect for patients’ preferences and choices, nursing has been linked to this methodology to support care decision-making, but still in an incipient way3.

Based on this premise, it is understood that leadership is one of the most influential factors in the formation of a health security culture, and can be described as an essential process for the motivation of members of organizations and for mobilizing resources towards achieving their missions. This study was anchored in the Transformational Leadership Theory, which considers charisma an essential attribute for leaders, who are considered capable of influencing the attitudes and behaviors of employees, that is, leaders who are admired, visionary, attentive to their subordinates and who encourage them to achieve extraordinary goals4.

In the different health scenarios, it is perceived that nurses have a strategic role in articulating care, since they mediate relationships between health team professionals, sensitizing and stimulating an integrated and effective work in search for quality promotion through the development of best care practices5, with a current trend towards the transformational leaders profiles6.

Environments in which organizational leadership contributed to the development of security policies showed a significant decrease in adverse events, demonstrating that leadership behavior has a direct influence on the results presented by the people being cared7. Therefore, nurses, as organizational leaders, need to improve their leadership competencies in transforming and advancing quality and safety in health, with a view to improving the care experience, to improve the society health, reduce costs and promote the professionals improvement8, which endorses the interest in carrying out this research.

It is understood that leadership behaviors and competencies are essential for strengthening EBP in safety and quality in healthcare environments, especially in the context of nurses’ leadership practices9. The participatory management modality also configures as a trend in health institutions, aiming at more dialogical and democratic practices, in a perspective of horizontal management, strengthening the role of the collectivity10. In this direction and based on the theoretical proposition that nursing practices should be based on the premises of quality and safety to strengthen the adoption of safe practices in health services, following international protocols and guidelines, the following research question emerged: What are the best leadership practices of nurses who contribute to hospital risk management?

In this perspective, the objective is to highlight the best leadership practices of nurses who contribute to hospital risk management.

METHOD

It is an explanatory and descriptive study, with a qualitative approach, with a single case study methodological strategy, composed by two integrated units of analysis (IUAs). As it is a critical and in-depth study, the case study has the purpose of confirming whether the theoretical propositions are in fact true. It is used to understand complex and significant real-life phenomena when the boundaries between the phenomenon and the context are not evident11.

The study had as scenario two public hospitals, of large size and generalist care, located in the South of Brazil and members of the Sentinela Network Program (Programa Rede Sentinela). The choice of such context was due to the fact that it is assumed that institutions participating in this program have already implemented actions for management and prevention of hospital and health risks, allowing to better explore the practices performed by nurses in their daily leadership. The IUAs, on the other hand, were composed by nurse leaders of each hospital and the investigated case refers to the leadership of nurses in hospital risk management.

The participants were nurses appointed by the institution’s nursing managers and risk managers, who met the following inclusion criteria: (1) acting as a nurse at the researched institution, (2) being recognized by nurses as a leadership in risk management, and (3) act in a management position for at least one year. From these criteria, 20 nurses were selected to conduct the interviews, which ended due to data saturation.

Data collection took place between April and November of the year 2018. Three sources of evidence were chosen that converged in a triangular way, which were: documentary research, non-participant observation and focused interviews. After recognizing the local scenario, all data collection was carried out by a single researcher in an orderly and concurrent manner, according to each source of evidence. The documentary research took place through the reading and analysis of institutional documents, such as operational protocols and procedures, routine manuals and minutes of meetings, provided for consultation by the risk managers of each hospital. The interviews were scheduled with the participants and carried out in an audio-recorded way, as well as periods for non-participant observation in the different sectors of the study hospitals were also scheduled. Meetings of the Patient Safety Nucleus (PSN), shift times, training and routines of the nurse’s leaders were observed.

Data analysis was performed according to the case study methodology, in a descriptive way to construct the explanation, following three stages. The first stage corresponded to the organization of the data forming clusters. This includes transcribing the interviews, documentary data and field notes. It is worth mentioning that, after transcribing the interviews, all of them were sent by email to the participants, so that they could perform the data validation. The second stage took place from the horizontal reading and texts classification in a thematic framework, establishing relationships between the ideas. In this stage, were identified the intelligible aspects and explanations for the studied phenomenon11.

