Leadership Strategies Used by Health Professionals in Hospital Units : Integrative Review

Introduction: Manager in its various operational levels, including the hospital management, needs in your profile to present leadership because this feature is an essential part to work with your team . Objective: Identifying leadership strategies employed by managers in hospital units. Method: Integrative review it was conducted in the following databases - Scopus, PUBMED, LILACS and SCIELO. It was considered all published articles in the last ten years until October 2015. Results: It were selected and analyzed 12 articles. Strategies communication among staff; participatory management and professional qualification were outstanding results in this study. Communication presented predominance as the most used strategy, present in 58.33% of the analyzed articles. Conclusion: Despite the scale of the challenges confronting leadership in hospital units is possible to bet on strategies that promote the achievement of objectives of these institutions. Descriptors: Leadership; Hospital Administration; Hospitals.


Introduction
The gradual transformation occurred in the hospital environment gave direct consequences in the health sector.In historical context, it is noteworthy that in the XIX century hospitals were institutions that was dedicated to charity.Nowadays (XXI century) these institutions are presented as a social and complex organization, occupying critical role in the provision of health services.Thus, it is necessary changes in hospital management, readily trained managers who understand great social recognition to work in this environment.This is all because hospital environment it is a place of building professional identities [1].
The hospital environment integrates health and social organizations.Its basic function is to provide integral assistance to curative and preventive manner to the population under any care systems.Moreover, this environment is education center, training of human resources and health research.Furthermore it is the place where occur referral of patients, and shall supervise and guide the health sectors linked to it technically [2].
Within the hospital organizations multidisciplinary staffs are collaborating in the routine and dynamics of the institution, distributed in various hospital departments.Thus, incumbent upon the hospital manager to use strategies that enhance work together to achieve their goals.But also to maintain the quality of services provided.The practice of management in the hospital dynamics leads to the need to manager to think in complex and challenging character that involves the context of managing staff in hospital units [3].
Management is understood as the management set of actions and strategies in public or private institutions.So to the manager to achieve its goals, it is necessary to have an integral view about the processes that involve the entire hospital dynamics.Thus, this will help manager in decision making and will allow to strengthen quality of services offered [4].
Thus, the manager needs in your profile to present leadership.Because this characteristic is an essential part to work with your team in order to expand knowledge and group skills.So from the leadership it is possible to provide continuous service development.In addition, this manager profile can foster its ability to learn to deal with adversity, conflicts and instabilities inherent to daily life and work [5].
It is emphasized that leadership is characterized as a group phenomenon in proposing the satisfaction and motivation of team members.In addition, the leadership influences the ability to promote joint work outlined in the valuation of each participant.Thus, the leader is the link of support for the team.Added to this that a leader presents as supportive both in education and in coordinating of the service.For this, the leader needs to use strategies that encourage collective potential development and aims to improve the quality of care [6].
Thus, it is the competence of health leaders managers use tools that help making strategic decisions to ensure the right to health [7].It is emphasized that the need to study strategies employed in hospital management was perceived during undergraduate degree in Hospital Management from the main author of this article.Starting from the course there was motivation during traineeships in hospital units where it was possible to share challenges faced by managers who lead staffs.
Based on this understanding, it was emerged the following guiding question: What strategies utilized by managers to administer health professionals in hospital units?Therefore, this study aims to identify leadership strategies employed by managers in hospital units.

Method
For reaching the proposed objective it was chosen the integrative review method.It is justified that this method makes it possible to search, critical evaluation and synthesis of evidence on the subject researched [8].This integrative review followed the following steps: 1) identification of the research question, 2) establishment of criteria for the selection of the sample and literature search 3) definition of information to be extracted from selected studies 4) evaluation of the studies included in the review 5) interpretation of the results and 6) presentation of the review [8].
Thus for identifying leadership strategies used by managers in hospital units, it was identified the guiding question: What strategies utilized by managers to administer health professionals in hospital units?In order to select sample and to research literature it were utilized the online databases SCOPUS, National Library of Medicine and National Institutes of Health (PubMed), Latin American and Caribbean Health Sciences (Lilacs) and Scielo.
It is emphasized that to search the Scopus and PubMed databases the following descriptors combined were used: Leadership, Hospital administration, Hospital units.These descriptors were obtained from the Medical Subject Headings (MESH).Concerning the databases Lilacs and Scielo descriptors used were based on Descriptores em Ciências da Saúde (DeCS).In both cases descriptors were crossed by Boolean operator "AND" as described in Table 1.
These databases were accessed by two raters simultaneously on different computers.Procedurally, then articles were selected and stored in the researcher's computer.It was used following descriptors of Medical Subject Headings (MESH): Leadership, Hospital administration, Hospital units.
Data were collected from December 2014 to October 2015.This amount of time is justified by the detailed application need, by two researchers, for the inclusion and exclusion criteria in the papers found.Inclusion criteria taken into consideration: full primary study freely available in selected databases; in Portuguese, English and Spanish; to answer the research question.Articles found in more than one database were counted only once.To the exclusion criteria considered themselves: studies in debates format, editorials, letters to the editor.Thus were included articles published until October 2015 produced in the last ten years.To define this time period it was aimed to include current leadership strategies.
Further, it was defined what information would be extracted from selected studies from the clinical chip developed by the Ministério da Saúde do Brasil and adapted by the authors.Studies were analyzed and refined from an analysis script constructed by researchers of present study.This script understood the levels of evidence applied in the abstracts.Later, this script was applied to guiding question in the articles.Thus, articles that answered the guiding question for this integrative review were selected.

