ABSTRACT

Objective:

To understand the perception of leadership in the work process and to promote its discussion within the Family Health Strategy scope.

Method:

A qualitative approach research, guided by the action-research referential, conducted with 15 Familiy Health Strategy nurses in the inland of the state of São Paulo. Data was collected in 2015 in two interdependent phases, interviews and intervention-action, and processed according to the methodological framework of content analysis and the theoretical framework on nursing management.

Results:

The nurses showed their conceptions of leadership and the inherent challenges of practice: leadership training, overlapping care and management, and management charges. In the discussion of common problems and peer learning, a conception of transformational leadership was constructed.

Conclusions:

The common and behavioral styles of leadership influenced on the conception of leadership and mobilized the attitudes of the nurses in the work process; however, there is a need for more engagement in the training/qualification of the professionals and the services about leadership.

Keywords:
Primary care nursing; Leadership; Health services administration

RESUMEN

Objetivo:

Comprender la percepción del liderazgo en el proceso de trabajo y promover su discusión en el marco de la Estrategia de Salud de la Familia.

Método:

Investigación qualitativa, guiada por el referencial de la investigación-acción con la participación de 15 enfermeros de la Estrategia de Salud de la Familia en el interior del estado de São Paulo. Los datos se recolectaron en 2015 en dos etapas interdependientes, entrevistas e intervención-acción, y se los procesó de acuerdo con el marco metodológico del análisis de contenido y con el marco teórico sobre gestión de enfermería.

Resultados:

Los enfermeros presentaron sus concepciones de liderazgo y los desafíos inherentes a la práctica: formación para el liderazgo, superposición de la asistencia y la gestión, y cargos provenientes de la gestión. Con la discusión de problemáticas comunes y aprendizaje entre pares se elaboró una concepción de liderazgo transformacional.

Consideraciones finales:

Los estilos común y conductual influencian la concepción de liderazgo y movilizan las actitudes de los enfermeros en el proceso de trabajo, pero se necesita mayor inversión en la formación/capacitación de los profesionales y de los servicios en cuanto a la temática.

Palabras clave:
Enfermería de atención primaria; Liderazgo; Administración de los servicios de salud

RESUMO

Objetivo:

Compreender a percepção da liderança no processo de trabalho e promover sua discussão no âmbito da Estratégia Saúde da Família.

Método:

Pesquisa de abordagem qualitativa guiada pelo referencial da pesquisa-ação, com participação de 15 enfermeiros no interior de São Paulo. Os dados foram coletados no ano de 2015 em duas etapas interdependentes, entrevistas e intervenção-ação, e processados pelo referencial metodológico da análise de conteúdo e do arcabouço teórico acerca do gerenciamento em enfermagem.

Resultados:

Os enfermeiros apresentaram suas concepções de liderança e os desafios inerentes à prática: formação para liderança, sobreposição da assistência e gerência, e cobranças advindas da gestão. Com a discussão de problemáticas comuns e aprendizagem entre pares construiu-se uma concepção de liderança transformacional.

Considerações Finais:

Os estilos comum e comportamental influenciam a concepção de liderança, mobilizando as atitudes dos enfermeiros no processo de trabalho, o que indica a necessidade de investimento na formação dos profissionais e dos serviços nessa temática.

Palavras-chave:
Enfermagem de atenção primária; Liderança; Administração de serviços de saúde

INTRODUCTION

Since its implementation in 1994, the Family Health Strategy (FHS) has been considered a priority for the expansion and consolidation of Primary Health Care (PHC), as it provides access to the Unified Health System (Sistema Único de Saúde, SUS) and reorganizes the model of attention focused on preventive and health promotion actions11. Fernandes MC, Silva LMS. Gerência do cuidado do enfermeiro na estratégia saúde da família: revisão integrativa. Rev Rene. 2013 [cited 2019 Feb 08];14(2):438-47. Available from: Available from: http://periodicos.ufc.br/rene/article/view/3407/2644
http://periodicos.ufc.br/rene/article/vi... .

