Management and leadership in the nurses' perception: A walk in the light of professional burocracy

Abstract

Objective

to analyze the styles and factors involved in nurses' management and leadership in three countries, Brazil, Portugal and Spain, in the light of Professional Bureaucracy.

Method

a descriptive and exploratory study with a qualitative approach carried out in three university hospitals located in different countries, namely: Brazil, Spain and Portugal. Thirty nurses participated in the research. Data was collected through a collection script with sociodemographic questions and interviews analyzed using the WebQda software.

Results

different perceptions about the integrating elements of participation in the three countries were revealed, highlighting communication from different perspectives. Some convergences in relation to teamwork were verified, where trust was the element that drives and motivates the team. It is a participatory relationship in the development of work.

Conclusion and implications for the practice

in the three countries, it was possible to identify the importance of communication in the management process, as well as the management and leadership styles, as elements that favor performance of the team. Presence of relevant intervening factors was also evidenced, such as choice, organizational climate, interpersonal relationships, transparency in work and delegation of functions, which involves professional bureaucracy in which the nurses' knowledge allows them to exercise their skills in a horizontal and participatory manner.

Keywords:
Nursing; Leadership; Leadership and Governance Capacity; Health Management; Nursing Team

Resumo

Objetivo

analisar os estilos e fatores intervenientes na gestão e liderança de enfermeiros em três países, Brasil, Portugal e Espanha, à luz da Burocracia Profissional.

Método

estudo exploratório e descritivo de abordagem qualitativa realizado em três hospitais universitários localizados em diferentes países: Brasil, Espanha e Portugal. Participaram da pesquisa 30 enfermeiros. Os dados foram coletados por meio de um roteiro de coleta de dados com questões sociodemográficas e entrevistas analisadas com auxílio do software WebQda.

Resultados

diferentes percepções sobre os elementos integradores da participação foram reveladas nos três países, destacando-se a comunicação em diversas óticas. Verificou-se algumas convergências em relação ao trabalho em equipe, sendo a confiança o elemento que impulsiona e motiva a equipe. Sinaliza-se para uma relação participativa no desenvolvimento do trabalho.

Conclusão e implicações para a prática

foi possível identificar, nos três países, a importância da comunicação no processo de gestão, bem como dos estilos de gestão e de liderança, como elementos que oportunizam a atuação da equipe. Também foi evidenciada a presença de fatores intervenientes de relevância, tais como escuta, clima organizacional, relação interpessoal, transparência no trabalho e delegação de funções, os quais envolvem a burocracia profissional em que o conhecimento do enfermeiro possibilita o exercício de suas habilidades de forma horizontalizada e participativa.

Palavras-chave:
Enfermagem; Liderança; Capacidade de Liderança e Governança; Gestão em Saúde; Equipe de Enfermagem

Resumen

Objetivo

analizar los estilos y factores implicados en la gestión y el liderazgo de enfermeros en tres países, Brasil, Portugal y España, a la luz de la Burocracia Profesional.

Método

estudio descriptivo exploratorio con abordaje cualitativo realizado en tres hospitales universitarios ubicados en diferentes países: Brasil, España y Portugal. Treinta enfermeros participaron en la investigación. Los datos fueron recolectados a través de un script de recopilación de datos con preguntas sociodemográficas y entrevistas analizadas con la utilización del software WebQda.

Resultados

se revelaron diferentes percepciones sobre los elementos integradores de la participación en los tres países, destacando la comunicación desde diferentes perspectivas. Se constataron algunas convergencias en relación al trabajo en equipo, siendo la confianza el elemento que impulsa y motiva al equipo. Se advierte una relación participativa en el desarrollo del trabajo.

