Repercussions of proactivity in the management of care: perceptions of nurses Repercusiones de la proactividad en la gestión del cuidado: percepciones de los enfermeros

Objective: To know the perceptions of nurses regarding proactivity in the management of care. Methods: Exploratory-descriptive study with a qualitative approach, data collection by vignette technique with 35 nurses, submitted to content analysis. Results: The information converged into four thematic categories: proactivity as a driver of organizational development; proactivity as an opportunity to go beyond the disease; proactivity as a stimulus for cooperation, leadership and team learning; proactivity for encouraging fulfillment and recognition in the work. Conclusion: The nurses understood that their actions, when undertaken proactively, can beneficially affect different areas related to the management of care: of the organization, of the user, of the team and of the individual. The study contributes to a reflection regarding the way of acting of the nurse, raising possible implications and stimulating opportunities for strategic articulations and for individual and collective actions that enable the development of best practices in the management of care.


INTRODUCTION
The contemporary work scenario has proved to be increasingly demanding, stimulating a professional pattern of an increasingly qualified, proactive and entrepreneurial worker.In the field of nursing, this perspective is no different, with the need emerging for nurses to visualize differentiated, qualified care directed towards the best care practices, which leads to a critical reflection regarding the actions they develop, their purposes and how these actions can be improved.Considering the singularities in the care practices and the individuality of each professional and each user, nurses are expected to manage adequately the processes and health needs, in order to exercise leadership and decision-making, with creativity, innovation and an expanded view of their actions.
However, different ways of working have been observed among professionals who share the same working environment and have the same responsibilities and circumstances.While some can launch new actions, take initiatives, seek new ways of acting and generate constructive changes in their work, others conform to the situation as it stands, limiting themselves to the comfort zone and a routine of obligations, not going beyond that merely prescribed.
Amid the complexity and uncertainties of this scenario, the person that just achieves enough to maintain his/her post and/ or simply fulfill the commitments of the employment contract, cannot keep up with the demands of today.Thus, workers are compelled to act proactively, demonstrating the initiative to identify future needs, anticipate impasses and (re)think strategies that assist decision making and allow the aims of the work to be achieved 1 .Thus, it is understood that the proactive professional will actively seek ideals to make improvements that are beneficial to the institution, the staff, the work environment in which he/she operates and perceive possible obstacles in advance, persistently confronting these, in the singular production of care.
The work of nurses includes attending to the health care needs of the human being, which reinforces the importance of their practices being grounded in proactive actions to comprehend the integrality of the human, biopsychosocial and spiritual aspects.However, the issue is permeated with paradoxical aspects, considering that proactivity has been highly extolled in the corporate world.It is often idealized as a model of behavior to be internalized that seduces the worker based on market interests, which are not always consistent with the object of the work.
In this sense, the proactivity of the nurse is associated with a kind of vanity, as instead of being undertaken in the name of the care it starts to adhere to a purely productivist logic, focusing on maximum profitability and on attending to the nurse's own interests.In nursing, it is hoped that the production of care will happen from the health needs of individuals and not in an immediate consumption nexus, due to the fact that its practice is materialized as it occurs and is consumed at the moment of its production, in an inseparable manner.Without losing sight of these considerations, the positive aspects of proactive action must also be recognized.It is through this that the professional can boost the action beyond the obligations, anchoring a more strategic perspective that anticipates the changes that are necessary in order to promote a more conducive working environment for the expression of the singularities both of the team and of the users.This favors making qualified decisions with a view to solving problems and seeking new solutions.Studies focused on business reaffirm that proactive professionals are driven by opportunities aimed at improvements, demonstrate initiative, persevere to achieve their objectives and adopt a posture directed toward creating more favorable, innovative conditions, developing professional activities which underscore interpersonal networks of work that enhance their careers [2][3][4] .
Currently, the managerial work of the nurse is highly valued because it has the purpose of articulating management and care activities, creating mechanisms to fulfill the care needs and improve the living conditions of the users, as well as fulfilling the objectives of the institution and nursing team, favoring the practice of care management 5 .Therefore, considering that the management of care is primarily performed by nurses, with them organizing the collective work of the nursing team so that care can be provided, it is comprehended that the proactive action of this professional can generate important repercussions in the work.
Thus, it is important for nurses to be able to interact proactively to expand entrepreneurial opportunities in their work, extrapolating the limits of disciplinary knowledge and of specific and linear actions 6 that reinforce the pluralistic, multifaceted and complex character of the health scenario.This condition invigorates the need to adopt proactive ways in the work that favor the expansion of bonds based on ethics and human values, which produce resonance in the care and establish a link between the needs of the institution, the work team and the user 7 .
Among the considerations presented and considering that nurses have opportunities and potential to be proactive in their actions, being able to link with the team to favor improvements in the care management, the following research question was raised: What is the perception of nurses regarding how proactive action can affect the management of care?
Given this question, a study was developed with the aim of investigating the perceptions of nurses regarding proactive action at work and the possible repercussions of this course of action for the management of care.Taking into account the importance that has been given to proactivity in the context of the nursing practice and the fact that investigations related to the theme are still scarce, especially in nursing, it was consider that the results of this study could add new perspectives to the knowledge produced, raising the possibility of further studies in nursing.It was also hoped that, from this, subsidies could be provided for reflection, critique and (re)organization of the actions in the work consistent with the principles and guidelines of the Brazilian National Health Service (SUS).
Proactivity in the management of care Ferreira GE, Dall'Agnol CM, Porto AR