From the data grouping it was possible to establish three central categories originating from the theoretical propositions of the study and eight subcategories. Then, the third stage of data analysis was entered, which involved an exhaustive reading of the triangulated evidence in an iterative way, reviewing the initial proposals and refining the ideas in order to present an explanation for the case. This data analysis technique aims to build an explanation for the case using combined evidence and according to the theoretical propositions and the chosen theoretical framework, in an elucidated way, explaining the phenomenon by a presumed set of causal links about how or why something happened11.

The research ethical principles were followed in all its phases, according to the recommendations of Resolution no. 466, of December 12, 2012, of the National Health Council, with approval by the UFSC Human Research Ethics Committee under Statement number 2,646,544 and Certificate of Presentation for Ethical Appreciation (CAAE) number 84192118,3,0000,0121. All participants were in agreement with the research and signed the Informed Consent Form (ICF). To guarantee the information confidentiality and the anonymity of institutions and participants, they will be represented by codes (H1L1, H1L2, H2L1...) throughout the text.

RESULTS AND DISCUSSION

Seeking to highlight the nurse’s leadership practices that contribute to hospital risk management, based on the concepts of Transformational Leadership Theory, it was pointed out that leadership is linked to the nurse professional profile. Mainly required in critical situations, in which teamwork impacts directly on the patient's treatment outcome, leadership can be developed with attributes and skills gained through practical experience and theoretical knowledge. Conjunctions that made it possible to highlight three thematic categories from the data of this research, presented below.

Leadership and nurse skills for effective risk management

The professional behavior of the nurse as the leader of the health team is essential to enable daily risk management actions in hospital units, regardless of their hierarchical position in the institution. Skills such as systemic vision and planning, linked to a proactive and engaged posture, reflect the behavior of an entire team:

I think that leadership involves a lot, because, like this, the nurse... he is the leader. But, if he is not a good leader, the team also does not perform well, right? (H1L4)

The statement above emphasizes the positive reflex of good leadership in team performance. Such a leadership profile is consistent with profiles of transformational leaders, who are able to influence the attitudes and behaviors of their followers4_. Leadership is considered a competence that can be developed or improved. It allows influencing other individuals, as well as improving the relationship between leader and followers, which can result in better performance and greater productivity of nurse leaders who work in hospital management12. The presence of nurses with a profile of transformational leaders in health organizations, especially in hospitals, where the alliance between knowledge, interaction with the environment and adequate professional practice contributes to the success of the results, therefore, also contributes to the success of the institution.

However, it is expected that the nurse has knowledge and takes possession of the tools that support one of the most relevant professional skills of his practice, leadership. Thus, this conjunction enables the promotion and delivery of technical and humanized care, planned with the objective of providing the satisfaction of both workers and patients, having the effect a organizational result safer and more effective1.

It was noticed that the nurse is the one who takes the lead, being a multiplier and demonstrating engagement for the cause. This was observed in the meetings and verified in the documentary research, since the substantial presence among the participants was of nurses, as well as the elaboration of documents, protocols, rules and routines, as well as the institution of the patient safety nucleus. This was also reported in the interviews:

The nurse has to be a model of care, concern, patient safety ... So, I think that, if the nurse does not show this concern, do not push it, it is difficult for a team to push it. (H1L5)

These statements highlight that the nurse is a model for the team, signaling, once again, aspects of transformational leadership, which indicates that the leader serves as a model of inspiration for his followers when exercising effective communication that stimulates trust, engagement and, consequently, greater satisfaction. Furthermore, the transformational style of leadership has been identified as capable of exerting a significant and positive influence on the satisfaction of the followers and this, when present, is associated with positive behaviors, such as the good performance of the teams4. These statements are reaffirmed, when observing the centrality of the nurses’ discussions regarding the objective of delivering the best and safest care to the patient within the institutional possibilities, based on broad discussion and a systemic and comprehensive thinking. A study carried out in Ireland highlights that the absence of effective leadership contributes to the occurrence of failures, resulting in errors that affect patients and professionals13.

In addition, the development of nursing leadership is positively associated with the hospital’s safety culture. It is asserted that strategies of individual and collective recognition of the professionals who adhere to the programs, associated with the provision of resources for the development of internal leaders, are essential to achieve improvements9.

Developing the ability to evaluate the behavioral profiles and technical skills of the employees of your team, in order to be able to allocate them in the areas where they have greater domain and affinity, provides less incidence of errors and improves the group dynamics. For this, it is required that the nurse recognize the characteristics of each professional with whom they live and can respect individualities, favor their skills and develop weaknesses.