Conclusión e implicaciones para la práctica

se pudo advertir, en los tres países, la importancia de la comunicación en el proceso de gestión, así como los estilos de gestión y liderazgo, como elementos que permiten mejorar el desempeño del equipo. También se evidenciaron factores intervinientes relevantes, como la escucha, el clima organizacional, la relación interpersonal, la transparencia en el trabajo y la delegación de funciones, que conforman la burocracia profesional en la cual el conocimiento de los enfermos les permite el despliegue de sus competencias de manera horizontal y participativa.

Palabras clave:
Enfermería; Liderazgo; Capacidad de Liderazgo y Gobernanza; Gestión en Salud; Equipo de Enfermería

INTRODUCTION

The Nursing work process requires exercising leadership from the Nursing team management to other organizational levels, such as management of the health service. Thus, considering the leadership theories, from the most classical to the most contemporary, leadership is defined as a necessary competence for nurses, enabling them to influence their team in order to ensure care focused on the real health needs of users and family members¹.

Even with various theoretical perspectives, there is still no consensual definition of the concept of leadership, since the multiple theories attribute different meanings to this competence. In Nursing, leadership is related to the nurses' actions as leaders of the care process and an example to be followed by their Nursing team. It is also based on the relationship of trust and horizontality built on mutual respect, on the fair and flexible attitudes of their actions, in which it enables the employees' participation in decision-making²,³.

In the managerial dimension, the nurses' work process aims at ensuring care quality and good functioning of the health services, which require not only dynamism from the professional but also the capacity for critical analysis, dialog and bonding with the health team. According to the Federal Nursing Council, the nurse-manager's work establishes attributes of management, coordination, planning, organization and evaluation of the Nursing activities as important tools for the nurse's managerial practice⁴.

This work process is diversified in different realities; however, the managerial component emerges as a common aspect among countries such as Brazil, United States, Canada, Chile, Australia, Portugal, United Kingdom, Japan, South Africa, China and Thailand. A similarity observed is certain concealment of the managerial dimension due to ideological reasons in which the nurses' duties are restricted to care activities and by the technical division of work in Nursing⁵.

It is noteworthy that, in complex social systems, such as those existing in Europe, leadership is inherent to managerial activities, and has been seen as enhancing the results of the Nursing care actions⁶.

The process of managing teams, common to the nurses' reality, requires due attention, as each scenario in which these professionals are inserted has a specific characteristic, so that it is sometimes necessary to work on the very idea of a team, reinforcing interdependent work⁷.

It is worth mentioning that a study carried out in Portugal indicated that leaders in the different services are facing the challenge of managing and coordinating knowledge and fostering the employees' competences and performance. Therefore, the health service creates quality systems and in accordance with the assumption of the Portuguese Nurses Association, where the leading nurses' actions are respected and gain prominence⁸.

In Spain, a research study observed that the excess of managerial and administrative activities imposed on the nurses' work distances them from the relationship with the patient. This denotes the concern of these professionals with the time devoted to patient care, and evidences that the process of managing work in health, as it has been planned and executed, ends up hindering care. It also highlights some essential aspects to become effective in care, such as healthy human relationships between professionals, patients and families, being satisfied with the work and being recognized and accepted in the work team, as well as creating bonds of trust with it⁹.

It is worth mentioning that, in Brazil, the nurses' competences and skills are highlighted during the training process, with presence of communication, leadership, administration, management and decision-making, which enable adequate development since undergraduation, expressed in recommendations by the National Health Council regarding the national curriculum guidelines proposed. The labor market and the technical-scientific innovations also corroborate the need for nurses' improvement, as they aim at high performance and actions based on people's intelligence and personality¹⁰.

One of the theories that contribute to this perspective of constant improvement, based on reality, is the Professional Bureaucracy model proposed by Henry Mintzberg. Such model argues that the skills and knowledge of the professions are formally programmed according to what is expected from the professional, followed by a long period of practice in the services, leading to the development of new knowledge and skills¹¹. Thus, management based on this perspective can be understood by specific and differentiated capabilities acquired through the professional experience and the knowledge achieved, whereas leadership is a process of constant evolution, which starts from the scientific knowledge and immersion in daily work.

