Becoming nursing manager in the nested and complex border of caring and management dimensions Tornando-se gerente de enfermagem na imbricada e complexa fronteira das dimensões assistencial e gerencial

The study aimed to understand the experience of managing medical-surgical inpatient units in a general hospital, highlighting the meaning of being a nursing manager, with the intention to qualify and instrument nurses for caring management practice in this scenario. This is a Grounded Theory research, conducted from August 2010 to August 2012, through interviews with 19 participants from the nursing team, distributed in 3 sampling groups. From the analysis emerged the phenomenon “Becoming a nursing manager in the nested and complex border of caring and management dimension”. To exercise caring management, nurses use management instruments as essential tools, they become capable theoretically and enhances, based on his experience, professional skills and personal characteristics. We conclude that competency mobilization beyond the clinical aspect is needed; allowing the use of management instruments to make caring viable and to improve relational and interactive processes. Descriptors: Management; Nursing; Nursing, Supervisory; Inpatient Care Units. RESUMO Objetivou-se compreender a experiência de estar exercendo a gerência de unidades de internação médico-cirúrgica de um hospital geral, destacando o significado de ser gerente de enfermagem, com o intuito de qualificar e instrumentalizar os enfermeiros para a prática de gerenciamento do cuidado neste cenário. Trata-se de uma Grounded Theory, realizada de agosto/2010 a agosto/2012, mediante entrevistas com 19 participantes da equipe de enfermagem, distribuídos em 3 grupos amostrais. Da análise emergiu o fenômeno “Tornando-se gerente de enfermagem na imbricada e complexa fronteira da dimensão assistencial e gerencial”. Para o exercício da gerência do cuidado, o enfermeiro utiliza os instrumentos de gestão como ferramentas essenciais, capacita-se teoricamente e aprimora, com base em sua vivência/experiência, habilidades profissionais e características pessoais. Conclui-se que a mobilização de competências para além do âmbito clínico faz-se necessária, possibilitando a utilização dos instrumentos de gestão para viabilizar o cuidado e potencializar os processos relacionais e interativos. Descritores: Gerência; Enfermagem; Supervisão de Enfermagem; Unidades de Internação. Lanzoni GMM, Magalhães ALP, Costa VT, Erdmann AL, Andrade SR, Meirelles BHS. Rev. Eletr. Enf. [Internet]. 2015 apr./jun.;17(2):322-32. Available from: http://dx.doi.org/10.5216/ree.v17i2.29570. 323 INTRODUCTION Professionalization of the nursing job highlights the nurse as one of responsible people for management questions in health institutions. This acting field collaborates many times for the professional to be away from direct care, a fact that brings divergence referring to comprehension of the nurse management activity. Management practice is linked to caring administration, team and caregiving. In contrast, dimensions between caring and managing, although complementary, shows evidence that there are nurses with good caring development, although with fragilities in management activities and vice-versa. Caring management inside inpatient units presents a challenge to nurses, that is to provide care, work in a multidisciplinary and inter sectorial team when considering actions and relationships that are built in a complex network. However, professional practice reproduces a technical division in their job, separating management tasks from those related to direct care to patients. The lack of clarity referring to the manager or leader function can limit nursing management practice, considering that is needed to know what is going to be develop, to avoid fragmentations of actions and fragility during performance, once leadership have been considered an indicator of care quality in management practice. Still, factors as lack of institutional support and little developed leadership aspects can be related to the intention of leaving the manager position, although it is not really clear the reasons for position retention, because it is a multifactorial phenomenon and it lacks robust literature about the theme. In Brazil, there is still the supposition that any professional knows how to manage and administration is learned with practice. There are few managers or administrators that have specific training, with knowledge apprehension and proper management abilities, within them: to lead groups, to favor motivation and to contribute for efficacy and effectiveness of organizations and better quality of life for people at work. Conflict management, which integrate the process of nursing management work, should be conducted in a way to avoid team work rupture, that could limit even more nursing management practice. A recent literature review about nursing rotation identified that managers directly influence satisfaction and retention of employees in their team and the consequences in this scope are linked to low care quality offered and increased of costs for health institutions. In adult medical-surgical inpatient units, clients are diverse regarding pathologies and care