ORIGINAL ARTICLES

The education of healthcare management: a view from the graduates – Grounded theory

Iraci dos Santos¹, Alacoque Lorenzini Erdmann², José Luís Guedes dos Santos², Patrícia Klock², Vilma Villar Martins¹, Euzeli da Silva Brandão³

¹Rio de Janeiro State University
²Santa Catarina Federal University
³Fluminense Federal University

ABSTRACT
Aim: To understand the views of nursing students about the education of healthcare management in terms of their academic background. Method: this is a qualitative study developing theory based on a data approach. The data was collected through semi-structured interviews with 18 students of two different Brazilian universities. To analyze the information, we used open, axial and selective codification. Results: the identification of defined categories: recognizing the interconnections among the subjects helped the client as a whole; associating healthcare management to the understanding of the real physical and mental necessities of the client; understanding healthcare management as a wide and complex activity related to the direct and indirect healthcare of the client, and; related to the fact there is a higher emphasis on the theoretical content compared with the practical, especially regarding healthcare management, which empowers the client with a more humanized and more complete healthcare service. Conclusion: the students understand that management, in the face of institutional demands, is a strategy to develop better healthcare.
Keywords: Management; Nursing; Nursing Care; Education, Higher.

INTRODUCTION

Historically, to take care and to manage constitutes the most important dimensions of nursing but, on the other hand, they are not articulated processes. Nowadays, there has been the rise of a new paradigm which refers to healthcare management focused on nursing caretaking practices, from a perspective that articulates management and assistance, centered on the healthcare service used, and on the preoccupation with an approach that goes beyond the technicalities, towards a full service⁽¹⁾.

Therefore, the term healthcare management is related to the articulation between the managerial and the assistive dimensions of the work of the nurse, in a way that management can be considered a mid-level activity that creates and implements ideal conditions in order to achieve the end-activity, specifically, healthcare^(2-3).

The complexity of healthcare management is well known, as it deals with the management of micro- and macro-environments where clients are located, such as hospitals, clinics, polyclinics, emergency care units, local communities, family health units, home care assistance, and is particularly associated with considering the steps of strategic planning to maximize client healthcare, wherever this client is.

As mentioned here, it seems that such complexity is non-existent, because both sides merge to better respond to the necessities of the client. However, the professionals who have experienced management - considering it a non-transferable task and inherent to the nurse, more than to any other health professional - found themselves in difficulty when being involved, including the fact of dimensioning it in the complementary parts of attending/caring and attending/managing⁽¹⁾.

In this study we intend to consider healthcare management as an indivisible task, either when it is performed in a therapeutic environment, in the micro-environment of the client, or even when systematizing nursing healthcare, in that the nurse provides direct and indirect healthcare to the client⁽⁴⁾. Certainly, such a consideration can be supported by other citations,^(1,3-4) related to the creation and implementation of the ideal conditions for the production of healthcare, the performance of the healthcare team and the interventions needed to create an integrated healthcare service for the final user. 

Therefore, nursing healthcare management can follow the propositions with regard to public policies from the Brazilian Ministry of Health regarding the many collectives/teams implicated in the managerial and health production practices aimed at overcoming any limitations, and to create new organizational possibilities for institutions and modes of healthcare production, by implementing the necessary conditions for this sort of production⁽⁵⁾.

Thus, nursing healthcare management mobilizes the actions in connections, interactions and associations among people as complex human beings, either because they are interdisciplinary professionals, or because they are clients.  This culminates in complex practice, involving steps such as managing the caretaker/student/researcher, taking care managing/studying/researching, educating caring/managing/building knowledge and articulating the many diverse hospital and para-hospital services, looking to qualify the healthcare service provided as a right to the citizen-user^(6-7).

In the literature review, it was observed that the managerial dimension of the nurse’s work is seen by this professional as a bureaucratic task, unrelated to healthcare production⁽⁸⁾. This happens because the separation between management and healthcare, based on the historical influence of models such as Taylorism/Fordism or classic and bureaucratic administration, which are still in vogue in terms of organizing and managing the health sector^(9-10).