In summary, the starting point is the principle that leadership is a fundamental competence for nurses in their professional practice, recognizing the different leadership styles existing in different countries. In addition to that, management is essential for the efficacy of Nursing care, both of which are indispensable for harmony in teamwork, which requires continuous updates from the professionals.

Therefore, the choice of the three countries allowed apprehending of different realities, thinking about the convergences and divergences, which are expressed through the models and practices of each country. It was considered that the quality of the care provided to the user through nurses' management and leadership is a reality shared by them. Given the above, this study aims at analyzing the styles and factors intervening in nurses' management and leadership in three countries, Brazil, Portugal and Spain, given Professional Bureaucracy.

METHOD

An exploratory and descriptive study with a qualitative approach, associated with the research entitled “Nursing Management Models: Nurses' Memories”. The qualitative approach establishes links between the phenomenon to be studied and concepts, representations, beliefs and behaviors¹².

The study settings were three university hospitals: in Brazil, Spain and Portugal. Choice of these services is based on the fact that, since the 1990s, these countries have adopted public health protection policies as a citizenship right through public and universal health systems. We also highlight a significant investment in training in health management to qualify and train public managers. Furthermore, in line with the studies by these authors¹³,¹⁴, the national health services of the aforementioned countries have implemented programs to improve efficiency and efficacy in the management of university hospitals.

The Snowball Sampling technique was used, where non-probabilistic sampling uses chains of references. This method is employed when studying rare characteristics or when seeking access to more restricted social groups¹⁵.

Selection of the study participants took place through invitations to professionals who met the eligibility criteria. A total of 39 individuals were invited to the research but, of those indicated in the technique used, only 30 professionals agreed to participate and, therefore, were included in the research. The eligibility criteria referred to nurses who exercised managerial care, as well as intermediate and direction management, at different levels, working in the service for more than two years.

Data collection took place at three interdependent moments, the first being in Portugal, the second in Spain and the third in Brazil, through interviews guided by a pre-structured data collection script, with participation of the main researcher or, when necessary, of a collaborator.

The interviews were carried out from September 2019 to February 2020, in a place and space previously booked by the interviewees for this purpose. The script was divided into two parts, the first comprising sociodemographic questions such as gender, marital status, self-reported race/skin color, schooling, time since graduation, higher education institution, management career in years (Trade Union, Association, Council, Political Party), total career time in management, religion, salary income, and area of professional practice in Nursing, aiming to characterize the study participants. In the second phase, the specific guiding questions of the study object were used. Choice of this collection instrument was due to the effective guidance it offers, in addition to providing fluidity in dialog and allowing the interviewees to reflect on the topics addressed¹⁵.

The interviews were recorded with the aid of a cell phone model that also incorporates some computer functions, whose operating systems are adapted for this type of equipment. Subsequently, the interviews were transcribed, evaluated in terms of coherence and organized in the WebQda program, in order to identify the absolute and relative frequency of the analysis categories of the material.

After organizing the data in this software, the texts were arranged into nuclei of meanings and aggregated into self-excluding categories in line with Minayo's operative proposal¹², for organization and categorization in the search for empirical material.

In order to preserve the participants' anonymity, they were identified by the name of their country of origin (Brazil, Spain, Portugal) plus a corresponding number as the example below: REF¹/BR, referring to Brazil; Portugal, REF¹/PORT; and Spain, REF¹/ESP.

With regard to the ethical precepts, the matrix project was approved by the Research Ethics Committee (Comitê de Ética em Pesquisa, CEP), under CAAE 15084819.4.0000.5531; still with regard to these requirements, it is stated that the university hospitals that participated in the study accepted approval in Brazil, having required translation of the Free Informed Consent Form into another language.

