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Introduction
Professions are activities that have emerged through the uniqueness of the occupational groups. Such groups construct a characteristic professional identity by means of a movement among internal and external elements that include the historical trajectory for each profession, the peculiar labor culture, the specific knowledge and the peculiar language. 1
The identity of a profession is anchored in social identification and is situated in the dynamic intervals between the social identity attributed by the others and the social identity attributed to the others. For such, it can not be mixtured with personal identity or with a group identity (collective belonging identity). 2,3
Such a concept, when taken to the Nursing area, more specifically for professional nurses working in managerial positions, derives in an identity-related plurality around that professional.
Throughout nursing historical trajectory, its epistemological assumptions have been and are being transformed in an attempt to (re)model health and care context. 4,5
In this aspect, much is discussed about the identity-related configurations of the nurse working in different contexts, since that in order to approach the said theme “implies to transit through a series of events conjugated over time”, (6: 2) which makes it possible to observe the misunderstandings on the activities developed by the nurses. 7,8
The nurse identity-related nuances were based on the vocation’s symbology, since their qualification was directed towards moral conduct, sometimes even in detriment of knowledge. 9
Nurse related activities flow together in actions that are not only caring, but also in the managerial behaviors that, to a certain extent, are related to the role and attributions of the said professional.
Structuring the managerial nurse identity attributes requires careful analysis based on scientific methodologies. In that direction, it is possible to use the concepts of the Structural Dialectic Care Model (SDCM), because its principles are based on social structures through the socialization process; therefore, it is possible to ascertain the aesthetic standards of cares from the point of view of professionalism, humanism, technology essence, among others, and thus transpose these concepts into the professional identity logic, 10 which makes it possible to reflect on the object of the study under a historical-contemporary cultural dimension.
Therefore, this study aims to identify, in the scientific literature, the identity-related configurations inherent to the managerial practices of nurses working in a hospital environment and to analyze them in the light of the SDCM.
Materials and methods
This is a qualitative research. An integrative review was performed as a method to reach the study objective, since that it allows for criticizing, evaluating, synthesizing and glimpsing evidences being inherent to the themes. 11
In this way, six steps were performed. The first was identifying the theme and selecting the research question: “According to the structural contributions of the SDCM, what are the identities models of nurses performing managerial actions in hospital institutions?”. The second step consisted in the inclusion and exclusion criteria (Figure 1). By that, the following inclusion criteria have been considered: Publications in Portuguese, English or Spanish, without restriction on publication time. As exclusion criteria: Repeated publications, abstracts, editorials, chapters and books, theses, dissertations, course conclusion papers and studies that did not address the proposed theme. The other steps consisted in defining the information to be extracted from the selected studies, evaluating the selected studies, interpreting them and displaying the data that was found. 11
Survey of the productions was carried out on November 2018 by consulting the Virtual Health Library (VHL), in the Bibliographic Database on Healthcare in Latin America (CUIDEN) and PubMed; in February 2019, in the databases Scopus and Web of Science.
For the selection of the studies where used the Health Sciences Descriptors (HSD) and the keywords, with which it was possible to carry out an advanced search from the Boolean operator “[AND]”, with the descriptors in Spanish for the CUIDEN and the VHL: rol de la enfermera, administración de enfermería AND enfermeros; with available as filter and Nursing professional role as main subject.
In PubMed, the search strategy occurred with the following descriptors: nurse’s role, hospital administration, hospitals and nurses.
In Scopus, the strategy was accomplished as follows: Nurse’s AND role AND organization AND administration AND nurses; with the filters: Nursing only articles; fully available and with the keyword: “Organization and management”.
In the Web of Science, the strategy was carried out as follows: Nurse’s role AND (“hospital administration” OR “hospitals administration” OR “hospital management” OR “hospitals management”) AND nurses.
Thus, 226 articles were found, of which 15 were selected and comprised the established pre-inclusion criteria (Figure 1).
After searching, deleting and selecting articles, codification and identification of the selected ones was carried out, as shown in Table 1.
Table 1 Coding and displaying of the selected articles, followed by the number displayed in the selection order
Source: Own elaboration.
The selected articles were analyzed from the viewpoint of the SDCM. Such a model was built based on the contributions of functionalism and structuralism. However, its origin comes from the thesis named Family structure and social function of woman in Alicante 1868-1993. The axes of the referent method, for data analysis, are subdivided into Functional Unit (FU), Functional Framework (FF) and Functional Element (FE). 10
The FU dwells on the basic social structure of socialization, where it brings together elements referring to beliefs, values, feelings and knowledge. Each of them focuses on a specific way of organizing and founding nursing: Domestic, religious, technical, professional and humanist”. (10:303)
In the FF, information related to the scenarios, rooms or places where the nursing activities are developed is gathered, such as: Hospitals, outpatient clinics, among others. 10
The FE groups data related to the people involved in the socializing scenario and who are in charge for the care. 10
The structures of the SDCM are grouped in Table 2 and represent the aesthetic standards in nursing cultural history.
Thus, after reading and re-reading the elected articles, it was possible to answer the guiding question proposed in this study.
