Being an entrepreneur in nursing: challenges to nurses in a strategic leadership position

Abstract

Objective:

To identify challenges to the development of entrepreneurial behaviors, from the perspective of nurses in a strategic position of leadership.

Methods:

This was a qualitative, descriptive, and exploratory study. Participants were twelve female nurses, working in a strategic leadership position in different health organizations and services of a municipality in southern Brazil. A semi-structured interview was administered between September and November of 2017. Analysis of the thematic content was conducted using the steps of pre-analysis, material exploration, treatment of results, and interpretation.

Results:

It was revealed that nurses in a strategic leadership position presented important challenges in the development of entrepreneurial behaviors, represented by the structures described in the thematic categories: movements of entrepreneurial actions by nurses in strategic positions of leadership; being an entrepreneur in a strategic leadership position: (im)mobilizing situations; learning to be an entrepreneur: challenges of advanced responsibility.

Conclusion:

In the context of the study, the position occupied by nurses represents an unparalleled opportunity for the dissemination of an entrepreneurial culture in diverse professional settings, both in terms of strategic potential for management of people and processes, as well as in stimulating the development of entrepreneurial actions in care management, and management of health and nursing services. The study awakens the need to search for means and possibilities to allow for management of the paradoxes that permeate the reality of being a female nurse in a strategic position of leadership in healthcare and teaching institutions, which is not always a favorable situation.

Keywords
Leadership; Organization and administration; Women, working

Resumo

Objetivo:

Conhecer os desafios ao desenvolvimento de ações empreendedoras na perspectiva de enfermeiras em posição estratégica de liderança.

Métodos:

Estudo de abordagem qualitativa, descritivo e exploratório. Participaram 12 mulheres, enfermeiras, em posição estratégica de liderança, em diferentes organizações e serviços de saúde de um município do Sul do Brasil. Foi aplicada a entrevista semiestruturada como técnica de coleta, no período de setembro a novembro de 2017. A análise de conteúdo temática se deu seguindo as etapas de pré-análise, exploração do material, tratamento dos resultados e interpretação.

Resultados:

Foi desvelado que as enfermeiras em posição estratégica de liderança visualizam desafios importantes no desenvolvimento de ações empreendedoras, representados pelas estruturas descritas nas categorias temáticas: Movimentos da ação empreendedora por enfermeiras em posição estratégica de liderança; Empreender em posição estratégica de liderança: situações (i)mobilizadoras; O aprender a empreender: desafios de uma responsabilidade avançada.

Conclusão:

No contexto do estudo, a posição ocupada pelas enfermeiras representa oportunidade ímpar na disseminação de uma cultura empreendedora em diversos cenários de atuação profissional, pelo seu potencial estratégico na condução de pessoas e processos, bem como no estímulo ao desenvolvimento de ações empreendedoras no gerenciamento do cuidado e na gestão de serviços de saúde e enfermagem. O estudo desperta para a necessidade de buscar caminhos e possibilidades que permitam gerenciar os paradoxos que permeiam a condição nem sempre favorável do ser mulher enfermeira em cargo estratégico de liderança nas instituições de saúde e de ensino.

Descritores
Liderança; Organização e administração; Mulheres trabalhadoras

Resumen

Objetivo:

Conocer los desafíos al desarrollo de acciones emprendedoras según la perspectiva de enfermeras en posición estratégica de liderazgo.

Métodos:

Estudio de abordaje cualitativo, descriptivo y exploratorio. Participaron 12 mujeres, enfermeras, en posición estratégica de liderazgo, en diferentes organizaciones y servicios de salud de un municipio del sur de Brasil. Se aplicó la entrevista semiestructurada como técnica de recolección, en el período de septiembre a noviembre de 2017. El análisis de contenido temático se dio siguiendo las etapas de pre-análisis, exploración del material, tratamiento de los resultados e interpretación.

Resultados:

Se desveló que las enfermeras en posición estratégica de liderazgo visualizan desafíos importantes en el desarrollo de acciones emprendedoras, representados por las estructuras descritas en las categorías temáticas: Movimientos de la acción emprendedora por enfermeras en posición estratégica de liderazgo; emprender en posición estratégica de liderazgo: situaciones (i) movilizadoras; el aprender a emprender: desafíos de una responsabilidad avanzada.