For consolidating this model of health surveillance in PHC, the nurse actions are essential for performing the necessary skills for integral care and the composition of the health team11. Fernandes MC, Silva LMS. Gerência do cuidado do enfermeiro na estratégia saúde da família: revisão integrativa. Rev Rene. 2013 [cited 2019 Feb 08];14(2):438-47. Available from: Available from: http://periodicos.ufc.br/rene/article/view/3407/2644
http://periodicos.ufc.br/rene/article/vi... . Therefore, the nursing work process has five complementary and interdependent dimensions: watch, manage, research, teach, and participate politically22. Paula M, Peres AM, Bernardino E, Eduardo EA, Sade PMC, Larocca LM. Characteristics of the nurses’ work process in the family health strategy. Rev Min Enferm. 2014;18(2):454-62. doi: https://doi.org/10.5935/1415-2762.20140034
https://doi.org/10.5935/1415-2762.201400... . The articulation between the managerial and care dimensions makes up nursing care management; however, with fragmented and curative actions in the context of the FHS11. Fernandes MC, Silva LMS. Gerência do cuidado do enfermeiro na estratégia saúde da família: revisão integrativa. Rev Rene. 2013 [cited 2019 Feb 08];14(2):438-47. Available from: Available from: http://periodicos.ufc.br/rene/article/view/3407/2644
http://periodicos.ufc.br/rene/article/vi... , this articulation is weakened.

Thus, it is necessary to act in the continuing education of health professionals to motivate them to produce health in the proposed model, since care management is a collective process and, even being exclusive to nurses, depends on the integrated action of the entire team33. Silva SS, Assis MMA, Santos AM. The nurse as the protagonist of care management in the estratégia saúde da família: different analysis perspectives. Texto Contexto Enferm. 2017;26(3):e1090016. doi: https://doi.org/10.1590/0104-07072017001090016
https://doi.org/10.1590/0104-07072017001... . In this perspective, leadership, a necessary and required competence of nurses, is fundamental for professional integration, as it influences the team to perform quality nursing care44. Balsanelli AP, David DR, Ferrari TG. Nursing leadership and its relationship with the hospital work environment. Acta Paul Enferm. 2018;31(2):187-93. doi: https://doi.org/10.1590/1982-0194201800027
https://doi.org/10.1590/1982-01942018000... .

Leadership has been required in health organizations, moving from a hierarchical and traditional model to teamwork, with semi-autonomous units, making the role of the nurse indispensable, as he is the team member that privileges collective interests and offers safe patient care55. Strapasson MR, Medeiros CRG. [Transformational leadership in nursing[. Rev Bras Enferm. 2009;62(2):228-33. Portuguese. doi: https://doi.org/10.1590/S0034-71672009000200009
https://doi.org/10.1590/S0034-7167200900... .

From this perspective, transformational leadership is presented as a leadership style focused on the quality of health care provided by nursing, especially in management, education and care, corroborating the expectations of the FHS.

The key feature of this model is the empowerment of team members, with a motivational relationship between leader and follower, which enables joint solutions to be achieved and a positive interpersonal work environment, contributing to low turnover rates, higher productivity and employee satisfaction55. Strapasson MR, Medeiros CRG. [Transformational leadership in nursing[. Rev Bras Enferm. 2009;62(2):228-33. Portuguese. doi: https://doi.org/10.1590/S0034-71672009000200009
https://doi.org/10.1590/S0034-7167200900... .

However, some barriers hinder nurse leadership in the FHS context, such as: biomedical health model, vertical and impersonal relationship with users, families and staff, exclusion of users in the construction of managerial activities and nurse work based on the classical administration models11. Fernandes MC, Silva LMS. Gerência do cuidado do enfermeiro na estratégia saúde da família: revisão integrativa. Rev Rene. 2013 [cited 2019 Feb 08];14(2):438-47. Available from: Available from: http://periodicos.ufc.br/rene/article/view/3407/2644
http://periodicos.ufc.br/rene/article/vi... .

Studies available in the literature on the theme of this study focus on nursing leadership experiences and competencies in the hospital setting and the challenges for leadership practice, including the context of academic education11. Fernandes MC, Silva LMS. Gerência do cuidado do enfermeiro na estratégia saúde da família: revisão integrativa. Rev Rene. 2013 [cited 2019 Feb 08];14(2):438-47. Available from: Available from: http://periodicos.ufc.br/rene/article/view/3407/2644
http://periodicos.ufc.br/rene/article/vi... ^,66. Balsanelli AP, Cunha ICKO. The work environment and leadership in nursing: an integrative review. Rev Esc Enferm USP. 2014:48(5):938-43. doi: https://doi.org/10.1590/S0080-6234201400005000022
https://doi.org/10.1590/S0080-6234201400... .