RESULTS

The sample consisted predominantly of female professionals (88.9%), with 11.1% male individuals, aged between 32 and 67 years old, 55.6% self-declared as brown race/skin color, 66.7% married, 66.7% with higher and graduate education, with a mean training time between 09 and 37 years, and 66.7% graduated from public educational institutions. None of the participants had a career in management in Trade Unions, Associations or Political Parties; it was observed that the total career time in management in the health services varied from 06 months to 27 years. The areas of practice in Nursing listed by the nurses were assistance, teaching, research, management, counseling, continuing education, audits, entrepreneurship, consulting, coaching, speaker and coordination of graduate courses.

The results were categorized according to the content of the speeches by the participants from each country; as these are different countries, it was decided to maintain the original language spoken in Portugal and Brazil, while the interviews from Spain were translated and validated by the participants for easier reading. The categories that stood out were the following: Integration of management and leadership in the nurses' work process; Teamwork as a mainstay in the process of managing/leading, and Different management and leadership models in care.

Integration of management and leadership in the nurses' work process

In the first category, certain aspects of leadership during the nurses' work process stand out, such as influencing, dialoging, listening, motivating and developing the team. The category also points out management activities when supervising, planning and implementing tools for care quality. In this way, integration between management and leadership in the Nursing routine emerges, which, even if distinct, they are inseparable. The participants also mentioned adequate communication between the team, patient and family as a facilitator for participatory care. In addition to that, they highlighted the importance of including the team in the management decisions to maintain engagement and motivation in the projects, permanent education with emerging themes in the professional practice and management involvement in the team's daily routine as aspects that contribute to a resolute work environment.

Proximity, there's no supervision if I'm not close [...] I don't need to be watching someone to see if they're doing anything wrong, I'll be there, I'm with the person, and I take advantage of these moments to speak, guide, influence about what to do and what not to do, influence the way we talk, the way we should talk, we often talk and don't help the person [...] (REF³/PORT).

In Brazil, it is noticed how management and leadership complement each other in the daily Nursing routine. The statements express a management process focused on planning and leadership aimed at the development, training and motivation of the team, in order to provide its collective participation in activities that promote care quality, as seen in the following fragments:

[...] there was a Center, at the time it was called TQC Center for total quality control, and I prepared all the planning to implement the quality process, trained all the professionals in all the quality tools, did all the people motivation and mobilization for them to absorb and implement, participate in the collective process of building a new management model in a university hospital [...] (REF¹/BR).

[...] The educational processes, we didn't have anything either, from the division to here, but we, when we set up the unit, we saw the need for this, to create, we do training, a lot of in locus training, we encourage participation in congresses, because there's a lot that we do in the unit and we need to disclose it [...] (REF⁶/BR).

In Spain, elements of leadership associated with interpersonal relationships were evidenced, reinforcing that the nurses' managerial work goes beyond the institutional dimension. Highlighting dialog and knowing how to listen, the nurses' concern to guide the patient and their family members, starting the welcoming stage with guidelines from the moment they receive them and throughout the hospitalization process:

If I'm going to receive an acute hospitalization that day and I introduce myself to the family, I introduce myself to the patient, I explain how the unit works, I tell the patient what we're going to do, I talk a little with the family, I tell them where I'll be even though they already know well that they won't find me in the office that I'll be in the unit, I'm more of being there [...] (REF⁸/ESP).

[...] Just sit and listen to the patients, or sit and listen and talk, it seems like we start this treatment, and it's good because we feel safe, we give help, that sometimes what he wants is it helps, not a technique that is done and now that there's no follow-up, the primary is a follow-up of the patient with which is kind that generates well-being that is unrelated to a pathology that he has, but the pathology improves when someone has 24-hour care [...] (REF¹/ESP).

