ISSN (impressa): 1414-8145
Volume 6, Número 2, Mai/Ago - 2002
E-mailARTICLES IN REFLECTIONS
The nurse's management in hospital health services: an alternative founded on human values
O gerenciamento da enfermeira em serviços de saúde hospitalares: uma alternativa alicerçada nos valores humanos
El gerenciamiento de la enfermera en los servicios de salud hospitalares: una alternativa cimentada en los valores humanos
Neide FáveroI; Marcia Regina Antonietto da Costa MeloII; Isabel Amélia Costa MendesI; Maria Auxiliadora TrevizanI
IFull Professor
IIAssistent Doctor - University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Center for Nursing Research Development, Brazil
ABSTRACT
In Brazil, management inefficiency in health organizations has been partly responsible for the discredit of such sector. When conducting her managerial practice, the nurse performing in this context has not effectively contributed with the development of efficient clinical nursing nor has she collaborated in the solution of specific problems in the area. This predicament makes it impossible to bring about transformations or innovative actions necessary for personalized and qualified care. Consequently, neither the client nor the human capital committed in such assistance is satisfied, which interferes in the nurse's self-fulfillment. Therefore, our purpose was to analyze the management carried out by the nurse aiming at presenting an alternative to transform such practice into one that is founded on more flexible, innovative and human values.
Keywords: Health services. Nursing. Nurse. Manages. Nursing management. Human values.
RESUMO
No Brasil, a ineficiência da gerência em instituições de saúde tem sido parcialmente responsável pelo descrédito desse setor. Durante sua prática gerencial, a enfermeira atuando nesse contexto não tem contribuído efetivamente com o desenvolvimento da enfermagem assistencial eficiente ou tampouco colaborado na solução de problemas específicos à área. Tal situação torna impossível a realização de transformações ou de ações inovadoras que são necessárias durante o atendimento personalizado e qualificado. Conseqüentemente, nem o cliente e nem o capital humano envolvidos nesse tipo de assistência ficam satisfeitos, o que interfere com a auto-realização da enfermeira. Assim, nosso propósito foi o de analisar (refletir sobre) o gerenciamento realizado pela enfermeira com vistas a apresentar uma alternativa para a transformação dessa prática em outra que seja alicerçada em valores humanos mais flexíveis e inovadores.
Palavras-chave: Serviços de saúde. Enfermagem. Enfermeira. Gerência. Gerenciamento de enfermagem. Valores humanos.
RESUMEN
En el Brasil, la ineficiencia de la gerencia en instituciones de salud ha sido parcialmente responsable por el descrédito de ese sector. Durante su practica gerencial, la enfermera actuando e ese contexto no ha contribuido efectivamente con el desarrollo de la enfermería asistencial eficiente o tampoco colaborado en la solución de problemas específicos del área. Tal situación torna imposible la realización de transformaciones o de acciones innovadoras que son necesarias durante la atención personalizada y calificada. Consecuentemente, ni el cliente ni el capital humano envueltos en ese tipo de asistencia quedan satisfechos, lo que interfiere con la auto-realización de la enfermera. Así, nuestro propósito fue el de analizar (reflexionar sobre) el gerenciamiento realizado por la enfermera con vistas a presentar una alternativa para la transformación de esa práctica en otra que sea cimentada en valores humanos mas flexibles e innovadores.
Palabras claves: Servicios de saúde. Enfermería. Enfermera. Gerencia. Gerenciamiento de enfermería. Valores humanos.
Since the beginning ot the century has been several attempts in Brazil to apply industrial managerial techniques in health care services. It was not until the 1960s and 1970s that their incorporation in hospital units was effectively verified, when technological advancement reached high levels and the costs of health care increased. (MENDES, 1993).
Despite the technological advancement, health care organizations have not followed the development of modern organizations as to management proposals. Hospital organizations have not offered significant improvement to the population's health, in addition to present higher cost care.
