The exemplary leadership from the perspective of pre-hospital care nurses: a descriptive study

Daniele Ellen Grivol¹, Andrea Bernardes¹, André Almeida de Moura¹, Ariane Cristina Barboza Zanetti¹, Carmen Silvia Gabriel¹

1 Univerisity of São Paulo, SP, Brazil

ABSTRACT

Objective: Identify and analyze the aspects related to the practices of exemplary leadership from the perspective of nurses of the Mobile Emergency Services (SAMU), distinguishing the self-perception of these professionals as leaders and characterizing the perception of leadership exercised by nurses in their teams. Method: This is a descriptive study, carried out with nurses from SAMU Regional of the 26 municipalities of a Regional Health Department of the interior of São Paulo. The data collection occurred through the application of the SELF and OBSERVER versions of Leadership Practices Inventory (LPI). Results: Considering the LPI versions, the participants' evaluations regarding the leader's behavior presented minimal differences compared to their self-evaluations. However, respondents rated themselves positively in most of the practices that delineate exemplary leadership. Conclusion: The practices of exemplary leadership were present in the behavior of the nurses who worked at SAMU, emerging as essential skills for nurses in pre-hospital care.

Descriptors: Nursing; Emergencies; Leadership.

INTRODUCTION

Leadership is a skill that has been much demanded of health professionals, in the labor market, especially nurses(1). The exercise of leadership, although complex, is essential to the organization of work, and requires preparation, creativity, and determination(2).

Among the various scenarios of nursing action, the urgency and emergency units are praised. In this context, leadership becomes fundamental in the work of the nurse, whether in the exercise of the art of caring or in the management of the team and its working conditions(3).

Among the services responsible for urgency and emergency care, the Mobile Emergency Assistance Service (SAMU - Serviço de Atendimento Móvel de Urgência) stands out, since its principle consists of attending to acute conditions at the first level of attention, outside the hospital environment. It is a free service, publicly activated from anywhere in the national territory by telephone number 192, and it is integrated to the National Policy of Urgent Care by means of Ordinance GM/MS No. 1,864/2006(4).

In this service, called Prehospital Care (PHC), nurses, nursing technicians, and coordinators or responsible technicians make up the staff of nursing professionals(5).  

It is important to point out that emergency units are places that need quick assistance in the face of patients' complaints and, for the care to take place with quality, the presence of a qualified team, with aptitude in the sphere of communication and capacity to make assertive decisions is essential, since it has the task of providing nursing care of greater technical complexity in patients with serious and imminent death(4).

Thus, in the urgency and emergency service, leadership is an essential item for the efficiency of nursing work, and can directly interfere in the effectiveness of the service among team members, reflecting the resoluteness of care and the possibility of patient recovery, as well as other skills such as communication and supervision(6).

Therefore, it can be seen that the success of a service at this juncture is due to the influence that leading professionals have on the team(7). Thus, it is necessary to rethink the managerial practice of the leading nurse, seeking to find out whether there is a relationship between the leadership style adopted and the services offered to patients.

An integrative review developed in Brazil presented, among its main results, the category "leadership styles exercised by emergency unit nurses". Three articles were listed in this category, one of them presenting transformational leadership as the leadership theory adopted in the emergency services, which resulted in a greater reduction in nursing staff turnover rates when compared to the rates of hospitals in which other styles were used. Another relevant aspect of this review is the scarcity of publications on the leadership of nurses in emergencies, which demonstrates the need for new research on this subject(3).

It is reinforced that the theory of transformational leadership leads those led to a high level of motivation through a relationship structured in trust, valuing creativity and innovation, so that leaders must pay attention to the concerns and needs of their subordinates(8). Furthermore, it is characterized as a leadership style that inspires and enables followers to achieve extraordinary results, since it transcends individual interests by aligning the objectives and goals of followers, leaders, groups, and organizations(9).

