A estrutura organizacional de serviços de enfermagem em hospitais de ensino / The organizational structure of nursing services in teaching hospitals

Resumo: Para atender aos objetivos de descrever a configuração da estrutura dos serviços de enfermagem; explorar as dimensões estruturais, formalização e descentralização destes serviços; e identificar as estratégias utilizadas pelos enfermeiros gerentes para organizar o cuidado em hospitais de ensino do Paraná-Brasil e Groningen-Holanda, foi realizada uma pesquisa de abordagem qualitativa, que se caracteriza como estudo de casos múltiplos. A pesquisa consistiu de 15 casos - 12 realizados no Paraná e 03 em Groningen. Foram realizadas entrevistas com 15 enfermeiros gerentes que ocupavam posição de destaque na estrutura organizacional destes hospitais, conduzidas por uma matriz elaborada com questões relacionadas à dimensão da divisão e coordenação do trabalho e outras para identificação de serviços de alta complexidade, trianguladas com a análise documental. Os dados foram coletados no Paraná de março a maio de 2014 e em Groningen, de abril a setembro de 2015. A teoria organizacional elaborada por Mintzberg foi utilizada para examinar as características e as relações entre os elementos da organização da estrutura de Enfermagem. O processo de análise e o cruzamento dos casos forneceu base para generalizações, e as estruturas dos serviços de enfermagem foram separadas em grupos. Posteriormente, foram exploradas as dimensões estruturais formalização e descentralização e suas variações. Para a identificação das estratégias utilizadas pelos enfermeiros gerentes para organizar o trabalho nos hospitais de ensino dos dois cenários, foi utilizada a análise temática de conteúdo e os seguintes temas emergiram: Definição da estrutura organizacional; Características dos trabalhadores; e As forças que influenciam o ambiente de trabalho. Baseando-se na abordagem metodológica e no modelo teórico, os resultados apontaram que os serviços de enfermagem apresentaram formas estruturais híbridas, com prevalência de estruturas profissionais e mecanicistas. Na estrutura dos serviços de Enfermagem pesquisados, foi encontrada a coexistência de alto grau de formalização e alto grau de descentralização; e alto grau de formalização e baixo grau de descentralização. Embora existam diferenças entre os dois países relacionadas à economia, população, sistema de saúde, entre outras, não houve diferença significativa entre o tipo de estratégia adotada pelos gerentes de enfermagem para organizar o seu trabalho. Concluiu-se que a melhor estrutura é a que melhor se adapta à situação do serviço, aos objetivos da organização, ao tipo de atividades desenvolvidas e ao ambiente externo. Outro aspecto é que as diferentes partes da estrutura podem exigir a diferenciação das funções e responsabilidades e diferentes níveis de descentralização e formalização do processo do trabalho para serem eficaz. Entende-se que os gerentes de enfermagem exercem papel fundamental na escolha e definição de elementos estruturais que irão determinar o tipo de estrutura organizacional do serviço e, consequentemente, a sua eficiência. Neste sentido, a principal contribuição desta pesquisa está relacionada à importância do gerente de enfermagem em encontrar um ponto de equilíbrio e coerência entre a estrutura adotada e as constantes mudanças nas demandas institucionais e dos sistemas de saúde para garantir um processo de trabalho alinhado aos objetivos organizacionais e às necessidades de saúde dos pacientes.