Conclusión:

En el contexto del estudio, la posición ocupada por las enfermeras representa una oportunidad impar en la diseminación de una cultura emprendedora en diversos escenarios de actuación profesional, por su potencial estratégico en la conducción de personas y procesos, así como en el estímulo al desarrollo de acciones emprendedoras en la gestión del cuidado y en la gestión de servicios de salud y enfermería. El estudio apunta a la necesidad de buscar caminos y posibilidades que permitan gestionar las paradojas que permean la condición no siempre favorable del ser mujer enfermera, en cargo estratégico de liderazgo, en las instituciones de salud y de enseñanza.

Descriptores
Liderazgo; Organización y Administración; Mujeres trabajadoras

Introduction

The contemporary work scenario has been increasingly dynamic and competitive, given the demands of qualified, proactive, and entrepreneurial professionals. These professionals, with differentiated characteristics, are adaptable to multiple organizational contexts, developing an aptitude for seeking creative and innovative solutions, which makes it possible to intervene in the face of wide ranging obstacles.⁽¹⁾ The Brazilian organizational context maintains a typical masculine stronghold, in which sex segregation and hierarchy remain within job roles, even with the increase in female participation in the labor market, and with the reduction of the wage differences between men and women.^(2,3)

The activity of women and men continues to be represented, in certain sectors, by “feminine” or “masculine” work, and presented in a discriminatory manner that reveals disparities which discriminate against women, placing them in disadvantaged situations. In general, the contemporary literature shows that women are devalued in relation to men, evidenced by “price discrimination” between these professionals, as well as in relation to the hierarchical levels and professional activities performed by them, which culminates in devaluation in relation to tasks, wages,^(2,3) and efforts to achieve professional visibility. These assertions are based on the findings of a study which revealed that 77% of Brazilian professionals occupying a strategic leadership position in companies are men, and this proportion is higher as the institutional hierarchy is taller; in other words, professional development in the world of work continues to be defined by male standards.⁽⁴⁾

In the context of nursing, a historically female profession,⁽⁵⁾ the participation of men has gradually increased, especially since the 20th century.⁽⁶⁾ The historical trajectory of the nursing class revealed the struggle for spaces of action and autonomy of women in nursing over time. This led to the assumption of multiple roles within work processes of the most diverse professional fields, including: responsibility, commitment, and involvement in care, managerial, educational, investigative, and political activities that focused on the promotion of best care practices.⁽⁷⁾

Facing this new scenario, and with the intent to explore opportunities for professional activities and new work settings, nurses are involved in entrepreneurial behaviors in a search for innovative health processes. Their multiple skills enable them to conquer new fields in health care,⁽⁸⁾ and to recognize the importance of entrepreneurship for national and international social and economic development.^(7,9) Thus, it is presumed that the promotion of entrepreneurship in nursing implies the mobilization of collectives, and the involvement of strategic individuals in the development of the social practice of care in nursing and health.^(7,10) Social entrepreneurship involves an alternative, dynamic, and strategic process capable of making the production of services sustainable in health and people management,⁽⁷⁾ combining social mission with nurses’ entrepreneurial behaviors, with their innovation and problem solving based on self-sustaining social integration strategies.

This condition reinforces the challenge for nurses in management positions, as this strategic position presupposes the exercise of leadership, resolution of conflicts, assertive decision making, and achievement of outcomes: a situation that constantly analyzes their values, skills, personal and professional attitudes,⁽¹¹⁾ awakening them to the indispensability of being entrepreneur even in conditions of inequality.

In accordance with the presented issue, the question is: What situations experienced by nurses in a strategic position of leadership stimulate the development of entrepreneurial behaviors? What challenges do these nurses face in the development of such behaviors? To answer these questions, the present study was conducted with the objective of understanding the challenges faced when nurses, in strategic positions of leadership, develop entrepreneurial actions.

