NURSE MANAGERS AND THE FACTORS WHICH INFLUENCE CARE LEADERSHIP: A QUALITATIVE STUDYABSTRACT
Objective: to understand the factors which influence care leadership by nurse managers in light of Frederick Herzberg’s theory.
Method: this is a qualitative, exploratory-descriptive study conducted in Luanda, the capital city of Angola, with three national reference hospitals. The participants were nurses holding management and leadership positions, such as nursing director, service head nurses and supervisors. The data were produced through interviews conducted from November to December 2023, using a semi-structured interview script. The IRaMuTeQ software was used for data processing with Descending Hierarchical Classification, followed by discursive analysis supported by Herzberg’s theory.
Results: a total of 43 nurses participated in the study. The speeches were divided by IRaMuTeQ into 361 segments (83.5 %), organized into six classes: Class 1, Recognition and respect among colleagues and leaders; Class 6, Career aspirations in nursing; Class 2, Organization and supervision of nursing practices; Class 3, Challenges and obstacles faced in nursing practice; Class 4, Factors related to motivation and professional achievement; and Class 5, Factors related to basic needs and well-being.
Conclusion: the results of this study highlight that motivational factors, such as recognition and opportunities for professional growth, are essential for job satisfaction among nurse managers. These factors are crucial to fostering a positive and engaging work environment. However, hygiene factors, such as poor working conditions and inadequate resources, were identified as predominant causes of dissatisfaction.
DESCRIPTORS:
Leadership; Management; Nursing care; Nursing; Motivation
RESUMO
Objetivo: Compreender os fatores que influenciam a liderança do cuidado por enfermeiros gestores à luz da teoria de Frederick Herzberg.
Método: Estudo qualitativo, exploratório-descritivo, realizado em Luanda, capital de Angola, junto a três hospitais de referência nacional. Os participantes foram enfermeiros detentores de cargos de direção e chefia, como diretor de enfermagem, enfermeiros-chefes de serviço e supervisores. Os dados foram produzidos por meio de entrevista, realizadas de novembro a dezembro de 2023, utilizando roteiro de entrevista semiestruturada. Para o processamento dos dados, utilizou-se o software IRaMuTeQ, com a Classificação Hierárquica Descendente, seguida de análise discursiva com suporte da teoria de Herzberg.
Resultados: Participaram da pesquisa 43 enfermeiros. Os discursos foram divididos pelo IRaMuTeQ em 361 segmentos (83,5 %), organizados em seis classes: Classe 1, Reconhecimento e respeito entre colegas e lideranças; Classe 6, Aspirações profissionais na carreira da enfermagem; Classe 2, Organização e supervisão das práticas de enfermagem; Classe 3, Desafios e obstáculos enfrentados na prática da enfermagem; Classe 4, Fatores relacionados à motivação e realização profissional; e Classe 5, Fatores relacionados às necessidades básicas e ao bem-estar.
Conclusão: Os resultados deste estudo destacam que fatores motivacionais, como reconhecimento e oportunidades de crescimento profissional, são essenciais para a satisfação no trabalho entre enfermeiros gestores. Esses fatores são cruciais para promover um ambiente de trabalho positivo e engajador. No entanto, fatores higiênicos, como condições de trabalho precárias e recursos inadequados, foram identificados como causas predominantes de insatisfação.
DESCRITORES:
Liderança; Gestão; Cuidado de enfermagem; Enfermagem; Motivação
RESUMEN
Objetivo: Comprender los factores que influyen en el liderazgo del cuidado por parte de las enfermeras gestoras a la luz de la teoría de Frederick Herzberg.
Método: Estudio cualitativo, exploratorio-descriptivo, realizado en Luanda, capital de Angola, en colaboración con tres hospitales de referencia nacional. Los participantes fueron enfermeras que ocupaban puestos de gestión y liderazgo, como director de enfermería, enfermeras jefas de servicio y supervisoras. Los datos fueron producidos a través de entrevistas, realizadas de noviembre a diciembre de 2023, utilizando un guión de entrevista semiestructurado. Para el procesamiento de los datos se utilizó el software IRaMuTeQ, con Clasificación Jerárquica Descendente, seguido de un análisis discursivo apoyado en la teoría de Herzberg.