I think that, we can also see the professional's potentialities... we can maximize this, which is positive, and try to improve what is negative. (H2L10)

The nurse leader, recognizing the potentialities existing in his team, contributes to offering personalized attention to his followers, advising and providing support whenever necessary, pointing to transformational leadership characterized by individualized consideration4. This allows an adequate dimensioning and the organization of people in known environments, optimizing the service and enabling nurses to plan and prioritize care according to the complexity of patients. In this same sense, this skill can be used as a positive factor for the development of small leaderships within the teams, to multiply the patient safety culture:

Because they have the leaders, in addition to the hierarchical leader that the nurse exercises over the team, there are the internal leaders in the technicians team. So, it is to know how to identify these people, and to bring more and more, and to identify others who are not so involved and try to work with them too. (H2L5)

The aforementioned statement corroborates the assertion that informal clinical leadership should be highly encouraged by organizations, since they have the effective potential to question the reality of the hospital and mediate the patients’ needs, with a view to improving the quality of the service offered14.

Reaffirming the findings, a Canadian study demonstrates that the development of small leaderships must be motivated, as they act as catalysts for changes within the team, having the power to positively influence safety practices, without necessarily being hierarchical or power figures within the institution, even though they have more impact and influence on the organizational culture15.

In addition, the complex management of risks arising from the hospital service involves human behavioral factors, deviation in the quality of inputs, lack of material, structural and human resources in institutions, planning and process failures, as well as the constant need for scientific updating to understand the exponential advancement of health technologies. However, the leadership of different generations of health workers and changes in language and form of communication need to be considered in the constitutional assessment of a nurse leader, wishing that he still has the ability to exercise resilience in the workplace.

Nursing practices based on quality guidelines for patient safety

A nurse who has the capacity to have a broad and systemic view on his performance becomes essential in the participation of planning, in the creation and implementation of protocols and safety standards, in the evaluation of processes, as well as in the definition of strategies and goals of the institution. These statements corroborate what was perceived by the researcher during the observations, since nurses are the most participative professionals in the management processes and strategies for improving hospital care.

When we don't work on the processes, the risks remain there and can happen at any time, some event, regardless if it is for the patient, family member, if it is for the professional. (H2L3)

The aforementioned speech exposes the need for the nurse leader, when carrying out risk management, to be guided by the adoption of structured processes, that is, it is necessary to assess and identify the risks in order, thus, to list their prevention and control actions2.

The presence and involvement of the leader in the team’s daily life, the stimulus to adopt safe practices, the guidance focused in loco and the professional attitude of this leader in the face of situations are described as multiplier models within the organization16. Thus, the commitment associated with ethical leadership and individual engagement is linked to a posture that arouses greater adherence when it comes to a risk management and patient safety program.

Therefore, it is necessary to emphasize that, when people are included in the construction of a change project, they tend to recognize themselves within it and feel motivated to believe it. This fact was evidenced in an PSN meeting, in which nurses outlined their concern with the near miss, also known as near misses or potential adverse events, having been encouraged to participate in decisions and suggestions about changing processes and building new practices. within a participatory management model10.

There wasn't the error because it was identified. But it has to be prevented, because this one was identified, the next one could not have been identified, right? (H2L5)

I did the SOP [Standard Operating Procedure], I did it with them, with the girls. So, I asked for help, and, from the moment we did the SOP, we follow the SOP, you know? (H1L5)

The active search for failures in the processes is carried out mainly through the notifications implemented by the PSN, as indicated by the official documents of the Ministry of Health. The records made mainly by the nurses were evidenced, as well as the investigation and the measures to correct the failure of the process. Nurses reported such action in the interviews:

When I show something in the patient's record, that I see some record, I go to the unit to talk to the nurse... to make a notification when the event happens so that we can do the investigation, be able to do... I don't know... if it is the change of material the evidence, provide that. (H1L8)

The above report identifies the important participation of the nursing team, especially the professional nurse, in hospital risk management. The registration of adverse events equips the nurse leader to plan actions that will contribute to the adoption of safe practices, with consequent qualification of care practices12.

The use of protocols and guidelines to standardize patient care in terms of safety and quality of services is encouraged, making actions an active part of nurses’ daily work and providing a progressive change in the safety culture within the service17.