Methods

This was a qualitative, descriptive, exploratory study, anchored in a dialectical proposal⁽¹²⁾ that aimed to understand, in depth, the phenomenon of entrepreneurship within the framework of nurses’ work relationships when holding a strategic position of leadership.

The health organizations and services that had nurses responsible for the development of managerial activities of an institutional scope, that is, whose responsibilities extended beyond the scope of nursing, were the setting for this investigation. The scenarios in which nurses were identified as occupying such positions included: Family Health Strategies, Health Surveillance Service, Emergency Medical Service, Emergency Care Unit, Clinical Care Units, and Institutions of Technical and Higher Education in Nursing.

A convenience sample was used, including all nurses who held a strategic leadership position in the municipality. The inclusion criteria were individuals who: declared herself to be female; were a nurse; were in a strategic position of leadership in the organization or service in which she worked for at least six months. The exclusion criterion was nurses who were removed from their position, for any reason, during the data collection period. For the purposes of this study, the term “strategic leadership position” was adopted, considering that some nurses held the position of leadership, however, others were integrated in strategic level in the institutional organization chart, although not necessarily titled as chiefs, and their production was essential because it directly impacted results of the organization and services to which they were linked.

Among the 14 nurses with a profile that matched the purpose of the research, 12 comprised the study sample; two refused to participate. A pilot test preceded the collection of data, which occurred in the period from October to November of 2017, through semi-structured interviews, conducted in the nurses’ own workplaces, in an space previously chosen and reserved for this purpose. The mean length of interviews was 32 minutes; audio was digitally recorded, and later fully transcribed. The questions were intended to stimulate the nurses’ critical dialogue and critical reflection on their experience of occupying a strategic leadership position. From this perspective, the researchers sought to identify situations that required entrepreneurial behaviors, as well as the challenges that accompanied the development of such behaviors.

The data from the semi-structured questionnaires underwent thematic content analysis,⁽¹²⁾ which consisted of highlighting the thematic nuclei that make up a classification of the findings, which were later grouped into themes that represent the summary the reports systematization.

The guidelines and regulatory norms for research with human beings, present in Resolution 466/12 of the National Health Council, were respected. The project, with registration CAAE: 71475617.4.0000.8135, was approved by the Research Ethics Committee, under opinion n° 2190648. All the participants granted their free participation in the research and signed the Terms of Free and Informed Consent. The confidential nature of the information, the right to free participation, and the preservation of anonymity were emphasized, as well as to ensure that there was no harm resulting from their participation. Thus, the interview reports were coded by letter N (nurse), followed by a sequential number.

Results

The participating nurses had: a mean age of 40.5 years and an average time in a leadership position of 5.2 years; 50% used to work in public network services. They all reported that the main reason they were chosen for the position was their length of work time at the institution or service. With regard to professional education, 10 (83.33%) had a graduate qualification (specialization), and two (16.66%) were doctorally prepared or in progress with their doctorate. The coding, material exploration, and interpretation proposed by the data analysis method resulted in three categories, as described below

Thematic category 1 - Movements of entrepreneurial behavior by nurses in strategic positions of leadership

The nurses participating in the study emphasized the movements of entrepreneurial behavior as necessary for innovative practices, mobilizing them for concrete work situations:

“You cannot do anything impromptu. When you work, you must know what can happen, what kind of people you will care for, and what their needs are. “ (N6)

“Although there are many obstacles, they do not prevent me from doing what I believe is right. We should always do the right thing. “ (N1)

“We said we would not do more health promotion groups, because no one came for the scheduled meeting. That's not how it's done; we need to be hopeful, focus on the needs of the patients, have positive thinking. “ (N5)

“I also want to obtain my master's degree and my doctorate. This was my goal from the day I entered college. “ (N8)

Thematic category 2 - Entrepreneur in a strategic leadership position: (im)mobilizing situations

Nuances for the development of entrepreneurial behaviors by nurses, in view of the need to rethink some skills and introduce others, were revealed by the study participants:

“There are situations in which you would like to perform or promote a certain behavior, and for political, financial, and administrative reasons you are not allowed to do so.” (N7)

“It has a project, in fact, it is encouraging and the manager says: no, this is not for now. Or, he is not interested and does not want to see what this is. It's frustrating! Disappointing! “(N2)

“When you start dealing with people, you manage teams, supplies, processes. You begin to realize how much the management of inter-professional relationships makes sense, because processes do not exist without people, and each individual brings his own conceptions and expectations “(N12).