Resultados: Participaron en la investigación 43 enfermeras. Los discursos fueron divididos por IRaMuTeQ en 361 segmentos (83,5 %), organizados en seis clases: Clase 1, Reconocimiento y respeto entre colegas y líderes; Clase 6, Aspiraciones profesionales en la carrera de enfermería; Clase 2, Organización y supervisión de las prácticas de enfermería; Clase 3, Desafíos y obstáculos enfrentados en la práctica de enfermería; Clase 4, Factores relacionados con la motivación y el logro profesional; y Clase 5, Factores relacionados con las necesidades básicas y el bienestar.
Conclusión: Los resultados de este estudio destacan que los factores motivacionales, como el reconocimiento y las oportunidades de crecimiento profesional, son esenciales para la satisfacción laboral de los gerentes de enfermería. Estos factores son cruciales para fomentar un ambiente de trabajo positivo y atractivo. Sin embargo, se identificaron factores de higiene como malas condiciones de trabajo y recursos inadecuados como causas predominantes de insatisfacción.
DESCRIPTORES:
Liderazgo; Gestión; Atención de enfermería; Enfermería; Motivación
INTRODUCTION
Care management in a hospital environment has recently undergone profound transformations and adaptations, affecting principles, guidelines, political orientation and contributions from health systems and services1. Nursing care management is interconnected with the care process developed in an organizational environment, and the efforts of each nurse must be integrated in order to achieve its objectives. This process requires adequate resources so that nurses can perform their activities successfully under the leadership of a manager2.
Maxwell, a researcher in leadership, defends the thesis that all professionals exercise leadership wherever they are developing their activities. Therefore, as those responsible for patient care, nurse managers holding management and leadership positions exercise leadership of nursing care when they develop activities, regardless of the area they are in3.
Leadership has been a determining factor in the success or failure of organizations around the world, and Angola is no exception. Leadership is the leader’s ability to influence people to achieve the organization’s goals4. In this context, management consists of a combination of well-planned skills, policies, techniques and practices, the objective of which is to manage the behavior of nurses, enhancing their responses to the organization’s demands with satisfaction. This is defined as the feeling of well-being in the organizational context resulting from fulfilling professional tasks and satisfying needs. In other words, job satisfaction is proportional to the achievement of professional desires5.
Several factors in addition to the nurses’ work environment can positively or negatively influence the care process, such as non-participative management, lack of materials, deficient training of professionals, leadership, communication, proportion of nurses, and salary, among others6.
According to Herzberg, whether or not needs are met in the workplace results in two groups of factors which explain people’s behavior in organizations. The first group of factors are hygiene factors, which are external to the person (politics, company administration, supervision, relationships, working conditions, salary, status, safety). When hygiene factors are adequate, they generate satisfaction; when they are precarious, they prevent satisfaction7.
Managers make the mistake of thinking of salary remuneration as a motivating element for employees, which is certainly a “Kick in the Ass” (KITA). When nurse leaders provide hygiene motivation to their subordinates, it arises so that the activity is enriched, allowing for effective use of personnel. This experience of motivating employees is considered manipulative, so the motivating factors have been temporary. Therefore, it is necessary for organizations to make these hygiene factors available in a balanced way to professionals as important elements which trigger stimuli to provide better nursing care to patients.
The second group are motivational factors, which are controlled by the person and involve: achievement, professional recognition, nature of work, responsibility, growth, and the need for self-achievement. These factors include: delegation of responsibility; freedom to exercise discretion; promotion; full use of skills; establishment of objectives and evaluation related to them; expansion or enrichment of the position7. Motivational factors are related to the activities of those holding management and leadership positions, such as feelings of growth and professional recognition. When they are excellent, they provoke people’s satisfaction. However, when they are precarious, they prevent satisfaction.
Motivational factors (also called intrinsic) are related to the position that those holding management and leadership positions occupy or the task they perform in the organization. Therefore, organizations need to understand and provide policies which bring these factors into effect for nurse managers holding management and leadership positions (Nursing Director, Service Chief Nurse and Supervisors) to provide the team with action and motivation to provide nursing care with efficacy, efficiency and effectiveness8.