Results
Fifteen articles composed the sample of this literature review. From these, it was possible to identify the components of the SDCM methodology - the FU, the FF and the FE -, as shown in Table 3.
Table 3 The selected articles were within the inclusion criteria from the SDCM perspective
Source: Own elaboration.
From the 15 selected articles, 9 had a central focus on leadership; 5, on care, and 4, on conflicts.
The studies that approach the subject leadership (T1, T2, T3, T4, T5, T6, T7, T14 and T15) bring about this competence, which evidences that the majority of the nurses who are in command and leadership position are female, and that a good part has one or no children at all. Some studies have positive and negative aspects related to leadership deficiencies or its lack.
In the category care, studies T7, T8, T9, T10 and T11 were found, which bring about another identity-related dimension found in the activities of the managerial nurse. Much of it points out the importance of nurses to articulate on care and management.
The conflicts axis was evidenced in four studies (T2, T11, T12 and T13). Some pointed out to the need and difficulties for interpersonal relationships, which impact on conflict management.
The cited categories (leadership, care and conflicts) were subsidized by the SDCM, which assisted in identifying the identity-related nuances of the nurse as a managerial agent.
Discussion
The professional identity of the managerial nurse has been placed here as the main research object for the FU, articulated to the hospital context (FF) and the FE; managerial/care nurse.
The leadership theme is widely discussed, since that most of the selected articles denote such competence, which emphasizes that this knowledge considerably integrates the nurse’s vital and essential skills.
Leadership, treated here as one of the nurses-related identity-related nuances, adheres to the FU which, as seen, constituted a basic social structure that, in this case, brings together values, feelings and knowledge. To obtain leadership, it is necessary to have abilities that allow the group to pursue common goals, exerting influence with intentional actions on its followers, which provides transformations in the work environment. 28-30
Values are qualities perceived by the expressed essence, as for example in a work of art, the melody of a song, the tenderness of a mother caring for her children and, 31 in this case, the nurse’s professionalism holding the technical-scientific knowledge for being able to lead. Thus, the set of values through which leadership leads focuses on self-discipline, honesty, commitment and mutual growth, and should not be confused with a posture of power and authority. 32
The leadership praxis assists the nurse in making decisions 33 and in professional recognition 13, although this may turn back to acceptance by the people and to the popularity of the leader. 16
It is important to emphasize that nurse competences in Brazil, recognized by the National Curricular Guidelines (NCG), consider lifelong education, communication, administration and management, decision-making, healthcare and leadership as general and specific skills for the nurse’s work. 34
To such an effect, it is pointed out that nurses need to possess and develop identity-related characteristics based on leadership, since that this competence is addressed even before they act effectively in their area.
It is believed that the nursing worker develops their professional identity even before entering in nursing, being transformed with years of studies and clinical experience, evolving throughout the career. Education and scientific research are portraits of this manifested identity and simultaneously influence such construction. The constitution of a set of concepts developed by each professional regarding the nursing role in society can be worked on for maintaining students and nurses in healthcare services. (35:2)
It should be evoked that the nurse professional identity begins at the undergraduate level, but is built up and consolidated from their performance in their knowledge field, given the interactions accomplished in the ambiance where they exercise their function, when interacting with the other actors included in the same scenario, 36 because, when practicing their role, the professional brings out identity models that are mediated by the dynamics of the biographical and relational transactions. 2,3,37 Therefore, “the identity is never given; it is always constructed and must be (re)constructed in a greater or lesser uncertainty and more or less lasting”. (2:135)
The FE, in the leadership category, points out to the social actors in charge of the activities developed by the professionals. Most of the studies selected in this study indicate that it is the nurse having adequate competence to lead, even in the view of the components that interact with them during their work, as, in the case, of the nursing auxiliaries and technicians, as studies T5 and T7 demonstrate.
It should be pointed out that nursing auxiliaries and technicians are professionals with complete school education who have accomplished a specific course to work in the said profession. The nursing auxiliaries accomplish mid-level activities involving “auxiliary Nursing services under supervision, as well as participation at the level of simple execution, in treatment processes”. The nursing technician also performs mid-level activity, but carries out activities involving “orientation and follow-up for Nursing work in an auxiliary degree, and taking part in the Nursing care planning”. (38:9273)
As said before, most of the studies selected in the leadership FU pointed out to the large contingent of female nurses. To such an effect, it is indispensable to recall factors related to gender that may, in some way, contribute to the problems in the process related to leadership and professional identity.
Gender issues in the Nursing context often define the professional aesthetic standard due to the “logical conformism” that was settled along the historical trajectory in this said area under a cultural perspective 31 where care was adequate only for women, because, very often, the characteristics of the woman/nurse were emphasized in the subject related to subservience, sweetness and femininity aspects, now legitimated by the Church and sometimes by the State, thus contributing to the invisibility of the nurse professional work because it is linked to the causal vicissitudes by virtue of gender.