Based on these premises, it is important to highlight the model described by Kouzes and Posner(10), based on the theory of transformational leadership, which establishes that exemplary leaders promote a culture whose relationships between aspiring leaders and volunteer followers can prosper. This model encompasses five principles called "exemplary leadership practices," which are: modeling the style, inspiring a shared vision, challenging the process, allowing others to act, and ultimately animating the heart. Given the current prominence of these concepts, this model was used as a theoretical reference in this research.

In short, it is noted that transformational leadership has been a benchmark applied in the nursing context. However, studies are needed to explore and interpret all aspects of this leadership model in the scenario of the professional category on the agenda(11).

In view of the above, this research aimed to identify and analyze aspects related to the practice of exemplary leadership, based on transformational leadership theory, from the perspective of SAMU nurses from a region of São Paulo countryside, distinguishing the self-perception of these professionals as leaders and, likewise, characterizing the perception of leadership exercised by nurses integrating their teams.

METHOD

This is a descriptive study that uses a quantitative approach, carried out with nurses of the SAMU Regional of the 26 municipalities that make up a Regional Health Department (DRS - Departamento Regional de Saúde) in the interior of the state of São Paulo.

Data collection took place in the first half of 2015, covering the entire DRS SAMU nurse population in question, corresponding to a total of 45 subjects. Those professionals who were on vacation or on leave of some kind at the time of collection were excluded from the study. It is reiterated that the monthly meeting with the nurses of the SAMU units of the municipalities involved was used for data collection.

First, nurses were asked to answer a sociodemographic questionnaire and the SELF and OBSERVER versions of The Leadership Practices Inventory (LPI), developed by authors Kouzes and Posner(10), based on transformational leadership theory. It is worth mentioning that the rights to use the instrument were obtained following the legal and copyright use rules adopted by the company. Pfeiffer®, which owns the use of LPI, translated, adapted and validated the version acquired into Brazilian Portuguese(10).

The two versions of the LPI are also composed of 30 statements, grouped into five major areas corresponding to exemplary leadership practices: model the style – the leader clarifies his values while sharing them; question the process – the leader seeks to analyze opportunities to promote innovations and improvements through experiences; inspire a common vision – the leader aligns the group's vision to a common vision, appealing to shared aspirations; Empower others to action – the leader fosters collaboration, trust and relationships, and strengthens those led by increasing self-determination and developing skills and; animate hearts – the leader recognizes individual contributions, as well as celebrating collective values and victories.

For each statement of the instrument in question, the possible answers are arranged on a scale ranging from 1 ("almost never") to 10 points ("almost always")(10). Therefore, the averages for each of the five domains have variability from 1 to 10 points, while the instrument average will vary from six to 60 points. In this logic, the higher the value assigned, the greater is the perception of leadership practice. In other words, according to this scale, the subjects questioned indicate the frequency with which they practice the actions reported in each of the statements. It is essential to stress that in the SELF version, nurses perform a self-assessment of their practice, judging their attitudes as leading nurses, while in the OBSERVER version, the respondents evaluate some member of their teams considered an exemplary leader(10).  

IBM® SPSS® Statistics (Statistical Package for the Social Sciences), version 17.0 (SPSS Inc., Chicago, IL) was adopted to compile and analyze the data collected. After processing the information, the descriptive analysis was carried out. The analyses were performed considering a 5% significance level (α=0.05) and a 95% confidence interval.

The research project was approved by the Research Ethics Committee of the Ribeirão Preto School of Nursing on March 4, 2015, under approval number 973220 and CAAE 40470615.1.0000.5393, meeting the requirements of the National Health Council.

RESULTS

Among the 45 nursing professionals who made up the population of this study, only 24 (53%) responded to the research instrument, since five nurses refused to respond, 12 did not attend the meeting requested and four met the exclusion criterion, because they were on vacation or enjoying some type of leave.

Regarding the socio-demographic data, it should be described that the number of female participants stood out, making up 62.5% of the respondents. Table 1 highlights the age group, training time, and working time results of the individuals surveyed at SAMU.

Table 1 – Distribution of the number of study participants according to sociodemographic characteristics. São Paulo, SP, Brazil, 2015 (n=24)

SAMU: Mobile Emergency Assistance Service (Serviço de Atendimento Móvel de Urgência).