Considering the relevance of Frederick Herzberg’s two-factor theory7 which distinguishes between motivational and hygienic factors in the work environment, this study’s guiding question is: “What are the factors which influence care leadership exercised by nurse managers according to Frederick Herzberg's theory?”; and the objective is to understand the factors which influence care leadership by nurse managers in light of Frederick Herzberg’s theory. This study is justified by the scarcity of academic works in the Angolan context on the subject, and highlights one of the existing gaps regarding the challenges and factors that influence leadership among nurse managers in Angola.
METHOD
This is an exploratory-descriptive qualitative study which used Frederick Herzberg’s Two-Factor Theory as a theoretical framework7. The study was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) to report the research9.
The researchers who conducted the study had advanced degrees in nursing, with experience in qualitative research and health management. There was no pre-existing relationship between the researchers and the participants prior to starting the study. Measures were taken to maintain a neutral and professional relationship during the interviews to minimize potential bias and ensure impartiality. In addition, the researchers reflected on their own experiences and perceptions regarding the topic of nursing leadership, recognizing that these could influence data collection and analysis. This recognition was used to guide conduct of the interviews and analysis of the results, seeking a balanced and objective interpretation.
The study was conducted in three nationally renowned hospitals in Angola. It involved 43 nurse managers holding management and leadership positions who were present at the data collection time, composed by six from hospital 1, 16 from hospital 2, and 21 from hospital 3. These are nurse managers and held the positions of Director of Nursing, Head Nurse and Supervisor, with at least one year of experience in the position. The Director of Nursing is responsible for directing, guiding, coordinating and leading nursing services. The Head Nurse of the Service is responsible for directing, guiding, coordinating and leading the nursing team, as well as the nursing care of an area/service of the hospital, while the Supervisor supports the Director of Nursing in supervising the inpatient and outpatient services.
The participants were selected through in-person invitations made by the lead researcher. Each potential participant received detailed information about the study, and those who met the criteria were invited to participate. Participation was voluntary and all participants signed the Informed Consent Form (ICF). The interviews were conducted in private rooms within the hospitals, providing a quiet and private environment for discussions. Interview times were scheduled according to the availability of the participants, minimizing interruptions and ensuring the quality of the responses.
The sampling technique used was non-probabilistic convenience sampling10. Data were collected through semi-structured interviews. A pilot test was initially conducted with five participants to ensure adequacy of the questions and the participants’ understanding, which resulted in adjustments to the questions. The pilot test data were not included in the final sample.
The interviews were conducted between November and December 2023, with an average duration of 28 minutes. Data saturation was considered and reached during the interview process. The interviews continued until the participants’ answers began to repeat themselves, indicating that no new information relevant to the study would emerge11.
The interview questions were: What is motivation for you in thinking about your professional practice? When do you feel motivated as a manager?; Could you point out which needs you consider essential for your motivation?; As a manager, describe the activities you perform; Explain how you feel about the possibility of being promoted; As a manager, describe whether you feel recognized/respected in your work environment?; What do you understand about self-actualization? Do you feel self-actualized? Can you detail the reasons for your self-actualization? What do you think could be improved? Can you report the factors which (positively and negatively) influence your care leadership activity?: Related to the nursing team; related to your superior and related to technical and administrative procedures.
All speeches were transcribed and coded, ensuring participant confidentiality. Meetings with participants were held to discuss the findings, resolving disagreements by consensus and ensuring a robust and reliable transcription. After transcription, a summary of the findings was shared with some participants for validation. They were invited to review and comment on the interpretations, and their suggestions were incorporated into the results.
The collected data were processed using the IRaMuTeQ software (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires) as a resource for discursive textual analysis. The Descending Hierarchical Classification (DHC) method developed by Nascimento et al.12 was used to segment the textual corpus into meaning classes, allowing a detailed and structured analysis of the participants’ speeches.
This study involved the following steps: transcription of the participants’ interviews; verification with some participants; construction of the textual corpus formatted according to the guidelines of the IRaMuTeQ tutorial; processing using the DHC method; and finally, discursive analysis of the results with support from Herzberg’s theory.
The study was submitted and approved by the responsible authorities in the three participating hospitals, also receiving favorable approval from the Ethics Committee of the Ministry of Health of Angola (CEMS)13.