METHODS
The study is characterized as exploratory and descriptive, with a qualitative approach, and was developed in a public university hospital in southern Brazil, which has 845 beds and a staff of approximately 6,300 employees.Data were collected from nurses of the surgical inpatient units, including those that were occupying management positions in their respective units.
The sample was non-probabilistic by convenience, with the following adopted as inclusion criteria: interest in participating in the study and availability to respond to the data collection instrument.Prolonged absences due to holidays, sick leave, or leave for personal reasons were considered as exclusion criteria.Instruments returned incomplete were also excluded.Thus, of the population of 62 nurses, the sample consisted of 35 participants, i.e. 56% of the total.
Data collection took place between May and June 2013, through the vignettes technique.The vignette consists of compact descriptions of a situation, being a methodological approach to detect opinions, coping attitudes and knowledge related to certain phenomenon.This configures an important strategy to arouse reflections, as it provides simulations of real events and its use in research allows knowledge, attitudes and/or opinions to be extracted and encourages respondents to express how they would (re)act in the situations outlined [8][9][10] .
In addition, vignettes can be used as a tool in the work of the researcher, facilitating the comprehension of the question for the participant, problematizing a particular situation, or even favoring the presentation of responses that, in many circumstances, the participant would not feel willing to give 11 .
National and international literature has presented studies in various fields of knowledge, using vignettes as research tools.Originating in the field of anthropology, in the 1950s, and later in social psychology, in the 1970s, the use of vignettes as a data collection strategy is still little explored in the nursing field 9 .This highlights that we must be alert to the potential of creative and innovative techniques that contribute to the strengthening of our research, such as the vignettes technique.
In this study, the vignette was constructed based on the concept of proactivity 2 and on a hypothetical situation accompanied by questions.The purpose of using the technique was to reproduce the simulation of a reality in order to explore aspects of proactivity that allow the objectives of the study to be achieved.Participants were given ten days to respond to the vignette questions, expressing in writing understanding, divergences and convergences related to the scenarios presented.They described the modes of action of two nurses who, despite having the same working conditions, adopt different positions, one characterized by proactive action and the other not.The purpose was to capture the perceptions of the participants regarding the repercussions of the different modes of action of the characters for the health institution, for the work teams, for the user and for the professional that manages the care.The following, Chart 1, illustrates the vignette of the study.

