Empowering behavior of the nurse-leader from the perspective of nursing technicians and assistants

Objective: Associate demographic and work data and the empowering behavior of the nurse-leader from the perspective of nursing technicians and assistants. Methods: Cross-sectional and correlational research carried out in a tertiary university hospital in the state of São Paulo. A total of 260 mid-level nursing professionals (nursing technicians and assistants) participated, using self-administered instruments from May to August 2021. To verify the association between the scale classes and the explanatory variables, a chi-square or Fisher’s exact test was performed in the SAS program. Relationships were statistically significant if p<0.05. Results: The profile of the participants was predominantly female, mean age 41.9 years, daytime workers, workload of 36.7 hours and satisfied with their work. The application of the Leader’s Empowering Behavior instrument showed that the domain with the highest average of empowering behavior was “meaningful work” and the one with the lowest average was “autonomy in relation to bureaucracy”. Nursing assistants and technicians who worked during the day did not have other work relationships and were satisfied with


Introduction
In Brazil, the work process in nursing involves the perspective of caring/assisting, administering/managing, teaching/educating and researching. (1)These processes are developed with the technical division of labor as a component, which involves the different categories -nurses, nursing technicians and nursing assistants -which are influenced from the point of view of history, economy, social policies, work organization model and care. (2)n the administering/managing process in nursing, the object includes the care agents and the resources used in nursing care.In the Brazilian context, the agent of this process is, exclusively, the nurse.
The instruments are the ideological and theoretical bases of administration and practice of resource management.The purpose is to coordinate the work process of assisting in nursing and uses planning, decision-making, supervision and auditing as a method, having as a product the conditions for care to be carried out efficiently and effectively. (3)or quality nursing care based on comprehensiveness, it is necessary for the nursing team to master the various processes existing in their work, and they need to maintain a relationship with each other, aiming at effectiveness, efficiency and effec-tiveness, also guaranteeing a high degree of social representation and professional satisfaction. (3)he good relationship between nurses and their team, made up of technicians and nursing assistants, as well as in the broader context of the interprofessional team -a form of collective work with reciprocity of relationships and interventions, in addition to multiple interactions and agents -allows actions to be articulated through instrumental and communicative action, creating a favorable and high-level environment for patient care and attention. (4)t should be noted that leadership has been experienced in health organizations, moving from a hierarchical and traditional model to a work shared by the members of the interprofessional team, making the role of the nurse indispensable, as he/she is the element of the team that favors collective interests and offers safe patient care. (5)he nurse, responsible for his/her team, needs to develop in leadership.Leadership concepts include four core elements in their definitions: leadership is a process, involves influence, takes place within a context or a group, and aims to achieve goals that reflect a common vision.It also has fundamental implications for the well-being of nurses, promotes the retention of professionals in their work and provides better care. (6)ealth care systems require knowledge from nurses to lead their team.The nurse's leadership enables the empowerment of the team, in order to guarantee safe care.Empowering the team, in turn, is crucial for them to actively express their opinion and for them to participate in the decision-making process.Leadership facilitates team learning and affects patient care. (7)he conceptual framework of empowerment aligns with workers' intrinsic motivation to continue their learning process, with an emphasis on their successful experiences at work.The construction of this structure takes place through five necessary behaviors for leaders: encouraging the meaning of work; promote participation in the decision-making process, emphasizing tools that contribute to problem solving and encouraging active participation; express confidence for the high performance of workers' skills; facilitate the achievement of goals, through the promotion of relevant resources and promote the autonomy of workers, considering the existing bureaucracies in the work context and the many rules that, sometimes, reduce workers' initiative. (8).To measure the leader's behavior in empowering his/her team, a scale was developed based on the conceptual structure of intrinsic motivation, originally in the English language, called Leader Empowering Behaviour (LEB), (9) which was culturally adapted and validated for Brazilian Portuguese, with the name Comportamento Empoderardor do Líder (CEL). (10)The use of this scale with nursing technicians and assistants allows knowing the behavior of nurses in empowering their team.2. International studies that associated sociodemographic and work factors with the leader's empowering behavior showed that the educational level was weakly related to the general perception of the LEB scale. (11)Most participants were female (91.6%), with a mean age of 45.6 years, with a degree in nursing school (41.3%), working all day long (54.9%), with an average time working in nursing for 20.3 years, in the same institution for 9.8 years and as nurses for 14.8 years; the average of the LEB scale was 4.45. (12)Another study showed that there was a significant correlation between sex and the domain autonomy in relation to the bureaucracy of the LEB scale (p<0.05),however, other sociodemographic and work variables were not significantly associated. (13). The study is justified because, in Brazil, the literature on the leader's behavior in empowering his team is scarce.The study that adapted and culturally validated the Brazilian version of the CEL scale was applied to nurses considering their role as leaders of the nursing team, not as followers. (10)Thus, knowing this behavior, from the perspective of those led, allows for more participatory and autonomous work processes of the nursing team, with a view to safe and quality care.
In the Brazilian context, university hospitals are linked to higher education institutions, with the purpose of training health professionals, with the recognition of being scenarios that promote support for teaching, extension and research.In this scenario, there is a need to use resources that can provide support for building autonomy and critical thinking to improve the decision-making process, (14) that is, a propitious scenario to know the behavior of the nurse-leader for the empowerment of his/her team.
Thus, with the question: "What are the work and demographic factors of nursing assistants and technicians that are related to the behavior of the nurse/leader?", the objective of this study was to associate demographic data, work and the empowering behavior of the nurse-leader, from the perspective of nursing technicians and assistants.

