4 5 7
NURSES’ MANAGEMENT I N THE CLI NI CAL PRACTI CE:
PROBLEMS AN D CHALLEN GES I N SEARCH OF COMPETEN CE
1Mar ia Au x iliador a Tr ev izan2 I sabel Am élia Cost a Mendes2 Gilber t o Tadeu Sh in y ash ik i3 Gen ev iev e Gr ay4
Tr ev izan MA, Mendes I AC, Shinyashik i GT, Gray GI . Nur ses' m anagem ent in t he clinical pract ice: pr oblem s and
challenges in sear ch of com pet ence. Rev Lat ino- am Enfer m agem 2 0 0 6 m aio- j unho; 1 4 ( 3 ) : 4 5 7 - 6 0 .
Wit h t h e pu r pose t o en able r eflect ion s con cer n in g n u r ses’ m an ager ial per for m an ce in h ospit alizat ion
unit s, t hr ee st udies conduct ed in t hr ee differ ent decades, in t he sam e univer sit y hospit al, w er e analyzed. Fr om
t his analysis, it w as obser ved t hat nur ses’ m anager ial pr act ice has been m ainly char act er ized by t he accent uat ed
com p lian ce t o p r e- est ab lish ed n or m s, t h u s sh ow in g a r eit er at iv e p r ax is. Un d er st an d in g t h e f r agilit y of t h is
m anager ial sit uat ion in t er m s of involvem ent w it h and com m it m ent t o client s and ser vice giver s, an alt er nat ive
m anager ial conduct , w hich is based on t he cr eat iv e pr ax is, is pr esent ed t o nur ses.
DESCRI PTORS: pr act ice m an agem en t ; n u r ses, m ale; pr ofission al com pet en ce; n u r sin g
GERENCI AMI ENTO DEL ENFERMERO EN LA PRÁCTI CA CLÍ NI CA:
PROBLEMAS Y DESAFÍ OS EN LA BÚSQUEDA DE COMPETEN CI A
Con el pr opósit o de facilit ar una r eflex ión sobr e el desem peño ger encial del enfer m er o en el ser v icio
d e in t er n am ien t o, los au t or es an alizar on t r es est u d ios ef ect u ad os en t r es d écad as d if er en t es en el m ism o
hospit al univer sit ar io. De est e análisis, const at ar on que la pr áct ica ger encial del enfer m er o se ha car act er izado,
sobr e t odo, por el v ín cu lo acen t u ado en n or m as pr eest ablecidas, con figu r án dola com o u n a pr ax is r epet it iv a.
Com pr endiendo la fr agilidad de est a sit uación ger encial en t ér m inos de inv olucr am ient o y com pr om iso con los
client es y pr est ador es de ser vicios, los aut or es pr esent an una alt er nat iva de conduct a ger encial par a el enfer m er o
basado en una pr ax is de cr eat iv idad.
DESCRI PTORES: m an ej o pr áct ico; en f er m er os; com pet en cia pr of esion al; en f er m er ía
GERENCI AMENTO DO ENFERMEI RO NA PRÁTI CA CLÍ NI CA:
PROBLEMAS E DESAFI OS EM BUSCA DE COMPETÊN CI A
Com o pr opósit o de possibilit ar r eflex ão sobr e o desem penho ger encial do enfer m eir o na unidade de
in t er n ação, os au t or es an alisar am t r ês est u d os ef et u ados em décad as d ist in t as n o m esm o h ospit al escola.
Dest a an álise, con st at ar am q u e o ex er cício g er en cial d o en f er m eir o t em - se car act er izad o, sob r et u d o, p ela
v in cu lação acen t u ad a a n or m as p r eest ab elecid as, con f ig u r an d o u m a p r áx is r eit er at iv a. Com p r een d en d o a
fr agilidade dest a sit uação ger encial em t er m os de env olv im ent o e com pr om isso com os client es e pr est ador es
de ser v iços, os aut or es apr esent am um a alt er nat iv a de condut a ger encial par a o enfer m eir o fundam ent ada na
p r áx is cr iad or a.
DESCRI TORES: ger en ciam en t o de pr át ica pr of ission al; en f er m eir os; com pet ên cia pr of ission al; en f er m agem
1 St udy pr esent ed at t he 4t h Meet ing of Regulat or y Aut hor it ies fr om t he West er n Pacific and Sout h East Asian Regions, Hong Kong, Novem ber 2002; 2 RN,
Full Pr ofessor, Univer sit y of São Paulo at Ribeir ão Pr et o College of Nur sing, WHO Collaborat ing Cent r e for Nur sing Resear ch Developm ent , Brazil, CNPq
Researcher 1A, e- m ail: iam endes@eerp.usp.br ; 3 Psychologist , Facult y, Univ ersit y of São Paulo at Ribeirão Pret o School of Econom ics, Business Adm inist rat ion
and Account ancy ; 3 RN, Facult y, Facult y of Nur sing, Univer sit y of Alber t a, Edm ont on, Canada.