Thus, there is a need for studies, especially Brazilian studies, which address the theme of nursing leadership in the PHC setting, as shown in review studies that showed “ambivalent actions of care and management, in addition to the gap in knowledge about nursing management care in the FHS”11. Fernandes MC, Silva LMS. Gerência do cuidado do enfermeiro na estratégia saúde da família: revisão integrativa. Rev Rene. 2013 [cited 2019 Feb 08];14(2):438-47. Available from: Available from: http://periodicos.ufc.br/rene/article/view/3407/2644
http://periodicos.ufc.br/rene/article/vi... and the need for research to investigate the relationship between the work environment and leadership performed by nurses66. Balsanelli AP, Cunha ICKO. The work environment and leadership in nursing: an integrative review. Rev Esc Enferm USP. 2014:48(5):938-43. doi: https://doi.org/10.1590/S0080-6234201400005000022
https://doi.org/10.1590/S0080-6234201400... in this setting.

Given the aforementioned, it is still necessary to know how the FHS nurses experience/portray their leadership practices allowing, thus, to innovate them with the intention to offer quality care to the population. In this context, this study aims to understand the leadership perception in the work process and to promote its discussion within the FHS.

METHOD

It is a qualitative approach research, guided by the assumptions of action-research being used with the intent to operating a strategic and participatory action, aiming at building up knowledge, starting from the experience of the involved actors77. Sampieri RH, Collado CF, Lucio MPB. Metodologia de Pesquisa. 5.ed. Porto Alegre: Penso, 2013..

In this process, data is processed in order to trigger changes arising from the resolution or questioning of a given problem77. Sampieri RH, Collado CF, Lucio MPB. Metodologia de Pesquisa. 5.ed. Porto Alegre: Penso, 2013.. Thus, this approach enabled a thorough understanding of the research object represented by the leadership performed in the nurse work in the FHS context.

The research was conducted in a medium-sized city in the inland of São Paulo, which, during the data collection period, had eight Basic Health Units (BHUs) and 12 Family Health Units (FHUs), where 15 Family Health teams were distributed. The BHUs are not integrated with the FHUs and had two nurses who performed the managerial and assistance functions separately, a different situation than in the FHS teams, where both functions are performed by the same professional.

Intentional sampling77. Sampieri RH, Collado CF, Lucio MPB. Metodologia de Pesquisa. 5.ed. Porto Alegre: Penso, 2013. was used for selecting the participants and as an inclusion criterion, acting as a nurse in a FHU. It was considered important to facilitate the insertion of all FHS nurses, because with this strategy of sample composition, we sought to share the deadlocks experienced and stimulate the exchange of knowledge among those with greater and less work experience.

To ensure the participants' confidentiality, an alphanumeric code consisting of the letter “E” followed by a digit was assigned.

Data collect occurred in two interdependent stages: interviews and intervention-action. In the first, all nurses were involved and, in the second, two could not participate due to sick leave.

The interviews were conducted through guiding questions related to the object of study, which allowed the expansion to other questions that arose, as the answers were obtained and the involvement of respondents in the elaboration of the research content77. Sampieri RH, Collado CF, Lucio MPB. Metodologia de Pesquisa. 5.ed. Porto Alegre: Penso, 2013..

This stage was performed by the first author between January and March 2015, audio-recorded and later on transcribed in full. The average duration of the interviews was 15 minutes.

The guiding questions of the interviews were the following: How do you perceive leadership as a nursing manager in your action? What is being a leader? What are the practicalities and difficulties to lead? How do you think a leader should behave? Do you think it is important to learn to lead? What would be the path to this learning?

From the results obtained in the individual interviews, the second stage was planned, which consisted of an action intervention with the purpose of offering a space for discussion and reflection on the leadership of nurses in the FHS, with the purpose of causing changes in the work process. The meetings of this stage made it possible to apprehend similarities and differences on the nurse's leadership and the values, attitudes and beliefs that permeate this whole process.