Chart 1. Vignette
Rosicler and Dioneia are nurses from the same Unit.They work under the same conditions, at different times, and, interestingly, they act quite differently.Rosicler acts in a "connected" way with the team, enhancing partnerships and relationships with the other professionals who interact, and welcomes suggestions for improvements presented for their team.Dioneia does not listen to her colleagues, and if any team member brings some new idea, she is usually the first to say it will not work, and that it is best left as it is.Faced with the difficulties encountered in their service, Dioneia is constrained, assuming a discourse of passive acceptance faced with what happens and formulates her strategies considering only the requirements of the management.Rosicler, in turn, seeks to anticipate, proposing new or alternative ways, and sees the problems that arise as opportunities for learning and growth.For Rosicler, to overcome obstacles makes her feel more engaged, accomplished and involved with her work, because there is positive.
From the reading and understanding of the vignette, the participants responded to the following questions: What implications could these modes of action have for the work teams of these nurses?What are the possible consequences of acting in these ways for the care provided to the patient?What kind of repercussions could the modes of action of Rosicler and Dioneia generate for themselves?
The information resulting from the data collection was submitted to thematic content analysis 12 , being processed, in operational terms, through the steps of pre-analysis, categorization and treatment and finally interpretation of the results.
The study respected the bioethical prerogatives, according to Resolution n.º 466, of December 12, 2012, of the National Health Council 13 , and was registered on the Plataforma Brasil, under protocol n.º 12801213.0.0000.5327.Approval was obtained for the project from the research ethics committee of the study institution under registration 13-0054.The participants signed two identical copies of the Informed Consent form, one copy being retained by the researchers and the other by the participant.The study assured free participation in the research and the anonymity of the participants in the publication of the results, who are represented by the letter E, followed by a sequential Arabic numerals.

RESULTS
The characteristics of the study participants showed a predominance of females (94.3%), in the age group between 41 and 50 years of age (48.6%), married (48.6%) and education to the lato sensu graduate level (68.6%).A total of 57.2% of the participants had worked as nurses for periods exceeding 15 years.Those who had worked in the hospital for more than five years accounted for 68.6%, while 62.9% had worked in the same Proactivity in the management of care Ferreira GE, Dall'Agnol CM, Porto AR unit for a period of up to five years.Among the participants, six (17.1%) occupied management positions.
When responding to the questions, the 35 participants expressed their positions regarding the situations illustrated, allowing the identification of actions that can be considered proactive and not proactive in the more diverse working conditions.The thematic analysis allowed the emergence of a number of units of meaning, which were grouped into two thematic categories that composed the theme of the study: "Repercussions of the proactivity of the nurse in the management of care".
In Chart 2 the thematic categories addressed are described and the statements of the participants, who expressed their convergences and divergences with respect to the contrasting positions of the characters of the vignette, are presented.

Repercussions of the proactive way of acting of the nurses
The following statements suggest that the proactive action of nurses affects the organizational development and show how the organization and care provided are perceived by society:

It has common goals to the institution and seeks continuous improvement of the work (E-10).
The hospital is recognized by the community and well regarded by the residents (E-15).

It is the ideal model for any institution and the worker model [...] it coordinates the workers well [...] it serves the clients well [users of the health services] and avoids waste of time and materials (E-28).
The predominant understanding was that the proactive actions of nurses have repercussions for the user, in that they determine the (dis)satisfaction with this health services and the organization, and represent an opportunity to go beyond the pathological condition:

You can go beyond the disease, and support the management and care activities in search for the best way to assist the patient (E-23).
Among the possible repercussions for the professional that manages the care, it was stressed that the proactive action of the nurse provides the opportunity for better performance in the work and management of the career, promoting recognition and professional satisfaction:

Repercussions in the:
Of the proactive action Of the non-proactive action

[...] more professional achievement, more valued by the team and by the immediate manager. She is satisfied and identifies with what she does, and this causes well-being and recognition (E-19).
If the people are proactive they are more employable, they have an advantage over other people [...] they feel the need to do a better job, rewarding, that gives pride and has recognition (E-28).
There was recognition that the nurse, when acting proactively, encourages other members of the team to adopt proactivity for themselves.This was associated with dialogue and autonomy within the group as well as with freedom to express opinions and propose strategies that improve the work and strengthen the learning: It valorizes the work of your team, listening and dialoguing.This way of acting motivates the team and generates trust, reflecting in the quality of the care (E-01).

