Liderazgo del enfermero : una revisión integradora de la literatura

Se trata de una Revisión Integradora de la literatura, que buscó evidenciar y discutir las principales características del concepto de liderazgo y del enfermero líder, así como sus contribuciones para la práctica en enfermería y salud, a partir de publicaciones científicas de enfermería indexadas en la base de datos Medical Literature and Retrivial System on Line (MEDLINE) entre 1998 y 2008. Siguiendo los criterios de inclusión, se totalizó 36 estudios seleccionados para análisis, de los cuales 89% (33 artículos) fueron publicados en periódicos extranjeros y 11% (3) publicados en periódicos nacionales. Los perfiles de enfermeros líderes encontrados fueron el autoritario y el auténtico, siendo el liderazgo evidenciado como una herramienta organizacional que articula comunicación, relaciones interpersonales, planificación, el compromiso con el éxito y la resolutividad de conflictos. La educación se presenta como fundamental para la formación de líderes, relacionando directamente la valorización de la titulación académica con el perfeccionamiento de esa competencia.


Introduction
The work of nursing, as an instrument of the process of work in health, is subdivided into several dimensions, such as to care/assist, to administer/ manage, to perform research and to teach.Among these, to care and to manage are the processes more evident in the work of the nurse (1) .Similarly, both in Primary Healthcare and in the hospital context, the nurse performs the care and managerial functions, taking the role of the nursing team leader and managing the health units, assuming the responsibility for the material and human resources.However, the adoption of the Family Health Program in 1994 as a model for the reorganization of care in the national context, which was later named the Family Health Strategy, imposed changes on the 'traditional' healthcare teams, which were faced with new concepts and guidelines, with the insertion of the Community Health Agent (CHA) and the proposal of an interdisciplinary approach.Thus, the multiprofessional teams, known as Family Health Teams, consisting of a nurse, doctor, dentist, dental assistant, axillary nurse or nursing technician, and Community Health Agents, began to perform common activities that stimulated interdisciplinary practice and "participation in the management of supplies needed for the adequate functioning of the Local Health Unit (LHU)" (2) .
Once all the professionals have become coresponsible for the management of the unit, which are the influential factors that enable a nurse to be positioned as a leader in the LHU or in the hospital context?Is the nurse a leader or not?Is being a leader an inherent function of the nurse?
The competence "leadership" refers to being able to assume the position of leader in the multiprofessional healthcare team, aiming toward the well-being of the community, and considering in its performance the commitment, responsibility, empathy, the ability to take decisions, communication, and effective and efficient management (3) .While the resourcefulness to communicate and the ability to persuade are inborn characteristics in some people, the development of leadership is facilitated by the existence of a potential, this potential exists in all individuals, but they often have no chance to refine it (4) .Thus, nurses emerge historically as team leaders for possessing or having developed during their formation an expanded vision of the "human", "care" and "health" systems, beyond what is visible, articulating knowledge and actions necessary to offer creative and quality care.However, considering the different perceptions and influences of the types of leadership adopted by the health services, the questions are: How have the concept of leadership and the profile of the nurse leader been described over the last decade in the scientific publications of nursing and health?
What are their contributions to the practice of nursing?
In this sense, this study aimed to highlight and discuss the main characteristics of the concept of leadership and of the nurse leader, as well as their contributions to the practice of nursing and health, from the scientific publications of nursing and health.

Methods
This is a qualitative study, to identify productions on the theme of Leadership and Nursing, between 1998 and 2008.The Integrative Literature Review (5) was adopted, since it contributes to the process of systematization and analysis of the results, aiming to comprehend a given theme from other independent studies.The Integrative Literature Review proposes the establishment of well defined criteria regarding the data collection, analysis and presentation of the results from the initiation of the study, from a research protocol previously developed and validated.Thus, the six steps indicated for the constitution of the Integrative Literature Review were adopted: 1) selection of the research question; 2) definition of the criteria for inclusion of studies and selection of the sample; 3) representation of the selected studies in table format, considering all the characteristics in common; 4) critical analysis of the findings, identification of differences and conflicts; 5) interpretation of the results; and 6) clear reporting of the evidence found (5) .
The strategy for the identification and selection of studies was the search for publications indexed in the database Medical Literature Analysis and Retrieval System Online (MEDLINE), in September 2009, which was accessed through the link provided by the University Library of Santa Catarina Federal University (BU/UFSC) (6)   .The following criteria for the selection of articles were adopted: all categories of article (original, literature review, reflection, training, case studies, etc.); articles with abstracts and full texts available for analysis; those published in Portuguese, English or Spanish, between the years 1998 and 2008; and articles which contained in their titles and/or abstracts the following Health Sciences Descriptors (DeCS): Leadership AND Nursing.
The resource used in the search was the expression "exact term" associated to the specific descriptors.The criterion for exclusion of articles was: studies that did not meet the inclusion criteria mentioned.From the material obtained, 58 articles, a careful reading of each abstract/article was performed, highlighting those which responded to the objective proposed by this study, in order to organize and tabulate data.For the organization and tabulation of the data, the researchers developed a data collection instrument containing: title, journal, year of publication, country of the study, category of the study, nature of the study, theoretical framework, analytical method, approach, concept of leadership, profile of the nurse leader, and contributions to the practice.Following the inclusion criteria a total of 36 studies were selected for analysis, which are referenced in this text.Bibliometric analysis for the characterization of the selected studies was next performed.Later, the concepts covered in each article and of interest to the researchers were extracted.The studies were compared and grouped by similarity of content, in the form of empirical categories, with three categories for analysis constructed, specified as: "Profile of the nurse leader"; "Leadership as an organizational tool"; and "Education for Leadership".