It was evidenced that nurses describe the processes and practices to be adopted in each of the hospitals, both to subsidize the activities of the nursing team, and as an attempt to guarantee the mitigation of care failures. Another point to be highlighted was that the nurses reported encouraging consultation and the use of this support material as a routine, according to the statement:

So, everything we have in doubt, the direction of the rules and routines, we have elaborated SOPs... Then, when in doubt, go there and look at 'the SOP, this is written', which is what we are going to follow. So, like this, we work to maintain patient safety. (H2L8)

The effective participation of the nurse as a care agent, together with the nursing team, was highlighted by the interviewees as something essential in the process of risk assessment and prevention, reaffirming the importance of non-dissociation of management work and nursing care:

Sometimes, when I see repeated names, I say: Look, there is a name repeated in the diaries, call by name and surname. (H2L1)

Then, sometimes I noticed a broken stretcher, or a broken bed, and then put it out of circulation. It is much better to have a closed bed than to have a patient fall. (H1L1)

Thus, these nurses are able to establish practical changes within their units, assuming responsibility for patient care and, consequently, leading to fewer errors13. Therefore, different positions taken by nurses define the model of thinking and its influence on other professionals3.

Routine standardization actions are important to prevent care failures, as well as knowledge of how to use each tool available. During the observation moments, it was possible to notice that the units had procedures described, implemented processes and still relatively new programs in implementation phase. In the monitored shifts change, situations were reported in which protocols were sought to support the practices adopted, as reported by nurses:

I use the shift change a lot to talk about the subject, when something happens on the shift change like: catheter exteriorization, patient in mechanical restraint, or any possible fall. (H2L5)

Likewise, the nurse is willing to teach the team, gradually inserting activities through new practices and technologies. This was widely discussed at meetings and reaffirmed by nurses during visits, as also observed in the implementation of facilities of the institutions’ computerized system so that the evaluation and registration process would be simpler and more practical for the teams, such as, for example, in the use of checklists:

The question of us also demonstrating, of doing the work, I don't say it a first time, we do it several times, until we demonstrate that it is important, you know? Demonstrate checklists, for example, pre-operative filling, they also sometimes do not value. And then, we have to sit down and fill in some of the first times together, until people automate. (H1L9)

The nurses’ reports evidenced a concern to demonstrate to the nursing team the relevance of the proposed activities for risk management, so that they could adopt similar behavior. This reflects one of the dimensions of the Transformational Leadership Theory, which corresponds to the observation of such characteristics in a leader by his followers as an attribute to influence their behavior4.

As the aforementioned report pointed out, nurses were also concerned in identifying weaknesses and work to promote an increasing and continuous improvement in care management, providing adherence to risk management practices, such as encouraging registration in medical records, with the implementation of computerized systems and the use of security checklist16.

The implementation of the Systematization of Nursing Care (SNC) was raised as an important risk identification tool, from which the nurse can, through the nursing prescription, mitigate and prevent the occurrence of care failures:

What is guidance and what do we encourage the team? That, when they go to make the history, they already identify what is that patient's need, to be signaling, to avoid these risks, and even to be implementing the nursing prescription according to the patient's need, with these risks already identified in the patient's history. (H2L6)

Direct monitoring allows the knowledge of the institutional reality, making the nurse manager to permeate strategic and operational plans, listing priority areas for the adoption of safety actions. In this sense, it is possible to reorganize the work systems using quality and people management tools, for the development of individual and collective competences and for the optimization of processes12, and to bring to the administrative management knowledge the main difficulties faced to obtain assistance of quality.

The use of virtual communication instruments was observed among nurses and between teams, gaining prominence in the researcher’s field records. What drew the most attention is that the feedback regarding decisions or responses in groups was facilitated in this way, as practically all nurses had access on their own cell phone.

We get together. As this previous management had a large team, they met weekly and always talked to the [WhatsApp] group and delegated functions. (H1L2)

As for the use of notification and risk identification tools in the electronic medical record, the speech in the interviews is that it was facilitated and made more professionals adhere to the new process, however, in the observations, low adherence and low quality information were highlighted in the nursing records. Even so, nurses were active in investigating notifications and feedback:

We can give feedback on notifications, for example, if someone notifies, if a nurse notifies something wrong with the patient... we go there, we try to find out, we give feedback. It is not just simply: he gives the notification and done! We give this feedback. (H1L5)

The documents point out and highlight the importance of communication, mainly as a means of raising awareness among people and professionals. Here also fit the reports and indicators evidenced in each institution, as they are a means of demonstrating to everyone how effective the group’s work is in reducing adverse events and how important is the exercise of participatory management of professionals10.