complexity, generating distinct and unexpected demands for the nurse. In this sense, it is understood that nurses should be prepared to coordinate the nursing team and manage with excellence care for patients. Organizational models of inpatient units classified as good performance based their actions having the quality of patient care as main strategy aiming to promote intraand interprofessionals relationships. Facing the exposed and considering that management practice can require development and/or clarification of competencies pertaining to the exercised function, a question arises: How is the experience of the nursing management dynamics in adults medical-surgical inpatient units in its relational and interactive processes? What is the meaning of being a nursing manager? Thus, this study aims to understand the management experience inside medical-surgical inpatient units in a general hospital, highlighting the meaning of being nursing manager, with the intention to qualify and instrument nurses for care management practice in this scenario. METHODS This research adopted the Grounded Theory as methodological reference, that aims to understand the reality from perceptions and meanings that a context or objective have for a person, generating knowledge, Lanzoni GMM, Magalhães ALP, Costa VT, Erdmann AL, Andrade SR, Meirelles BHS. Rev. Eletr. Enf. [Internet]. 2015 apr./jun.;17(2):322-32. Available from: http://dx.doi.org/10.5216/ree.v17i2.29570. 324 increasing comprehension and propitiating a meaningful guide for action. The study was conducted in a university hospital in the South region of Brazil, with participation of professionals integrating a nursing team of medicalsurgical inpatient units. Data collection occurred during August of 2010 and August of 2012. The invitation was done in person to participants at their work site with the presentation of the research project. In case the professional demonstrated interest in participating, a second meeting was scheduled for the interview. The study selection, by theoretical sampling was intentional; being the first sample group integrated by five manager nurses from inpatient units, from those, two worked in the surgical inpatient unit and three in the medical unit. They were all women, with seven to 23 years of professional experience in nursing and worked as managers from one to three years. Only one nurse had specific training in Health Management and Nursing. Data collection was conducted by open interview, from the questions: How do you experience nursing management dynamics in adult medical-surgical inpatient units? What is the meaning to manage the nursing in this unit? During data collection and analysis from the first sample group (E1-E5), the hypothesis that care management in a task of the manager nurse, as well as from the caring nurse was identified, but the care demands of the nursing management are shared with the nursing team. Thus, it was perceived the need to include caring nurses and nursing technicians in the study, as they significantly contribute with the process of becoming a nursing manager and care manager. Thus, the second sample group (E6-E14) was composed by nine nurses, being five attending nurses and four ex-managers that worked as attending nurses in inpatient units. For this group, guiding questions were: What is the interface of your work as caring nurse with the nursing management? Tell me what you understand by care management. The generated hypothesis from data analysis of the second sample group confirmed the findings of the first group, pointing that managing nursing care is a nurse competency, but it is necessary to articulate different professionals of the team to work in collaboration, with the intention to directly attend the patient’s needs. Thus, the third sample group (E15-E19), composed by five nursing technicians, answered the following questions: How is your work related to the nursing management process? How do you participate of care management? The sample size was determined by data theoretical saturation, a process in which the researcher observe information repetition and absence of new data relevant to the study. Therefore, 19 participants were obtained in total and the interviews were audio recorded and transcribed in full for analysis. Data were analyzed simultaneously to collection, following open, axial and selective codification steps. On the open codification, data were analyzed line by line to identify each idea and create preliminary codes. After, those studies were gathered by similarity and differences, elaborating conceptual codes. On the axial coding, data separated in the previous step were regrouped, aiming to relate categories to their subcategories in order to obtain a clearer and complete explanation about the phenomenon. Selective coding is the search and development of the phenomenon or central category, around which


INTRODUCTION
Professionalization of the nursing job highlights the nurse as one of responsible people for management questions in health institutions.This acting field collaborates many times for the professional to be away from direct care, a fact that brings divergence referring to comprehension of the nurse management activity (1)(2) .