These meetings were recorded in a minute book, with the reading of the content validated at the subsequent meeting, previously scheduled and held during September 2015. In addition, they occurred in a place easily accessible to all participants, lasted an average of two hours and were composed by nurses and two researchers, authors of this article. Thus, the group showed homogeneous characteristics, allowing all the involved parties to talk about their work practice.

At the first meeting, the research project was resumed and the qualitative material produced in the first stage was displayed and validated collectively by the participants. Then, the presentation dynamics was performed, where everyone had the opportunity to point out their expectations related to this stage of the research, as well as the lived and perceived perceptions regarding leadership in the work process.

The strategies used in the second meeting were the following: previously-referred text reading involving leadership55. Strapasson MR, Medeiros CRG. [Transformational leadership in nursing[. Rev Bras Enferm. 2009;62(2):228-33. Portuguese. doi: https://doi.org/10.1590/S0034-71672009000200009
https://doi.org/10.1590/S0034-7167200900... ; recognition of problem situations about nurses' work practice and their discussion in small groups, based on the recommended literature. Based on a hypothetical case created by all participants, each small group reflected on actions and interventions regarding the identified problems. Finally, in a single group, a synthesis of the discussions was elaborated.

At the last meeting, the nurses built up a concept of transformational leadership and discussed applicability in their realities. The closure of the activity occurred through a two-part evaluation, considering the entire second stage and seeking to assess the effectiveness of the executed proposal.

The assessment started with a Likert type scale with four criteria (great, good, fair or bad) related to ten attributes of the second stage: objectives, importance for professional performance, importance for training, content, methodology, group relationship, knowledge of researchers, motivation of researchers, possibility of reorientation of meetings and dedication of the participant. Three open questions followed on, to which the participants answered continuing the sentences started by the following expressions: “I didn't even expect it and it happened...”, “I was a little disappointed with...”, “If I were to advertise to a colleague about this educational intervention I would say that...”. Finally, a score from zero to ten was assigned to the second stage in its entirety.

The data from the first stage was processed through content analysis. Data processing operationalization, through theoretical reference, is based on the definition of the term condensation as a process of reducing speech, preserving their essence. In this sense, in this study the model was adopted that describes the following: meaning unit, condensed meaning unit (close text description), interpretation of the underlying meaning, sub-theme and theme. The theme is expressed by the latent content (interpretive level) of the text and can bring together several sub-themes88. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24:105-12. doi: https://doi.org/10.1016/j.nedt.2003.10.001
https://doi.org/10.1016/j.nedt.2003.10.0... .

The second stage started from the records made in the minutes, the researchers' perceptions and the evaluations completed by the nurses, descriptively searching for similarities and differences with the results found in the first stage; this analysis was guided by the assumptions of nursing management99. Marquis BL, Huston CJ. Administração e liderança em enfermagem (teoria e prática). 8. ed. Porto Alegre: Artmed; 2015..

In consideration of the ethical precepts, this research was approved by the Ethics and Research Committee of the Botucatu School of Medicine, on 11/02/2014, under opinion No. 855,870. All participants were informed on the research details and agreed to participate by signing the Free Informed Consent Form.

RESULTS

Stage I

Analyzing the interviews allowed us to build two themes around the leadership process performed by the nurse in the FHS context. The first - the nurse leadership - consisted of four sub-themes: the nurse’s perceptions; the attitudes of a leader; the leader as a mediator; and interpersonal relationship as an ability to lead. In the second, - leadership challenges - three sub-themes emerged: the training of nurses to lead; to assist and to manage as overlapping activities; and the dichotomy between the reality of health services and their managers.

The nurse leadership

This first theme expresses how the study participants perceived leadership and, in short, explored the attitudes, behaviors, and mediation expected in the role of the leading nurse. The overlapping of the actions of the “to assist and to manage” sub-processes appeared to interfere in the exercise of leadership in the FHS context.

The subjects' perceptions regarding what is expected of the leader's role were brought with similarities in the speeches and expressed with the following terms: example, mentor, reference, link, mediator, master, mirror, among others.

It was observed that the participants attributed the importance of acting as a model to the leader figure, having a behavior consistent with their speeches and playing the role of a health work mentor.

Regarding attitudes, respondents conceived democratic leadership, characterized by a relationship of trust and a horizontal relationship built over time and based on mutual respect; for fair attitudes and flexibility in their actions; and by including all team members in the decision making.