Methods
Exploratory, descriptive, cross-sectional and correlational study, through the checklist Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).
It was developed in a large public university hospital in the state of São Paulo, tertiary level of care, reference of the Health Care Network (RAS-9), in units grouped into outpatient clinics, wards, intensive care units, urgency and emergency units, diagnostic imaging center, surgical center, materials and sterilization center, special and administrative units.
Nursing technicians and assistants were invited to participate in the study, ensuring anonymity and clarification of all stages of the research.Those who agreed to participate were asked to sign the Free and Informed Consent Form.
At the time of the study, there were 800 nursing technicians and assistants (730 technicians and 70 nursing assistants) in the research hospital.The calculation for the sample size used a prevalence of 50% with a margin of error of 5% and 95% confidence interval, obtaining n=260 of professionals corrected by the finite population.The sample was intentional non-probabilistic, composed of 260 professionals, including three nursing assistants, 256 nursing technicians and one who did not inform his professional category, working from May to August 2021.
For data collection, a questionnaire was used with sociodemographic and work data, considering professional category (nursing technician or assistant), sex, age, workplace, weekly workload, time working at the institution, other work relationships and job satisfaction.
The CEL scale was applied with 27 items divided into five domains: meaningful work (items 1 to 6); participatory decision-making (items 7 to 11); employee confidence (items 12 to 17); facilitating the achievement of goals (items 28 to 21) and autonomy in relation to bureaucracy (items 22 to 27).Items 22 and 25 are reversed.The highest score on the scale is 189 and the lowest, 27.The response scale is of the Likert type, which varies between one and seven points, with the options strongly agree (seven points); partially agree (six points); agree (five points), neither agree nor disagree (four points), disagree (three points), partially disagree (two points) and strongly disagree (one point).Thus, the higher the score, the greater the presence of attributes favorable to the practice of empowerment. (10)The instrument containing sociodemographic and work data and the CEL scale was printed and distributed by one of the re-searchers to the participants who answered it at their convenience.
Statistical analysis of data was performed, with frequency and percentages for qualitative variables and means, median, standard deviation and minimum and maximum values for quantitative variables.
To verify the association between the scale classes, mean values closer to seven were considered as more empowering behaviors. (9)The chi-square test or Fisher's exact test was performed when necessary.P<0.05 was considered as the significance level.The program used to perform the analyzes was SAS, version 9.4.
The project was approved by the Research Ethics Committee (Opinion 4,730,604)/ Certificate of Presentation of Ethical Appreciation (registration 12221719.2.0000.5411).