Rev Lat ino- am Enfer m agem 2006 m aio- j unho; 14( 3) : 457- 60
w w w . eer p. usp. br / r lae Ar t igo de Revisão
4 5 8
W
i t h t h e d e v e l o p m e n t o f h o s p i t a l o r g a n i z a t i o n s a n d t h e i r t r a n s f o r m a t i o n i n t obureaucrat ic inst it ut ions, t he nurse’s role has changed,
p ar t icu lar ly as a r esu lt of p h y sician s’ ex p ect at ion s,
since t hey believed t hat t hey w er e pr ofessionals w it h
an adm inist rat iv e capacit y. Phy sicians’ w illingness t o
t r an sf er t o n u r ses t h e adm in ist r at iv e f u n ct ion s t h at
t hey did not w ant t o car r y out is r elat ed t o t he suppor t
in t he pr ocess of pat ient ’s t r eat m ent in w hich t hese
pr ofessionals becom e inv olv ed, m ainly as a r esult of
f o r m a l o r g a n i za t i o n . Th e r e f o r e , n u r se s b e g a n t o
assum e t he r esponsibilit y for t he unit ’s m aint enance,
for t he pr ov ision and cont r ol of dr ugs and necessar y
m a t e r i a l s a s w e l l a s f o r t h e o r g a n i z a t i o n a n d
coor dinat ion of t he car e act iv it ies t hat ar e pr ocessed
by dif f er en t pr of ession als con j oin t ly w it h t h e cu r in g
a c t i v i t i e s p e r f o r m e d b y p h y s i c i a n s i n t h e
hospit alizat ion unit .
I n t h is con t ex t , n u r ses’ m an agem en t in t h e
c l i n i c a l p r a c t i c e h a s b e e n f o u n d e d o n t h e
or g an izat ion ’s b u r eau cr at ic an d f or m al n eed s, t h u s
p r iv ileg in g an d b ecom in g m u ch m or e com m it t ed t o
or g an izat ion al ob j ect iv es in d et r im en t of at t ain in g
w or k er s’ and pat ient s’ indiv idual goals, t hus br inging
about t he exist ence of an im balance t hat has caused
t ension, discour agem ent and ev en disbelief at w or k .
Of t h e i n v e st i g a t i o n s co n ce r n i n g n u r si n g
bureaucrat izat ion in our m ilieu, t he st udies conduct ed
b y Tr e v i z a n( 1 , 2 ) a n d Fe r n a n d e s( 3 ), w h i c h w e r e
dev eloped in t he sam e univ er sit y hospit al in t he last
t h r ee decades of t h e 2 0t h cen t u r y, ar e em ph asized.
The analysis of t hese st udies has t he pur pose t o enable
r eflect ions on nur ses’ m anager ial per for m ance in t he
hospit alizat ion unit and, t hen, pr esent consider at ions
in or der t o guide and enable m anager ial act ions t hat
ar e m or e dir ect ed and com m it t ed t o t he hum an capit al
involved in t he w or k cont ext by locat ing and r eplacing
p r of ession al v alu es an d clien t s’ n eed s on a h ig h er
t h r esh old .
METHODOLOGY
This st udy present s a reflect ion on t he result s
obt ained fr om t hr ee st udies developed at a lar ge public
hospit al. The fir st st udy, dev eloped by Tr ev izan( 1) in
1 9 7 8 , a n a l y z e s t h e a ct i v i t i e s o f n u r se h e a d s a t
h o s p i t a l i z a t i o n u n i t s ; t h e s e c o n d , b y t h e s a m e
a u t h o r( 2 ), o n e d eca d e l a t er, a d d r essed a sp ect s o f
n u r s i n g a d m i n i s t r a t i o n a n d b u r e a u c r a c y a t t h e
h o sp i t a l ; f i n a l l y, t h e t h i r d st u d y, ca r r i e d o u t b y
Fer nandes( 3) in 2000, also discusses nur ses’ funct ions
at t he sam e inst it ut ion, r eplicat ing t he first st udy( 1).
