Transformational leadership in nursing practice: challenges and strategies

Liderazgo transformacional en la práctica de enfermería: desafíos y estrategias

ABSTRACT

Objective:  to understand the challenges and strategies adopted by nurses for the exercise of Transformational Leadership in a university hospital.

Methods:  qualitative and exploratory study, in which 25 nurses working in a university hospital in the state of Bahia, Brazil participated. Data collection took place through semi-structured interviews and categorized according to Thematic Analysis, using Nvivo software.

Results:  The prevalent challenges involved: lack of encouragement from the institution for the training of leaders; professional inexperience and young age; resistance to leadership and insubordination. The strategies adopted by nurses consist of acting as team examples and establishing dialogic relationships.

Final considerations:  The practice of Transformational Leadership has been relevant in the daily lives of nurses and contributes to the quality of care.

Descriptors: Leadership; Nursing; Health services; Nursing Staff; University, Hospitals

RESUMEN

Objetivo:  comprender los desafíos y estrategias adoptadas por los enfermeros para el ejercicio del Liderazgo Transformacional en un hospital universitario.

Métodos:  estudio cualitativo y exploratorio, en el que participaron 25 enfermeros que trabajan en un hospital universitario en el estado de Bahía, Brasil. Los datos se recopilaron a través de entrevistas semiestructuradas y se clasificaron de acuerdo con el Análisis Temático, con la ayuda del software Nvivo.

Resultados:  los desafíos predominantes involucraron poco incentivo de la institución para la formación de líderes; inexperiencia profesional y jovialidad; resistencia al liderazgo y la insubordinación. Las estrategias adoptadas por los enfermeros consisten en actuar como ejemplos de equipo y establecer relaciones dialógicas.

Consideraciones finales:  se ha demostrado que la práctica del Liderazgo Transformacional es relevante en la vida diaria de los enfermeros y contribuye a la calidad de la atención.

Descriptores: Liderazgo; Enfermería; Servicios de salud; Recursos Humanos de Enfermería; Hospitales Universitarios

RESUMO

Objetivo:  compreender os desafios e quais as estratégias adotadas por enfermeiros para o exercício da Liderança Transformacional em um hospital universitário.

Métodos:  estudo qualitativo e exploratório, do qual participaram 25 enfermeiros atuantes em um hospital universitário no estado da Bahia, Brasil. Os dados foram coletados por meio de entrevistas semiestruturadas e categorizados conforme Análise Temática, com auxílio do software Nvivo.

Resultados:  os desafios prevalentes envolveram: pouco incentivo da instituição para a formação de líderes; inexperiência profissional e jovialidade; resistência à liderança e insubordinação. As estratégias adotadas pelos enfermeiros consistem em atuar como exemplos da equipe e estabelecer relações dialógicas.

Considerações finais:  a prática da Liderança Transformacional demonstrou ser relevante no cotidiano dos enfermeiros e contribui para a qualidade da assistência.

Descritores: Liderança; Enfermagem; Serviços de Saúde; Recursos Humanos de Enfermagem; Hospitais Universitários

INTRODUCTION

Leadership stands out as one of the managerial skills necessary to nurses’ practice, especially in the current scenario of frequent overcrowding and scarcity of beds, material resource deficits and insufficient staffing. The reality of some public health services has weaknesses in serving the population and lacks nurses with the knowledge, skills and attitudes to act as leaders, able to contribute constructively to achieve the goals and meet the health needs of users.

As managerial competence, leadership directly interferes with the professional satisfaction of nurses and staff, in order to promote a healthy work environment that gives visibility to the profession and facilitates care management^(1-2). Since leadership is a central aspect of the care management process, skilled professionals are needed to achieve goals in care promotion with quality and to prioritize work effectiveness, the people management process, and the provision of adequate physical and material resources⁽³⁾.

In the international scenario, researches^(2,4-5) point to the importance of leadership in the hospital environment, and the need to implement programs that favor the development of this capacity, especially among nurses.