Results
Study participants had the following characteristics: most nursing technicians were women, with a mean age of 41.9 years.Regarding work data, they worked with an average workload of 36.7 hours a week, on the day shift, with an average of 11.1 years at the institution, did not have another formal job and were satisfied with their work (Table 1).
The application of the CEL instrument showed that the domain with the highest average of empowering behavior was "meaningful work" and the one with the lowest average was "autonomy from bureaucracy".The domains "participatory decision-making", "employee trust" and "facilitating the achievement of goals" had similar averages.Table 2 demonstrates these data.
The correlations made between the professional categories (technician and nursing assistant) and the five domains of the CEL scale, as well as sex with the same domains of the scale, did not show statistical significance.However, when the domains of the CEL scale were correlated with work shifts, other work relationships and job satisfaction, there was statistical significance, as shown in Table 3.It is noteworthy that not all participants responded to Graça EP, Oliveira PB, Spiri WC these scale items, leading to a change in n of the items other work relationships and job satisfaction.

Discussion
Most professionals interviewed were female, with a mean age of 41.9 years, weekly workload of 36.7 hours and predominantly during the day.(13) However, with a significant correlation only between gender and mastery of the "autonomy from bureaucracy" scale of the CEL scale, the other sociodemographic and work variables were not significantly associated. (13,15)tudies highlight the issue of sex/gender in nursing, showing that positions in the profession are occupied predominantly by women.This is due to a sociocultural construction, in which the woman was placed in the role of caregiver, so that men who wish to enter the profession have to break these sociocultural barriers. (16,17)hese data are also in agreement with the research carried out by the Federal Council of Nursing (Cofen), which highlighted that 82.3% of technicians and assistants in the state of São Paulo are female; 28.7% work in their institutions from 11 to 20 years, 48.9% with a workday of 31 to 40 hours and 89.9% in the daytime. (18)ost of those who agreed to participate in the study worked the day shift.This can be explained by the fact that, at night, most of the time, the work units remain with fewer professionals, which makes it possible to infer that there is less time to participate in research by completing self-administered instruments.
The leader's empowering behavior, when associated with work shifts, showed, in all domains of the scale, that nursing assistants and technicians on the night shift are less empowered than those on the day shift.However, the average of the domains remained in the extract from 4 to 5.9, with the exception of the domain "Autonomy from bureaucracy", which, in both shifts, varied, on average, from 2 to 3.9.
Studies report that nursing professionals who work night shifts have a higher level of stress, as the work schedule is contrary to the circadian rhythm, resulting in physical, psychological and physiological changes, such as exhaustion, poor diet, weight gain, poor quality of sleep/rest.They also point out that poor sleep quality decreases the professional's mental capacity, which affects not only their health, but also the care provided to the patient.21) The averages obtained in the domains of the CEL scale were close to 5, which shows that, in the studied hospital, the empowering behavior is good.The study carried out with nurses to validate the scale in Brazil revealed an average of 5.56, (10) that is, very close to that obtained in the present study.It is important to consider that this study was carried out from the perspective of nursing technicians and assistants, something, until then, unheard of in Brazil, making comparison with other studies difficult.
Research carried out with clinical nurses who evaluated their leader also obtained scores that revealed good empowering behavior, with averages of 4.64, (22) 4.71, (23) and 4.45, suggesting that the leader's empowering behavior is an important factor to support the nursing team in the work environment. (12) study that correlated the leader's empowering behavior with resilience showed that high scores of resilience were associated with good and excellent scores of empowering behavior. (15)It is emphasized that coaching leadership, as a model that aims to develop and encourage those led to achieve results, is a relevant strategy in people management, as it has an impact on increasing the resilience of nurses in the context of hospital institutions with challenging experiences. (24)he reliability of the CEL scale showed an overall Cronbach's alpha coefficient of 0.93.Most studies carried out using the CEL scale showed a high Cronbach's alpha coefficient -around 0.96, (22) 0.89, (23) 0.97 (12) and 0.95, (25) demonstrating the reliability of the scale.In our study, separating Cronbach's alpha by domains, it was found that domain 5 ("autonomy from bureaucracy") had a low score (0.35), which does not differ from the study carried out in the validation/adaptation of the CEL scale in Brazil. (10)A health professional management model that is based on professional bureaucracy states that professional knowledge and skills are planned to achieve objectives, through acting based on professional experience and knowledge developed, (26) however, excessive bureaucracy in nursing services contributes to unmotivated and uncreative behavior, impacting on the reduction of autonomy.