Teamwork as a mainstay in the managing/leading process

In the second category, the importance of knowing how to listen and involve the team emerged from the interviews, through the creation of bonds of trust and the professionals' co-responsibility with the service to be provided, which drives and strengthens interpersonal relationships and motivates the team. The following testimonies evidence this posture:

[...] It was a moment for me to welcome, listen [...] I had to hear from people what was happening, what they were feeling, to see what I could work on, in what I could help. It was that welcoming moment and together with them I worked out what could be improved within the context of the Nursing division, I started too, even to get to know my team, because to work you also need to know people [...] (REF²/BR).

[...] I prefer to hear people, involve them, hold them accountable, that I know from then on have the listening, if you say something, say, outside the group, I want a group to function, I don't want several groups with each one by their side, I want the group to wear the shirt, put on the flag, hold the flag and that, in fact, shall have a sense of team spirit and work sustained with the horizon, with the defined objective. [...] (REF⁴/PORT).

In Spain, the participants reported understanding the importance of management and joint work, mainly with the multidisciplinary team:

The truth is that since I'm in management in this sense, on the one hand, I believe that supervisors exist to work with the multidisciplinary team [...] (REF²/ESP).

To work, we have to approach the care actions, the assistants and the other nurses have to comply with this [...], we share it with the assistant because, perhaps, she also has information that I don't know and she can share them along with all of us, we share this [...] (REF³/ESP).

Cooperation among the health professionals, so that the team consolidates its efforts and offers mutual support, was highlighted in Portugal:

So at this moment in the team, my concern in terms of training was to create experts in almost all the areas, [...] therefore, the groups are already working, producing knowledge and working in this area, and the colleagues already know if they have doubts in that area, they'll consult and, therefore, this is how I organize training (REF¹/PORT).

This often happens with very little things, which I try to do, go to someone who is more expert in this area and try to help at the time, and it works very well, as among the peers they help each other, understand? If I see that this doesn't work, then I try to provide training in the service (REF¹/PORT).

For the Brazilian participants, communication is an efficient resource for maintaining interactions and cooperation among the professionals:

[...] the team members have their voice, they manage [...] their specific area of expertise, so that we can allocate in the best way the resources as we know that in the health area there are few [...] (REF¹/BR).

[...] So, I try to listen, I try to be their partner, but when I have to pull the ear I pull, I'm demanding yes [...] (REF²/BR).

[...] in the same way, work has been carried out with the entire management process, we have a regulation that's the heart of the hospital, and there's interconnection with everyone, my connection, for example, with the Nursing head as the division is unique, I need the Nursing team all the time, for admission, to understand the patient's processes regarding discharge from the hospital, for transfers, for exams, anyway, it's this communication all the time, before that, we plan all the processes [...] (REF¹/BR).

Different management and leadership models in care

In Brazil, nurses' management and leadership was highlighted as something that provides opportunities for the work of other Nursing professionals, as long as nurses have the capacity for leadership and governance in conducting the health services. From this perspective, a model of participatory management and leadership was evidenced, with horizontalized communication, in which the team's motivation is valued. It was from the statements that the understanding that both are strengthened throughout the nurses' experience emerged:

[...] management is knowing how to deal with conflicts, because that's what's going to happen, it's the skills that she's going to have, technical and behavioral, it's what will make her sustain or not stay in a space like this [...] (REF¹/BR).

[...] my management is participative, it's open, it's a management that listens, hears, shares, makes decisions and meets [...] (REF²/BR).

[...] in relation to the management instruments, supervision and communication, our communication is very horizontalized, there's a lot of dialog between the coordination and the team (REF⁸/BR).

The speeches of the participants from Portugal and Spain corroborate the above statements, showing the need to implement nurses' management and leadership permeated by sharing and joint development:

I recognize the nurse director even more as a leader than at heart, as a manager, but I think that she has leadership ability in the sense of involving everyone, seeking to involve everyone in this process, I believe that there's an increasing trend for us to get involved in decision-making obviously within the possibilities, but listening to the professionals and seeking to involve them [...] (REF²/PORT).

[...] management is the first necessary focus in interpersonal relationships, you have to know what potential your teams have and what their weaknesses are, so you can reap the best from the group [...] (REF³/ESP).