Results and discussion
It was found that 89% (33 articles) were published in foreign journals and 11% (3) published in national journals.

Profile of the Nurse Leader
In some applied studies in the area of nursing, researchers sought to outline the personal characteristics of nurse leaders and the leadership styles used by them in their various fields of operation.Characterized as a process of influencing others and facilitating the achievement of common goals in the individual and collective sphere, leadership is based on relationship oriented behavior which includes the support, improvement of personal skills and adaptation to the work, the recognition of the other and their aptitudes, aiming for the commitment, between the employees and the organization, to becoming one unit (7)(8) .Thus, the profile of nurse leaders and their professional conduct are closely related to the philosophy of the institution in which they operate, with two types of leadership encountered in the selected studies: the authoritative and the authentic.
The authoritative leader was viewed as the solidification of the objectives and functions of the Lanzoni GMM, Meirelles BHS.position held, with its followers promoting values that emphasize respect, commitment and acceptance of traditional ideas (9) .In this style of leadership, the leader is positioned at the top of the hierarchy, centralizing the decision-making power, enjoying the prestige, status and social stability resulting from their administration, as well as responding alone for the failure of their actions.This style of leadership is guided by the normative planning model, which understands the reality based on the separation between the subject and the object, the existence of a unique reality identified from the diagnosis of the manager, an absence of uncertainties, negation of other subjects and resistance, as well as the exclusion of the political dimension and comprehension of the project as a closed system (10) .Although this profile of leader can receive criticism, mainly due to the verticalization of decisions, at times when there is a need for rapid and timely decision making, its efficiency is evidenced by the generation of an atmosphere of work performed and security, therefore it is well accepted by the nursing team (9) .Corroborating this idea, studies show that the traditional profile of leader/manager is predominant in the healthcare services, even though the scientific production provides a significant quantity of articles that explore the notion of democratic management (11) .Authentic leadership, conceptualized as the "glue" that holds everything together in a healthy work environment, was cited as a form of management that can incorporate other forms of positive leadership, such as transformational leadership (12) , and that allows a shared vision of the goal by the group, being indicated to the leaders with the so-called "intermediate maturity", related to the length of experience (13) .To implement this style of management, skills are required such as audacity, availability, persuasion, courage and creative freedom (14) , it is necessary to involve the whole team not only in the decision making process, but also in the development of action strategies and the resolution of problems.Thus, in response to problems that cannot be solved through the normative model, a shared leadership based on situational-strategic planning that emerged between the years 1970 and 1980 is presented.To implement this model it is necessary to comprehend the reality at a higher level of complexity, i.e. the subject and object are confused, a unique diagnosis of the reality does not exist, it incorporates uncertainty and conflict, requiring an open process without a defined end (15) .The breakthrough achieved by this model of health planning was the comprehension that the resolution of health problems transcends the sectoral limits, implicated in the recognition of the social as the totality.However, studies attribute poor adherence to the participatory model, to the additional effort that should be made by the leader to continuously involve the other participants of the process, and to the resistance to changes on the part of others involved (11,16) .