For the participants in this study, there is a clear distinction between heading and leading. It was also noticeable that incorporating this profile in the work of the nurse in the context of the FHS is a complex task.

It was observed that the participants elaborated their leadership conceptions based on common styles, highlighting a mixture of behavioral, autocratic and democratic concepts. The work practice of the FHS takes the leading nurse to mobilize certain behaviors in themselves that are associated with these conceptions; however, the managerial functions trigger a more centralizing posture.

Clarity in interpersonal relationships at work was among the factors that make it difficult for nurses to exercise leadership, since that the participants' discourses allow us to interpret that the relational dimension and the way that the involved parties weaken the interventions performed by the nurses.

Mutual support, such as the exchange of experience among peers, was identified as a facilitator for the nurse leadership in decision-making at work.

For the nurses, the FHS leadership work process comprises a complex practice that requires mastery in interpersonal relationships, coherence between speech and action, facilitated by the support they have among themselves. There was a conceptual reduction in leadership, which justifies the importance of discussion spaces on the subject.

The challenges of leadership

This theme encompasses the academic and professional education of nurses to lead, the overlapping of care and management in the work process and the demands of PHC management to services as factors that make the practice of transformational leadership impossible.

The exercise of leadership was described as a challenging process for participants and its development involved three aspects: the content learned during undergraduate studies being insufficient, the importance of professional performance and self-development to elaborate and incorporate the experiences lived at work.

The knowledge, skills and attitudes of the nurse in order to play the role of a leader involve several attributes, among which the previous experiences, personal characteristics, intentionality for teamwork and inter-professional, flexibility and creativity to experience situations of shared way are highlighted.

Regarding the educational leadership process, this sub-theme reflected the fragility of professional education and continuing education activities that often do not meet the needs of the services. The nurses identified the need for in-service training strategies that put them in contact with the different experiences they had in the work context at the FHS.

In this sense, it was also observed that discussions about the practice are more effective than specific educational actions, such as courses and lectures, which disadvantage the exchange of experiences and distance themselves from the reality of health services. Therefore, sharing experiences with peers and teams could be a means for effective learning, producing changes in management, work process and the provided assistance.

The nurse's withdrawal from the care management and the difficulty in delegating and sharing functions were also observed, which ends up disregarding the concept of leadership adopted by the participants presented in the previous theme.

Another difficulty related to the leadership challenge was attributed to the service-management relationship, characterized as vertical, mobilizing the way how nurses set up contact with the health team. A second aspect referred to the valuation of management by the quantitative production over the qualification offered in care.

In summary, the participants' speeches pointed out that leadership challenges are related to factors for which nurse governance is limited, especially where shared management is not a practice.

Stage II

Considering the results found in the first stage, aligning them with the interests of the participants, the action-intervention was designed to problematize the conceptions and practices exercised around the leadership of nurses in the FHS context. It is noteworthy that the reports pointed out to the scarcity of continuing education strategies; thus, in the analyzed context, action-intervention represented a first approach of the nurses to the theme of leadership in the work context.

During the meetings, it was noticed that the participants felt open to place themselves, being in an environment where, together, they could identify and share weaknesses and challenges common to the practice of leadership in the FHS. These characteristics integrate fundamental elements to the realization of learning.

Action-intervention provided the collective validation of the themes and sub-themes of the first stage. In this sense, there was convergence about the motivation of the leader in the work process, the weaknesses in the training for the exercise of leadership and the overload generated due to managerial and care duties. About this sub-theme, the nurses argued that, in other services of the care network, these attributions are divided between two professionals, so that this factor can facilitate leadership performance.

Other topics were further explored, including PHC management. In addition to validating the content of the individual speeches, participants discussed their expectations regarding management, which should act as an example and as a great motivator of leadership.

However, its distant and vertical positioning shows to the nurses a disregard of their experiences and responsibilities, as well as the lack of characterization of the health care model linked to the FHS work. According to the subjects, the interference exerted by the management is one of the factors that weaken the collective actions of promotion and prevention, leading to prioritizing actions aimed at the spontaneous demands.

During the discussion of problem-situations that occurred between the second and third meetings, teamwork appeared as a potent tool for the collaborative practice; the reports generated by the information systems, when used by nurses, were seen as facilitators for the work process management and the human resources deficit was perceived as a challenge for developing leadership in the FHS.

