Director of Nursing tried to communicate bad news. He tried to notify
the surgical nurses of a series of extraordinary measures that came
as a result of the application of a recently adopted decree of cuts
by the public administration (salary reductions, increased working
hours, suspension and readjustment of bonuses and incentives, etc).
The unrest among the attendees grew, as he outlined, with the precision
of a surgeon, the insidious measures that would have a decisive
impact on the lives of each person. Faces of perplexity and indignation
appeared as they realized that in the logic of the administration
they were only numbers, easy to tally as a rudimentary balance between
workers and hours, seeing if they could let go of any workers. Any
attempt at reasoning was cut short with a single argument, monotonous
and heavy as a stone, like the bunch of papers he brandished in
an upheld fist in a mix of indignation and hidden delight: "I have
not made this decree, what you have to say about the subject, you
know who is responsible." The irrelevant argument about figures
frustrated all attempts at dialogue (Julián Marías
said the reason is always narrative). It ended with an angry
refusal to give further explanation. Among the nurses there were
no reactions other than conversations during shift changes and refusal
to cooperate with supervisors in some activities entailing wilfulness.
is the scene of a conflict between professionals and their command
structure, so common in healthcare organizations that it is easily
recognizable, no matter where it is carried out. The question is
whether clinical nurses, on top of suffering though this, are aware
of the origin of the problem and are capable of analyzing it and
discerning a reasonable explanation. The answer is yes, although
they rarely verbalize it in public forums. To my question, this
is the response given by a clinical nurse: "In our healthcare system
coexist two models of management, those that generate conflicts
internally (with oneself) and externally (with other professionals)
when understanding work, especially among nurses. This is probably
due to that we play with the rules and requirements of one model
and the convictions of the other, making it so that the quality
of work is declining. Working for objectives, as proposed by the
clinical management style, can be a source of patient safety, motivation
for professionals and efficiency for the healthcare system but can
also be a double edged sword when no one believes in the objectives,
when people work for tax purposes and above all, when the objectives,
instead of becoming a source of motivation, become a numbers game.
To work for goals, people must believe in and trust them. And to
believe in goals they need managers who know how to negotiate, explain
and communicate them in a coherent way" (María Gálvez
González, vía email 08/16/2012).
a time in which organizational engineering advocates new ways of
managing people, in which each day the role of shared decision making
acquires a greater importance, as well as the responsible participation
of qualified professionals, how is it possible that nursing directives
anchored in obsolete administrative models survive? How do they
persist in places that are ready for a health alternation? How are
nurses who serve as directors able to install management styles
that represent opposing values? Is it consistent that those responsible,
who were trained and selected based on organization models of the
past, have passed through various reforms without adapting their
management style? How have they marginalized highly qualified emerging
professionals in the area of decision-making, professionals who
have reached higher cycles of education, including specialized management
programs and who would opt for a performance more fitting to the
time we live in? Why do knowledge and culture have such bad press
in some management styles?
scientific literature is providing some clues to answer these and
other questions. This issue of Index de Enfermeria includes
two papers about conflict management in the context of institutional
This issue is not new to the journal, which in recent years has
been promoting alternative views on nursing management, an area
as innovative as it is necessary. I will try to systematize some
of the latest published works with the aim to arouse interest in
this line of suggestive research.
seems necessary to start by mentioning the economic crisis, which
has mainly affected Western countries. Given the shocking figures
engineering economics produces daily, some legitimate democratic
governments are being impersonated by technocratic governments,
sustained by the supposed capabilities of redemptive super-executives
that accumulate unusual powers and a rare ability to control. These
concessions to democracy would not be made without the belief that
organizations are complex entities that are highly conditioned by
the model of government they adopt. Mintzberg, who maintains a critical
stance regarding the sustained formula of the "manager who can do
everything," has identified five possibilities of administrative
management (machine and performance monitoring, network administration,
virtual administration and regulatory control), recognizing that
none of these models is better than the other and that we currently
operate with all of them.3
In fact, it is common in health organizations to juxtaposition theoretically
antagonistic management models, which is often a source of conflict.
The Spanish case may become emblematic: although the healthcare
system opted more than a decade ago for a new participatory and
decentralized management model, utilizing Clinical Management Units,
that gives autonomy and responsibility to clinics,4
what still predominates in healthcare institutions is a compartmental
and hierarchal style with vertical power structures and excessive
dependence on the managers by members of the organization, managers
who are almost always imposed by the organization itself.
in the case of the nurses? It has been noted that the healthcare
system, its resources and their distribution, the nature of healthcare
systems and the type of management of the organizations have a direct
influence on the practice of nursing, which impacts the patient
and the family as an object of care.5
In the analysis of Brazilian production, it was found that the hospital
is the focus of studies related to conflict management by nurses,
which allude to issues such as the institutional physical conditions,
the organization of work, logistics, and the guidelines defining
In their proposal of edifying use of conflict in the nursing profession,
Machado et al. identify the sources of inequality that cause practitioners
to express their differences; the presence of disparities in technical
implementation, in position and social valuation, and in the autonomy
the first aspect, the technical application of care, the work of
Betrán Salazar records the significance of the lack of nursing
care to patients. He shows that the lack of nurses at the bedside
of patients (i.e. neglect) and the lack of interaction in care leads
to distrust and rejection.7
the position of nurses in their organization and their social valuation,
the Foucaultion perspective by Irigibel Uriz is enlightening. He
reflects on the docility of nurses; its power to individuals and
communities and the weight it holds in hegemonic healthcare systems.