In this study, we chose the theoretical aspect of Transformational Leadership, although there are other approaches, because when it is performed by nurses in the workplace, it generates trust in the team and, consequently, contributes to greater effectiveness of the leader⁽⁶⁾.

Researchers⁽⁷⁾ define Transformational Leadership as a set of transformative actions promoted by the leader over his followers, in order to raise awareness about the importance of the activities performed and the well done work, acting in defense of the institution’s mission and the reach of its goals. In addition, this model allows us to see each other’s personal and professional needs⁽⁶⁾.

The authors⁽⁷⁾ describe four elements that ground Transformational Leadership, which they refer to as the “Four I’s,” namely: a) Idealized Influence: transformational leaders are models to be followed, admired, and respected for idealized goals or behavioral aspects, regarded as reliable and described in terms of the sense of values, beliefs and mission to be achieved, with high ethical and moral standards; b) Inspirational Motivation: this relates to the leader’s ability to inspire confidence, motivation and a sense of purpose in his followers. It requires good communication skills, optimism in reaching the goal and enthusiasm; c) Intellectual stimulation: leader who encourages and values creativity, and encourages participation in decision making and autonomy; and d) Individualized consideration: a leader who sees individuals and their needs, both personal and professional, not just as employees. This leadership model enables learning opportunities to be created and demonstrates acceptance of individual differences.

The theoretical perspective of Transformational Leadership can be adopted for various research objects. A study⁽⁸⁾ sought to synthesize pedagogical strategies to apply this leadership modality in the teaching of drug safety by adopting the four elements mentioned above. It was identified that this leadership is characterized by the nurse’s focus as an educator and the development of students’ skills, by creating a supportive culture and encouraging creativity, motivation and ethical behavior among those involved in the teaching-learning process.

Similarly, studies in other countries^(9-10) with directors, managers, nurses and professionals from different hospital settings have showed the relevance of Transformational Leadership exercised by nurses. It allows to add and develop skills essential to the strengthening of the professional and the institution, with positive results in the commitment and satisfaction of the team and their patients.

Transformational Leadership emerges as a theoretical aspect that proposes new possibilities of thinking and applying this competence in different contexts, being pertinent to various professions. Studies on Transformational Leadership with nurses in the hospital environment are important because of the theoretical support, extent and flexibility offered by this perspective. Given the above, this study was guided by the following question: “What are the challenges and strategies adopted by nurses to exercise Transformational Leadership in a university hospital?”

The research aims to collaborate with the recognition of the challenges that interfere in the perform of leadership and the strategies adopted by nurses to strengthen and conduct their practice, as well as providing subsidies to improve the institutional dynamics and the relationship between members of the nursing team, which favors care management.

OBJECTIVE

To understand the challenges and strategies adopted by nurses to exercise transformational leadership in a university hospital

METHODS

Ethical aspects

The study met the guidelines and regulatory standards involving research with human beings, according to Resolution n. 466/12 of the National Health Council of the Ministry of Health. It was approved by the Research Ethics Committee of the Federal University of Bahia. The ethical precepts of confidentiality and the right to drop out from the research at any time without prejudice were respected. Participants signed the Informed Consent Form in two copies, one being held by the participant and the other by the researcher.

Study design

Exploratory, qualitative research. The theoretical framework adopted was the Bass and Avolio Transformational Leadership perspective⁽⁷⁾ and the data analysis methodology was the content analysis, using Minayo’s assumptions⁽¹¹⁾.

Study setting

Study conducted at a university hospital in Bahia, which provides specialized care of medium and high complexity by the Unified Health System, specifically in a hospital and outpatient teaching and research complex composed of outpatient, pediatric and hospital units. Since 2012, the institution has been managed by a Brazilian Public Company of Private Law (EPDP) linked to the Ministry of Education and its purpose is to manage federal university hospitals.