RESULTS
The study involved the participation of 43 nurses, the majority of whom were from Hospital 3 (48.8 %), aged between 36 and 45 years (39.5 %) and predominantly female (76.7 %). Regarding academic level, 93 % of the participants only had a bachelor’s degree, with no additional training (53.4 %). The majority of the nurses had more than 21 years of professional experience (30.2 %) and had assumed their current position in the last one to five years (81.3 %).
IRaMuTeQ software identified 43 discursive units in the speech analysis, with a total of 1,717 different words, 15,417 occurrences, 1,172 reduced forms, 1,078 active forms and 84 supplementary forms. After quantifying and determining the frequency of the reduced forms, IRaMuTeQ divided the corpus into 361 (83.5 %) classified segments out of a total of 432 text segments, organized into six classes. Class 4 presented the highest utilization percentage for processing with 21.3 %, followed by Class 6 with 20.2 %, Class 2 with 19.1 %, Class 5 with 13.6 %, Class 1 with 13.3 %, and finally, Class 3 with 12.5 %. The thematic structure of the classes generated by IRaMuTeQ and organized in a vertical dendrogram is presented in Figure 1.
Thematic structure of the classes generated by IRaMuTeQ the Descending Hierarchical Classification. Luanda, Angola. 2024.
Class 1: Recognition and respect among colleagues and leaders
A total of 48 ECUs were identified in this class, corresponding to 13.3 % of the corpus, which demonstrate elements of recognition and mutual respect between colleagues and leaders in nursing practice. Terms such as respected, colleague and recognize highlight the importance of a respectful and collaborative work environment. These findings highlight the relevance of mutual recognition for the promotion of a positive work environment and professional self-fulfillment, which are central aspects in Frederick Herzberg’s theory.
I feel respected and recognized by the hospital management and colleagues due to my conduct and the treatment I receive from them. However, I realize that the management only values nursing professionals when it is convenient (p16).
I feel respected and recognized by my colleagues, but I often feel disrespected by the hospital management, especially when decisions are made without the consent of the department head, which takes away my authority by not listening to me (p30).
I am respected and recognized by the hospital management and colleagues in some situations, but I feel undervalued at certain times, especially when the management only comes to us if something is wrong and some colleagues disrespect the work (p38).
Class 6: Career aspirations in nursing
A total of 73 ECUs were identified, corresponding to 20.2 % of the corpus, reflecting professional aspirations and the search for continuing education in nursing. Terms such as aim, master’s degree and specialization illustrate the desire for career advancement. These findings resonate with Herzberg’s principles, which emphasize personal and professional growth as crucial elements for motivation and job satisfaction.
I have the desire to pursue a specialization, master’s degree or doctorate, even if the hospital management does not pay for it. Management has been an obstacle to continuing my studies. Many nurses are not interested in management and leadership positions (p22).
Although I do not wish to hold any more management and leadership positions, I do wish to be promoted to a higher category to improve my salary and guarantee my retirement. However, I do not feel that the hospital has this intention, just as I do not believe that management would pay for my specialization due to the unclear selection criteria (p30).
I would no longer like to hold management or leadership positions, as this responsibility was imposed on me by hospital management. For me, it would be better to not be in this position, as I feel overwhelmed and I am afraid of not living up to expectations (p40).
Class 2: Organization and supervision of nursing practices
Next, 69 ECUs were identified in Class 2, representing 19.1 % of the corpus, which point to organizational and supervisory activities in nursing. Terms such as handover, shift, and schedule highlight the nurse’s role in coordinating nursing practices, aligning with the importance of supervision and organization as motivational factors, according to Herzberg.
As for activities, I am currently involved in crisis management. I do not have a defined daily routine due to the various situations to resolve, as demands vary according to the context, location, and needs of the moment (p6).
My activities include participating in nursing council meetings, providing nursing care, collecting supplies in the pharmacy, ensuring equipment maintenance, talking to patients’ families, participating in shift handovers and ongoing training, in addition to supervising nursing interns (p14).
I distribute tasks, collaborate by providing nursing care, perform the duties and schedule of work, in addition to supervising interns. I am not interested in holding management positions due to stress and lack of human and material resources (p43).