Regarding the construction of a transformational leadership concept, after reading the theoretical framework and discussing contextual problem situations, the participants collectively elaborated the following formulation:

Regarding the applicability of this concept in practice, the participants agreed on the possibility, but rescued the challenges that were listed in the interviews and validated in the intervention-action, such as political issues, weak management support, lack of regulations and institutional incentives, self-esteem and personal motivation.

The resistance of the participants to incorporate the elaborated concept of transformational leadership was observed, when pointing to a supposed overload of nurse work in the FHS. It was necessary to problematize the concepts of leadership, the role of the leader, teamwork and collaborative, to clarify that transformational leadership proposes the sharing and inclusion of the team in the planning and execution of actions, leading to reduced workload.

Another weakness pointed out is the local management for not valuing these attitudes, which makes it difficult to change the paradigm that supports the actions performed by nurses. This fact draws attention to the fact that this professional does not realize that transformational leadership should be inherent in their professional practice.

Evaluating the intervention-action was considered positive, since the attributes of importance for professional performance, importance for formation, group relationship, motivation and possibility of reorientation of the meetings were evaluated as “great” by all participants. And the other half of the attributes - objectives, content, methodology, knowledge and motivation of the researchers and the participant's dedication - was evaluated as “great” and “good”, with a higher concentration of the former.

Evaluating the intervention-action from the open questions was positive because it allowed for the exchange of experiences, support in the face of similar problems in the services and reflection of management practice. Regarding the grade attributed to the strategy, its mean value was 9.5.

DISCUSSION

The conceptions of the participants around the leadership concept evidenced behavioral aspects that transited between the persuasion and the integration of the team in the decision-making processes. In the first one, the centrality of the organizational and administrative dimensions in the nurse's performance related to the scientific administration is rescued and that may come to reduce the role of the leader to the mere ability to influence their team, leading to certain outcomes1010. Fonseca AMO, Porto JB, Borges-Andrade JE. [Leadership: a portrait of Brazilian scientific production]. Rev Adm Contemp. 2015;19(3):290-310. Portuguese. doi: https://doi.org/10.1590/1982-7849rac20151404
https://doi.org/10.1590/1982-7849rac2015... , making the nurse accountable for the direction taken by the team in carrying out the work.

In turn, the second conception indicates an expansion of the posture and performance of the leader in front of the health work, characterized by the integration of the health team in the decision-making processes. Aspects of the democratic leadership, of the co-responsibility and of the autonomy of the various team workers are elements that articulate the participants' discourses regarding their leadership conceptions99. Marquis BL, Huston CJ. Administração e liderança em enfermagem (teoria e prática). 8. ed. Porto Alegre: Artmed; 2015..

Despite the contradiction observed in the different leadership conceptions for the FHS nurses, it is convergent that leadership is a critical and priority element in the health work practice, including actions from the managerial nursing dimension.

The nurse's work in the PHC is divided between managing and assisting, triggering feelings that oscillate between pleasure - when playing the articulating role among team members, when having the work recognized by the patient's eyes, or when they are perceived as care facilitator - and suffering, resulting from work overload, health system weaknesses, physical conditions of the services and exposure to various occupational risks1111. Guimarães E, Souza MMT, Passos JP. Desafios do enfermeiro como líder na atenção básica à saúde: do prazer ao sofrimento. Rev Pró-UniverSUS. 2016 [cited 2019 Feb 08];7(2):34-8. Available from: Available from: http://editora.universidadedevassouras.edu.br/index.php/RPU/article/view/346
http://editora.universidadedevassouras.e... .

At this juncture, transformational leadership appears as a model that promotes an integrated approach to organizational and personal dimensions, dealing with situations of change and resilience, with decision-making in the exercise necessary for including risk and coping with reality55. Strapasson MR, Medeiros CRG. [Transformational leadership in nursing[. Rev Bras Enferm. 2009;62(2):228-33. Portuguese. doi: https://doi.org/10.1590/S0034-71672009000200009
https://doi.org/10.1590/S0034-7167200900... . These characteristics refer to the concept of transformational leadership built by the participants of this study and it is expected that, with its practice, there will be team development, communication, conflict management, cohesion and trust.