Data source

The population of this study consisted of care and management nurses from a total of 237 professionals. The number of participants was defined by simple random draw using the Microsoft Excel 2010 program. For the draw, the names of the nurses were organized alphabetically and identified by numbers. In this study, 25 nurses were interviewed and this amount was based on the information saturation criterion, reached by preliminary analysis, when the interviewees’ statements did not add new relevant information to the results. Inclusion criteria were restricted to being a nurse and working for at least six months in the hospital. Professionals on leave for any reason during the data collection period were excluded from the draw.

Data collection and organization

Data were collected between September and November 2017. Semi-structured interviews were conducted by the researcher and two undergraduate students in scientific initiation and lasted 30 minutes on average. Two recorders were used so that no data would be lost due to eventual failure in one of the devices. The interviews were previously scheduled on days and times chosen by the participants, held at the institution, in a private space and individually, to ensure the privacy of each interviewee. Information on the characterization of respondents regarding age, gender, employment and education was collected. As a guiding question, two questions were used: what strategies do you usually use to facilitate the exercise of leadership? What difficulties could you mention for exercising leadership? During the interviews, when behaviors related to transformational leadership emerged, other questions were asked in order to deepen the theme and get further clarification to favor the researcher’s understanding and reveal the difficulties and strategies for exercising leadership in the hospital environment.

Data analysis

Data were organized and processed using Nvivo 11.0 software and analyzed according to the Content Analysis technique in the Thematic Analysis modality⁽¹¹⁾. Operationally, this technique unfolds in a pre-analysis of the data through fluctuating reading and constitution of the corpus, with formulation and reformulation of hypotheses and objectives, followed by the material exploration, treatment and interpretation of the obtained results.

The analysis process resulted in three thematic categories. For this manuscript, from the objectives, we used “Challenges for the exercise of Transformational Leadership” and “Strategies for the exercise of Transformational Leadership”.

In order to preserve anonymity, we used the letter “N” was assigned to all nurses, followed by the number received according to the draw order, after agreeing to participate in the research (for example: N1, N2 to N25).

RESULTS

Respondents were between 28 and 49 years old, 92% (n=23) were female and 8% (n=2) male. Regarding employment bond, 92% (n=23) were public employee with Consolidation of Labor Laws (CLT) and only 8% (n=2) statutory public servant. Regarding training, participants reported had finished nursing school between 5 and 19 years, being 88% (n=22) graduates, 8% (n=2) were about to finish the nursing course and one declined to respond to this question. Of this total, five at stricto sensu (doctorate and master) levels and 19 lato sensu.

Challenges for the exercise of Transformational Leadership

This category evidenced the presence of three subcategories, which portray the difficulties faced for the exercise of Transformational Leadership: lack of encouragement from the institution for the training of leaders; professional inexperience and young age; and resistance to leadership and insubordination.

Lack of encouragement from the institution for the formation of leaders

This subcategory identified that the recognition of leadership as a nurse’s own skill was a challenge for the institution, regardless of the professional’s position. This fact contributed to weaken this type of leadership, evidenced the lack of encouragement from the institution for the training of leaders and the dissatisfaction of nurses in this context, as shown in the following statements:

I see the implementation of leadership increasingly being distanced in this process. (N21)

There is the reference nurse here, who is more in the administrative field. They are having leadership training. They have had, but from the five of us, only one is having this training, and our profession requires it, so it should have. (N02)

Professional inexperience and young age

Inexperience emerged significantly in the speeches, followed by age-related prejudice. Younger nurses had difficulty being welcomed by the team as leaders, which sometimes suggests prejudice. The young age was an aspect questioned by other professionals about the professional capacity of some study participants, which also showed barriers for more experienced people to accept being led by them. This one stood out as one of the difficulties for the exercise of transformational leadership:

In the beginning it was more because of my age. So, at the beginning, there’s a lot about this younger person question: “oh, is she younger than me and I will receive order?” (N23)

Work with people who think they know everything because of years of experience. (N20)

Resistance to leadership and insubordination

The resistance of employees to accept the leadership exercised by nurses was linked to suspicion of the recognition this professional had.