Results
Four crossings were performed with the Boolean operator "AND" resulting 817 documents as Table 1.
It is noteworthy that it was included during the crossings those described hospital administration and hospital units.This is justified by the intention to expand the search and to refine the articles in keeping to problematic faced in the hospital context, central theme of this research, which promote leadership capacity of managers.
In this perspective, 409 of excluded articles were unavailable for free in databases (five LILACS, 263 SCOPUS, 138 MEDLINE three SCIELO), 39 editorials or letters to the editor (three LILACS, 21  In Table 2 shows SCOPUS with predominance of five articles, four LILACS, MEDLINE only one and SCIELO two articles.About it 12 articles were obtained.
Table 3 shows the characterization of selected articles.It is observed that eight were published in Brazilian journals.Most articles show a prevalence level of evidence VI, only two are a quantitative approach as well as two others have mixed methods.These observations were identified during the process of data analyzis of selected articles.
To extract of information it was used a clinical record developed by Ministério da Saúde do Brasil [21] adapted by authors of this integrative review.Thus, after detailed analysis of the articles it was possible

Discussion
After analysis of results presented was possible to identify that key leadership strategies observed in articles were: communication (58.33% -seven articles); participative management (50% -six articles) and; professional training (16.66% -two articles).Thus, the results were discussed in conjunction with relevant literature on the subject studied in order to relate these findings to national and international studies.Thus, the results found in integrative review were discussed by means relevant additional literature on the theme investigated.Through this strategy it was possible to relate the findings of the review to national and international studies.
Communication is a leadership strategy in hospital management that allows leaders to meet their goals and objectives necessary for the hospital service organization.Therefore, communication is relevant to improving the performance of organizations.Moreover, developing this tool together with the staff in the hospital management also enables the improvement of the working process [19].
The act of communicating makes it possible for information to be provided in an orderly and correct manner.Thereby it is possible to prevent occurrence of errors in the services offered [22].Thus, the existing communication in hospital staff contributes to the development of a leadership that considers involved subjects in the work process and provides quality services [23].
However, undue attention intended for communication has a negative impact on the performance of organizations.Thus, the communication failure is directly related to the absence of effective internal communication.This can be exemplified by the following actions: information overload, syncretism, inadequate internal policy to its reality, communication inefficiency of objectives, values and mission of the company to employees and use of e-mail for most of the transmission of information [24].
Communication in institutions can not be limited only to what should be done in terms of procedures and activities routines of everyday life.The absence of dialogue may have oppressive character, besides being a failure in interpersonal relationships.In this context, it is clear that leaders must seek a balance in the relationship between multiprofissinais staffs [25].In addition, communication was characterized as indispensable in the negotiation process in the hospital organization, since it is considered as nearest channel to share knowledge and experiences [26].
A study conducted in a university hospital with nursing staff indicated to communication as a leadership strategy for the execution of activities.According to the study consulted communication favors change of habits, forms of social interaction and relationship team.Thus, managing nursing services with focus on communication promotes: professional growth, open dialogue and increase incentive leading to the qualification of care to clients [9].
Regarding participative management it is observed that staff professional participates in decisionmaking processes involving the hospital organization with the leader.This co-participation allows discuss problems and solutions to outline actions in the service.Thus, it becomes possible to cover and diversify the services provided.This leadership strategy contemplates aspirations and perspectives of contemporary leader.With this, participation by professionals that make up the hospital staff is facilitated.This fact contributes to everyone involved in the management collaborate in decision-making [25].
Thus, participatory management is seen as a strategy for the leader to resolve conflicts and allow the participation of the various hospital departments in management.As a result management in this way proposes to professionals being co-responsible by hospital decisions.Thus, conflict can also be perceived as a power game and the leader's role is to make this game brings positive results for the organization and prevents improductivity [23,27].
A study conducted in Spain showed participatory management as effective for solution, accommodation or balance between different groups.In that Spanish research it was possible to verify difficulties of heterogeneity of demands and needs of each professional category.However, when adding opinions, experiences and expectations for the realization of effective relief work the problems were solved [19].