An integrative literature review study on leadership assessment tools found that “the transformational leadership model contributed to increased motivation and job satisfaction by providing collective discussion, broadening dialogical communication and active listening to workers, leading to greater commitment”1212. Carrara GLR, Bernardes A, Balsanelli AP, Camelo SHH, Gabriel CS, Zanetti ACB. Use of instruments to evaluate leadership in nursing and health services. Rev Gaúcha Enferm. 2017;38(3):e2016-0060. doi: https://doi.org/10.1590/1983-1447.2017.03.2016-0060
https://doi.org/10.1590/1983-1447.2017.0... corroborating the findings in this research.

The weakness in the initial and continued qualification of leadership as a nurse competence is one of the factors that justify the challenges of care and management that were identified in the individual and collective discourses. This aspect corroborates the results of a study conducted in the Southeast region of Brazil, as it identified that leadership and management are challenges to be overcome, as well as the dissonance between what is taught in academia and what is experienced in the workplace1313. Souza LPS, Silva WSS, Mota EC, Santana JMF, Santos LGS, Silva CSO, et al. Os desafios do recém-graduado em Enfermagem no mundo do trabalho. Rev Cubana de Enfermer. 2014 [cited 2019 May 18];30(1):4-18. Available from: Available from: http://www.revenfermeria.sld.cu/index.php/enf/article/view/127
http://www.revenfermeria.sld.cu/index.ph... .

Among the teaching-learning strategies applied to developing undergraduate leadership identified from a study conducted with teachers from all the regions of Brazil, it was observed that the expository dialogued lecture is among the most used, followed by discussions and work in group, and online courses1414. Caveião C, Peres AM, Amestoy SC, Meier MJ. Teaching-learning tendencies and strategies used in the leadership development of nurses. Rev Bras Enferm. 2018;71(suppl.4):1531-9. doi: https://doi.org/10.1590/0034-7167-2017-0455
https://doi.org/10.1590/0034-7167-2017-0... . This note identifies the distance between graduation and the actual practice scenarios, reinforcing the dissociation in dialectic work and training in teaching leadership. This weakness was observed in a study conducted in the southern region of the country, where nurses reported that the leadership content addressed in undergraduate studies influenced their professional performance and made it difficult to act1515. Andrigue KCK, Trindade LL, Amestoy SC. Academic formation and permanent education: influences on leadership styles of nurses. J Res Fundam Care Online. 2017;9(4):971-7. doi: https://doi.org/10.9789/2175-5361.2017.v9i4.971-977
https://doi.org/10.9789/2175-5361.2017.v... .

Therefore, this negative repercussion from the weakened approach to leadership during undergraduate studies demonstrates a gap in the curriculum, as leadership is an essential competence for the nurse and it is highlighted in the National Curriculum Guidelines for Nursing Courses1616. Ministério da Educação (BR), Conselho Nacional de Educação, Câmara de Educação Superior. Resolução CNE/CES nº 3, de 7 de novembro de 2001. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Enfermagem. Brasília (DF): MEC; 2001 [cited 2019 Mar 19]. Available from: Available from: http://portal.mec.gov.br/cne/arquivos/pdf/CES03.pdf
http://portal.mec.gov.br/cne/arquivos/pd... .

In addition, formal training can increase nurses' skills in leadership practice and address gaps in the teaching-learning process inherited from undergraduate education, as demonstrated in a study conducted with 512 nurses from 23 hospitals in Arizona, United States1717. Kelly LA, Wicker TL, Gerkin, RD. The relationship of training and education to leadership practices in frontline nurse leaders. J Nurs Adm. 2014;44(3):158-63. doi: https://doi.org/10.1097/NNA.0000000000000044
https://doi.org/10.1097/NNA.000000000000... . The offering of courses organized by the management of health services was identified as a facilitating strategy for the development of leadership by nurses from southern Brazil in the PHC1818. Lanzoni GMM, Meirelles BHS, Cummings G. Nurse leadership practices in primary health care: a grounded theory. Texto Contexto Enferm. 2016;25(4):e4190015. doi: https://doi.org/10.1590/0104-07072016004190015
https://doi.org/10.1590/0104-07072016004... , and this is a necessity pointed out in the speeches of the participants in this investigation.