There have been reports of emerging conflicts between leaders and professionals who work as nursing technicians but went through nursing school. The technicians now question the decisions of the nurse, who, in turn, recognizes in this attitude an attitude of insubordination:

I see that in some cases there is a conflict, perhaps of position. We now have technicians who are nurses, but in the institution, they do not work as nurses, and may not see themselves as technicians, and then from that knowledge acquired as a nurse, want to confront the one who is actually working as a nurse. So, this situation may be what makes things more difficult. (N14)

Another situation of resistance identified in the participants’ statements involves the performance of hired leaders under different employment bonds, as seen in the statement:

It is difficult in the sense that we have many employment bonds in the institution, there is the Statutory public servant, the public employee [CLT]. So, whether you like it or not, there is prejudice! [...] All this you feel the resistance. How am I going to be led by a someone with a bond, that is perhaps, weaker, inferior to mine? (N22)

Strategies for the exercise of Transformational Leadership

The statements of the interviewed nurses enabled the creation of two subcategories that highlight the strategies they use to exercise leadership, namely: Leadership by being an example; and Dialogical relations.

Leadership by being an example

Nurses highlighted the need to act by being an example for positive leadership, and considered this to be a key strategy.

And I think we end up being a good leader by being an example, by acting, I think we teach a lot more when we do it than when we tell someone to do it. If the person sees in me that I am an active person, that I do my tasks, I think I end up passing it on to the person, through my attitude at work. (N09)

Being an example, Being on time, with cordiality ... (N15)

Dialogical Relations

Of the various strategies used by nurses to exercise this type of leadership, dialogue and attentive listening were expressively mentioned. Through this behavior, the leader can figure out what the needs are for the employees, the sector and the institution, thus promoting leadership.

The dialogue with the professionals, with the whole team. To dialogue and try to see what, in fact, will be common sense among all. What everyone agrees, what people are agreeing to. (N12)

The other strategy is more democratic leadership and a more horizontal relationship, where the team sees that the leader really cares about the problems that end up happening within the unit itself. This way of listening and a more horizontal relationship is what I do to establish my leadership. (N07)

DISCUSSION

The exercise of leadership is not always facilitated and has barriers, which may fall directly on the quality of care provided to the user and undermine the level of job satisfaction of employees.

The lack of support and assurance from institutions to provide environments that foster this ability can affect leadership development when it is seen as inherent to the professional, who should perform a job of excellence, according to the expectations of the boss, and having as main incentive is the need to keep his/her the job⁽¹²⁾. Studies^(6,9) show the importance of encouraging health institutions to train leading nurses in order to improve job satisfaction and the effectiveness of actions. Therefore, these professionals should be encouraged to adopt a leadership attitude, and aimed at improving the behavioral, organizational and relational attributes considered essential to cope with various situations.

Implementing Transformational Leadership in institutions favors relationships with the team and thus the achievement of common goals. The role of a transformational leader is capable of changing the work environment in its various scenarios and situations. Transformational leaders are characterized as visionaries and strategists for their ability to captivate and excite the team, and to organize the work⁽¹³⁾.

Transformational Leadership favors the involvement of employees in fulfilling the proposed mission for the collective, motivated beyond individual interests. In this sense, the interest is fostered by changes in the culture of the organization that aim to enhance actions and provide greater security in decision making⁽¹⁴⁾.

The young age associated with inexperience was one of the obstacles identified in the study, which evidenced a prejudgment regarding the professional’s ability. Although leadership is part of the nurse’s professional practice, it is not always an easy task and the professional’s lack of posture can put their credibility at risk⁽¹⁵⁾. In fact, poor practice, low confidence and poor academic background can hinder the development of this skill⁽¹⁶⁾, and in some cases frustrate and demotivate the nurse to take over the position of team leader. But in other situations, such features may be a stimulus to overcome difficulties and thus, and thus encourage willingness to seek qualification to exercise Transformational Leadership⁽¹⁵⁾.

