28 NURSES ’ LEADERSHIP STYLES IN THE ICU : ASSOCIATION WITH PERSONAL AND PROFESSIONAL PROFILE AND WORKLOAD 1

This study aims to explore the association between nurses’ leadership styles and personal and professional nursing profile and workload. The sample consisted of seven nurses and seven nursing technicians who were grouped into pairs. At the end of three months, nurses were queried regarding what leadership style would be adopted when the nursing technician under their evaluation delivered care to patients admitted to the ICU. Relevant data was analyzed by applying descriptive statistics, Tukey’s multiple comparison test and Student’s t-test (p< 0.05). Nursing workload reached 80.1% on average. The personal and professional profile variables did not show any relation with the leadership styles chosen by nurses (p>0.05). The determine, persuade, and share leadership styles prevailed. However, whenever the nursing workload peaked, the determine and persuade styles were used (p<0.05).


ESTILOS DE LIDERAZGO DE ENFERMEROS EN UNA UNIDAD DE TERAPIA INTENSIVA: ASOCIACIÓN CON EL PERFIL PERSONAL, PROFESIONAL Y CON LA CARGA DE TRABAJO
Este estudio tuvo como objetivos verificar a relación que existe entre los estilos de liderazgo de los enfermeros con el perfil personal, profesional y carga de trabajo de enfermería.La muestra fue constituida por siete enfermeros y siete técnicos de enfermería que formaron parejas.Durante tres meses los enfermeros fueron cuestionados sobre cual sería el estilo de liderazgo adoptado cuando el técnico de enfermería, bajo su evaluación, prestase cuidados a los pacientes admitidos en la Unidad de Terapia Intensiva.Los datos fueron analizados aplicándose estadística descriptiva, el método de comparaciones múltiples de Tukey y la prueba t de Student (<0,05).La carga de trabajo de enfermería alcanzó el valor promedio de 80,1%.Las variables de perfil personal y profesional no presentaron relación con los estilos de liderazgo escogidos por los enfermeros (p>0,05).Los estilos de liderazgo: determinar, persuadir y compartir fueron los predominantes, sin embargo, cuando la carga de trabajo de enfermería era mayor, se observaron los estilos determinar y persuadir (p<0,05).DESCRIPTORES: enfermería; liderazgo; carga de  Situational leadership is centered on the premise that there is no such thing as a single appropriate leadership style for each and every situation.In this approach, the leader's behavior in relation to subordinates in a specific task (1) is emphasized, i.e. it is founded on the interrelation b e t w e e n t h e l e a d e r 's t a s k b e h a v i o r, h i s / h e r r e l a t i o n s h i p b e h a v i o r, a n d t h e s u b o r d i n a t e s ' maturity (2) .
The task behavior refers to the leader's act of telling people what, when, and how to do something.In other words, it means establishing and defining roles.The relationship behavior involves bilateral communication with a view to providing support and encouragement, which i m p l i e s t h a t t h e l e a d e r s h o u l d l i s t e n t o t h e collaborators carefully and support their efforts (2) .
Subordinate maturity refers to people's c a p a c i t y a n d w i l l i n g n e s s t o d i r e c t t h e i r o w n attitudes.Two dimensions are considered: work maturity (capacity), which is centered on technical abilities, and psychological maturity (willingness), which indicates the motivation to do something.
These two aspects should be considered only in relation to a specific task to be performed (2) .
In a dynamic and interactive environment, such as the ICU, involving intensive nursing workload and different professional profiles, where decision-making must be swift and assertive, it is essential that nurses have leadership competence.
Nevertheless, is there a strong tendency for leaders to perform instead of delegating actions?What nursing styles do ICU nurses use?Are leadership styles associated with the ICU nurse's personal and professional profile and workload?
The intention, herein, is to analyze the development of ICU leadership competence and the factors affecting its development, since studies using the theoretical framework of situational leadership have evaluated nurses' leadership styles (3) .Hence, the purpose of this study is to verify the association between nurses' leadership styles and their personal and professional profile and workload.were obtained from nurses and nursing technicians.

METHOD
To quantify the ICU nursing workload, the Nursing Activities Score (NAS) was administered, considering that this instrument was translated to Portuguese and validated according to the reality of Brazilian ICUs (4) .It consists of 23 items that include, besides physiological variables, administrative and managerial tasks (5) .A total NAS score is obtained from the individual item scores, and it expresses the percentage of time spent by a nursing professional in direct care to critical patients in an ICU work shift (6) .
The patient selection criteria for calculating the NAS were: to be hospitalized in ICU for at least 24 hours, to freely agree to participate in the study when their physiological condition permitted them to make that decision, to receive family permission for patients whose health conditions made it impossible for them to decide, and to be evaluated by every nurse in the sample within the first 24 hours in the ICU.
Twice a day, patients admitted to the ICU over the previous 24 hours were identified, the period in which the number of procedures and patient contacts is greater was determined (7) and NAS was This same question was asked of the other pairs formed whenever a new patient was admitted.
Data treatment was performed using the situational leadership style classification and the level of maturity validated in a previous study (8) , which include: determine (E1) -"explains his/her decision and closely supervises performance"; persuade (E2) -"explains his/her decisions and gives an opportunity for clarification"; sharing (E3) -"shares ideas and the decision-making process"; and delegate (E4) -"passes on the responsibility for the decisions and the implementation".
The maturity level of the subordinates was evaluated for the following nursing activities:

RESULTS
Seven nurses (leaders) and seven nursing technicians requiring leadership to perform their duties (subordinates) participated in the study, composing seven pairs, four of which worked in the morning, and three in the afternoon.
The average time since graduation from nursing school was 3.8 years (min=1.Repeated measures analysis was used for ordinal data and revealed that the pairs were statistically different when comparing the variables concerning personal and professional profiles (p<0.001).Hence, the analysis of leadership style and nursing workload was done separately for each pair.
The association between workload, mean NAS score, and leadership style could not be performed for each style (E1, E2, E3, and E4) due to the low frequency of some styles.To do this, for each pair, the patients were assigned to two groups: those who received care through leadership S1 or S2, and those who received care under leadership E3 or E4.
These data are presented in Table 2, considering the seven pairs.nurses mostly chose the leadership styles E2 and E3 to deal with their subordinates; the seven nursing technicians presented considerable to plenty of maturity for capacity and willingness; and the leadership styles were associated with the workload, i.e. in situations of high nursing workload, it was observed that nurses used the leadership styles determine (E1) and persuade (E3).
In the light of these conclusions, the ICU nurse should consider that the nursing workload required by patients affects the way their leadership occurs in that unit.In order to improve their human resource management, leaders should know the capacity and willingness of their co-workers and partner them to the complexity level demanded by the clientele.Thus, team members would have the chance to develop and improve their knowledge, abilities, and attitudes when providing nursing care.This is a continuous process that requires deep dedication and constant evaluation, so that the results can be converted into better quality care and improved team work in ICU.

T h i s
d e s c r i p t i v e , c r o s s -s e c t i o n a l a n d correlational study was performed in the General ICU of the Pain, Anesthesiology, and Intensive Care Class at Hospital São Paulo -Federal University of São Paulo -Escola Paulista de Medicina (Paulista Medical School) (UNIFESP/EPM).This ICU has 16 beds for clinical and (mostly) surgical patients.The sample consisted of ICU nurses and nursing technicians, according to the following inclusion criteria: having worked in the ICU for at least six months, freely agreed to participate in the study, worked during the day due to the researcher's inability to collect data at night, and be present throughout the three-month data collection period, i.e., with no planned vacation, maternity/paternity leave, marriage, or sickness leave.Data collection was performed from March 7 to June 7, 2005, after the project had been a p p r o v e d b y t h e U N I F E S P R e s e a r c h E t h i c s Committee.The nurses who agreed to participate in the study were randomly assigned a member from the nursing technician team under their supervision and, with their agreement, formed a working pair.Data regarding the personal (age and g e n d e r ) a n d p r o f e s s i o n a l p r o f i l e ( t i m e s i n c e graduation, time working at the institution and ICU, work shift, and contact with the leadership theme) administered.Following that, to obtain data about the nurses' leadership style, the following question was asked: "Considering this patient and the nursing technician under your evaluation, what leadership style would you use to instruct them in nursing care?".
and E3 (persuade and share), followed by S1 (determine) with their subordinates when performing the nursing activities established for the 87 patients hospitalized in the ICU.Most of the seven nursing technicians presented considerable and plenty of maturity (M2 and M3), for both capacity and willingness.It should be noted that, in pair 5, the nurse used only the styles determine (E1) and persuade (E2) in view of the nursing technician's little (M1) capacity and willingness.On the other hand, observing pair 3, it was found that, despite the nursing technician's considerable (M2) capacity and complete (M4) willingness, the prevalent leadership style was determine (E1).In addition, pairs 6 and 7, despite the subordinates having plenty (M3) of maturity for both capacity and willingness, styles E1 and E2 prevailed.This inconsistency could be due to the fact that these are young leaders and have little work experience.They acknowledge that their subordinates have the capacity and willingness to provide the nursing care, but they are unable to delegate the necessary actions.Nevertheless, this hypothesis should be tested with a larger sample.Using Tukey's multiple comparison method, it was verified that there was no significant statistical association between the variables related to the personal and professional profile and the l e a d e r s h i p s t y l e s w h e n a t e a m m e m b e r w a s assessed (p>0.05).

Table 1 -
Nurses' leadership styles and subordinates' maturity.São Paulo, SP, 2005 According to Table 1, nurses mostly used E2 h o u r s , r e v e a l e d t h a t , o n a v e r a g e , 8 0 . 1 % (min=62.4;max=101.8 and sd±7.98) of the pairs' work shift was dedicated to patient care.Considering the 87 patients admitted during the data collection period, the nurses adopted leadership styles as presented in Table1.

Table 2 -
Nurses' leadership styles according to NAS scores.São Paulo, SP, 2005 The data in Table2show that, when leadership styles E1 and E2 were used, the average NAS score was higher (p<0.05)when compared to the average NAS score observed in group E3 or E4, excluding pairs 5 and 6.