In Portugal, patient care emerged as a management model to be valued, as observed in Spain, where quality care and patient safety are recognized as paramount. It is noteworthy that a similar result emerged in Brazil, in the “integration of management and leadership in the nurses' work process category”, through the nurses' focus on strategies in the face of training planning, efficiency was seen to ensure patient safety.

There was some confusion, the school itself didn't have this model that we follow, what matters here is not the model, it's the scope of the care I provide in a planned and consistent way for a global approach to the person I have under my responsibility [...] (REF¹¹/PORT).

Well, what comes first is care quality, patient safety and care quality, but we don't work with productivity [...] (REF¹/ESP).

In Spain, the need for constant knowledge updates by the team was highlighted, in order to monitor the changes in the health processes, which is similar to the result of the first category in Brazil, also with a view of nurses focused on the concern in the training of the team.

[...] it has to be more versatile and it has to be up to date [...] but people aren't motivated and aren't versatile [...] so like any evolution, change is very important, and that the Health Professionals, such as nurses, are updated is fundamental when performing, for example, new cures, as new materials are constantly appearing and there are many new things [...] (REF³/ESP).

DISCUSSION

When analyzing the preceding category, different perceptions were found in the three countries and, in Portugal, communication and dialog with the team were identified as facilitators in the nurses' leadership management process, in which they need to allow and maintain horizontalized dialog with the other team members. In Spain, the emphasis was on the exercise of leadership in the personal relationships that include the patient, family and health team, prioritizing that the proper way of speaking favors understanding of the care that will be provided.

In Brazil, the nurses' concern was identified regarding planning care and training that allow ensuring care assistance quality and motivate the Nursing team to participate in training and educational processes such as congresses, in order to favor the development of effective work for the benefit of the patient. Thus, for this planning to take place efficiently, single and aligned communication with the team members is necessary.

It is possible to observe that, even with a common work object, that is, patient care, the nurses from both countries follow the management/leadership notions differently and, in Brazil, the leadership process is based on an investment in the team, while in Spain it is linked to the care flow, bringing communication as a common point between them.

A study carried out in a hospital from southern Minas Gerais contributed similar results, when it showed that communication is an essential tool for nurses to effectively manage an organization. Communication allows activities to take place efficiently with the group that is leaded and, in such sense, contributes to the development of work and team satisfaction¹⁶.

In such sense, related to the aforementioned category, the nurses' concern with having horizontalized dialog with their teams is perceived, meeting the professional bureaucracy in which they value their employees' autonomy through their knowledge and skills and not in an authoritarian manner. Given the above, it is opportune to point out that professional bureaucracy brings about a small need for direct supervision over the professionals, it is differentiated by becoming sufficiently autonomous and with low hierarchy¹⁷.

It is worth emphasizing Mintzberg's concept of professional bureaucracy, in which training requires the professionals to spend long periods at the university or in specialized institutions, in order to acquire knowledge and skills specific to their profession. Subsequently, the service locus will provide new training in order to improve their practical skills. However, training will be a continuous process of new learning and knowledge¹¹.

Thus, it was identified that Brazilian nurses are concerned with continuous preparatory processes that may encompass new knowledge in favor of the quality of Nursing care.

The interviews with the participants from Spain showed the nurses' attention to the patient and family members since the beginning of their treatment, with ample explanations, from the functioning of the hospitalization place to guidelines about the treatment. Attentive communication and really concerned about listening to them became evident.

Nursing leaders are responsible for ensuring the best care possible to the patients and, to such end, they need to work closely with the patients and their family members. Thus, it is up to the nurse-leader to provide achievement of the most important objective, that is, ensure the well-being of patients in distress, with humanized and individualized treatments. The care provided by Nursing professionals can be noticed when the Nursing leaders facilitate good care in Nursing units, as indicated in an international research study¹⁸. This result shows another aspect evidenced in the interviews with participants from Spain: nurse-leaders aspire to well-being and attention in the care provided to the patients and family members.

