A face oculta de um processo participativo para escolha de chefias de enfermagem

The study presents a discussion about the articulation of nursing staffs in the development of a consulting process for the selection of head nurses in a university hospital. This is an exploratory-descriptive, qualitative study. Data collection was performed by means of interviews with nursing workers. The data were analyzed using thematic content analysis. Through the workers' expressions, two lines were observed that represent integration movements and separation movements in the trajectory of each staff. In some departments, the process takes place in an integrated way, guided by participation and democratic relationships. However, in others, the functioning of a group is characterized by internal division and underlying conflict. An overview on the totality of departments indicates that nursing staffs are at different evolution stages regarding the ways they participate and get involved in the dynamics of political-institutional life. DESCRIPTORS: Health management. Nursing staff. Selection behavior.


inTroducTion
Modern world management has searched for models that value people and favor their commitment to the institutions' objectives through an investment movement of organizations in human and social potential.Under this view, a development proposal emerges for a participative culture where the working individual is motivated to join the organizational life, exercising an influencing role where they are also influenced while influencing others.
However, working in a participative proposal requires team, leader and staff preparation.From leaders, it is expected that they provide a motivating environment that promotes growth to the team by valuing dialogues, listening, and individual potential.From the workers, they are expected to be motivated, ready, and willing to commit to the collective work environment.
This transformation in management models in hospital organizations towards a participative, shared and collegiate culture is still a challenge within Brazilian reality.A Brazilian study demonstrates many obstacles yet to be overcome in order to effectively democratize power relations in health organizations, especially in hospitals. 1he participative model, when appropriately managed, aggregates value to individual competences, strengthens teams and promotes organizational development.On the other side, when improperly conducted, it can generate disorientation, lack of confidence and waste of potential, leading to institutional instability.
Reaching a participative environment, with work relations democratization, leads organizations leaders to being trained to encourage and support those initiatives.Therefore, the instituted hierarchy in nursing teams reproduces a traditional management model, where decision making is focused on nurses. 1 Nurse present, therefore, difficulties and insecurity in leading the nursing team towards creative and intellectual development. 2lthough participative management is understood as a tool to institutional, professional and personal success, there is no proof that it is an organizational reality in nursing teams' workspaces, especially in Brazil.][5] Participative and democratic processes consolidation in modern nursing leadership and managing models go through the analysis of how participation movements are built and occur in different scenarios of health organizations.
In a previous research, in which the leader in a university hospital selection was analyzed, the nursing workers' organization models within different hospital sectors could be explored.Aspects raised in articulating nursing teams for the construction of a collective process for selecting leaders signal vulnerability spots that must be discussed by nursing professionals expressed as internal groups divisions. 6Hence, this current study, through a more detailed view, has searched to discuss this process, contributing on this theme knowledge.

MeThod
The study is composed by an exploratory and descriptive qualitative approach investigation.Hospital de Clinicas de Porto Alegre (HCPA) was the study field.It is a university hospital from the hospital network of the Education Department, and it is academically connected to the Federal University of Rio Grande do Sul (UFRGS in Brazilian acronyms).
The sample was composed of 62 interviews with nurses, nursing technicians and assistants, covering a proportional representation of the 36 units of the institution.The inclusion criterion adopted was experiencing the leader selection process in 2009 and not exercising a leader position at the time of the study.They were randomly selected through a raffle.All professional nurses who agreed to participate in this study signed a Free and Informed Consent Form.Considering ethics aspects, the project was approved, in 2007, by the Research and Ethics Committee of the institution where the study was performed, under the number 07-275.
8][9] However, when the number of hospital sectors and the expressive number of nursing professionals are considered, the researchers understood the need for a more expressive sample quantity, performing 62 interviews.Searching to ensure opinions diversity in the sample composition, the criterion of having individuals from all sectors was respected to ensure proportionality between nursing professional categories.
Data collection was performed through semistructured interview and aimed at learning about The hidden face of a participatory process for the selection of head... participants experience in this process.This phase was performed between June and September of 2009.It was performed during the working hours of professionals and in the unit studied, at a location to ensure privacy.The recorded interviews were completely erased after full transcription.For data analysis, the thematic content analysis technique was used. 10ach interview required participants to talk about the process adopted for the selection of head nurses in the hospital unit, reporting the strategies employed in the process, criteria used in the selection and expectations regarding the future leader.We must highlight that articulation strategies were the focus of this manuscript and that previous publications 6 presented other findings in this research.
Data analysis was performed by the following phases: pre-analysis, material exploration, results analysis and results interpretation. 10In the first phase, the material was organized according to the purpose of the study.Later, material exploration was performed through repetitive reading, searching for register units, context units and meaningful excerpts, classifying and grouping relevant ideas with a view to build theme and the respective categories.The third phase sought for inferences articulations and opinions registry about the message as a theoretical reference, in addition to unfold underlying contents to what was manifested. 11