Source: Elaborated by the authors, 2015.

The average age of the participants was 38.6 years, which represents a young age group. As for the time of training of nurses, there was an average of 10.8 years. In addition, the average time spent by nurses in the urgency and emergency services was 4.3 years, with a striking contrast between the different intervals of time spent at SAMU revealed by professionals, since some participants had only two years working at the institution and others had 15 years dedicated to it.

Considering the SELF and OBSERVER versions of the LPI instrument, it was noticed that the participants' evaluations concerning the leader's behavior showed minimal differences compared to their self-evaluations.

Although the scores achieved from the application of the LPI questionnaire SELF version reached extreme maximum and minimum values, ranging between two and ten points, the average score for each item varied between 7.21 and 9.46. Thus, with regard to the self-assessment of nurses as leaders (LPI SELF version), it can be observed that they were generally judged as more flexible leaders.

In a similar way, these subjects carried out, as observers, an evaluation of the other nurses, considered leaders in their teams, regarding the leadership practiced. This evaluation presented 10 as the highest score and 01 as the lowest score awarded. The average points of each item of the LPI OBSERVER version ranged from 7.38 (lowest average value) to 8.79 (highest average value). It is distinguished that scores below five were more frequent in the OBSERVER version than in the SELF version of the instrument.

Data on exemplary leadership practices are shown in Table 2. Regarding the score obtained in the five IPL domains, it can be seen that among the leadership practices covered by the instrument, the domain entitled "encourage the hearts", concerning the SELF version, presented an average score higher than the others, with 8.29 points. On the other hand, the highest mean score obtained in the OBSERVER version was verified in the practices "question the process" and "enable the others to take action", both with an average score of 7.71.

Table 2 – Comparison between the mean scores of LPI SELF and LPI OBSERVER versions considering the five dimensions regarding exemplary leadership practices (n=24). São Paulo, SP, Brazil, 2015

LPI: Leadership Practices Inventory; * Wilcoxon test was used for related samples; **Significant (p < 0,05).

Source: Elaborated by the authors, 2015.

According to the information contained in Table 2, the five practices pertinent to exemplary leadership were present in the actions of the professionals surveyed. However, only the practices "model the style" and "encourage the hearts" presented average scores with differences considered statistically significant between the two versions of the instrument (p<0.05).

Despite the fact that most of the participants rated themselves more highly, it should be noted that the number of respondents who rated another team member more positively was also significant, so that 11 participants (45.8%) made a better judgment about their leaders than themselves, as shown in Table 3.

Table 3 – Distribution of the number of participants in the groups "Total LPI SELF score > Total LPI OBSERVER score" and "Total LPI SELF score < Total LPI OBSERVER score", according to the absolute scores verified in the two LPI versions (n = 24). São Paulo, SP, Brazil, 2015

LPI: Leadership Practices Inventory.

Source: Elaborated by the authors, 2015.

With regard to the set of information portrayed in Tables 2 and 3, it was noted that, when comparing the results of the SELF and OBSERVER versions at the same time, the divergences found between the scores were minimal.

Regarding the variables age and time of professional training, when compared between the groups "Total LPI SELF score > Total LPI OBSERVER score" and "Total LPI SELF score < Total LPI OBSERVER score", it was found that there was no relationship between the scores obtained in the versions of the instrument and the variables in question, i.e., the age and time of professional training of respondents had no influence on the evaluation of exemplary leadership practice, as explained in Table 4.

Table 4 – Characterization of the variables age and time of vocational training according to the groups "Total LPI SELF score > Total LPI OBSERVER score" (n = 13) and "Total LPI SELF score < Total LPI OBSERVER score" (n = 11). São Paulo, SP, Brazil, 2015

*The t test was used at a 5% significance level (p < 0.05). LPI: LPI: Leadership Practices Inventory.

Source: Elaborated by the authors, 2015.