According to Braga Neto (1991), management inefficiency in health care organizations has been partly responsible for the discredit in such sector. For a long time, the question concerning health management has been regarded as second in importance by government agencies and research institutions when compared to other problems faced by the sector. Presently, this subject has been frequently discussed, especially in relation to public institutions, which indicates that the area of health services management has acquired a new status in the last few years.
We agree with Dussault (1992) when she states that "the challenge in any country consists in increasing the coherence between resources, services and the needs of the community"... she also asserts that the increase in resources will not, by itself, ensure good quality in health services and points out that "a great amount of resources managed inefficiently will result in cost increase without a significant improvement in the impact of services".
In this context, the managerial function reaches beyond administrative and technical knowledge once it requires the capacity to deal with people, to know their needs, values and to encourage them to meet the organizational objectives. Therefore, its performance is fundamental as to interpersonal relations, which prevail in a scenario of conflicts between values and interests and the power relations established by the organization itself (JUNQUEIRA, 1990).
Considering that health care management activity, whose main action consists in articulate-integrate, and at the same time, permits the transformation of the work process while it is also subject to the transformation due to needs present in the everyday organizations activities. We believe that the manager's condition of articulate and integrate such actions is essentially required from each one. It is inherent to his capacity and ability to "conduct" people (conduct with the meaning of guiding, providing conditions for, enabling) with flexibility and authority (FÁVERO, 1996).
Therefore, the need to consider the conception that the performance of the managerial function requires knowledge and abilities that go through the technical, administrative, political and psychosocial dimensions are inevitable. Such dimensions have their own meanings, which are not isolated, however, quite related. This permits the characterization of not only one efficient management style, but also the qualities that must permeate the manager's action (JUNQUEIRA, 1990).
Thus, when health services are mentioned, there soon emerges the idea of organizations that are capable of proposing alternatives to promote health or its recovery, furthermore, services that are capable of improving the population's health conditions. Quoting Cecílio (1997), "a hospital is a virgin territory in terms of work in the perspective of humanization in assistance and life defense". In this way, efficient and effective management that contemplates human values is essential for its existence, survival and success.
Facing this predicament, it is important to point out that "radical changes in the nature of work are revolutionizing the role of human being (human being's role) in modern society. All institutions are changing the relations between employees and employers, woman and man, father and child, teacher and student deeply and permanently alter in reply to the need for all to contribute to society with their intelligence, creativity and responsibility. After years of a limited focus, employees are asked to consider the whole, to be innovative and concerned about their clients, to work as the members of a team, to determine their own work and coordinate it with others, instead of simply following orders. Almost all expanding work sectors require technical and human understanding, penetrating observation, creative problem solving and collaboration ability" (PINCHOT e PINCHOT, 1994).
NURSING ASSISTANCE MANAGEMENT - AN ALTERNATIVE FOUNDED ON HUMAN VALUES
Ever since its institutionalization as a profession, nursing has received the influence of concepts from Business Administration. Taylor's presuppositions have been so intensively disseminated that they are still strongly present in Brazilian nursing up to this day.
In practice, it can be observed that Taylor's presuppositions added to those of Fayol and Weber have directly interfered with nursing work relations in the hospital level, influencing its organization as to its development according to a rationality that has led to the decomposition of work and to its rigorous control while workers remained aside its conception process. In this way, the managing nurse becomes the planning and coordinating element of the actions carried out by workers as well as the one in charge of the conception and control of the work process (ROZENDO, 1995).
The way according to which such traditional structures establish their work division, authority distribution and communication system determine a high level of formalization, which standardizes individuals' behaviors. This takes place by means of the designation of how, when and by whom activities will be carried out, since they are prescribed for all workers. Communication takes place from top down, according to the hierarchic chain, from the boss to the subordinate, in a verticalized fashion. In relation to the decision process, these structures have shown to be highly centralizing.