With regard to other employment relationships, the results show that individuals who have more than one employment relationship attributed lower scores to the empowering behavior of their leaders, which may be due to the fatigue of working two or more jobs, impairing the time and quality of rest.It is noteworthy that the double working day in nursing is related to low wages in a society with a neoliberal model of the work process of the profession and culture, which facilitates the reconciliation of multiple jobs. (27)Multiple professional ties are one of the main causes of stress for nursing professionals. (28)hen related to job satisfaction, the most satisfied nursing technicians and assistants considered the leader's empowering behavior to be more appropriate.A motivated nursing team performs the work with better quality, and the lead nurse plays an important role in this motivation. (29)Professionals who are more satisfied with their work consider a positive environment essential, with a satisfactory organizational climate, focus on objectives, articulated work process stages, shared actions, consistent relationships and collective purpose. (30) study with the purpose of analyzing the scientific production regarding the empowerment of nurses in Brazil, identified that, although the term is not new, it was only from 2007 that empowerment began to be studied in the country, with most studies being carried out in the Southeast and South regions.Most of the studies carried out adopt qualitative methods, aiming to know the meaning of nurses' empowerment (31) and contrasting with the present study, which has quantitative variables from a validated and culturally adapted scale.
In this study, domain 3 of the CEL scale refers to the trust that the leader places in his subordinates and obtained an average of 4.88, considered a good empowering behavior.A study carried out on which factor motivates an empowering behavior for followers reports that this behavior is linked to performance and perceived integrity in their followers, which motivates them to have confidence in the work carried out by their subordinates and to delegate tasks that require greater responsibility.Empowerment, when associated with a leadership style with an emphasis on relationships, demonstrated positive results in team performance, emphasizing the importance of leaders being prepared to encourage and engage their team through collaborative behavior. (7)t is noteworthy that the leader with more contemporary and less authoritarian styles influences the team's self-determination, promoting social changes, moral behavior and performance, according to the proposed care model. (32)he results of this research make it possible to carry out other studies and represent an advance in knowledge about leader behavior for the empowerment of their team from the perspective of those being led, which can contribute to the elaboration of more effective strategies in the leadership process, especially in nursing, since the perspective of nursing assistants and technicians is fundamental for the work process in the Brazilian context.
The scope of the study stands out as a limitation since the setting was a public university hospital in a region of the state of São Paulo.

Conclusion
The study participants were mostly nursing technicians, women, working during the day, without other employment relationships and satisfied with their work.Nursing assistants and technicians who worked during the day did not have other employment relationships and were satisfied with their work, demonstrating greater empowerment.Nurses' behavior to empower their team, from the perspective of technicians and nursing assistants in the studied hospital, was good in most domains.Only in the "autonomy from bureaucracy" domain was the leader's behavior to empower his team reasonable.It is recommended that more studies be carried out on the behavior of the nurse leader to empower the nursing team and to provide leadership strategies that ensure greater satisfaction and commitment to work.

Collaborations
Graça EPS, Oliveira PB and Spiri WC contributed to the design of the project, relevant critical review of the intellectual content, analysis and interpretation of data, writing of the article and approval of the final version to be published.

Table 1 .
Demographic and work data of mid-level nursing professionals

Table 2 .
Domains of the Leader's Empowering Behavior scale (n=260)

Table 3 .
Shift correlations, other ties and job satisfaction with the domains of the Leader's Empowering Behavior scale