In this context, it is important to point out that the integration between management and leadership was highlighted in this first category, as they both complement each other, although they are differentiated competences. However, a study carried out in the Brazilian South region indicates paths in the same direction as this finding and reinforces that, in addition to caring, the nurses' work involves different dimensions, such as administering/managing, teaching and research, as well as care management is evidenced as an instrument for integrating the scope of nurses' work and associating their actions, considering leadership as a fundamental attribute for their practice¹⁹.

The importance of Teamwork as a mainstay in the process of managing/leading also emerged in the testimonies. In it, data from the three countries converge in relation to the understanding and perception of trust among the professionals as a factor that drives and motivates the team.

In this sense, a study corroborates such finding, bringing up that teamwork is necessary and constitutes one of the strategic components to face the growing complexity, both of the health needs that require a broad and contextualized approach and of the organization of the services and systems that comprise the health care network²⁰.

The report of the interviewees from Spain shows that the multidisciplinary team is involved in the team management process, with teamwork that involves professionals from different categories and sectors being more significantly strengthened.

A research study states that the search for comprehensive health care and the structuring of a multidisciplinary team transform this work into a care-producing unit that needs new forms of collective mobilization that overcome isolation of the practices by different professionals and contribute to their integration. Therefore, in addition to driving and motivating the team, interprofessional work exerts an impact on patient care, as it generates holistic care and integrated practices²⁰.

This perception was latently observed in the speeches by the respondents from Portugal, who reported that cooperation among the professionals generates mutual support and more qualified assistance. It is identified that, working together and in an articulated manner, the health teams expand their ability to care and solve health problems, as they manage to make the existing health care devices more accessible, provide more comprehensive care, and share the responsibility for improving the quality of health and life for a given population.

In Brazil, it is possible to notice the adoption of an important resource aiming at more efficiency: communication. According to some authors²¹, teamwork in health is complex and is considered a driver of transformations, with effective communication being the key point.

With regard to the different management and leadership models in care, the results show a mostly participatory relationship, encompassing leaders, subordinates, families and other teams in the development of work, which diverges from the reality of countries with high underdevelopment rates and which maintain verticalized constructs, without the possibility of consultative or shared decision-making. In these cases, leadership is still an individualized element, exercised by medical professionals in a stratified way, in which those led have little personal management of the work and relations of power, coercibility and intimidation prevail. This reality can weaken the organizational climate, sustain an idea of guilt and foster a mechanistic provision of services, in which interpersonal relationships are undervalued²².

However, in general, users of the health services benefit more from interdisciplinary care, in which relationships among the professionals are friendly and collaborative and communication is efficient, than from fragmented care. However, a study carried out in the United States shows the persistence of a directed relationship between the management and the medical team, disregarding nurses in the decisions, which is a loss for both health teams and patients. The exercise of leadership should focus on reinforcing the importance of all professionals in each scenario, providing support in the clinical courses of action and providing the necessary means for the professional practice. It is known that, when they enjoy autonomy, nurses contribute to teamwork, as they exert a positive influence and increase the teams' efficiency and engagement²³.

There are successful experiences with the strengthening of Nursing management and leadership in critical scenarios with some characteristics similar to the countries that make up this study, such as immigration, lack of structure in the health service, shortage of professionals, and significant levels of poverty and social inequality. Governmental investment for the technical-scientific development of nurse-leaders and structural and salary enhancements contribute to the improvement of the entire system. It also directly affects dimensions such as the strengthening of permanent education, mechanisms for efficient communication among the leaders of different units with regard to solutions and best practices, strategic planning in health care, better distribution of the workforce, transformation of practices, and greater collaboration²⁴.