Management practice is linked to caring administration, team and caregiving (3) .In contrast, dimensions between caring and managing, although complementary, shows evidence that there are nurses with good caring development, although with fragilities in management activities and vice-versa (4) .
Caring management inside inpatient units presents a challenge to nurses, that is to provide care, work in a multidisciplinary and inter sectorial team when considering actions and relationships that are built in a complex network.However, professional practice reproduces a technical division in their job, separating management tasks from those related to direct care to patients (3) .
The lack of clarity referring to the manager or leader function (5) can limit nursing management practice, considering that is needed to know what is going to be develop, to avoid fragmentations of actions and fragility during performance (6) , once leadership have been considered an indicator of care quality in management practice (7) .Still, factors as lack of institutional support and little developed leadership aspects can be related to the intention of leaving the manager position, although it is not really clear the reasons for position retention, because it is a multifactorial phenomenon and it lacks robust literature about the theme (8) .In Brazil, there is still the supposition that any professional knows how to manage and administration is learned with practice.
There are few managers or administrators that have specific training, with knowledge apprehension and proper management abilities, within them: to lead groups, to favor motivation and to contribute for efficacy and effectiveness of organizations and better quality of life for people at work (9) .
Conflict management, which integrate the process of nursing management work, should be conducted in a way to avoid team work rupture, that could limit even more nursing management practice (3) .A recent literature review about nursing rotation identified that managers directly influence satisfaction and retention of employees in their team and the consequences in this scope are linked to low care quality offered and increased of costs for health institutions (10) .
In adult medical-surgical inpatient units, clients are diverse regarding pathologies and care complexity (11) , generating distinct and unexpected demands for the nurse.In this sense, it is understood that nurses should be prepared to coordinate the nursing team and manage with excellence care for patients (4) .Organizational models of inpatient units classified as good performance based their actions having the quality of patient care as main strategy (12) aiming to promote intra-and interprofessionals relationships.
Facing the exposed and considering that management practice can require development and/or clarification of competencies pertaining to the exercised function (8) , a question arises: How is the experience of the nursing management dynamics in adults medical-surgical inpatient units in its relational and interactive processes?
What is the meaning of being a nursing manager?Thus, this study aims to understand the management experience inside medical-surgical inpatient units in a general hospital, highlighting the meaning of being nursing manager, with the intention to qualify and instrument nurses for care management practice in this scenario.

METHODS
This research adopted the Grounded Theory as methodological reference, that aims to understand the reality from perceptions and meanings that a context or objective have for a person, generating knowledge, increasing comprehension and propitiating a meaningful guide for action (13) .
The study was conducted in a university hospital in the South region of Brazil, with participation of professionals integrating a nursing team of medicalsurgical inpatient units.

RESULTS
From the analytical process the following categories emerged: "Care management as concept", "Becoming a manager nurse at an inpatient unit"; "Characteristics needed for a nursing manager" that sustain the phenomenon: Becoming a nursing manager in the nested and complex border of caring and management dimensions.

Care management as concept
Composed by two subcategories: "Differentiating On the first subcategory, it is emphasized that managing the unit and manage care are distinct actions.
Participants affirm that unit management on a daily basis is linked to bureaucratic part and administration of the sector.They understand that sector management requires lots of attention and dedication, as if not performed adequately; the care management will be compromised.Already, care demands, for example, how care will be conducted, why and where they are linked to care management; emerge from the direct relationship between nurse, nursing team and patient, being supervised by the nurse manager, as illustrated in the following lines: Thus, in accordance with participants, nurse managers conduct indirect care, interacting with assistance, knowing the patients in order to organize the work and act as assistance nurse when there are employees absent, for example.

Becoming a manager nurse at an inpatient unit
This category is composed by three subcategories: "Motives for accepting the position", "Preference for assistance dimension" and "Questioning your capacity for the position" that sustain the training process of being a manager nurse.
Participants noted the opportunity to take on the unit management came suddenly, and they accepted the position with the intention to contribute with the sector and the health team, without, however, having another Some nursing managers question about effectiveness of their work, as they are unsatisfied with their performance for not being able to meet all management demands.