The fact is highlighted that, during the daily work routine, the nurse faces institutional challenges regarding the difficulties and amenities, and professional recognition, due to his nursing background, that focuses on solving the demands of the clients and the health institutions. Consequently, it is important to construct and reconstruct more adequate formats to take care of these demands⁽¹¹⁾. However, the reconstruction of this to do/to make must give some privilege to the technological fundamentals for healthcare management, aimed at widening the visibility of nursing activities⁽¹²⁾.   

Then, the need to incorporate new understandings and abilities to the managerial activities of the nurse outweigh the relational, ethical, political and humane competencesM⁽⁷⁾ To incorporate such competences, we need to rethink the formation of this professional, aiming to overcome the dichotomy between healthcare and management, and then introducing diversifying experiences throughout the college years, especially for positions of leadership in a nursing team⁽⁸⁾.

It is important to remember that, in Brazil, the curricular changes and leaning outcomes proposed for courses in the area of health, aim to meet the health needs of the population and to consolidate the Brazilian Unified Health System (SUS, in Portuguese), increasing access to the population and the area of coverage⁽¹³⁾.

From this perspective, the questions of this study were developed: What are the students’ views about their learning experience in terms of healthcare management in nursing? How do undergraduates see their professional construction in terms of healthcare management from the public policies scenario and the complexity perspective that involves healthcare and nursing practices?

This study aimed to understand the views of nursing students with regard to their professional development in order to manage the healthcare service provided to human beings under public policies, based on its complexity.

We adopted the theoretical reference proposed by Edgar Morin ⁽¹⁴⁾, of a complex thought in a Latin etymological sense of the word complexity, which refers to “…what is fabricated in a group”, and questions the principles of disjunction, reduction and abstraction that contribute to the fragmentation of knowledge in subjects, under the auspices of a paradigm of simplification. Such a paradigm states, “…the group of principles of intelligibility that come from the classical scientificity, and that, as connected to one another, produce a simplified conception of the universe (physical, biological, anthropo-social)”(14:330).

Based on this thought, the above-mentioned author⁽¹⁴⁾ invites us to give an account of the separation between knowing and making, articulating the world of ideas with the world of life. The logic behind this complexity twists the many supporters of the Cartesian ideology, subverts the logic of the order of knowledge, denounces the unpredictability of the understanding and the connection to life, breaks the barriers between the producer and the product, cause and effect, in order to construct a body of information which is open to experimentation⁽¹⁵⁾.

METHOD

This is a qualitative study, based on the Theory Based on Data approach (TFD, in Portuguese), which uses a group of systematized proceedings to investigate a certain phenomenon through the production and analysis of data simultaneously⁽¹⁶⁾.

This is an inter-institutional piece of research between the Nursing Department of the Santa Catarina Federal University (UFSC, in Portuguese) and the College of Nursing of the Rio de Janeiro State University (FENF/UERJ, in Portuguese), and is part of the proposed project by the Study and Research Group in Administration, Healthcare Management and Educational Management of Nursing and Health (GEPADES/UFSC, in Portuguese).

In this research, 18 nursing students participated. These were divided in three sampling groups, depending on the phase of the College course they were involved in: five students were in the initial semesters, seven were in intermediate semesters and the final six were in the last semesters of their undergraduate course. The sampling groups were composed of students from both institutions, because one of the TFD main elements is the concept of theoretical sampling, which recommends the process of data collection aiming to find places, people or happenings that allow the discovery of variations among concepts and the densification of categories, their proprieties and dimensions, according to the need for information that arises throughout the research⁽¹⁶⁾.

The data collection happened from August 2011 to March 2012, through the use of a semi-structured interview.  This had a designed thematic axis which was discussed with the participants of the study.  They expressed themselves and responded to the researcher’s questions ⁽¹⁶⁾. The interviews were performed individually, using a prepared guide, and included the following questions: how do you perceive the correlation between healthcare management and nursing? How have you lived/experienced the learning of healthcare management and of nursing during your time at college? How is this topic presented-focused-discussed-taught in the classroom, in practical classes or in an internship program? How do you view your college education regarding healthcare management?

The interviews lasted around 30 minutes and were recorded using an electronic audio device. Those recordings were stored on CDs and were also fully transcribed. The data were analyzed through a process of a constant comparative analysis, in steps involving open, axial and selective codification.