Repercussions in the work when the nurse does not act proactively
However, when the nurse does not act proactively:

Patient care will be called into question because patient safety is compromised and the care is permeated with insecurity (E-19). [...] looking only to meet emerging demands, and by doing so, proves that the professional is not able to provide comprehensive care that values the needs of the other person and goes beyond the patient's condition (E-24).
The repercussions related to not being proactive were also identified:

DISCUSSION
Favorable perceptions and/or contrary to the scenarios presented in the vignette were inferred from the data when seeking a reflection between the modes of action of Rosicler and Dioneia.By positioning themselves for or against each character, the nurses highlighted possible repercussions of proactivity in the management of care, which were notable in four different areas, namely: For the organization of health, for users of the services, for work teams and for the nurse that manages the care.
The proactive nurse proved, in this study, to be a professional model appropriate to the scenario of contemporary work, since this professional is shown to be aligned with the organizational objectives and goals, seeking the continuous improvement of practices and processes and the optimization of time and resources, promoting organizational development.From the same perspective, a recent study 14 presents proactivity as a desirable qualification for the current labor market, with merely performing tasks no longer being enough, because, in the work where employees are proactive, the goals related to the pursuit of continuous improvement of the processes and of the results are clearly defined.
Thus, managing institutional resources effectively, coordinating and promoting teamwork wisely and intermediating actions to ensure better service for the users and their families are significant requirements for the work of nurses in the current market, as well as for the potentialization of the practice of care management.Furthermore, the nurses expressed a favorable view of the employee that acts in an engaged and committed way, associating this practice with the proactivity of this professional.
Researchers 15 have shown that the key to the success of the organizations is an engaged and committed workforce, which acts proactively.From this perspective, proactive management in nursing is shown to be an important strategic factor for organizational performance, since nurses will work in the active and preventive control of adverse events that may affect the quality of the patient care.
This assumption is consistent with a study in which the authors, after analyzing several dissertations and theses, in the management area of nursing in the hospital context, highlighted the need to rethink theoretical positions from the perspective of reconstituting practical ideas, transforming the everyday challenges, overcoming and seeking new knowledge and skills to help in critical thinking related to the problems that emerge from the work quotidian 16 .
The improvement of the processes and practices refers to the idea that the proactive nurse can identify activities that add value to the care, considering the alignment of the needs of the organization with those of the users of the service.This proposal reaffirms the need for a strategic articulation of this professional, which favors the development of emancipatory actions shared with the user, with a view to longitudinal monitoring 17 .
The participants also understood that the proactive approach reflected favorably in the way the users perceive and recognize the organization and the services offered, a condition that can affect their degree of satisfaction.User satisfaction relates to the quality of the care provided by the health services, with this condition being an important factor for the (re)orientation of the working practices 18 .The initiative characteristics of the proactive worker in anticipating situations and problems, in order to solve Proactivity in the management of care Ferreira GE, Dall'Agnol CM, Porto AR them 2 , may positively impact on the work organization.These characteristics also possibly reflect in the satisfaction of the users and their families, with the individual attention to their health needs that they receive from the health team, as proactive professionals go beyond their prearranged activities, promoting the provision of integral care to the users and their satisfaction with the health service.
Proactive action was seen as an opportunity to go beyond the disease and valorization of the complaints and subjective aspects of the user, showing concern for the effectiveness of the care and of the actions developed.From this perspective, the importance of actions that encompass the multiple dimensions of management is emphasized, as well as the importance of strategies that consider the multi/interdisciplinarity and nonfragmentation of the processes, aimed at continual improvement of the practices 19 .Similar meaning was found by researchers who analyzed the concept of management in nursing, as guidance to employees in a strategic and multidisciplinary manner to provide quality care 20 .
A recent study 21 raised many facets involved in the complex hospital environment, confirming the need and the importance of the proactive practice of managers through a visionary perspective that allow them to pay attention to aspects related to patient safety.A similar proposition was reinforced by the participants of this study, who associated proactivity with a higher quality of care and with distancing of risks and undesirable effects that call into question the comfort and safety of the patient.
Regarding the repercussions for the work team, leadership was emphasized as the potentiating trigger for proactive actions.In the leadership process, proactivity emerges as an important motivator to encourage proactive action in the team, since, from this process, there is greater incentive for collective action that not only facilitates relationships of support among the members, but also provides a transforming influence 22 .
Thus, the proactive action of the nurse was shown to be favorable for the exchange of knowledge in the team, translating into potential opportunities to exercise leadership and (inter) act with the various professionals related to the management of care, strengthening the development and implementation of best care practices.Conversely, non-proactive attitudes result in the accumulation of backlogs in the work, therefore, by expecting things to just happen, nurses fail to act in advance and are limited to operate in their comfort zone, merely reacting to what is prescribed.In a vicious circle, accommodated, individualized and mechanized positions will be adopted in their work.
The realization that proactive action has consequences for the professional who manages the care was also found in this study.There was the understanding that the proactive approach resonates favorably for the nurse in that it provides greater visibility to the institution and the team, being the target of choices for future organizational projects.This condition strengthens the confidence of the management in these professionals by providing them with recognition of their way of working and their conduct prior to events.
In the proactivity, the nurses perceived an important resource to better manage their careers and demonstrate commitment and engagement at work, as it favors improvement in the work and stimulates the trust of the management.These data corroborate another study that associates proactivity with greater employability, more promotions and increased satisfaction in the work 23 .Furthermore, proactive people tend to create more favorable conditions for personal success at work 24 , being asked to act in situations of greater complexity due to credibility earned and trust placed in them.
The proactive mode of action was also associated with the search for self-fulfillment, expressing the desire of these nurses to design, create and implement new ways to intervene in health, being entrepreneurs in the actions that they develop and motvated by doing better 25 .In addition, it enables better performance at work and the constant search for feedback,4,26 which meets the perception of nurses, who related proactive action to the need to perform qualified work that will inspire others to act in the same a way and enable greater satisfaction, recognition and professional achievement.