Class 3: Challenges and obstacles faced in nursing practice
A total of 45 ECUs were identified in Class 3, corresponding to 12.5 % of the corpus, which highlight challenges faced in nursing practice. Terms such as absence, deficiency and absenteeism reveal the difficulties of the hospital and administrative environment, highlighting the importance of facing such challenges to promote professional satisfaction according to Herzberg’s theory.
Deficiencies in the work environment include the low number of nursing professionals to care for patients, lack of material resources and medicines, lack of specialized personnel, communication failures between teams, among other issues which affect performance and professional satisfaction (p7).
The challenges I face include lack of motivation, professionals leaving for other areas, absenteeism, low salaries, lack of professional promotion, treatment incompatible with the diagnosis, failures in compliance with therapy, lack of family participation in the care process, administrative factors unrelated to the nursing team, as well as inadequate professional training policies (p31).
Lack of recognition, low wages, poor working conditions, lack of overtime pay and lack of promotion are constant challenges. Even so, I remain committed to the profession, seeking improvements for our category (p41).
Class 4: Factors related to motivation and professional achievement
Then, 47 ECUs were identified in Class 4, corresponding to 21.3 % of the corpus, evidencing motivation and professional achievement in nursing. Terms such as motivate, motivation and drive reflect the importance of an environment that recognizes and values the efforts of professionals, as emphasized by Herzberg.
Motivation is the degree of satisfaction that drives the professional. I feel motivated when the activities in the service flow, when I maintain a good relationship, when we have enough professionals to meet the needs of patients and when I am able to meet the needs of nursing professionals (p1).
I feel motivated when I see nursing professionals dedicating themselves to their activities, when we are able to meet the goals, when I receive a salary compatible with my academic level and when the patient is discharged (p4).
I feel motivated when patients are discharged to continue their lives in society, when I have good working conditions, when I am recognized by hospital management for achieving the goals, and when I am respected for what I do (p11).
Class 5: Factors related to basic needs and well-being
Finally, a total of 49 ECUs were identified in Class 5, corresponding to 13.6 % of the corpus, which highlights the importance of basic needs and well-being for nursing professionals. Terms such as transportation, family and home illustrate the challenges of reconciling professional demands with personal well-being, as well as demonstrating the influence of these factors on job satisfaction and performance, also in line with Herzberg’s theory.
I have several needs, such as feeling good with my family and friends, having a home worthy of the work I do, a means of transportation to facilitate my commute, money to meet my needs and see my children graduate (p5).
In the extra-professional context, my needs include physical, mental and spiritual well-being, a good relationship with family and society, adequate transportation, housing consistent with my profession and access to food (p16).
My needs include a change of category every three years to increase my salary, a salary which covers my basic needs so I can travel on vacation, see my children studying abroad and live close to the hospital to avoid waking up early every day to get to work (p37).
DISCUSSION
Recognition and mutual respect between colleagues and leaders are essential for employee satisfaction and achieving organizational goals. Personal recognition involves the manager valuing the employee’s performance14. Factors which satisfy nurses include recognition for their work, praise, leaders’ understanding of their teams, and support from colleagues8. Nevertheless, few participants in the study reported recognition by hospital management, despite being given management responsibilities.
Colleague cooperation was also considered a positive factor in achieving organizational goals. The literature indicates that recognition and respect from colleagues and leadership are fundamental to the self-esteem, motivation, and the quality of care of nursing professionals15. On the other hand, participants reported that management tends to pay attention to some and neglect others, which leads to demotivating many people in management and leadership positions, and in some cases resulting in resignations. It is essential that management bodies integrate those in management and leadership positions into the organizational process.
Meritocracy can stimulate employee performance and motivation, strengthening operational efficiency and promoting a more engaging work environment, which positively influences nursing care management leadership16. Distributing responsibilities and authority equitably prevents negating competencies and optimizes resource use, maintaining the integrity of hospital operations. Management bodies can promote a healthy and productive work environment by adopting an approach based on meritocracy and assigning responsibilities, benefiting health professionals, patients and the community in general.
However, it is important to address an underlying concern, where those in management and leadership positions are instructed to not admit the lack of certain products to their subordinates, claiming possession of unavailable resources. Such an approach can generate a perception of prioritizing personal growth over commitment to professional responsibilities, which can undermine team trust and cohesion.