With regard to open codification, an attentive and detailed job was done. The researcher codified each incident in all possible analytical categories, closely questioned the data, in an attempt to comprehend their meaning from the answers given by the students. In terms of axial codification, the codes were regrouped in terms of their conceptual similarities and differences, thereby generating categories with temporary and more abstract names that the codes themselves.

The interrelationships among the categories and their subcategories delimits a step recognized by the inductive-deductive movement, demanding a degree of reflection and theoretical sensibility on the part of the researcher. Subsequently, using selective codification, there was an integration and refining of the categories, which were organized by considering a central explanatory concept⁽¹⁶⁾.

In terms of the ethics aspects, details of this project were sent to the Ethics in Research Committee of the Santa Catarina Federal University, approved under protocol 996/2010. The participants of the research were informed about the proposed objectives and methodology, and were assured of their right to access the data. Besides that, they signed the Free and Clear Consent Agreement, guaranteeing their autonomy, anonymity and answers with regard to the research. It is important to mention that the recordings of the interviews were deleted after they were transcribed.

After the integration and refining of the categories based on a central explanatory concept, we describe the two emerging categories from the answers given by the students with regard to questions 1 and 3 in that order: what are your views about the teaching of healthcare management and nursing during your college education? How has this topic been developed, focused, discussed and taught in classrooms or in practical education and/or internship, throughout your undergraduate course?

The answers given generated four categories: 1) Recognizing that the interconnections between the subjects support the views of the client as a whole  ; 2) Associating healthcare management with the discovery of the real physical and mental necessities of the client; 3) Understanding healthcare management as a vast and complex activity related to the direct and indirect care of the client, and; 4) Indicating that there is a greater emphasis on theoretical content compared with practical content regarding management, which is made up of the following phenomenon: Understanding management as a strategy that empowers a humanized and complete healthcare service regarding the client. Next, we describe these categories.

The category Recognizing that the interconnections between the subjects support the views of the client as a whole, highlights that, despite the fragmentation of the syllabus for didactical purposes, there is an equal necessity to merge knowledge acquired from the many subject areas offered during the undergraduate nursing course, aiming to provide a substantial healthcare service, considering also the human physical, mental/emotional and spiritual aspects, as observed in the following testimonies:

[...] we always try to link the subjects. This is good because we know the human being is not divided, he is a complete being. (Student A)

We observe, in the discourse from student A, that there is a necessity to merge and complement the acquired knowledge in many subjects and, among those, the nursing assistance administration, which has a practical application in terms of healthcare.  This was also observed on the following statement:

] we usually mix all disciplines during the assisting care practices. (Student C)

Management was mentioned as essential to provide an effective healthcare service

] I don’t think you can provide a service without management. (Student G)

In the category entitled Associating healthcare management with the discovery of the real physical and mental needs of the client, the students reveled the necessity of evaluation and personalized care, highlighting the application of the systematization of nursing assistance.

[...] We have to provide a humanized care and a whole perception of the client. (Student A)

Yeah, I agree with that ] following steps, do well what the patients need. What can we do for him? How is the best way to take care of him? ], many times [the user] has some sort of mental health problems and needs more than just a conversation, a dialogue. (Student H)

In the other category, Understanding healthcare management as a vast and complex activity related to the direct and indirect care of the client, the responses reveals the controversies arising from the learning of the students regarding healthcare management., From the comments of the students, we can identify a division related to the comprehension of the above-mentioned management, when we contrast one of the speeches, the sovereignty of the nursing team management, under the responsibility of a nurse for the direct healthcare of the client.

In this context, the mistake is revealed in terms of the possibility of managing the healthcare service without knowing or responding to the real necessities and desires of the client, which is the main aim of nursing care. Such a fact can be seen from the following speech:

I believe that the meaning of healthcare management is vast and complex… we can be direct and indirectly in nursing team leadership; we need to manage the people who are with us ]. (Student C)

It has been here since the basic care, and then suddenly, we use it in a FHP [Family Health Program], or in a clinic, or yet in a more complex structure, like a hospital, where you have to organize the supplies and manage the human resources, and even the direct contact with the client. I think that if you don’t have something organized, it becomes too confusing, each one that comes to work in a certain section does it in a different way, and then the caring is not as careful as it is supposed to be. I think it ends up being harmful to the client somehow. (Student A)