Leader by using participatory management strategy, considers human resources as most valuable allies, and seeks a path to excellence.However, studies have revealed that leadership in the hospital area is characterized by centralization, thus being able to influence decisions and assistance to clients [27][28].Thereby is necessary continuous development of skills and abilities for teamwork.Consequently can be improved coexistence with differences of the people who make up the hospital staff [22].
In trying to find balance and healthy relationships at work, leaders must use participatory management with an emphasis on good human relations.Also, the leader must consider ethical standards in the appropriate communication and team spirit.The combination of these actions will enable mutual respect, transparency in attitudes, recognition of individuality, willingness to offer and receive help.So the team will be able to avoid prejudgments and stressful immature clashes [26].
Research carried out in Sweden, which aimed to describe views of professionals on participatory management, obtained positive result of this leadership strategy.At the end, the professionals said that participatory management influenced positively on job satisfaction, social interactions and even there was increased confidence in the workplace [13].
From this, use of participatory management as a leadership strategy allows to encourage people to unity and commitment to carry out joint work.When existing common goal it is possible to develop a sense of team, to create achievable expectations, to get results, to recognize and reward efforts.Thus, staffs feel empowered and achieve high standards of performance [27].
Related to professional training it has been seen the necessity of the hospital units to invest in professional staffs from the acquisition of new technologies and professional skills to improve care.Note that the leaders of these services has advocated investment in intellectual capital.About this item, it is considered the main asset of a hospital.Added to this is added the labor force in perspectva to maintain qualification and professional training for the performance of functions [29].
However, often the courses, training and other educational modalities occur disjointed of the context of services and do not always respond to the needs of managers and workers.This causes to team demotivation to develop a work effectively [30].
A study conducted in England, composed of staffs of intensive care units, presented the risks they manage, due to technological complexity utilized in the sector and extensive working hours.Staffs showed similarities in behavior and skills in respect of they are highly stressful.In this sense, vocational training staffs collaborated to avoid occurrence of errors, and mitigate the consequences of possible errors [15].
In this understanding, staffs with constant training have visible impact on the attitudes of other professionals in teamwork.However, despite evidence such a strategy has not been predominantly adopted.Therefore, the use of vocational training needs to be present mainly in public hospitals, because these institutions receive less investment for qualifying staffs [22].
From this perspective, vocational training appears as a leading strategy that provides the leader to improve service and professionals inserted in the hospital space.The leader must be aware of the updates aimed at professional improvement.From this behavior the leader can qualify the team to develop practices that exclude individuality.Thereby fragmentation of actions and dispositions of the working process will be reduced.Through such transformations in the team, the leader strives for bond formation to minimize problems that impact in the workplace.
Therefore, results summarize form major leadership strategies used to manage hospitals.Briefly the strategies highlighted were: communication, participatory management and professional training.Such strategies need to be operationalized in order to contribute to the improvement of care provided by these services.

Conclusion
The results showed communication, participative management and professional training as main strategies utilized by managers in hospital units.The communication was mentioned as a factor in the decisions of the managers because it is used as a tool to develop actions and health practices in the hospital environment.Already participatory management has been identified from the perspective to expand solutions and to resolve conflicts between staff and management.Finally, professional training was presented as necessary to improve the services offered and to provide the value of of hospital staff ties.
Studies focused on leadership strategies employed in hospital units staffs are insufficient to assess leadership styles proposed in the current literature.Conducting a systematic review is needed to get to know other methods of leadership and the strategies used by managers.From the resulting research findings it is possible to strengthen discussions on the use of the subject discussed in the hospital enviroment.
Thus, despite the scale of the challenges that confront the leadership in hospital units, it is possible to bet on strategies that promote achievement of objectives of these institutions.Through results obtained it is understood that managers need to know and to appropriate strategies to cope challenges inherent in the practice of leading staffs in hospital units.

Table 2 .
Distribution of articles found and selected in databases, Natal, Brazil, 2015.

Table 4 .
Strategies used by managers to manage hospital units, Natal, Brazil, 2015.

Table 3 .
Characterization of articles included in integrative review, Natal, Brazil, 2015.