Thus, perception and communication skills need to be developed in the nursing service and, therefore, it was demonstrated that several nurses promoted the exercise of empathy and resilience in a line of dialogical leadership in these hospitals. The use of dialogue for conflict mediation benefits multiprofessional relationships and provides the understanding that mistakes can happen to anyone and it is up to everyone to adopt preventive conducts6.

In this sense, the literature brings data that, currently, the transformational leadership style favors a security environment. In this style, both the leader and the followers develop their ability to learn together and simultaneously, using communication as a fundamental part of the process, promoting the reduction of adverse events and providing opportunities to improve the systems, encouraging notifications4.

Importance of knowledge in the leadership of nurses and the development of a safety culture

Among all that has already been highlighted, the question of scientific knowledge appeared unanimously in the interviews, in the observations and in the documents analyzed. It is notable that nurses were concerned with continuous learning, so much that there was a specific sector in the two hospitals focused only on the demands of training and health education, commanded by nurses.

Access to information is available and closer to people, as was observed during the study. The protocols and educational materials were present in several hospital units, whether in folders, posters or in the documents of each sector. During the observation, it was highlighted that the two hospitals periodically promoted several continuing education activities and that the invitations were displayed on the hospital information boards, in addition to being disseminated by nurses. However, in the interviews it was highlighted that the number of professionals who participated in the activities was low and that, due to difficulties in dimensioning, absenteeism or high demand for work, it was difficult the participation of people with had an interest.

I think there is a lack of safety culture in the institution itself, of valuing the theme, of knowledge of the theme, of the managers' involvement, about implementing these policies and making them become effective in practice, to reach all professionals in all the spheres and categories. (H1L9)

The hospital, it has a very punctual problem, I would even say it is cultural, that people don't come down to take the courses that are offered... I think, I don't know, I think that 70-80% of the hospital shouldn't do it. (H1L10)

The modalities of continuing and permanent education were inserted within the health units in order to strengthen the learning of professionals, as well as to develop knowledge, skills and practices, promoting safer and more qualified care. Recent research has corroborated that the main factors that negatively influence the participation of professionals in these activities are linked to the team’s undersized and the hours offered. Even if hospitals start from a participative management proposal, activities related to the education of professionals need to be anchored in the real understanding of the need for their participation. Factors that can influence participation are linked to the themes presented, applied methodology, theoretical-practical relationship and relationship between team and headships18.

In addition, attitudes towards commitment to education, engagement with safety and people's involvement in the discussion and decision making also affect the way of working and reflect on the institutional view and should come from both sides. The use of values ​​in the act of leading transcends relationships and brings all involved closer together, providing an environment of construction and exchange, improving productivity and results. Attitudes, beliefs, values, perceptions and patterns of behavior of an organization and its employees directly reflect on adherence to a program to prevent adverse events and the patient safety culture19. Therefore, encouraging the proactive participation of all team members in decision making emphasizes the involvement and responsibility of everyone in the success of risk management and results. In the same way that the non-involvement of the leader with employees can compromise the planning of necessary changes20.

However, there are also worrisome reports related to academic education that still do not sufficiently address the aspects that involve the participation of nurses in risk management and patient safety within hospitals:

They come without having a lot of notion, it’s that everyday practice thing and it seems that there’s still no professional training at school, not much is said about it at school. (H1L8)

Risk management is part of an adequate and effective care management, and this also takes place under the scientific domain of nurses and the use of the best and most updated evidence available. From the moment they know their institutional reality, their team, nursing techniques, protocols and care recommendations, the promotion of safety is facilitated and with institutional support in order to promote moments of dynamic learning, and risk management processes can be better disseminated:

One of the actions that we have been doing is updating, so that these professionals have knowledge of what is a risk, what is damage, and scientific knowledge of those pathologies that are more common, which affect more the patients who are here. (H2L7)

They need to know what risk management is, what good practices are, what's new, what are the new recommendations. (H2L7)