r e s u l T s p r e s e n T a T i o n a n d discussion
Parting from a previous categorization grouping themes about the process of selecting a nursing leader in a university hospital, this study aimed at understanding the main aspects signaling teams' articulation in this processes.In the team articulation category, 6 two dimensions were observed constituting the sub-categories here named integration movement and separation movement in each team's path, which emerged from interviewees' manifestations as they described how they articulate to select their leaders.

integration movements
In teams where there is a more integrated and cooperative underlying communication and construction space, manifestations indicating participative strategies in decision making processes emerge, including for the recommendation of can-didates for the unit head nurse selection process.Hence, statements demonstrating mobilization movements emerge through meetings, debates and compound proposals elaboration among group members, as the following statements demonstrate.
I had the feeling of a previous articulation in the group in indicating a person who had our working group's profile, within the activities we develop here in the unit, someone who knew the unit, with good relationship with other leaders, knowing all the nursing practitioners group leaders […] (48).
The group was articulated in order to select this candidate, especially for the interpersonal relations […] (62).
[...] when time came, I and all my colleagues said: hey you, you have to run, you have the profile!And she accepted (59).
People talk among themselves and workers from the unit, then they invite people who they would like to be led by (16).
[...] through meetings, the group ended up building a joint platform where the candidate endorsed and assumed the collective platform as her own (13).

Lectures were offered throughout elections where people could place questions. They are always very interesting, candidates are open to receive our opinions we can question and suggest changes we expect to see after the election (28).
There were debates, debates between two candidates.A work proposal was issued from both of them and printed in the unit, a folder.As a campaign for each one of them (33).
In sectors where interviewees described a more participative and integrated situation of the nursing team, a reference to the importance of the leader process in the groups emerged, not only for the role exercised by the nurse, but also by the role exercised by all group members.Hence, team components assume an argumentative critical position about the best members for the unit and about the necessary features to the future leader who will coordinate the team's efforts, as verbalized by the nursing technician in the following excerpt: [...] because in this last one [election] the candidate performed a research among the workers and asked what people thought about her running for head nurse, it was nice.So she asked for people's opinion before running […] (11).
In an ecological and organizational social capital point of view, these integration movements can be described as strategies investment for strengthening trust, values and behaviors sharing that unite human networks and community members and make cooperative actions possible.This way, the first step for head nurses to apply social capital concepts would be in the understanding that networks and groups formation make people able to access resources and collaborate to reach shared objectives in health practice environments. 5ntegration movements signal enhancing actions for the group, making divergent opinions possible among group members.The search for continuous group education and overcoming conflicts strategies resulting from this process favor the construction of a more participative space. 6The fact can be seen from shared decision-making in the selection for head nurses and leaders, to the whole team's commitment to objectives.
In the health care system complexity view building competent or enhanced teams are presumed from the acknowledgement of participation, autonomy and responsibility principles in transforming realities. 12rocesses in selecting head nurses can be constituted into opportunities to strengthen networks in nursing teams that will favor communication, trust, participation and autonomy to achieve a collaborative, cooperative and integrated action.Commitment and responsibility for the selection of head nurses can be one of the strategies to enhance teams towards more participative and democratic models that are less centralized and hierarchic.
In the nursing teams' working routine, incentive to adopting participative processes to select head nurses can be a strategy to developing integrated and cooperative teams that will enhance social capital.

separation movements
Within many sectors, the articulation of the nursing team in the selection process for head nurses still reflects the reproduction of traditional management models with its hierarchy marked by the nurses' decision-making processes centralization.This management model and teamwork coordination favors an internal group division and the distancing among its members, enhancing the hardening of roles as bosses/subordinates and nurses/nursing assistants.The following excerpts represent such fact.The interviewees refer to "them" -nurses, and "us" -nursing technicians and assistants.