Frederick Herzberg’s two-factor theory distinguishes between hygiene factors, such as policies and salary, and motivational factors linked to the position. Favorable factors increase satisfaction, while precarious factors decrease it17.
Therefore, in observing the recognition and respect among colleagues and leadership in the context of this study, those holding management and leadership positions are valued by the hospital management only when it suits the institution, which does not promote satisfaction, but rather dissatisfaction among employees, negatively influencing the care leadership of the nurse manager.
The United Nations (UN) and the World Health Organization (WHO) highlight the importance of health education in the Sustainable Development Plan until 2030 to achieve Sustainable Development Goals (SDGs) 3 and 8. SDG 3 focuses on the continuous training of health professionals, while SDG 8 seeks fair and safe working conditions. These goals promote the health of patients and the development of nurses18.
The participants in this study want to advance in their training, but face difficulties due to the lack of clarity in the criteria for courses and low salaries, leading some to finance their training personally due to the lack of opportunities, which can negatively interfere in the care leadership of the nurse manager. In turn, organizations must establish clear expectations, provide adequate materials and equipment, value performance, and invest in training to ensure the efficiency of healthcare professionals. Incentives are needed to motivate employees and improve patient satisfaction. Policies focused on ongoing training can support professionals in their activities19.
Despite challenges such as lack of resources, incentives help professionals stay motivated and productive. It is important to review regulations to ensure equity in nursing training and meet the needs of the population.
From the perspective of Herzberg’s two-factor theory, the search for additional education and professional development reflects the desire for job satisfaction, positively influencing professionals’ performance7. However, the lack of funding for training by the Hospital Management, the lack of clarity in the selection criteria for courses and low salaries are factors that can cause dissatisfaction, which can negatively impact nursing care provision and the leadership activities of the nurse manager.
Nurses represent 60 % of the staff in the global national health system and play a crucial role in providing nursing care, especially in Angola18. It is imperative that there is effective supervision of nursing practices to ensure efficiency and patient safety. This is the responsibility of those in management and leadership positions, who must evaluate performance and implement recognition programs that promote professional commitment13.
In this context, the statements by the research participants highlighted several activities related to organization and supervision of nursing practices, such as team coordination, task distribution and conflict resolution. In addition, they emphasize the monitoring of mid-level and higher-level nursing interns, without any remuneration by the Hospital Management.
The lack of recognition and adequate remuneration for additional activities performed by nurses has caused dissatisfaction and demotivation20-21. This has resulted in some professionals seeking other activity areas, negatively affecting care provision to patients.
Nursing supervisors play a fundamental role in ensuring working conditions and motivating nurses. However, the lack of remuneration for activities such as monitoring interns during working hours is demotivating for these professionals. Herzberg’s two-factor theory highlights the importance of motivational and hygienic factors in the work environment. The lack of recognition and adequate remuneration for additional activities reflects hygiene factors which can negatively impact nurses’ satisfaction and performance, negatively interfering in nursing care provision and in the nurse manager’s leadership7.
Based on evidence from the research field, several challenges and obstacles faced by nursing professionals in providing care were identified, such as the lack of human capital, the flight of nurses to other areas, the scarcity of material resources and the lack of medicines, which negatively impact the care quality and the leadership of the nurse manager.
Therefore, the study revealed that the lack of family involvement in care, especially in African cultures, is a barrier. Implementing policies to involve the family is crucial, as their lack of involvement affects communication and care quality6,22-24.
Low salaries contribute to nurse absenteeism and hinder care quality. Many seek other jobs, resulting in high absenteeism in Angolan hospitals. Studies show that financial rewards do not improve performance, but organizational objectives are complementary25.
The lack of professional recognition by hospital management and society leads to professional demotivation, negatively impacting the care provided. Several obstacles faced by nurses, including administrative problems unrelated to nursing management, such as diagnoses incompatible with treatment and the lack of specialists, impair the care quality, even resulting in deaths. Participants in this study highlighted deficiencies such as professional promotion, compliance with hospital referrals, motivation and inadequate working conditions, negatively affecting the care provided.