At this juncture, the lack of encouragement from the organization to promote and stimulate the development of leadership compromises the efficiency and quality of the services provided⁽¹⁷⁾, which makes it essential to support and accompany these professionals during their adaptation process, to face the difficulties^(3,18).

In turn, such difficulties may contribute to consolidate the resistance of the nursing staff. The position of the nurse to a nursing technician with the same degree of education is another point that has generated resistance to leadership, either by the nursing technician’s desire to show knowledge and preparation to be in the same position as the nurse, or by his/her difficulty in welcome the suggestions and criticism.

It is a context that makes the exercise of leadership even more relevant in order to promote changes that favor the respect and recognition necessary for effective and appropriate leadership. The leader is characterized by his/her moral and ethical, accessible, empathic, motivating and inspiring behavior, understandable to the needs of others, and focused on the organization’s mission⁽⁷⁾.

Perhaps, if instead of feeling threatened or bothered by the suggestions of other workers, these nurses used them in favor of the group’s growth, this kind of situation could be better managed and perceived. When the leader favors dialogue and has an empathetic relationship with the position of employees, he/she can motivate and inspire the team, in order to create a bond of trust with their actions and decisions, as they believe in a relationship of listening, teaching and help with what is needed^(2,19). At the same time, the leader can solve any questions or concerns the team may have about the new leadership, regardless of employment bond type.

The aspect mentioned above is confirmed by identifying that the findings regarding the subcategories Leadership by being an example and Dialogical Relations foster the developmental potential of transformational leaders. It was observed that the exercise of leadership guided by example represented the fastest and easiest way to teach, noting recognition, acceptance and fulfillment of delegated actions, which provides a horizontal relationship. In addition, the act of nurses performing the same activities as others and being able to finish them is a great motivator and influencer for employees to follow the same posture. The proactive leader tends to stimulate the employees’ sense of gratitude, companionship, respect and trust, precepts advocated by Bass⁽²⁰⁾ about Transformational Leadership.

Researchers point out that nurses’ participatory performance brings them closer to the team during the execution of services, making them a reference for the group and a supporter of quality care for the benefit of patients⁽²¹⁾. The leader, when engaged and effectively integrated into the team’s activities, favors the feeling of cooperation and improves interpersonal relationships, which consequently contributes to reducing conflicts, increasing trust and creating a healthy environment⁽²²⁾. Taking advantage of these moments to approach the team can be a strategy in building an interpersonal relationship based on trust and respect through the leader’s example and dialogue. These situations require the leader to be charismatic in essence, capable of influencing and enthusiastic about the team, a common aspect of the Transformational Leadership style causing admiration and a high degree of confidence⁽¹⁴⁾.

In this dynamic, dialogue is an essential tool for nurses to exercise leadership, as it expands the space for the explanation and reception of ideas, a moment in which the leader can position him/herself, advocate problems, listen, evaluate and implement creative and resolute ideas, listen to the difficulties and abilities of employees and assist in facing and overcoming challenges^(19-23). These aspects are common in the practice of Transformational Leadership⁽¹⁴⁾, when the leader encourages his/her team to solve the problems raised and involves them in decision making.

Despite these benefits, some criticisms are currently linked to the theoretical model of Transformational Leadership. International studies reinforce weaknesses of transformational leadership and question the morality of this model. This kind of leadership is claimed to have strong potential to motivate followers through strong emotions, regardless of the effects they bring about. When the leader uses underlying mechanisms to influence the team, this attitude is even considered incompatible with moral values. In this respect, Leadership lacks prudence and balances of compensatory interests and in order to be authentic and beneficial, it must value the principles of honesty, loyalty, fairness and respect for human rights^(24-25). Authors⁽²⁴⁾ consider that in health, the goal would be to lead transformative change rather than change to be a leader with transformative characteristics.