Characteristics needed for a nursing manager
This category is composed by two subcategories: "Subjective characteristics" and "Use of management instruments" that reveals the nursing management being from personals qualities and their working tools.
Democratic action is fundamental to participants, once it stimulates communication and value of the team knowledge.Although they believe to be possible for all intervene on management, they consider the application of this management model laborious, demanding an accurate justice sense to obtain better results, as the following line: It is necessary to have a sense of justice, same rights and duties.[...] Thus, to be democratic is a consequence (E3).
They perceive promoting changes should rely on persuasion and capacity to influence the other team members, and to exercise their leadership they try to perform their activities correctly and be the example.In Nursing managers consider important a guided work during planning, pointing implementation of the nursing care management as a necessary tool for care management, as described in the lines: My work is the planning part as well as to perform care, guide, supervise (E3).
To practice care management, we have the assistive methodology that helps on that, for example, the nursing prescription (E14).
The statements cited above highlighted nursing care systematization, in special, nursing prescription, as instrument that allows caring assessment.
Another management instrument used by nurses is the performance assessment of unit employees, mentioned as being a constant activity, highlighting the need to perform it whenever possible.For this reason, nurses try to conduct it as soon as possible, whenever they notice a difficulty or a mistake, aiming to minimize the risk or damage to the patient's health, as demonstrated in the statement: In this assessment moment it's not so easy.The more time passes, it gets more difficult.We have to intervene as earlier as possible, aiming to guarantee a care with quality (E5).
The statements relate performance assessment of employees with the guarantee of quality of care.This implicates that when the nurse stops considering a situation that needs to be scored in the assessment of an employee, she can be contributing with the strengthening of unsafe practices for patients and, for that, this practice is noted as immediate intervention.
Supervision was mentioned by nurses as another management instrument integrating care management, highlighting supervision of employees and care provided, in accordance with the statement found below: The supervision part also, that is part of care management, of employee's supervision as well as the supervision of care provided.So, I think this is very important (E12).
Nurses associate the observation of employees' actions as an activity allowing them to know the nursing team and strengths the supervision, allowing higher control of care and/or assistance.This can be noted in the statement: The observation goes in everything [...] I think the main thing is to observe.This way, you are attentive to what is happening and you will know the professionals working with you (E7).
Other activities mentioned by participants as part of nursing management exercise in inpatient units, include articulation between teaching and research practices and supervision of students during supervised internship.This should be considered essential for care management, as it can be illustrated in the following statement: To supervise students [...] we have to be supervising this part, managing this as well (E12).
It is pointed out that to have change of thoughts in the context of nursing care practice, it is essential to theory and practice to strengthen the management actions of nurses.

DISCUSSION
The theoretical definition of nursing care management concept in hospital scenarios have been awakening interest of researchers, as many nurses, in their professional practice, perceive administration and care as separated processes.Besides that, they consider activities composing their parts as concomitants and less likely to be achieved (2) .Although searching for a new caring model, nursing is still fragmenting its work process, separating management tasks, considered indirect, from those involving direct care (3) .In this sense, the management exercise of nurses brings out questions causing misunderstanding and incomprehension (1) .On the other hand, it advocates the assumption that nurses' professional exercise is constituted from different dimensions, considered complementary and interdependent, in which assistance and management dimensions are highlighted (4) .
A fragility to build a concept about nursing care management is noticed in the literature, which should direct practice of those professionals (2) , causing change in training and work process of nursing managers.
Nursing has as priority, mark and nucleus, caring; and as finality, quality of care in a way that it cannot have separation between assistance and management dimensions, because it would harm performed assistance (4) .
Actions of direct and indirect care happen in an integrated and articulated way that defines nursing care management as a dynamic, situational and systemic process (2) .Nowadays, organizational care dimension is a paradox, once if we want to achieve effective results we have to prioritize management processes, among them, leadership.The leadership exercise by nurses, besides strengthening their management practice, especially when referring to managing their team, facilitates articulation of dimensions from the nursing work process, constituted by assistance and management practices (4,6) .