THE STUDI ES UNDER ANALYSI S
When inv est igat ing nur ses’ act iv it ies - heads
of t h e h ospit alizat ion u n it s in t h e abov e- m en t ion ed
h o sp i t a l i n t w o t i m e p e r i o d s: – 1 9 7 3 a n d 1 9 7 6 ,
Trevizan( 1) obser ved t he developm ent of adm inist rat ive
act iv it ies as w ell as of t hose inv olv ing dir ect pat ient
care, t eaching collaborat ion and research, w hich m ust
be assigned t o t he auxiliar y per sonnel and per for m ed
by ot her ser v ices, including pr iv at e ser v ice giv er s. I n
relat ion t o t he adm inist rat ive act ivit ies, it w as observed
t hat , in 1973, t he m ean per iod of t im e spent on such
act iv it ies w as 3 8 . 9 0 % and in 1 9 7 6 , 5 3 . 1 5 % . I n her
conclusions, t hat aut hor point s out t hat m ost of t he
a ct i v i t i e s p e r f o r m e d b y h e a d n u r se s w e r e n o t i n
accor d an ce w it h w h at t h e p r of ession ex p ect s f r om
such pr ofessionals, since m ost of t he t im e spent on
t h e i r a t t r i b u t i o n s w a s r e l a t e d t o a d m i n i s t r a t i v e
a ct i v i t i e s, p a r t i cu l a r l y t o t h o se o f a b u r e a u cr a t i c
ch ar act er.
Fr om t h e diagn ost ic m ade by Tr ev izan( 1 ), it
w as under st ood t hat nur ses did not m ak e effor t s in
or d er t o v alu e t h e p r of ession ’s in t en t ion s an d t h at
t hey w er e under used and r est r ict ed in t heir pot ent ial
as pr ofessionals and cit izens. I t w as also under st ood
t hat t heir per for m ance had t he pur pose t o m eet t he
r eq u i r em en t s of t h e or g an i zat i on al p ow er an d t h e
ex p ect at ion ar isin g f r om p h y sician s, t o w h ich t h ey
w er e su bm it t ed.
Ma n y r e f l e c t i o n s , q u e s t i o n s a n d s t u d i e s
em er g ed as a r esu lt of t h is b eh av ior f r om n u r ses.
The lit er at ur e r egar ding t hat issue cont inued t o show
t hat t he m anaging nur se’s pr act ice had not changed.
Wit h t he convict ion t hat nurses privileged t he
a d m i n i st r a t i v e a ct i v i t i e s, Tr e v i za n( 2 ) a n a l y ze d t h e
funct ions per for m ed by t hem in t he light of a t ypology
of bu r eau cr at ic an d n on - bu r eau cr at ic adm in ist r at iv e
f u n c t i o n s . Th e a u t h o r f o u n d t h a t 7 4 % o f t h e
adm inist rat iv e funct ions had a bur eaucrat ic charact er.
I n face of t h e im posit ion s of h ospit al or gan izat ion al
pr ocesses, she st at es t hat t he nur se should assum e
an d p er f or m m an ag er ial f u n ct ion s, b u t em p h asizes
t hat t he cont ent and for m of such ur gency m ust focus
on clien t s’ car e( 2 ). Th u s, by com bin in g m an agem en t
and car e, nur ses w ould hav e a new spir it t o r edir ect Nur ses' m anagem ent in t he clinical...
Tr evizan MA, Mendes I AC, Shinyashiki GT, Gr ay GI .
4 5 9
and r eact iv at e t heir pr ofessional pot ent ial.
I n t he 1990s, Fer nandes( 3) elaborat ed a replica
of t h e st u d y con d u ct ed b y Tr ev izan( 1 ) in t h e sam e
h ospit al. Wit h t h e pu r pose t o iden t if y t h e act iv it ies
per for m ed by nur ses and evaluat e t heir developm ent .
The r esult s of bot h st udies w er e com par ed and it w as
t h en con clu d ed t h at , alt h ou g h m or e t h an 2 0 y ear s
h av e passed, m ost of t h e act iv it ies per for m ed w er e
cent er ed on bur eaucr at ic m anagem ent ( 43.4% ) . When
invest igat ed( 3) as t o w hat act ivit ies t ook m ost of t heir
t im e, n u r ses, on ce ag ain r ep or t ed , am on g ot h er s,
t hose w it h an adm inist rat ive and bur eaucr at ic nat ur e.
The aut hor expr esses her concer n about t hat sit uat ion
an d st at es t h at a lot of h esit at ion s an d u n cer t ain t y
st ill persist in nurses’ daily conduct ; t hat t he problem s
point ed out in t he past st ill ex ist at pr esent . Finally,
she assert s t hat w e “ st ill experience t he old dilem m as
of our pr ofession”.