They made extra-official invitations, it is a legend within the HCPA, always having a candidate in the nurses' election and a nursing technicians and assistants' candidate (17).
This one was in favor of the technicians.It happened in a conversation just like this one, the name of this person came up and she liked the idea.And the other one who won, was in favor of nurses (18).
[...] little groups are always set in order to assist: ok, who are we voting for!Both from nurses and technicians (25).
[...] a large group had already decided that she was going to be their boss.That they would vote for this former boss.Then, a small group emerged and they placed another candidate.[...] The first group was made of technicians.The second group was made of nurses (24).
And among nurses, they decide among themselves.In general, they suggest a candidate […] (26).
[...] I don't know, that's something they choose.We only analyze candidates after they are chosen (32).

...] nurses had their candidates, everyone was trying to manipulate the technicians into voting for her. [...] There was one who was already in charge and was a candidate again, the one that was indicated by nurses and another one indicated by the technicians, some of them went for her in another unit [total of three candidates] (11).
The distancing between nurses and nursing assistants/technicians has already been approached as one of the critical points in working teams' relationship. 13One possible explanation for this situation can be related to the technical and social work division, strongly affecting the construction of group relations. 14he inequality among the nursing team professional categories points to a social and cultural gap, filled with elements related to power and knowledge that lead to feelings of disintegration from the nursing team and inferiority felt by medium level professionals. 4espite consulting processes for the selection of head nurses represent progress towards the construction of a participative management model, there is still the need for a larger reflection by nurses about their construction in building this reality.
Experiences demonstrate that, for nurses, the indication process of names is naturally built, not The hidden face of a participatory process for the selection of head... acknowledging or not expressing the division of groups -nurses and nursing assistant/technicians -as illustrated bellow: in the previous process, the group itself, almost all nurses in the unit invited this one candidate to run for the position (13).
so, we mentioned among ourselves who would have the profile.I believe that the name we chose for this selection was chosen almost unanimously by us nurses.Because the technicians decided in the moment we presented her as a real candidate (30).
[...] these names came up in a meeting at the Hospital Nurses Association, where nurse from many units were present […] (53).
Although, in the interviews performed with assistants and technicians, they mentioned that the candidates' names came from nurses.Therefore, when this group experiences this, it is discriminatory, in other words, it is clearly and objectively expressed, a criticism of the way names emerge.Within some sectors, these comments are so diverging that they seem to come from different locations, as demonstrated by the following comments, respectively by nurses and nursing assistants/technicians from the same unit: Unit