Therefore, leadership has been a challenge for nurses in their daily activities. However, this competence can be developed in the daily work, through commitment and confidence in its potentials, to be prepared to assume the numerous functions assigned to them. Thus, preparing nursing professionals with regard to leadership skills and the possibility for learning them is essential, as it comprises a managerial function that requires individual qualities and specific skills that can be learned by any individual1111. Guimarães E, Souza MMT, Passos JP. Desafios do enfermeiro como líder na atenção básica à saúde: do prazer ao sofrimento. Rev Pró-UniverSUS. 2016 [cited 2019 Feb 08];7(2):34-8. Available from: Available from: http://editora.universidadedevassouras.edu.br/index.php/RPU/article/view/346
http://editora.universidadedevassouras.e... .

It is also worth mentioning that continuous learning in leadership requires organizational environments, where workers must participate in decision making, leave comfortable positions and learn new ideas and experiences.

Other factors, shown in a study conducted in the inland of the state of São Paulo and corroborated by this study, are those that can cause weaknesses in nurse leadership, such as: lack of management support; lack of time for exercising care and management; loss of clarity of the role as a nurse; valorization of production to the detriment of the offered care quality; demotivation; centralization of power in the figure of the nurse; team and user conflicts1919. Spagnuolo RS, Bocchi SCM. Between the processes of strengthening and weakening of the Family Health. Rev Bras Enferm. 2013;66(3):366-71. doi: https://doi.org/10.1590/S0034-71672013000300010
https://doi.org/10.1590/S0034-7167201300... .

PHC complexity demands from the nurses a higher degree of qualification to perform their duties; in this context, the fragmentation, disarticulation of health work and the overlapping of managerial and care actions were identified as characteristics that hinder leadership exercise.

In this sense, continuing education is a tool to settle the fragmentation of the work process in the dimensions assist-manage and service-management, because the overlapping of managerial and care attributions in the health unit, through work overload, negatively affects the exercise of leadership that dissociates from the care sub-process.

A study conducted in Zambia showed that, after the investment by the Ministry of Health of that country in the training of nurses and PHC obstetricians for leadership, development of management skills and abilities and improvement in the use of technologies, there was a strengthening of these competences, empowerment of the nurses and obstetricians and institutionalization by the government for the continuing education of these professionals, as it was considered the advancement of PHC and improved access for universal health coverage2020. Foster AA, Makukula MK, Moore C, Chizuni NL, Goma F, Myles A, et al. Strengthening and institutionalizing the leadership and management role of frontline nurses to advance universal health coverage in Zambia. Glob Health Sci Pract. 2018;6(4):736-46. doi: https://doi.org/10.9745/GHSP-D-18-00067
https://doi.org/10.9745/GHSP-D-18-00067... .

As reported by the participants in this research, the management team tends to value the traditional and individual model of health care and, in effect, reduces leadership actions to supervision and control activities, based only on the rationality of scientific administration1515. Andrigue KCK, Trindade LL, Amestoy SC. Academic formation and permanent education: influences on leadership styles of nurses. J Res Fundam Care Online. 2017;9(4):971-7. doi: https://doi.org/10.9789/2175-5361.2017.v9i4.971-977
https://doi.org/10.9789/2175-5361.2017.v... .

Although the submitted content cannot be generalized, as it is a local study, its relevance is emphasized since it adds knowledge on the theme, besides providing moments of reflection and evaluation of the leaderships in their practices.

FINAL CONSIDERATIONS

For nurses working in the FHS, leadership conceptions are influenced by the various roles they exercise in this context and by the behavioral concepts and common styles that eventually interfere with the way the leading nurses perform their role. Thus, it was possible to grasp the challenges in the exercise of leadership in the work process and the weaknesses that underlie this finding.

The similarity in the nurse’s perception on being a leader is highlighted, with teamwork being the central facilitator for their performance. Challenges include the overlapping of assisting and managing the work process and political issues, such as management demands, which interfere with the establishment of transformational leadership. Greater investment in initial and continuing education and the acknowledgment of nurses' leadership by the services are strategies that contribute to the transposition of these challenges.

Finally, providing opportunities for discussion favored the exchange of experiences and mutual learning on the subject, contributing to the construction of a collective and integrative conception aiming at transformational leadership. Moreover, it enabled a strategy of collective validation of qualitative material built up based on dual interviews, corroborating the findings in this research.

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