The lack of familiarity with the theme means that professionals do not feel they are active members of the risk prevention program and do not recognize their role within the entire process. In this sense, hospitals tend to adopt a more dialogical management practice, guided towards problem solving, however, even so, the perception was that the nursing category took the lead through the PSN and ended up overloaded, in a isolated “fight” and without support:

In relation to risk management, for example, patient safety, people think that the responsibility is only here at the Patient Safety Nucleus. However, the responsibility is for all of us, patient, family, visitor, everyone who circulates in the hospital. (H2L3)

Thus, as demonstrated in the findings of this study, the managers' perception of how risk management is evidenced and their attitude towards it is strengthened through the experiences lived in their daily work, and, therefore, the retention of qualified professionals becomes an important challenge within the institution, since expertise is combined with highly reliable service, as it favors technical mastery, knowledge, trust and security of the service20.

It was observed in the visits and found in the documents that the effective participation in the safety nucleus was that from nurses. It is foreseen the participation of several professionals in risk management actions, but one of the greatest challenges pointed out to a very low adherence, being somehow justified by the smaller contingent of other professionals in the organization, leaving the impression that the service was an assignment of law and nursing appropriation and not an institutional initiative. This makes knowledge about the subject stay limited and does not meet the purpose of the patient safety program.

There is no culture of risk minimization and security within the institution. So, this ends up generating a profile of people who have a greater concern with the security theme, and others who do not have a minimum notion like that, nor what it is about. (H1L9)

In the institutional documents, as in the SPP, it was highlighted as essential the active participation of several professionals in the actions of promoting safety, such as physicians, pharmacists, clinical engineers, physiotherapists, nutritionists, psychologists and employees of the administrative sectors, as well as representatives of the administration of each hospital. In the observations, what was evidenced is that the effective participation was actually from the nurse. For example, in observing the PSN meeting, even with the participation of other professionals, the nurse was the one who took the lead to address the issues that were relevant to the subject under discussion, bringing ideas for changing processes, as well as for their implementation and in controlling such changes.

The institutional documents addressed the issue of continuing education as a central action to foster a security awareness. From that, based on individual action, culture will be formed at the institutional level. And, to be possible, nurses need to assume their responsibility to lead and seek education, developing their self-confidence and competences as managers. The improvement of leadership skills enables nurses to improve their organizational awareness, strengthening their practice and allowing them to assume roles for decision-making autonomously, as well as being a reference and training model for other new leaders.

Based on the theoretical framework that supported the discussion of leadership concepts in this study, it is understood that, although the data portrays some aspects of transformational leadership, it was noticed that hospitals were based on participatory management, but had transactional components. As, for example, management by exception, characterized by the intervention of the leader in a more active way on some occasions, and less active on others, with the purpose of preventing possible deviations in behavior from the norms of conduct. This points to an urgent need to analyze the leadership style exercised in health organizations, so that the profile of leaders is worked on in order to develop this competence.

The triangulation of data sources, necessary to understand the case presented in this study, showed that nurses’ leadership behaviors and practices pervaded technical skills and/or formal positions. Such practices consider individual values as attributes and skills acquired through experience and scientific knowledge based on safe and quality conducts.

CONCLUSION

From the developed study, it was possible to highlight the best leadership practices of nurses who contribute to hospital risk management, recognizing how they were applied in all institutional scopes. It is adopted as a leadership practice, the professional valuation in a unique way within the process emphasizing the importance of scientific knowledge and the professional reference model that nurses exercise in hospitals.

The transition between risk management, safety in hospital units and nursing leadership goes beyond technical skill and recognizes nurses as people with emotions and feelings, who will work and coordinate other people as unique as themselves.

Although there are several studies on the theme of patient safety, it is still incipient the approach relating nurses’ leadership with hospital risk management, which has limited a greater debate of the research findings with the literature. This research contributed to demonstrate that leadership is a fundamental competence in stimulating and motivating to improve communication, the application of science in daily practice, the valorization of experience and individual commitment, resources and the health system that qualify the processes for achieving the success of a risk management program.

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• Funding:

  The present work was supported by the Coordination for the Improvement of Higher Education Personnel - Brazil (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES) - Funding Code 001.

Edited by

Associate editor:

Dagmar Elaine Kaiser

Editor-in-chief:

Maria da Graça Oliveira Crossetti

Publication Dates

• Publication in this collection
  26 Mar 2021
• Date of issue
  2021

History

• Received
  19 June 2020
• Accepted
  22 Sept 2020