] we are providing healthcare treatment to the client because we are able to manage the people who are in contact with the patient.  It is not necessarily the case that we are going to be directly managing the treatment, but the people involved in this process. (Student F)

For me, healthcare management is really important: the direct treatment of the patient; the attention he needs, at the right time, the availability of supplies so I can do the right proceedings at the right time; the good harmony in the team so that assistance is well done; a good inter-relationship between the sectors so that we can all work together and in the best shape, and all that to provide the best results for the patient. (Student H)

Healthcare management would involve attention to all the methodological processes that you choose, in terms of any nursing theory or technique. And it would also be the implementation and evolution of these healthcare proceedings. The registry of the caring you provide ]. (Student I)

] healthcare management is to try to organize and manage all these factors that you have inside of a hospital to better aid the patient. (Student J)

Regarding the question to the students about their experience/teaching experience/healthcare management learning, we called attention to the category Indicating that there is a greater emphasis on theoretical content than on practical content regarding management. The responses are as seen below:

From my point-of-view, this is a task for the teacher. I think this is a new content. I think the teacher who is running the classes also needs to make it interesting for the students and he also needs to link the various aspects so that we are not only focused on the administrative and bureaucratic part, but also on the caring, which is what nursing is for. (Student D)

] That’s what I feel. Sometimes, the practice is missing [...]. The theoretical content is beautiful, great. Read the board, the articles, but, for us, the practice is still missing. (Student E)

The complementarity between the theoretical content and the managerial practices was illustrated by one of the students when he mentioned that, besides all the theoretical content regarding human resources and personnel management, the learning of “how to prepare a work schedule” happened during a supervised internship during the classes associated with Administration and Management in Nursing and Health:

With regard to the part related to human resources, I think they [the teachers] should have prepared more practical activities aimed at real situations ]. We even had a fake schedule to prepare ]. But I only learned for real how to prepare a working schedule during an internship. (Student R)

The students consider management to be an important dimension of their work as nurses, and recognize that, throughout their undergraduate nursing program, they do practice some managerial tasks, but without any theoretical discussion and without going further into the topic. This is done, as the participants of this study mentioned, in the last semesters of their courses.

I’ve heard [about the importance of nursing management] and I asked the teacher to explain it better, and the answer I got was that I was going to learn that on the seventh semester, by the end of my course ]. (Student C)

On the other hand, by the third semester we see something, to have everything organized. This is managing somehow. It is organization. But we don’t see this concept as part of management, there is no relationship. (Student J)

I think it is a very interesting area, but very little is taught during the course. I think we should see it more comprehensively. (Student P)

From the interconnection of the presented categories, the phenomenon Understanding management as an empowering strategy of a humanized and full healthcare provision to the client was constituted. This can be observed, from the classes of the undergraduates about healthcare management, as a necessary condition to promote a dignified caring environment, looking to the human being in his totality and complexity.

DISCUSSION

The results of this study point to the necessity to make more effort with regard to the teaching of healthcare management, aimed at the adoption of managerial models and technologies focused on the inclusion and the complexity of the therapeutic and clinic environment, not only from the point of view of the healthcare team, which takes care of the client, but also^{(1, 3-4)} with regard to the full caring for the client. Such a caring modality can be facilitated by the technological and methodological instruments present in the organization of nursing assistance^(2-3,12).

In some of the discourses we can observe a narrow view of healthcare management, giving priority to the direct care of the patient and the registering of nursing actions, which express the existing dichotomy in terms of the studied management practices. Therefore, we point out that the integration of understanding from the many subjects taught throughout the nursing course can be better valued by the teachers, alerting the students not only to their meaning, but also to their use in terms of their future professional activities⁽⁷⁾.

This will put in evidence the ethics and the aesthetics of the nursing profession beyond the dichotomy between caring and managing^(10-12).

The students who are in their senior year, understand the articulation between managing and caring in their practices when managing the healthcare procedures of the nurses, exemplifying it through the caring process itself, the coordination of the caring process with other health team professionals, and the provision of necessary supplies for quality assistance. 