Leadership as an organizational tool
Nurses have traditionally occupied leadership positions in health.For years, nurses have articulated and advocated collaborative and shared visions of care (17) , acting in a complex manner, interlinking the activities of care, management and education (18)(19) .
Nursing management is experienced at a corporate level by the head nurse, at middle management level by the nursing directors, and at the practical interface by the nursing managers (20) .However, the management of the care is exercised by each nurse in their care practice, listing attendance priorities, allocating roles in the team, and relocating materials and resources for quality care.In this sense, communication can be used as a resource for the success of the leadership exercised by nurses, promoting inter-relationships with the client, the institution, the medical team and the nursing personnel.The relationship between leadership and communication allows nurses to work actively on the problems, and to promote sought-after changes towards a new moment (21) , favoring the reduction of employee turnover (22) and of their physical and emotional exhaustion (23) , as well as strengthening skills and knowledge regarding the nursing role (24)(25) .To this end, a greater use of leadership-oriented relationships, defined as giving constructive feedback (26) , and the construction of coalitions supporting the changes, facilitate the incorporation of the goal by the others involved in the process, creating a sense of need and demonstrating the shared commitment to change (7,27) .In this sense, the presence of women in the profession is highlighted as a positive factor, because women are considered comprehensive, involve themselves in practices of participatory leadership and tend to encourage their team more than the male leaders (28) .
The low satisfaction with the services may not be exclusively related to the lack of resources, but also to the lack of strategic vision and leadership (29)(30) .
Unfortunately, there are few studies that have deepened the thematic of leadership quality (31) , however, there are no recipes for good performance, since, even with experience, the leader cannot predict the problems that will appear daily (31) .However, breaking with the www.eerp.usp.br/rlaeRev. Latino-Am.Enfermagem 2011 May-Jun;19(3):651-8.
traditional model, leadership transitions (32) , processes of change may provoke uncomfortable answers within the services, but through thoughtful actions, the leader and followers may drive the group to the aspired level (32) , in which temporary situations can become permanent (31) .Therefore, nurses must make themselves visible and available (33) in order to facilitate the process of change, as well as the extent to which the service and clients require (34) .Respect, the commitment to professional success (9) , the monitoring of operations and performance upholding the efficient use of the resources (7) , helping to resolve personal conflict and generating confidence in the team are emphasized (26,35) .
The activities related to the care and management of the services are group processes, as there is no ignoring the interdependence established between caregiver and cared for, leaders and followers, who are connected and constitute structural webs that comprise and characterize interactions, identified as a "tangle of networks embedded in larger networks" (36) .Thus, the actions of the nursing leaders significantly affect the structural factors and work processes of the institutions; despite the overlapping of functions, they perceived as an influential group within their organizations and confident in their ability to provide effective leadership when the theme is nursing (37) , generating essential impact for the sustainability of the role (38) .

Education for leadership
Leadership "is linked to a sense of action, a sense of movement, and is subject to being learned" (4) .However, it can be understood and developed, provided there is interest and initiative, because it is considered one of the core competencies to be acquired by nurses in their formation (1) .It is expected that the preparation for leadership is a declared goal of most nursing education programs, as the formation of the nurse aims to equip the individual with the following skills required for the practice of the profession: healthcare, decision making, leadership, communication, administration and management, and ongoing education (3) ; professional leaders with training continue to be considered valuable in their institutions due to the low availability of workers with this profile (39) .This fact can be linked to the small amount of attention given to the acquisition of such knowledge, since leadership development should be initiated in the basic level, together with research activities and clinical/community experience (40) .The possibility exists of strengthening it through continued education (40) and improving it in MSc and PhD programs, where many leaders flourish fully in all the domains of nursing: practice, education, administration and research (21,41) .For success in the formation of young nurse leaders, the importance is stressed for a positive atmosphere of supervision and "good leadership" (42) , with well-qualified professors that posses a leadership profile, aimed at the exchanging of experience and the appropriation of the main characteristics to act as leader (43)(44)(45)(46) .
It was observed that changes in leadership style often occur in the sense of an autocratic leadership moving to a more participative leadership.This fact considers corporeality, temporality and spatiality of being that leader, who is rescued, while being taught, by the influence of socio-political proposals which, at different moments, have indicated the same direction.
Administration theories have also been down this road, with influences of different thoughts in the chronological trajectory, which equally occurs in education (47) .Thus, the overlaps that have occurred have not happened by chance.

Conclusions
The trend toward authentic/participatory leadership is surmised, focusing on communication as a means of achieving better health outcomes and overcoming the non-linear challenges with a single cause.Institutions that possess a solid leadership also benefit from the increase in the creation of bonds, with lower staff turnover, fewer conflicts, greater involvement of the people in the work process and better utilization of resources.It is understood that the leadership has little chance of advancing in nursing, unless it is deliberately encouraged through innovative attitudes, personal and group projects and investments, and the union of all nurses.The stimulation for continuing education is presented as fundamental for the formation of leaders.
In this sense, the valorization of academic titles for the profile of the leader and the direct relationship of this with the improvement of the competence are highlighted.

Figure 1 -
Figure 1 -Distribution of the studies according to year of publication, 2009