Based on t he infor m at ion abov e, w e believ e
t hat it has been possible t o configur e t he m anagem ent
per for m ed by clinical nur ses unt il now . Ther efor e, it
can be under st ood t hat such m anagem ent has been
m ainly char act er ized by t he accent uat ed com pliance
w it h t o pr e- est ablish ed n or m s in agr eem en t w it h a
r eit er at iv e pr ax is.
An im it at ive or r eit er at ive pr axis is based on
a pr ev iou sly ex ist in g cr eat iv e pr ax is, “ fr om w h ich it
t akes a r uling nor m . I t is a second- hand pr axis w hich
does not pr oduce a new r ealit y, does not pr oduce a
q u alit at iv e ch an g e in t h e p r esen t r ealit y, d oes n ot
t r an sf or m cr eat iv ely, alt h ou g h it m ay con t r ib u t e t o
en lar ge t h e ar ea of w h at h as alr eady been cr eat ed
and, t herefore, t o quant it at ively m ult iply a qualit at ive
change t hat has alr eady been pr oduced. I t does not
cr e a t e ; d o e s n o t ca u se a n e w h u m a n r e a l i t y t o
em erge, and t hat is w here it s lim it s and inferiorit y in
r elat ion t o t he cr eat iv e pr ax is lie”( 4).
Next , w e w ill pr esent consider at ions t hat can
pr ov ide a basis for t he w or k of nur ses ar t iculat ed t o
t h e cr eat iv e pr ax is.
N U RSES’ M AN AGEM EN T: D ELI N EATI ON
ARTI CULATED TO THE CREATI VE PRAXI S
Wit h t he invasion of post - m oder nit y affect ing
sciences, t echnology, art s, t hought s, as w ell as social
and individual spher es, a new envir onm ent and a new
condit ion for m an began t o be configur ed. The post
-m o d e r n e n v i r o n -m e n t e x p r e s s e s t h e p o w e r o f
elect r on ic t ech n olog y in ev er y d ay lif e t h r ou g h t h e
sat urat ion of inform at ion, ent ert ainm ent and services.
I n t h e econ om ic con t ex t , it r ep r esen t s t h e
per sonalized consum pt ion, w hich seduces indiv iduals
t o it s hedonist m or al, t hat is, seek s m an’s seduct ion
t h r ou gh v alu es based on t h e pleasu r es ar isin g fr om
using goods and ser v ices. The post - m oder n condit ion
r eflect s in div idu als’ difficu lt ies t o feel an d r epr esen t
t o t hem selves t he w orld in w hich t hey live as not hing
has a definit e ident it y( 5).
Po s t - m o d e r n i t y i s s t i l l o b s c u r e i n o u r
envir onm ent , but it has alr eady invaded t he developed
societ ies t hat are fundam ent ally t ied t o t his new age,
t h e Ag e o f I n f o r m a t i o n , i n w h i ch k n o w l e d g e a n d
i n f o r m at i o n ar e t h e p o w er f u l so u r ces t o g en er at e
w ealt h .
Th ese p er sp ect i v es b r i n g a ch an g e i n t h e
p ar ad ig m of or g an izat ion s. As in st it u t ion s t h at ar e
r epr esent at iv e of an Age, or ganizat ions in dev eloped
cou n t r ies began t o u n der go t r an sf or m at ion , t h at is,
r eal r evolut ions t hat have been paved by globalizat ion,
b y t h e p o w e r o f i n f o r m a t i o n t e ch n o l o g y, b y t h e
collapse of t he hier ar chical st r uct ur e, by dow nsizing
and, now , by t he at t ent ion t o m an’s need t o giv e a
m eaning t o life, t hus r e- encount er ing hum anit y.
I n t he Brazilian case, inst it ut ional boundaries
need t o be m or e per m eable so t hat or ganizat ions can
b e c o m e p r e p a r e d a n d c a p a b l e , a i m i n g a t t h e
im plem ent at ion of t he changes r equir ed by t he new
w or ld cont ext and t hus adapt t o t he new or der w hich
“ i s n o t a m er e t en d en cy, b u t r at h er t h e r esu l t o f
pow er ful and uncont r ollable for ces. . .”( 6).
As an organizat ion rendering healt h services,
h o sp i t al s m u st al so em b r ace t h i s t ask i f t h ey ar e
w illing t o com m it t o new ex pect at ions. I n t his case,
o u r a t t e n t i o n i s f o c u s e d o n n u r s e s ’ m a n a g e r i a l
behav ior in t he clinical pr act ice.