Leadership development is considered a continuous process and, also, an indicator of satisfaction in the work environment.Leadership practice needs to be strengthen, once nursing managers mentioned to be little satisfied in their work environment (7) .Still, it is important to highlight that patients' satisfaction is used as an indicator of assistance quality (14) .
A study that assessed level of satisfaction of patients regarding nursing care found aspects as continuity of care and team work were considered requirements positively assessed by patients and it characterized a high level of satisfaction.Yet, aspects related to little time that nurses spend to directly care for patients were considered a dissatisfaction reason.Low levels of satisfaction were related to technical inability, lack of personnel and little nursing autonomy (14) .
To exercise management, it is not enough to select the nursing manager by professional history and their development inside the institution, but consider if the nurse is capable to deal with attributions and responsibilities of the position, as well as knowledge about the health management process (15)(16) .
Contemporary organizations look for managers with a profile beyond scientific knowledge, with skills and competencies capable to detect and analyze organizational problems and propose alternatives for solution.It is still fundamental for the manager to be able to recognize and attend the needs of the team, trying to propitiate harmony in the work environment.Their daily routine in an inpatient unit is challenging and stressful, involves multiple barriers that discourage nurses to take this position.Another factor contributing for avoidance of the management position is the idealization that direct care has more value than to work as unit manager (17)(18) .
It is necessary for nurse managers to recognize the complexity of this position on its uncertain, unstable, insecure, illogical, contradictory, ambiguous, variable, random, undetermined aspects, and others that scape order, objectivity, certain or determined (18) .
Allied to the complex dynamics of nursing management, the work overload and high rotation of team members limit implantation of those practices in an articulated way.A study about characteristics of leader nurses in hospitals in United States found an increase in workload of those professionals over time (19) .Another study conducted in Netherlands found high rotation of nurses as a delicate problem, where the nursing manager should make efforts to identify the determinants of this situation, as well as to elaborate strategies to solve it (20) .
Thus, nursing managers, through their leadership abilities should guarantee favorable work conditions, with consequent satisfaction and permanence of the team.
Leadership with emphasis in democratic actions, communication power and sense of justice, were considered in this study as subjective characteristics inherent to the nursing manager.In Chile, one of responsibilities pointed in nursing is care management that involve a series of competencies and abilities, within them, communication, information, and knowledge for right decision making in this scope (21) .Corroborating with this evidence, a study about management profile of nurses working in a public federal teaching hospital, highlighted those characteristics as relevant (22) .In another study conducted in Rio de Janeiro, it was noted experience and professional maturity as well as planning, organization, coordination and direction capabilities as needed to manage (18) .
To act with good humor, responsibility, respect, flexibility in nursing management can minimize existing conflicts between the manager nurse and assistance team (23) .Creativity of nurses in decisive processes, adapting material and human resources with the intention to plan a quality assistance (3) could be needed, as well as the presence of educational practices turned to nursing employees and patients (4) .
The present research fount manager nurse work relying on activity planning.This management practice is considered by nurses in hospitals a strategy of fundamental management to develop leadership and essential for smooth leadership transitions (19) .Thus, planning of actions as exercise of the manager nurse results in constant assessment of the whole production system in the hospital organization.From this view, this management tool can facilitate detection of flaws in care processes, allowing a strategic differentiate view within organizations (22) .
Within management tools, the SNC -Systematization of Nursing Care is considered a quality assessment tool that allow nurses to dominate their work process, assessing their action, favoring organization of the care provided and, thus, retro-feeding itself (24) .Also, the implantation of electronic health registries in hospitals is considered a challenge for the practice of manager nurses and this technology can propitiate improvements in service quality (19) .
Supervision activities, control and assessment, considered as multiple management dimensions, concretize as the best practices of the manager nurse (25) .
Such activities were also highlighted by manager nurses in the present study as relevant instruments for care management.This demonstrates these professionals in search of adoption of better practices to propitiate more safety and care quality.
The literature shows that a better theoretical definition and apprehension by nurses, about the concept of care management in nursing; the development of leadership; and the identification of determinants for the high team rotation are themes that, besides being highlighted in national literature and, especially international, constitute challenges in care management practice context of nursing in inpatient units (2,7,11,20) .