From the perspective of nursing technicians and assistants, the literature also shows that the leadership exercised by nurses should include characteristics such as recognition, motivation, knowledge, interaction and leading behaviors. This reiterates the speeches by the interviewees in this study, in which democratic leadership was identified as an essential factor for promoting a healthy work environment, being ethical and allowing flexibility of elements in favor of better results, the exercise of creativity and better conflict management.

Therefore, it is noted that the categories highlighted in this study contribute important characteristics related to Mintzberg's professional bureaucracy, as nurses demonstrate the power of knowledge, with managerial and leadership skills such as: communication, listening, horizontalized dialog, planning, training, problem solving, decision-making and participation, among others, which strengthen teamwork and ensure care quality for patients and family members, as well as allow nurses to highlight their autonomy in the work process.

Thus, it is worth reinforcing that professional bureaucracy is an axis of the organizational structure, which involves coordination of the workforce in its tasks. It adapts to a stable environment, which seeks professionals with high skills, holders of control over their own work and valuing the professionals' autonomy, through complex activities of an organization¹⁷.

CONCLUSIONS AND IMPLICATIONS FOR THE PRACTICE

In the three countries, it was possible to identify the importance of communication in the management process of nurse-leaders since, through it, they are able to develop their teams and ensure the quality of care provided to the patients and their family members.

In Brazil, certain concern with the team's motivation was evidenced, although in the sense of maintaining it engaged in the training offered by health institutions. This attitude is in line with Mintzberg's professional bureaucracy, in which training is continuous for professional improvement, and when they become qualified, they will strengthen their autonomy through the practice of their activities.

Motivation is fundamental for teamwork, as it is a means for cooperation and mutual learning, which provides a holistic and interdisciplinary view of the individual and also impacts on the quality of care provided to the patients. This perception was more latent in Spain and Portugal while, in Brazil, communication emerged as a determining factor for teamwork and also as a guide for management and assistance.

In the three countries analyzed, facilitating elements stood out in the management and leadership styles, such as providing opportunities for the performance of the Nursing team, behavioral skills for conflict management and good communication. Relevant intervening factors were also evidenced, such as listening, organizational climate, interpersonal relationships of the team, transparency in work and delegation of functions when appropriate.

Finally, it is warned about to the need to expand the spaces for learning in academic training about leadership and its driving elements, as well as to reinforce permanent education of the professionals on the subject matter. It is also necessary that the institutions recognize and provide autonomy for nurses, with a view to overcoming the challenges in health management.

Regarding the study limitations, we can firstly point out the pandemic period experienced, which hindered to a great extent the data collection period, especially to conduct the interviews, in the three study scenarios. As this is a qualitative study, there is no intention to make generalizations, although the findings can support nurses to reflect on their professional practices in the management of university hospitals.

The fact that only one professional category has been interviewed can be configured as a restriction, since other professionals working in university hospitals were not considered for this research. Another limiting point is linked to the impossibility of generalizations, since the study was conducted in 3 university hospitals in three countries; therefore, any comparison is impossible against the universe of university hospitals in each country. We can also indicate that the configuration of the institutions as teaching hospitals confers them characteristics which are different from the hospitals that have other organizational structure definitions. In this sense, it is important to develop new research studies that encompass a greater number of hospitals and nurses.

ACKNOWLEDGMENTS

We are grateful to the Teaching Hospitals of the Federal Universities of Bahia, Castilla-La Mancha and Coimbra for hosting the study and contributing to its development; to the Health Sciences Research Unit: Nursing, from the Coimbra Nursing School; and to the nurses from the aforementioned health services for their time and precious collaboration.

• FINANCIAL SUPPORT

  This paper was carried out with the support of the National Council for Scientific and Technological Development (CNPq) – Brazil – Number: 205736/2018-1.

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Edited by

ASSOCIATED EDITOR

SCIENTIFIC EDITOR

Publication Dates

• Publication in this collection
  25 Oct 2021
• Date of issue
  2022

History

• Received
  04 Sept 2021
• Accepted
  16 Sept 2021