From this point of view, Nursing history was narrated through various disciplines, such as Sociology, Medicine and History, which then emphasized the characteristics of religious and subalternity origin, and then of immorality and profanity. Such a story had not yet been told by the women, acting effectively and actively in the profession, which caused a social imaginary that led to the non-recognized identity for the nurse profession. 39
It is known that gender, perceptions, and identities related conceptions are often constructed through stereotypes. In this way, actions and skills are assigned to each individual within a society and culture; the leader role is one of them, since many societies point out men to be with a greater capacity to act in that position, and that women should be focused on care. 40,41
It is important to emphasize that there is a large presence of women in courses focused on health and education (biological and human areas), while there is a greater contingency of men in the exact areas. 42,43
Thus, in the leadership issue, articulating the object of study as professional identity to the SDCM, the FU reveals that this practice is treated as an essential nurse related competence, which needs understanding and perception on this ability on the part of the actors socializing with the nurse, to perform this incumbency in accordance with an adequate model, style, behavior and liberal strategies, according to the prescribed reality, irrespective of the area related to their performance in the various FFs, public, educational, university, philanthropic or federal, and regardless of whether they perform managerial or assistance activities, as seen in the FE.
Entering the care category, it is relevant to point out that Nursing, considered one of the oldest arts and the most modern science, is known by the pre-professional and professional frameworks. 44
Nursing is intrinsically entangled in the field of cares, which, initially, were denoted by means of survival actions to perpetuate and preserve the species. 45
Cares were shaped according to the social pattern of each era and each scenario, which brought about gaps in the perspective for professionalism, since that the genesis of the practices in this area relied on religious and maternal ideologies. 46 Such a scenario has been observed since the beginnings of the so-called Modern Nursing, 45 when Florence Nightingale claimed to have received a “call from God” to care for the wounded soldiers in an English military hospital. 47
The historical-cultural process on nursing care underwent several transformations. Initially, feelings and values in this area were based on maternal care aesthetics. With the advent of critical and feminist thinking, this profession underwent a process of deconstruction, 48 where feelings and values gradually became grounded in science, technology and professionalism. 31
The hospital, in the FF prism, constitutes a primordial environment when it comes to the Nursing care ideology, whose aesthetics responds to the FU characteristics. Society itself associates the image of a nurse as a caregiver agent acting primarily in hospital environment. It is true that many nurses carry out their professional activities in this area, but care should not only refer to this FF, be it philanthropic, general, or university-related, since that nurses can perform care activities in several areas, in the health-related promotion and prevention ambience.
The FU, on this axis, points out to the nurse identity-related nuances in the logic of care and management articulation and in the direct and indirect care, given that care represents a form of “curative power”, as listed in this SDCM component, highlighted specifically in the study T9.
It is important to highlight that understanding the “power” of the nurses in the study T9 is that acting in management brings out visibility to the nurse, but this only occurs because the nurse exercises an administrative activity that legitimizes them. Their action in care also demonstrates the meaning of the “cure power” yet, even so, such an element is almost invisible in this FF: The hospital.
The FE, in this category, reveals that care is developed and perceived by the social peers involved in the nurse role in action. This unit expresses “the motivation for pre-professional and professional cares, based on an aesthetic that is a product of coexistence and of the group’s socialization process”, (31:6), which allows us to uncover the roles, norms, values, and beliefs, among others.
In the conflicts aspect, in general, interpersonal relations are inserted, since that attitudinal and dialogical actions may be divergent. To that end, the FU reveals that one of the nurse identity-related characteristics is to mediate/manage conflicts in the proposed FF - hospital - be it university or for public education.
Conflicts occur when there are external and internal incompatibilities, because there are different ways of thinking and different feelings, values and beliefs in each individual. 49-51
For being the professional incumbent on managing the services and mediating the relationship among the professionals, in their work environment, the nurse is able to face conflicts among the managed professionals and to be the mediator for the resolution in these situations. (49:420)
Social conflicts are associated with the social actors that shape FE, fundamentally related to cultural identities and not only by their strategic interests.
Conflict management within the FF (hospital) can often lead nurses or their staff to dissatisfaction and frustration. This can impact on the nurse professional identity, because this may emphasize dual feelings on the effect of knowing what kind of professional they are and what is their place in a given environment, in addition to emerging internal questions related to the lack of need to accomplish their care and management aspirations. 52
These are moments, such as those presented above, where the professional may experience an identity-related crisis, 2 since that this arouses a devaluation feeling. Therefore, it is fundamental to understand how the transactional movements inherent to the representation of a profession occur in the attempt to evidence an ideal identity-related image of the nurse.
Conclusions
This study aimed mainly to identify, in the scientific literature, the identity-related configurations inherent to the nurse managerial practices working in the hospital environment and to analyze them in the light of the SDCM.
From this, it can be concluded that the SDCM and its structural constructs (FU, FF and FE) offer subsidies to understand the subject at issue, since that, without the socializing action of the related units, it is often not possible to perceive the identity-related nuances through which the singularities of the nurse in their managerial and curing role.
Thus, SDCM analysis made it possible to highlight three themes (leadership, care and conflicts), which allowed a critical-reflexive discussion about the work and the professional identity-related to the managerial nurse.
Thus, it is concluded that the SDCM made it possible to ascertain the nurse identity-related nuances, as a managerial agent, in the various pluralities articulated with the work process of this professional.