It is expected that manager nurses will face those challenges instrumenting themselves to reflect their practices.This implicates assistance improvement and advance for excellence of care managing practices.

FINAL CONSIDERATIONS
The phenomenon "Becoming nursing manager in the nested and complex border of caring and management dimensions", presents main contribution and challenges faced by nursing managers for care management, being sustained by the inter-relationship of the categories: "Care management as concept", "Becoming a nursing manager of an inpatient unit", "Characteristics needed for a nursing manager".
Nursing care management presents itself as a complex unit that understands the diversity of administrative activities and assistance as a nested net of actions of the manager nurse.To be a manager nurse in inpatient units revealed as being a challenge for professionals that did not expect to work in this position.To make the management exercise something attractive and rewarding for nurses constitute a challenge, because in many times, the process to manage the unit is still discouraging facing the demands, the long term results and the little support received from the high levels of administration of health institutions.Besides that, it is important to create discussions at the educational context, while the nurse is still in training process in order to facilitate and awaken the desire for management in the professional practice.
For future investigations, it is pointed out as a need, to address elements that could contribute to the nurse manager exercise, aiming to broadly recognize the factors intervening and that generate repercussions in health related work, as well as in safety, professional satisfaction and assistance quality.
management care and assistance care" and "Integrating assistance management and care".When referring to nursing management, participants emphasized the importance of the relation of being a nursing manager and care management activities executed by members of the nursing team.Still reveals multiple faces of care management, being one of them detailed and, posteriorly, seen as interdependent, articulated and dynamic.
this sense, they believe to be identified as team leaders, as they do not have difficulties to lead and direct some activities.Still, they believe to possess some qualities which facilitate their insertion into management (technical knowledge, communication, leadership, discipline, organization and integral donation).They understand that to act in positions of elevated levels of responsibility, in many times they need to work over their work hours, taking home work related worries and tasks, as illustrates the statement: Technical knowledge, communication and leadership spirit are three basic things to conduct the group well (E5).They highlight that besides difficulties presented in their work field, professional relationships should have humor, responsibility and respect.These qualities strengthen the bond and allow the group to work in harmony.Flexibility and malleability are also cited as important qualities to act in the field, being fundamental to adequate the level of requirement regarding the employees as well as with themselves.Participants revealed that they learned to balance requests and comprehension, once people are different in attitudes and potentialities.Thus, this reflection was directed to their own management work, considered invisible many times to produce direct care, as described in the assertions: I see management as really flexible.So, everyone have the power to give opinion and share information (E15).I've never had a hard time dealing with authority, for example.[...] When it wasn't possible to negotiate, I demanded.I really demanded, from top to bottom (E8).Regarding the use of management instruments, effective communication is considered fundamental for a good management, being used as motivation strategy and exchange of experiences.To use it objectively makes the difference in reaching goals and establishing a friendly environment, as presented in the statement: The communication is effective in the unit.[...] We have good communication and a good relationship between teams (E3).
Those nurses identified subjective characteristics, as flexibility, good humor, sense of justice, leadership, effective communication, democratic acting, and the use of management instruments, as elementary tools for an action that enables effective care in their relational and interactive processes.Besides using these tools, the professional with potential for management requires development, training and being gradually challenged to apply those new competences.This nursing management complexity permeates in all professional action, facing the relationships and interactions that are established in the complex net of care and health management.Adult medical-surgical inpatient units are complex, specialized and care for patients with diverse pathologies and with multiple care needs.This situation requires knowledge from nurses, abilities and attitudes to understand the health-sickness process in an amplified dimension, favoring resolute care.Mobilization of competencies for beyond the clinical scope is necessary, allowing the nurse to assume his/her nursing care manager function.Results from this study shows the experience of professionals from the nursing team from day shifts of medical-surgical units in a general hospital, whose management abilities were developed over time and with the interest of the nurse, especially the nursing manager.This development implicates search for individual theoretical knowledge and training, and specializations in the field of administration/management in nursing.