The organizations structured on traditional models hinder the participation of workers, blocking their creativity and development. As to the external market demands, policies and technological innovations that give impulse to faster internal changes and adjustments, the responses from organizations are slow, which evidences too small flexibility to bring about transformations.
These structures in nursing services at the present have being severely questioned because they have not been able to give effective responses to the transformations that have been taking place, which has occurred in relation to the knowledge of new processes and technology as well as to the requests from workers increased participation at work management.
Some questions encouraged us to do this research, such as the realization that the success of all organizations will depend on the performance of its human resources and the agreement on the necessity to face and overcome the obstacles and limits stemming from conventional administrative processes applied by hospital and nursing services. Relevant and efficient measures are frequently idealized in these organizations; however, they are rarely concretized in practice either as a result of the fragility in political decisions or because traditional administrative models are not adequate to the complexity and dynamics of current problems and necessities.
In this context, we understand that one of the possibilities consists in understanding the managerial process in nursing service, in the same time, to create work alternatives that can collaborate with the construction of a managerial practice more adherent to human values and to current needs of the population.
We believe that one of the alternatives refers to the participating management that is specifically centered on the development of human resources, aiming at permitting the search for values that can give subsidy to new practices, that is, the search for new management paradigms in nursing assistance, thus preconizing the adoption of a performance involving people, with the purpose of providing patients with individualized and qualified assistance.
Mendes (2000) and Mendes et al (2000) warn that the appreciation of man as a person is a basic premise for humanization in the nursing context, in which both the patient and the nurse must be valued. If the nurse has been valued as a person, she/he will recognize the importance of her/his performance not only to the institution, but also, to her/his own growth and self-fulfillment. She/He will be able to see a person in her patient and, through this view, guide her/his professional conduct.
Some proposals have emerged with the orientation of constituting more open, flexible, participating and decentralized structures in which work organization would no longer be focused on tasks or formal aspects, but rather on teams formation, that would have the autonomy to define their own activities with the patient by taking into account the abilities, competence and interests of their members, thus opening opportunities for their participation, creativity and initiative.
We understand that a group only makes up a team when it operates in a cooperative manner complementing it, and not simply an addition. The integration among its members must be such that the team will behave as an articulated whole, where participation is essential from the conception of a work plan to evaluation processes and final results. Operating this way, does not imply working without conflicts, Its presence is inevitable and universal. According to Wisinski (1995), "the real question is how to deal with them. We cannot always avoid or solve them, but it is usually possible to administrate them and come to a conclusion". Therefore, we will be far from establishing team performance if work carried out under hierarchized management and individual decisions remain in the nursing practice. Such teamwork will also be impossible if authority keeps a connotation of power and if control remains external to those who actually provide nursing care.
In our everyday life, nurses have carried out a type of hospital administration that is much more frequently directed by norms, routines and regulations, taking a posture of obedience and passiveness towards the criteria that are pre-established by the organization in detriment of a more human, more creative, more innovative and more participating managerial performance. This prevents them from being closer to workers and to their clients as well as from favoring the knowledge of the real needs of their team and from making efforts so as to meet such needs whenever possible (FÁVERO, 1996).
Treating the administrative practice carried out by the Nursing Division of a school hospital, Ferraz (1995) has recently pointed out that such administration "is shown to be old-fashioned and incapable of practically ensuring principles that are considered to be important and largely defended in educational institutions and in hospitals themselves, such as: the qualification of nursing assistance, the effective participation in decisions by all those who contribute with nursing care, the utilization of strategies for adaptation to current conditions as well as others that are taken by us as being obvious, such as scientific, technological and managerial development. Despite the fact that such principles are obvious, nursing has not been able to find ways in its performance that would be capable of implementing them in the everyday practice". To the author, in spite of its efforts, nursing has not followed socio-cultural and scientific advancements, which evidences important organizational delays in the context of the service-rendering institutions".
We believe that the management transformation constitutes the core of the question and it can be a fundamental instrument, it can be one of the decisive elements for the transformation or maintenance of this predicament (FÁVERO, 1996).