“Being a woman is favored, mainly, in the area of nursing. However, administratively in a health institution, mostly managed by men, is difficult to be heard and respected. My journey is much longer than that of men. Men speak and are supported! When I speak, a series of arguments have to be presented and […] the questioning is longer. “(N3)

“Sometimes I even get suspicious: is it because I'm a nurse? But no. We've had male nurses here, who also had some difficulties. However, there were some other facilities that we do not have […]. I feel that something remains about it, with these restrictions.” (N10)

Thematic category 3 - Learning to be an entrepreneur: challenges of advanced responsibility

The nurses participating in the study revealed details about learning about entrepreneurial behaviors with situations they encountered, and whose experiences led them to innovate at work:

“At first I had no way of knowing everything. I did things right, I did things wrong. I got disappointed and started all over again. I had to go far behind things to learn, but I wanted to learn, to know how to do and, especially, I wanted to do and then to teach. “(N9)

“It was not easy at the beginning, it was a challenge, an innovation that made me grow, […] I had to look for information, ask for advice, and specialize.” (N4)

Discussion

Despite the favorable context that highlights multiple spaces in the social organization of nursing care, the nurses indicated, as fundamental characteristics of entrepreneurial behavior, perseverance, planning, proactivity, commitment, and an orientation for the future. In a study conducted in Brazil, with 116 nurses using a questionnaire with entrepreneurial tendencies, the main characteristics of entrepreneurship in nursing were identified as proactivity, impetus, and determination. However, this same study revealed that such characteristics are sometimes difficult to put into practice, due to the low autonomy and independence of these professionals.⁽¹³⁾

This condition needs to be demystified in nursing education, which, in spite of having a high concentration of women, and regardless of the gender relation, needs to encourage development of entrepreneurial behaviors within in management practices. The concept that entrepreneurial behaviors need to be stimulated, in the scope of education, corroborates the findings of a previous study, in which the importance of teaching methodologies was highlighted, which enable one to break away from tying practices and restriction to comfort zones, favoring an orientation toward entrepreneurship in nursing behaviors.⁽¹⁰⁾

This perspective is reinforced when nurses express the need for continuous qualification and improvement in order to maintain strategic positions, and the importance of innovative, calculated risk taking and proactivity in the behaviors they develop for care, and for changes in its management. This perspective reveals the entrepreneurial competence of nurses, as in other research this competency is related to the: search for constant qualification, proactive potential in performed actions, and, observance and creation of new and different opportunities, aimed at advancing nursing care practices.⁽¹⁾

The international context has presented remarkable characteristics for the exercise of entrepreneurial leadership, listing emotional intelligence and empathy as important characteristics for leadership, fundamental to the promotion of the well-being of people.⁽¹⁴⁾ In addition, the findings of the study show that the nurses perceive, in the people under their management, an important manner of mobilizing resources to reach idealized results, in a propositional way. When they wish to be an entrepreneur, they commit themselves in a manner that inspires their teams to be guided, also, by entrepreneurial behaviors.

On the other hand, in order to maintain organizational dynamics and professional spaces, the participants showed that sometimes they feel paralyzed in their efforts to develop entrepreneurial behaviors, in the face of cultural questions that challenge their skills and competence as professionals occupying a managerial position in the organization. They considered that they are affected by gender discrimination, and difficulties in the development and implementation of projects, confirming that their immediate leadership, in general, hampers their entrepreneurial endeavors, endorsing behaviors that discredit the ability of these women to manage.