Abstract: The aim of the research was to describe the structure configuration of nursing services; explore the structural dimensions of formalization and decentralization of these services; and identify the strategies used by managers to organize nursing care in teaching hospitals of Paraná-Brazil and Groningen-Holland. It was held a qualitative approach research, which is characterized as a multiple case study. The survey consisted of 15 cases - 12 performed in Paraná and 03 in Groningen. 15 nurse-managers, who assumed a prominent position in the organizational structure of these hospitals, were interviewed. The survey was conducted by a matrix composed of questions about the dimension of division and coordination of work, and others, for identification of high complexity services, triangulated with document analysis. Data was collected in Paraná from March to May 2014, and in Groningen, from April to September 2015. The organizational theory developed by Mintzberg was used to examine the characteristics and relations among the elements of the organization of nursing structure. The process of analysis and cross cases provided the basis for generalizations, and the structures of nursing services were separated into groups. It was later explored the structural dimensions of formalization and decentralization and its variations. To identify the strategies used by managers to organize the nurses' work in teaching hospitals of the two scenarios, it was used the thematic analysis of content and the following themes emerged: Definition of the organizational structure; Characteristics of workers; and forces that influence the work environment. Based on the methodological approach and the theoretical model, the results showed that the nursing services presented hybrid structural forms, with prevalence of professional and mechanistic structures. In the structure of the surveyed nursing services, it has been found that there are high coexistence degree of formalization and high degree of decentralization; and high degree of formalization and low degree of decentralization. Although there are differences between the two countries, such as economy, population, health care, among others, there was no significant difference between the type of strategy adopted by nursing managers to organize their work. It was concluded that the best structure is the one that best fits the service situation, the organization's objectives, the type of activities developed, and the external environment. Another aspect is that different parts of the structure may require the differentiation of roles and responsibilities of the nurses, and different levels of decentralization and formalization of the labor process to be effective. It is understood that nursing managers play a fundamental role in the selection and definition of structural elements that will determine the type of organizational structure of the service and, therefore, its efficiency. In this sense, the main contribution of this research is related to the importance of nursing manager to find a balance point and between of the adopted structure and the constant changes in the institutional demands and health systems to ensure a working process aligned with organizational goals, and, consequently, the health needs of patients. Keywords: Organisational structure, Decentralization, Formalization, Nursing service, Management, Teaching hospital, Nursing; Strategies; Personnel Administration; Teaching hospitals. The aim of the research was to describe the structure configuration of nursing services; explore the structural dimensions of formalization and decentralization of these services; and identify the strategies used by managers to organize nursing care in teaching hospitals of Paraná-Brazil and Groningen-Holland. It was held a qualitative approach research, which is characterized as a multiple case study. The survey consisted of 15 cases - 12 performed in Paraná and 03 in Groningen. 15 nurse-managers, who assumed a prominent position in the organizational structure of these hospitals, were interviewed. The survey was conducted by a matrix composed of questions about the dimension of division and coordination of work, and others, for identification of high complexity services, triangulated with document analysis. Data was collected in Paraná from March to May 2014, and in Groningen, from April to September 2015. The organizational theory developed by Mintzberg was used to examine the characteristics and relations among the elements of the organization of nursing structure. The process of analysis and cross cases provided the basis for generalizations, and the structures of nursing services were separated into groups. It was later explored the structural dimensions of formalization and decentralization and its variations. To identify the strategies used by managers to organize the nurses' work in teaching hospitals of the two scenarios, it was used the thematic analysis of content and the following themes emerged: Definition of the organizational structure; Characteristics of workers; and forces that influence the work environment. Based on the methodological approach and the theoretical model, the results showed that the nursing services presented hybrid structural forms, with prevalence of professional and mechanistic structures. In the structure of the surveyed nursing services, it has been found that there are high coexistence degree of formalization and high degree of decentralization; and high degree of formalization and low degree of decentralization. Although there are differences between the two countries, such as economy, population, health care, among others, there was no significant difference between the type of strategy adopted by nursing managers to organize their work. It was concluded that the best structure is the one that best fits the service situation, the organization's objectives, the type of activities developed, and the external environment. Another aspect is that different parts of the structure may require the differentiation of roles and responsibilities of the nurses, and different levels of decentralization and formalization of the labor process to be effective. It is understood that nursing managers play a fundamental role in the selection and definition of structural elements that will determine the type of organizational structure of the service and, therefore, its efficiency. In this sense, the main contribution of this research is related to the importance of nursing manager to find a balance point and between of the adopted structure and the constant changes in the institutional demands and health systems to ensure a working process aligned with organizational goals, and, consequently, the health needs of patients.