DISCUSSION

Regarding the sociodemographic profile of SAMU nurses and specifically regarding gender, the findings of this study corroborate four other surveys. The first corresponds to a study characterizing leading nurses in the United States(12), according to which 91.4% of the subjects were female. The second study, which applied LPI in intensive care unit nurses, reported that 77% of respondents were women(13). The third, which used the same instrument in nurses of four hospitals in the interior of São Paulo state, found a percentage of female individuals equivalent to 90.5%.(14). Finally, the fourth study, whose population was composed of nursing professionals, presented an 84.3% rate of female participants(9). It is worth highlighting that, throughout its history, nursing is distinguished for being a profession mainly constituted by the female public, legitimating such findings.

As for the professional training time of the participants in this research, the data found are in conformity with those published in a work developed in southern Brazil: 79.5% of the professionals who worked in a SAMU unit graduated more than five years ago(15).

With respect to age group, most respondents were aged between 31 and 35 years. Thus, it is possible to infer that a large portion of the participants was composed of young nurses, a fact that coincides with the results of a study to characterize the professionals working in the SAMU service in the state of Rio Grande do Sul(15), which evidenced a higher frequency of individuals in this age group, as well as information from two other studies that used LPI as a collection tool, one of which was developed in intensive care units in the United States(13) and another in a hospital in China(16).

Regarding the time of dedication to the emergency services, according to Table 1, the average for this study was 4.3 years, with an interval ranging from two to 15 years in the area. Complementary to these findings, it is emphasized that the study did not detect statistically significant association between the variables age and time of professional training with the exemplary leadership practices described in the SELF and OBSERVER versions of the LPI (Table 4). Regarding these results, it is stressed that nurses in the emergency services need discernment and maturity to develop their skills, because in addition to specific duties and responsibilities of assistance, these professionals contribute with planning, organization and management coordination actions(7).

The urgency and emergency mobile PHC service is an important component of health care, and has required increasingly flexible professionals, both for the management and leadership of their teams, providing quality service for users(3). It is observed that, faced with such a demand to professionals in the urgency and emergency services, leaders in this area are prone to perform a dynamic self-evaluation, since leading people is a complex task, requiring management when dealing with human values, feelings, rights and duties and, therefore, requiring that professionals in the sector be rigorous with themselves.

Therefore, according to Table 3, the difference observed between the results from the two versions of the evaluation made it possible to verify that the survey respondents pointed out some difficulties faced by nursing professionals with regard to issues of relationship between leaders and members of their team. Moreover, based on the adopted theoretical framework(10), it is essential to consider that leadership is not only about having the ability to instigate a certain group to reach a goal, but also includes the ability to improve human potential, that is, to inspire, motivate, enable and promote the development of its followers(9,17,18).

Currently, the studies associate the dialogical relationship between the leader and his led in accordance with the culture of the organizations in which they are inserted, bearing in mind that, in some situations, the leader delegates authority to those led, leveling and supporting the activities performed by his team and obtaining better results(19).

In this sense, it is necessary to highlight the complexity of leadership in the context of urgency and emergency, emphasizing the relationships between nursing teams and other professionals, in addition to the structure of health organizations, which reflect the hierarchy of social institutions, articulated through power bonds(3). Therefore, such a hierarchy hinders the flexibility demanded and sought by contemporary leaders(10,17).  

The leader should also be guided by other skills such as communication, dialogue, conflict resolution, team motivation, and harmonization of work proposals in the nursing team, achieving the goals of the institution(19).

According to the tables referring to the SELF version and OBSERVER version, one can assume that the participants and the leaders they evaluated presented the five practices of exemplary leadership during their performance as nurses of the SAMU Regional in São Paulo countryside, in accordance with the definition of Kouzes and Posner(10).

Regarding Table 2 specifically, the minimum scores attributed to each practice of the SELF version instrument ranged from 5.0 to 7.0, since none of the participants had an average lower than 7.88 for the five exemplary leadership practices. As to the maximum scores, the highest score reached was 9.0, and the general average of participants was 8.29, a conjuncture that reinforces the existence of a regularity between the answers of the subjects questioned and attests that the path to be followed by the professionals until receiving the title of leader is not something standardized, but rather acquired.