In a contextual analysis conducted in the United Kingdom, at Heriot-Watt University, evidence that characterized entrepreneurship in terms of characteristics of men or women was discussed. The study considered that there are no gender-related distinctions with regard to entrepreneurial characteristics, given that both women and men can present characteristics considered masculine or feminine, deconstructing the specific characteristics of gender.⁽¹⁵⁾ In this sense, the findings of the research corroborate this contextual analysis, which concludes that the principal obstacle to the development of entrepreneurial behaviors is in the sexist discourse that women and men do not have equal capacities, or that women, through the cultural discourse of fragility, cannot assume leadership positions under the same conditions of work that a man would have.⁽¹⁵⁾

Several paradoxes involved in women occupying strategic positions of leadership were reported in situations experienced by participants of this study. Nurses who occupy this position in health organizations and services have the constant need to prove their proactiveness, innovation and creativity, even though they are restricted in terms of autonomy and freedom to be an entrepreneur. This dichotomous situation reinforces the unjust condition imposed on women, typical of a society of domination, which holds the nurse responsible for the mishaps with which they are faced and which, at the same time, demands mobilization and subjective engagement in the pursuit of actions that contribute to the service, preventing their actions, denoting a lack of credibility related to the gender issue. In other words, it is important for nursing to gradually invest in the development of a professional culture which turns toward social entrepreneurship, especially in the fields of knowledge, skills, and attitudes.⁽¹⁶⁾ In this sense, stimulating and motivating interpersonal relationships at work can also cause apprehension and suffering that needs to be addressed within the ethical principles of the profession, considering the condition of domination implicitly viewed as plausible by the study participants.⁽¹⁷⁾

When nurses understand the entrepreneurial behaviors as advantageous to the expansion and development of their nursing management practice, they are able to promote the entrepreneurial culture in the environment under their management, finding a stimulus for professional and institutional development, visualizing opportunities for innovative actions, and dealing with the adversities of the environment.⁽¹⁰⁾

At the same time, however, the nurse in a strategic leadership role is mobilized in a context that demands greater improvement and qualification, and favors the achievement of greater professional autonomy, as well as the dissemination of precepts based on co-responsibility, teamwork, determination, creativity, and innovation.⁽¹⁶⁾ This instigates a constant (dis)qualification condition which forces them to deal with situations of dilemmas, in a common way. In this dynamic, they sometimes find themselves obliged to give up other desires, to remain in the position in which they find themselves. Under such rhythm and pace, they sometimes call into question social coexistence and social relationships, for privileging unlimited investments in the operationalization of the organization's strategic actions, evidenced in the long work days demanded by those occupying their position, as well as in extra commitments that are required.⁽¹⁸⁾ This implies an expansion of the vision of proactive leadership, and ensuring the process of innovation and social transformation.⁽⁷⁾

Conclusion

The findings of this study demonstrate that the nurse who occupies a strategic position of leadership in health organizations and services faces existing tensions and challenges between the managerial dimension and the gender issue, which require the need to clarify the circumstances that refer to the convergence of these two spheres. The challenges that affect and (im)mobilize them in the development of entrepreneurial behaviors unveil the dichotomy that circumscribes the context in which they operate; at the same time that high institutional performance of these women is required, they have little autonomy and credibility. The identification of such challenges is important because, although the nurses involved in this context assume more and more strategic positions in health organizations and services, they face dilemmas in the work practice which can compromise their health in this environment. Thus, the present study contributes to the expansion of knowledge on the subject of entrepreneurship in nursing, raising possibilities for new research in this field, as a necessity that is imposed on a society facing complex challenges. However, the limitation of this study is that it describes the reality of a specific scenario, in which cultural influences are echoed, and that may not translate into a macro contextual reality; this makes the extension of the spectrum of research such as this relevant, as multicentric studies. The challenges faced by nurses in a strategic leadership position reaffirm the importance of considering the inter-subjective dynamics that permeate the work relationships of these professionals; while they occupy positions of intermediate management in these institutions, they experience situations of resilience and failure resulting from the not always favorable conditions experienced by female leaders. At the same time, they reveal the importance of their performance in the most diverse health scenarios, giving professional visibility for their strategic potential as they manage work teams and develop entrepreneurial behaviors in nursing.

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Publication Dates

• Publication in this collection
  Jan-Feb 2019

History

• Received
  10 July 2018
• Accepted
  07 Feb 2019