Another important finding of this study is that the participating students helped to articulate their perceptions with regard to practice, and the integration with the teachers in the process of teaching/learning. Considering that the educational process is affected by the dialogue between teachers and students⁽¹⁷⁾, it is possible to motivate students to adopt better choices in terms of practices which are compatible with the philosophy and ideology of nursing, and not only those destined to fulfill the established institutional policies.

Thus, we need to highlight the contribution from the undergraduate courses and from the professional practice to the development of competencies that happen on many levels, in service management and in healthcare management. As a whole, the curricular subjects deal with the basic concepts and point out the directives for such processes. However, it is the responsibility of the teacher of Administration Applied to Nursing to discuss with the student the relationship between theory and managerial practice. This is made possible by the development of theoretical-practical activities, together with health service units that will introduce the student to nursing management practices. As a result of theoretical and reflective approximations supported by the teacher, the student will widen his understanding of the intersection between the management of the service and caring, among other objectives of the teaching-learning process⁽¹⁸⁾.

It is also the responsibility of the teachers to generate reflections on the part of the students with regard to the political dimension of the managerial process, to provide an instrument for the student to engage in critical-reflexive action regard to real work situations. This means that the student needs to understand the underpinnings of the political-ideological and economic character of the organization, of society, of health and education public policies and they should relate theories of administration with the process of the work of the nurse and the role of these professionals in a certain context ⁽¹⁹⁾.

At the same time, we report the situation of the managerial nurses of the SUS who are in relevant positions and who work predominantly as senior executive health managers⁽²⁰⁾. Such a fact is characteristic of the complexity of health management, especially when this is done at the level of supervision of community agents and nursing teams, involving other health professionals who are responsible for  providing essential resources on a daily basis⁽²⁰⁾.

It is in this sense that the students become alerted to the complexity⁽¹⁴⁾ of understanding, to the teaching aimed at knowing and learning/acquiring knowledge of professional practice. These are the actions on the part of teachers and students who are interested in transforming static realities, which contribute to the individual and professional growth of both teachers and students.

CONCLUSION
           
Historically, the confrontation involving institutional challenges regarding the obligations of command and leadership by nursing professionals is well known. The role of leader poses serious difficulties for nurses, as they are used to the easiest tasks due to their background in nursing. This also means an appreciation of professional education, subject aimed to teach how to administrate/manage. The nurse’s greatest difficulty is regarding the resolution of institutional demands, characterized by the promotion of micro and macro therapeutic environments to host the users of the institution under consideration.

It is important to highlight that the prevision, provision and maintenance of a therapeutic environment depends on the competence and ability of the head nurse, considered to be the professional in the health field who has the most appropriate profile for such a task. In addition it is currently the case that other professionals in this area search for a more specialized course in administration/management and are placed in leadership roles without any preoccupation with the availability of people and material, environmental and documental resources which are necessary to better serve the client.  

Therefore, the educational investment related to the teaching of the theories of administration in nursing courses is justified in terms of the fulfillment of the present legislation. However, it is understood that such a fact is not justified if it separates the application of acquired knowledge in terms of how to treat clients, using the organization of nursing practices as the raison d’être of this profession.

Analyzing the results acquired in this study, we conclude that the nursing undergraduates observe the reality of the situation and have coherent thoughts about the necessity to change the perspectives in healthcare management and, consequently, its teaching. The aim is to respond to the client/health institution, to meet service demands with a higher quality of provision and a consideration for the well-being of the user.  This is necessary  as it is an institutional mission, which the leadership and the disciplinary and interdisciplinary teams must aspire to achieve. For the continuity and deepening of this topic, we suggest the need for research that considers the interaction of the perspective of the nursing administration/management teachers by looking back to their nursing students ‘..studies..’ PERHAPS?, an aspect we did not contemplate in this present study.

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Contribution from the authors

Bibliographical research and data collection: Iraci dos Santos, Vilma Villar Martins, Euzeli da Silva Brandão, José Luís Guedes dos Santos and Patrícia Klock; Concept and article design: all; Analysis and interpretation of the results: all; Writing of the article: all and; Critical review and final approval of the article: Iraci dos Santos and Alacoque Lorenzini Erdmann.

Received: 27/05/2012
Approved: 27/11/2012