The discipline of nursing, which shows its usefulness as an instrument
of government in the service of state ideology, focuses on the construction
of heteronymous subjectivity in the health of people and communities,
and distances the discipline of its fundamental ethical principles
and its ideal goal.8
the communication mediums, Heierle Valero has observed that nurses
are not identified in papers as individuals but instead are perceived
as a group within the work team. The social collective image represented
in the media that returns to each nurse does not help them to understand
the abilities they possess or the work that they do.9
The discordance between identity and image, according to Calvo Calvo,
is due in part to the fact that the nurses themselves have not worried
enough, individually and collectively, to effectively communicate
their true identity to society.10
Other authors attribute the lack of social recognition of nursing
to the influence of gender in the nursing profession, being symbolically
associated to feminine characteristics.11
third issue that is a source of organizational conflict (autonomy
of decisions) has produced articles, such as that of Yáñez
Gallardo et al. about the emotional consequences of distrust in
nursing leadership, identifying anger towards the perception of
injustice as the primary emotion and the trigger situation of organizational
silence while associating with non-participating management styles.1
A silence that if at an individual level decreases self-esteem and
provokes feelings of frustration or anger, at a group level can
produce even greater cohesion to avoid discussion of any kind.12
we also find proposals that seek to balance the nursing performance
in the organization, such as one that advocates informational literacy
(support of evidence based practices) by proven impact on the quality
Undoubtedly one of the most daring is one that proposes the nursing
proffesion to live reflectively, by the domination of others as
a risk and a challenge at the same time.14
The theory of practice of Bourdieu, Acebedo-Urdiales et al. defends
the necessity to work beyond autonomous job descriptions and collaboration
and to situate nursing practice in a culture of compromise with
the ability to promote an environment with the capacity of offering
knowledge and recognition of intentional care.14
the nurses of that hospital's surgical unit should reflect on the
symbolic capital that constitutes the accumulated experience in
their field, that qualifies and gives them authority and that opens
the possibility of cultivating co-responsibility with respect to
their bosses, other professions and the people they serve. Their
"trade" and practical wisdom allow them to follow the rules with
authority and autonomy. But these rules must be tested with bravery
and validation of consequences.
1. Yáñez Gallardo,
Rodrigo; Valenzuela Suazo, Sandra; Dagnino Rivera, Paulina; Cuadra Olmos, Rossana.
Las consecuencias emocionales de desconfiar en las jefaturas de enfermería.
Index de Enfermería 2012; 21(1-2):28-32.
2. Machado, Bruna Parnov;
Paes, Lucilene Gama: Diaz, Paola da Silva; Santos, Tanise Martins dos; Lima,
Suzinara Beatriz Soares de; Prochnow, Adelina Giacomelli. Conflictos en las
instituciones de salud: desafío necesario al trabajo del enfermero. Index
de Enfermería 2012; 21(1-2):58-61.
3. Mintzberg, Henry. Gestionar
el gobierno, gobernar la gestión. En Losada i Madorrán, Carlos
(ed.). ¿De burócratas a gerentes? Las ciencias de gestión
aplicadas a la administración del Estado. Banco Interamericano de Desarrollo.
Washington, DC: 1999. Cap. VII: 197-211.
4. Matesanz, Rafael. Gestión
clínica: ¿por qué y para qué? Med Clin (Barc) 2001;
5. Molina Mula, Jesús. El sistema sanitario: efecto
sobre la práctica clínica de las enfermeras. Index de Enfermería
2011; 20(4): 238-242.
6. Guerra, Soeli Teresinha; Prochnow, Adelina Giacomelli;
Cartana, Maria do Horto Fontoura; Santos, José Luís Guedes dos.
El conflicto en la gerencia de enfermería: un análisis de la producción
científica brasileña. Index de Enfermería 2010; 19(2-3):
7. Beltrán Salazar, Óscar. Cuando las enfermeras están
ausentes. Index de Enfermería 2010; 19(4):240-244.
8. Irigibel Uriz,
Xabier. Enfermería disciplinada, poder pastoral y racionalidad medicalizadora.
Index de Enfermería 2008; 17(4): 276-279.
9. Heierle Valero, Cristina.
La imagen de la enfermera a través de los medios de comunicación
de masas: La prensa escrita. Index de Enfermería 2009; 18(2):95-98.
Calvo Calvo, Manuel Ángel. Imagen social de las enfermeras y estrategias
de comunicación pública para conseguir una imagen positiva. Index
de Enfermería 2011; 20(3):184-88.
11. Arroyo Rodríguez, Almudena;
Lancharro Tavero, Inmaculada; Romero Serrano, Rocío; Morillo Martín,
Mª Socorro. La Enfermería como rol de género. Index de Enfermería
2011; 20(4): 248-251.
12. Leyva-Moral, Juan M. El silencio entre los profesionales
de la salud, un arma de doble filo. Index de Enfermería 2008; 17(1):
13. García-Martínez, Montserrat; Lleixà-Fortuño,
María del Mar; Nieto-de la Fuente, Carmen; Albacar-Ribóo, Nùria.
Competencia informacional en enfermería y otros profesionales de la salud.
Index de Enfermería 2011; 20(4):257-261.
14. Acebedo Urdiales, Sagrario;
Jiménez Herrera, María Fca.; Rodero Sánchez, Virtudes;
Vives Relats, Carme. Re-Pensando las complejidades del rol profesional desde
la teoría de Bourdieu. Index de Enfermería 2011; 20(1-2):86-90.