By taking this into account, we believe that significant changes will take place when the managerial role played by the nurse is founded on competence, sensibility, respect, understanding and flexibility of all those involved in the process, which will result in a better-quality assistance to the client.
We recognize the nurse's importance as an articulator and integrator of the activities developed with the patient, whether such activities are performed by the nursing personnel or by other elements on the health care team. It is also up to the nurse to develop her/his communication capacity as well as adequate interpersonal relationship, thus providing a favorable work environment and favorable work conditions. She/He must also be capable and available to listen to each team member, to know their needs, values and to stimulate them to reach the organizational goals.
In this context, people must be stimulated to participate and to develop their creativity potential by conceiving common work objectives, which will pre-establish the team's performance standard and will ensure the effective development of nursing care. We agree with Ferraz (1992) when she claims that the productivity and efficiency of a group are closely related not only to the competence of its members, but above all, to the dynamics of interpersonal relationship and with their integration level. Each member is strengthened in the group as he feels accepted, appreciated and considers himself to be definitely integrated when feeling as an effective participant in each action of the work process.
In this way, we must try to stimulate everyone's participation (the participation of each one), aiming at ensuring that the work will be developed according to the cohesion and integration of each individual's possibilities, since the development of a group's integration process leads people to the involvement and to the commitment of their actions at work.
That all work proposals imply the adoption of a philosophy and of organizational policies that are coherent with the meaning attributed to such work is inevitable. This permits effective attitudes and commitments to the objectives or to the institutional mission by all, which means staying commited to the patients' needs.
The availability of information is essential for the managerial performance to become adequately effective; therefore, it is necessary to create and maintain efficient communication mechanisms.
It is necessary to recognize that the management style performed by a nurse in a hospital must be in agreement with the style that rules the institution. Therefore, in order to be able to effect a more participating management style, it is necessary to go through an organizational change that will bring about structural and behavioral alterations as well as structural and functional ones.
These changes require an enormous effort to transform the current rational-bureaucratic administration model into managerial models that are more committed to assistance quality, to the best possible utilization of resources and that are focused on the client.
According to Cecílio (1997), there is no tradition in the Brazilian public administration to think of the users, as clients. Introducing the client idea means making him into a legitimate bearer of rights and needs. The client concept in governmental hospitals must be developed from the ethics of solidarity and commitment to the construction of citizenship.
In this context, the change in managerial practice involves processes that require re-shaping the way people comprehend and treat everyday reality as well as the motivation that gives them impulse to achieve results. We agree with Carvalho & Tonet (1994) on that relevant organizational changes will occur if there is a change counterpart in culture. In this way, "creating new culture means breaking up with values, beliefs, taboos and with other elements of the organizational culture that permeate the past and the present by replacing some of them, reinforcing others, bringing about expectations and truths that were up to then unknown or undesirable".
There seems to be an agreement on that the success of an organization depends, in a higher or lower level, on the performance of the people; therefore, we understand that in order to attain a new managerial behavior, the first step to be taken is the recognition and analysis of the organizational culture predominating in the institutions.
This new managerial conduct by the nurse presently approached by us leads to the clear understanding that managing is a dynamic process that includes technical, administrative and political dimensions in permanent articulation and integration with people, materials, technology and the environment, which will require reflections for decision making, aiming at developing among workers a spirit of involvement and commitment to the organizational objectives and to the population to be assisted.
FINAL CONSIDERATIONS
We believe that by counting on greater flexibility in assistance management, we will create possibilities for all to participate, aiming at making them responsible for the reconstruction of nursing work. In this way, managerial practice becomes urgent as to transforming bureaucratic tasks into a practice that contains more flexibility, more critical and more human attitudes, consequently becoming more creative and innovative, aiming at continuously searching for progress in the service, equating the work so as to permit the development of human resources in their personal and professional dimensions, culminating in the better assistance that we can offer the client.
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