-[…] one volunteer and the other was invited by the group (27). The informal invitation came from technicians. It happened in a conversation just like this one where the name of this person came up and she liked the idea. And the other one who won, was in favor of nurses (18).
Unit 2 -[…] there was only one candidate and she was available again (19).Candidates' names are usually settled among themselves.[...] We don't get involved in this question, We only participate after in the election, in selecting from the given names (28).
Unit 3 -[…] first, a name was indicated, then the indicated person thought about it and accepted the idea.Then, the campaign started and by the end there was another candidate who was also interested in participating (31).I don't know, this is something they choose.We only analyze candidates after they are chosen (32).
Unit 4 -[…] the group starts to ask the probable candidates, in this case, the nurses in the unit (01).First, part of them, the election groups, and we are the ones… [...].They set their election group and launch it and we choose (02).
Interpretations of these expressions lead to internal divisions and subgroups within teams which picture the ways in which power relations are built.In some situations, there is the polarization of power between people, featuring the hier-archy in these relations, among those who think, therefore, they can do more, and those who know less, therefore, they can do less. 15ven though we are talking about a participative selection process for head nurses, internal relations maintain concentrated power among nurses, since in the situations reported here, candidates' names are chosen by a thinking groupnurses, who can do more, and part of this power is shared with those people who think less -nursing assistants and technicians, who can do less.The later can vote, but they can only vote for those pre-defined names by nurses.
Also, this fact is mentioned by the night shift team.This group, in some units, seems to be at the edge holding a conformity position, a patient or even a distant position with little involvement in intra-institutional politics.Although finding differences and peculiar situations among working shifts was not the aim of this study, the following excerpts demonstrate some aspects that were emphasized regarding the night shift.
I work nights, so we are a little like that...We don't effectively participate in the selection process (22).
[...] because at night, we don't participate so much in the subject (58).
At night, we usually talk to each other like in a cordless telephone talk.We talk, then we pass over to the day shift, the day shift talks to us then the afternoon shift does it too (46).
Working organization into shifts in order to develop full care within hospital environments is a feature of nursing teams which provide care for patients with health problems 24 hours a day. 16his condition requires special attention from leaders, in other to include all working groups in a compound proposal with shared objectives and targets.
These findings suggest a more careful look to the issues involving night shift workers.In addition to the inclusion and participation strategy, there is the need for searching ways to improve communication and information exchange among different working shifts with a view to decrease the distance of night shift workers.
Reaching a participative environment, with democratized working and power relations, requires leaders to mobilize efforts to build this scenario.In this process, all individuals and groups involved need to be educated in how to support and disclose the existing initiatives, working towards a common objective.

final consideraTions
Participative and democratic processes consolidation in modern nursing leadership and managing models go through the analysis of how participation movements are built and occur in health organizations.Nursing teams' articulation ways in the selection process for head nurses process signals aspects of how relations networks are built among groups, reproducing the adopted management models.
The integration movements reported in the teams' articulation are represented by situations that lead to a more cooperative and integrated work space that emphasizes communication, participation and autonomy in the process of selection of head nurses demonstrating a higher investment in the organizations' social capital.
These separation movements identified by this research point out the internal division of groups and the distancing among their members, favoring the centralization and hierarchy of power relations, even under a participative context of the selection process for head nurses.Hence, participation is therefore related to the power slice of each group within the team.
This present study demonstrated that in some units the process is unfolded as a theater script, holding harmony, integration and democratic relations as scenario.However, in other sectors, fragile and vulnerable points in the existing articulation are exposed, and they seem to reveal a group functioning featured by division due to an underlying conflict.A broader look over all sectors point out that nursing teams are in different stages of evolution expressed in different ways of participation and involvement with the institutional politics life dynamics.
Nursing within a consolidation movement of its scientific thinking searches, implements and tests new management models.Peculiarities in this collective work require the adoption of practices that will better answer demands of the profession and of the context in which it is inserted.The participative process of selection for head nurses in a unit is developed under a rough hospital scenario for this proposal, since nursing has been the only professional area to adopt this method of appointing head nurses.Therefore, although this study has revealed sectors in which the process needs to be improved, in other sectors this practice has been successful and has demonstrated the strength and toughness of a group action.Management models in which participation is enabled, as in the analysis process, reinforce conviction on the importance of social capital in collaborative networks in order to execute organizations and groups' objectives.
Concluding this manuscript, the authors consider the investigation target as achieved.Due to the characteristics of this study, findings are limited to the context in which it was performed.No generalizations are seen as possible.However, these results are seen as a contribution for understanding the phenomenon, and worthy for hospital internal analysis.
Findings about the situations in this study reveal aspects that can be explored in future studies, as follows: a) learn if the situations identified in this study correspond to the group's functioning only for the theme Head Nurse Selection or these characteristics are also present in other work routine activities; b) compose a list of actions from leaders that might contribute to speed the division among professionals and favor group integration; c) identify the importance of the leader to the participative selection process for head nurses in sectors where the group is in need of integration; d) reveal the understanding about the term participation by nursing team members: if it is understood in its essence or if it is only a voting possibility.