Direção ou coordenação? Repensando a representatividade institucional da enfermagem / Direction or coordination? Rethinking the institutional representativeness of nursing / ¿Dirección o coordinación? Repensando la representatividad institucional de la enfermería

Trata-se de pesquisa descritiva, de abordagem qualitativa, do tipo documental, que teve como local o Hospital das Clínicas da Universidade Federal do Paraná (HC-UFPR), na cidade de Curitiba-PR. O objetivo foi analisar comparativamente a descrição de dois cargos que representam o Serviço de Enfermagem, adotados em modelos gerenciais distintos. A análise de conteúdo dos documentos referentes aos cargos nos respectivos modelos de gerência evidenciou diferenças significativas. Os resultados apontaram várias alterações na descrição dos cargos e, dentre elas, do termo Direção de Enfermagem para Coordenação de Enfermagem, com a supressão da autonomia e poder de decisão sobre assuntos inerentes à profissão. Conhecimento e competência no exercício profissional são condições para que o enfermeiro mantenha sua autonomia e representatividade na estrutura organizacional.

This is a documentary-type descriptive research, using a qualitative approach and, which was carried out at the Hospital of the Federal University of Paraná (HC-UFPR), in the city of Curitiba-PR. It aimed to comparatively analyze the description of two job positions that represent the nursing service, which were adopted in different managerial models. The content analysis of the documents related to the job positions in the respective management models showed significant differences. The results pointed out several changes in the description of the job positions, i.e. the term Nursing Direction was changed into Nursing Coordination, involving the suppression of autonomy and decision-making power over matters intrinsic to this profession. Knowledge and competence in the professional practice are required by the nurse practitioners in order to keep their representativeness in the organizational structure.

Se trata de una investigación descriptiva, de abordaje cualitativa, de tipo documental, que tuvo como local el Hospital de Clínicas de la Universidad Federal de Paraná (HC-UFPR), en la ciudad de Curitiba-PR. El objetivo fue analizar comparativamente la descripción de dos cargos que representan al servicio de Enfermería, adoptados en modelos gerenciales diferentes. El análisis del contenido de los documentos referentes a los cargos en los respectivos modelos de gerencia puso en evidencia diferencias significativas. Los resultados apuntaron varias alteraciones en la descripción de los cargos, entre ellas el término Dirección de Enfermería por Coordinación de Enfermería, con la supresión de la autonomía y poder de decisión sobre asuntos inherentes a la profesión. Conocimiento y competencia en el ejercicio profesional son condiciones para que el enfermero mantenga su autonomía y representatividad en la estructura organizacional.

A influência da estrutura organizacional nos controles internos de uma fundação para pesquisa, prevenção e assistência do câncer do interior paulista / The influence of the organizational structure on the internal controls of a foundation for cancer research, prevention and care in the interior of the state of São Paulo, Brazil

O estudo centra-se na discussão de que o nível da estrutura organizacional interfere nas práticas de controle interno das organizações não governamentais (ONGs), sobretudo ligadas à saúde. O objetivo deste trabalho foi o de observar a eficiência dos testes de controle interno aplicados dentro de uma estrutura organizacional da Fundação para Pesquisa, Prevenção e Assistência do Câncer, verificando a confiabilidade nos relatórios contábeis e controles operacionais. Como metodologia, realizou-se um estudo de caso em uma organização de saúde do terceiro setor. O estudo de caso ocorreu por meio de entrevistas e análises de relatórios confidenciais. Diante de uma avaliação da estrutura organizacional (das relações entre funcionários e voluntários) e da aplicação de procedimentos de avaliação da qualidade dos controles internos, avaliou-se o quanto o nível da estrutura organizacional interfere nas práticas de controle interno do hospital. Observou-se que existem mecanismos de controle estruturados na instituição, porém a execução desses controles deixa a desejar. Pode-se constatar também que o nível da estrutura organizacional interfere, sim, nas práticas de controle interno da entidade.

This work focuses on a discussion about the extent to which the level of organizational structure interferes in the internal control practices of non-governmental organizations (NGOs), especially those related to health. The objective of this work was to observe the efficiency of the internal control tests applied within the organizational structure of the Foundation for Cancer Research, Prevention and Care, checking the reliability of the accounting records and operational controls. A case study in a third sector health organization was the chosen methodology. The case study involved company interviews and the analysis of confidential reports. After an evaluation of the organizational structure (of the relations between officials and volunteers) and the application of evaluation proceedings on the quality of the internal controls, the extent to which the organizational structure interferes with the internal control practices of the hospital was assessed. It was revealed that there are structured mechanisms of control in the institution, however the implementation of these controls is inadequately performed. It was further detected that the level of the organizational structure does indeed interfere in internal control practices at the entity.