We should recall that in this study, among the five practices of exemplary leadership, the domains "encourage the hearts", "empower others for action" and "model the style" presented the highest averages in the SELF version of the LPI, data similar to those described in an American study(9) in which the domains "encourage the hearts" and "empower others for action" displayed the highest averages.

According to the transformational leadership reference employed(10), "encourage the hearts" corresponds to the recognition of individual contributions, showing appreciation for excellence, celebrating victories and establishing a team spirit. Thus, in accordance with the literature, the importance of leadership for the synchronism of teamwork in pre-hospital care is observed(3,5).

The practice called "empower others to take action" obtained the second highest average in the SELF version and, in parallel, the OBSERVER version also presented itself as one of the two areas with the highest average. The concept of this postulate involves the ability to promote collaboration, trust and power-sharing(10). Likewise, a study developed in São Paulo countryside, using the same instrument, exhibited the highest average in the mentioned field(14), in the same way as a study developed in "magnetic" hospitals(20).

In this sense, the need for nurses in emergency units to be prepared to perform the activities assigned to them in a correct and effective manner(6) is reaffirmed, thus enabling the establishment of a network of collaboration and trust that allows for the sharing of power among professionals aimed at action.

The practice entitled "model the style" includes the exercise of clarifying personal values, defining examples and aligning actions with the shared values of the team, that is, it is a way of elucidating the values of those led, encouraging them to find their own qualities(10). A study developed in an intensive care unit in the United States showed a positive association between the domain "model the style" and the work satisfaction variable, strengthening the significance of this practice of the exemplary leader(13). Transformational leadership of nursing managers has a major effect on the level of job satisfaction, and the development of training programs to improve knowledge about competence and develop skills in nursing managers is essential(16).

The results achieved in this study showed that the practices established by the leaders are in line with the practices perceived by them, because although there is discrepancy between the scores, the difference was not significant in all practices, except for "model the style" and "encourage the hearts", which presented, respectively, averages of 8.08 and 7.38 in the SELF version, while the OBSERVER version showed average values of 8.29 and 7.42.

Judging from the information provided, it was possible to see that, for those interviewed, the capacity to promote collaboration, trust and the sharing of power revealed a greater number of barriers related to the exercise of leadership in the profession than when compared to the actions resulting from the practice of "encourage the hearts". Such a scenario is conflicting, since in an urgency and emergency environment, actions of collaboration, trust and power-sharing among team members become fundamental, allowing for efficiency in the conduct of the team(7).

Finally, the need for new studies using the same instrument was observed in the context of SAMU, since the leader develops modern visions for the organization and mobilizes team members to agree on and fulfill the tasks, transforming these visions into concrete actions. In addition, the transformational style of leadership, unlike traditional leadership, truly improves the performance of a pre-hospital care team.

CONCLUSION

The execution of this survey made it possible to attest that, among the five practices that delineate exemplary leadership, the respondents rated themselves positively in all of them. In addition, it was possible to notice that there is no possibility of any leadership style being incorporated by the nurses of SAMU units without these professionals knowing the management philosophy of the institution, the personal characteristics of their leaders, and the likely difficulties to be faced.

There is a need to develop research that investigates the improvement of the quality of care through the use of innovative leadership practices, such as transformational leadership, stimulating and satisfying the professionals in their functions, as well as making them co-responsible for the results of the care provided to the patients.

This research allowed certifying that the five practices of exemplary leadership were present in the behavior of nurses working in the urgency and emergency services. In addition, with respect to data obtained through LPI application, it was found that leadership is essential in ensuring the effectiveness of nursing work in the PHC, interfering directly in the joints between team members and thus reflecting on care, satisfaction of professionals involved and patient care.

Finally, leadership emerges as an essential competence for nurses in the emergency services, becoming a primary condition in the management of the nursing team, requiring investment by managers to improve this competence among professionals in the category.

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Received: 04/06/2017

Revised: 11/22/2019

Approved: 11/22/2019