By analyzing the results of the present study about the Transformational Leadership exercise of a group of nurses with the support of Bass’s theoretical framework⁽¹⁴⁾, it was possible to identify the contributions of this leadership style to care management from the most varied perspectives. Although challenges are common to the leader’s daily life, they are best overcome when a leadership style allows the development of an interpersonal relationship based on respect and trust, more horizontal and open to listening and empathy.

Nurses who had a Transformational Leadership profile were more open to suggestions and attentive to the needs of users and staff. This model promotes the integration of its members by orienting them to the tasks according to their technical capacity, which optimizes the workforce.

Study Limitations

Although the objective of this study was achieved, conducting interviews with nurses only was considered as a limitation, as it opened the door for future studies to investigate whether the perception of these professionals is compatible with that of other members of the nursing team.

Contributions to nursing

The present study contributed to reflections about the relevance of Transformational Leadership exercised by nurses in hospital practice and highlighted the main challenges faced by these professionals in situations where they acted as leaders. In addition, it was possible to identify the strategies available to improve care and living in the workplace by exercising this leadership style.

It is noteworthy that this study was conducted in a referral hospital, with an innovative management, 70 years of service to the population and a new configuration of professionals. In this context, employees, working for a significant time and newly arrived ones, need to adapt to these changes. Therefore, it is essential to follow the leadership profile present in the hospital.

FINAL CONSIDERATIONS

This study revealed challenges and strategies adopted by nurses in the exercise of Transformational Leadership, with emphasis on some essential skills for those who play this role in the hospital context, especially charisma, dialogue and leadership by being an example. The performance of a leader with such skills favors care management, as it inspires and motivates the nursing staff and contributes to the quality of care. Nurses recognize the importance of leadership as something that favors the autonomy of everyone involved in the nursing work process, especially for conflict management, decision making and communication with the team.

Given the above, the Transformational Leadership proved to be an appropriate way to lead, as it allows facing some challenges that make it difficult the recognition of the performance of nurses as leaders. The study identified the need for institutions to invest in leadership among nurses as a way to enable them to cope with conflict management and problem solving, regardless of their hierarchical position (care or administrative). In addition, the inexperience and prejudgment of the staff regarding the young age of some of the newly hired nurses could also be better addressed if there was a culture of training leaders in the institution.

Strategies that allowed the exercise of transformational leadership were also identified, such as leadership by example and dialogue. The proactive nurse shows in a practical way the importance of a job well done and focused on quality care and contributes to a better interpersonal relationship as a way to favor dialogue with the team. Dialogue was identified as an important tool for leadership and allowed openness to a horizontal relationship and strengthening respect and trust. Nurses who act as transformational leaders need to play this role with extreme moral responsibility and respect for the nursing staff, always attentive to the satisfaction of these professionals in the workplace.

We hope that this study will contribute to develop leading nurses in their work practices, causing a more critical perspective, which strengthens teamwork and, at the same time, meets the expectations of health institutions. Thus, it may be possible to achieve common goals that effectively allow transformations in reality.

We suggest the development of new research focusing on transformational leadership, which deals with the perception of other nursing team members regarding leadership styles.

• FUNDING
  This research was funded by CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) in the Graduate Support Program for the Master’s degree, and by the Federal University of Bahia to finance the macro project to which this study is linked, gratified in the PROPESQ (Programa de Apoio a Jovens Professores Doutores), which allowed the acquisition of Nvivo 11 software for qualitative data analysis.

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Edited by

• EDITOR IN CHIEF: Antonio José de Almeida Filho

• ASSOCIATE EDITOR: Alexandre Balsanelli

Publication Dates

• Publication in this collection
  10 Aug 2020
• Date of issue
  2020

History

• Received
  05 Aug 2019
• Accepted
  14 Dec 2019