FINAL CONSIDERATIONS
The repercussions of the proactive action of nurses, from the perspective of the study participants, highlight elements that signal the importance of adopting proactive measures in health practices.They provide the opportunity to view actions that resonate in different areas related to the management of care and provoke reflections on ways to operate in the work.
The proactivity of the nurse was associated with the opportunity for improvement of processes and optimization of resources, favoring the improvement of the practices, as well as institutional development and visibility.It was demonstrated that it can affect the degree of user satisfaction with the services and that it is an important potentializer in the identification and development of preventive strategies and solutions that contribute to the quality, safety and integrality of the care.In addition, it can instigate other professionals to be guided by proactive action, favoring the practice of leadership, cooperation and learning in the group, and promoting satisfaction, fulfillment and professional recognition.
The repercussions visualized by these professionals show proactivity as fundamental in the practice of the nurse, which enables continuous improvement of processes and practices in the management of the care.This condition requires complex knowledge, which is able to promote the freedom to act, to think about new possibilities and to stimulate action, to make it happen.
This study inaugurates an approach to the outline of the actions of management and nursing management, giving emphasis to positive aspects of proactivity.Thus, it opens up avenues for new investigations that lead to (re)thinking about the proactivity in health services, which includes the collective articulation aimed at the emancipation of individuals in the nursing teams.
Proactivity in the management of care Ferreira GE, Dall'Agnol CM, Porto AR