However, it is important to highlight that the main administrative obstacle to implementing training policies in the national health system in Angola is the lack of nurses in prominent political positions (Minister, Secretaries of State, Hospital Directors). Health policy is perceived as decisions, plans and actions undertaken by the State to achieve health objectives for the community, and the lack of nurses in the training policy interferes negatively, limiting their development and compromising the care quality26.
An inadequate ratio of nurses to the number of patients can lead to serious problems, such as the omission of care and even increased mortality among patients. Thus, it is essential to find a balance between the workload of nurses and the number of professionals available to meet the needs of patients to ensure the care quality and safety27.
The literature shows that the motivation of professionals, with adequate remuneration and appreciation is crucial for satisfaction, performance and productivity27. Meeting the needs for autonomy, competence and relationships strengthens motivation, increasing involvement and well-being, and is associated with greater productivity and achievement of objectives28.
A lack of motivation and professional fulfillment among those in management and leadership positions is related to a lack of personal transportation, an adequate residence and a salary that is sufficient to cover basic needs. This results in demotivation and impacts the care quality.
The results also revealed that most of the research participants did not receive a salary in accordance with their responsibility or academic level, which translates into dissatisfaction in performing their activities. Having a salary that dignifies the profession provides well-being and professional satisfaction. However, salary should not be the only basis for motivation. According to Herzberg, insufficient salary, lack of transportation, an inadequate home and the lack of appreciation of nurses by the Hospital Management are hygienic factors and are the organization’s responsibility7.
Those in management and leadership positions highlighted the lack of transportation and insufficient salaries as the main challenges. The importance of family well-being and the need for adequate housing were also highlighted as crucial factors for well-being. Namely, the well-being of nursing professionals is influenced by social appreciation, good relationships with colleagues and competent leadership, where appreciation by society can reduce employee stress29.
This study also identified that the salary does not cover all needs, which is an essential factor for maintaining mental and spiritual well-being. Living close to the hospital is also advantageous for avoiding traffic stress and improving patient care quality. Therefore, to ensure satisfaction and quality in care, it is essential to meet the basic needs of professionals, such as food, transportation and housing, according to Maslow’s pyramid30. The study reveals that these needs are still unmet, highlighting the importance of adequate remuneration.
This qualitative study faced some limitations, especially related to the reluctance of participants to discuss technical and administrative issues of the hospital. This hesitation may have influenced the depth and scope of the information collected, limiting complete understanding of the internal procedures that impact the work policies of nurses. Although the study strictly followed ethical principles and guaranteed confidentiality of participants to minimize possible concerns, the lack of details on technical and administrative aspects may restrict applying the findings to formulate effective policies.
Furthermore, it is crucial to recognize the intrinsic limitations of qualitative studies, such as subjectivity in data interpretation and potential bias in selection and analysis of responses. The interpretative nature of these studies can result in multiple interpretations of the data influenced by the individual perceptions and experiences of the researchers. However, a summary of the findings was shared with some participants for validation to mitigate these challenges. Additionally, IRaMuTeQ software was used for data analysis, which helped to reduce interference from researchers and increase the objectivity and robustness of the results.
CONCLUSION
The results of this study demonstrated that motivational factors, such as recognition and opportunities for professional growth, are essential for job satisfaction among nurse managers. They are essential to foster a positive and engaging work environment. However, hygiene factors, such as poor working conditions and inadequate resources, were identified as predominant causes of dissatisfaction. In addition, important themes emerged, including the need for institutional policies which foster a collaborative and respectful work environment, and the importance of continuous development of leadership skills. Implementation of structured recognition and professional development programs for nurse managers was also shown to be essential. These findings underscore the need for a balanced approach that addresses both motivational and hygiene factors to improve satisfaction and effectiveness in the workplace.
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NOTES
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FUNDING INFORMATION This study was financed by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brazil (CAPES) - Finance Code 001.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research of Angola, opinion no. 07/CEMS/2024, Certificate of Presentation for Ethical Assessment on June 18, 2024.
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TRANSLATED BY
Christopher J. Quinn.
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DATA AVAILABILITY
The dataset supporting the findings of this study is not publicly available.
Edited by
The dataset supporting the findings of this study is not publicly available.
Note - *ECUs - Elementay Context Units.