Assum ing t hat people ar e our m ost im por t ant
a s s e t , t h e i m p o r t a n c e o f h u m a n c a p i t a l , o f t h e
st r uct ur al capit al and of t he client ’s capit al has been
em phasized. I n int egr at ion, t hese const it ut e t he asset s
of know ledge, t hat is, of an organizat ion’s int ellect ual
capit al. Hum an capit al is t he source of innovat ion and
r en ov at ion ; h ow ev er, “ in t elligen t in div idu als ar e n ot
sy nony m ous t o int elligent com panies”( 6). I n t his way,
t he st ruct ur al capit al m eans t he lever ing of know ledge,
it s sh ar in g an d t r an sm ission am on g people t h r ou gh
st r u ct u r al i n t el l ect u al asset s, su ch as i n f o r m at i o n
s y s t e m s , d a t a b a s e s , g o o d m a n a g e m e n t , a m o n g
ot her s, w hich “ t r ansfor m indiv idual k now - how int o a Rev Lat ino- am Enfer m agem 2006 m aio- j unho; 14( 3) : 457- 60
w w w . eer p. usp. br / r lae
Nur ses' m anagem ent in t he clinical...
4 6 0
g r ou p ’s p r op er t y ”( 6 ). Th e clien t ’s cap it al m ean s t h e
v alu e of t h e r elat ion sh ip s b et w een an or g an izat ion
and it s client s.
Nursing organizat ions represent a fert ile field
for t heir m em ber s t o becom e w or k er s of k now ledge
and m anaging nur ses com m it t ed t o t he dev elopm ent
of hum an capit al, of t he st r uct ur al capit al and of t he
cl i e n t ’ s ca p i t a l , w h i ch p o t e n t i a l l y co n st i t u t e t h e
int ellect ual capit al of such or ganizat ions.
I n t h is sen se, n u r ses’ m id d le m an ag em en t
posit ion in hospit al or ganizat ions places t hem at t he
c e n t e r o f l e a r n i n g a n d k n o w l e d g e d e v e l o p m e n t
p r o c e s s e s t h a t a r e e s s e n t i a l f o r a c q u i r i n g
com p et en cies w it h a v iew t o t h e q u alit y of p at ien t
c a r e . N u r s e m a n a g e r s a c t a t t h e v e r t i c a l a n d
h o r i z o n t a l c r o s s r o a d s o f i n f o r m a t i o n a t t h e
h o s p i t a l i z a t i o n u n i t , w h i c h t u r n s t h e m i n t o a
com m u n icat ion lin k age bet w een h igh adm in ist r at ion
and fr ont line w or k er s( 7).
Thus, t her e is a need t o st im ulat e t eam w or k
and ot her social form s of lear ning in or der t o develop
hum an capit al w hich t hen begins t o shar e t alent and
know ledge. The best st r uct ur es ar e t hose t hat pr esent
few er obst acles and, t her efor e, easier t r ansit , as w ell
as t hose w hich allow , as far as possible, w ork direct ed
t o t heir client s( 6). The r esult of t his lear ning pr ocess
f av or s ch an ges in or gan izat ion s’ beh av ior.
B y c o n t e m p l a t i n g n u r s e s ’ m a n a g e m e n t
ar t iculat ed t o t he cr eat ive pr axis, w e under st and t hat ,
i n v i e w o f t h e e x p e ct a t i o n s o f co n t e m p o r a n e i t y,
m anaging infor m at ion and k now ledge becom es t heir
m ost im por t ant t ask, alt hough t o do so, t hey begin t o
depend on new abilit ies. The goals and st r at egies of
t h i s m a n a g e m e n t i n cl u d e t h e se a r ch f o r o p t i m a l
r e s u l t s , t h e d e v e l o p m e n t o f i n t e r d e p e n d e n c e
aw ar en ess, t h e com m on v iew of t h e in t er est in t h e
s e r v i c e ’ s o b j e c t i v e s , t h e v a l o r i z a t i o n a n d
im p lem en t at ion of cr eat iv e d ecision s m ad e b y t h e
t eam and t he t eam ’s involvem ent w it h new know ledge.
S u c h g o a l s a n d s t r a t e g i e s a r e r e f l e c t e d o n t h e
m anager ial pr oposals of t he cont em por ar y par adigm
and on creat ive praxis, w hich is det erm inant , since it
enables m an t o face new needs and new sit uat ions.
Finally and above all, t he m anager ial pr act ice
t hat w e aim at finds an essent ial dim ension in hum an
v al u es.
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Recebido em : 16.1.2006 Apr ovado em : 28.4.2006
Nur ses' m anagem ent in t he clinical...
Tr evizan MA, Mendes I AC, Shinyashiki GT, Gr ay GI .
