ARTÍCULO ORIGINAL / ORIGINAL ARTICLE / ARTIGO ORIGINAL
Dialogic leadership: strategies for application in the hospital environment
Liderazgo dialógico: estrategias para su utilización en el ambiente hospitalario
Liderança dialógico: estratégias para sua utilização no ambiente hospitalar
Simone Coelho Amestoy1; Vânia Marli Schubert Backes2; Maira Buss Thofehrn3; Jussara Gue Martini4; Betina Hörner Schlindwein Meirelles5; Letícia de Lima Trindade6
1RN, Ph.D. Professor Universidade Federal de Pelotas -UFPel- Pelotas (RS), Brazil. email: firstname.lastname@example.org.
2RN, Ph.D. Professor Universidade Federal de Santa Catarina- UFSC- Florianópolis (SC), Brazil. email: email@example.com.
3RN, Ph.D. Professor UFPel- Pelotas (RS), Brazil. email: firstname.lastname@example.org.
4RN, Ph.D. Professor UFSC Florianópolis (SC), Brazil. email: email@example.com.
5RN, Ph.D. Professor UFSC Florianópolis (SC), Brazil. email: firstname.lastname@example.org.
6RN, Ph.D. Professor UFSC Florianópolis (SC), Brazil. email: email@example.com.
Receipt date: April 30, 2013. Approval date: August 20, 2013.
Article linked to research: Dialogic Leadership: perspectives in the education of nurse leaders, presented to the Graduate Nursing Program at Universidade Federal de Santa Catarina -UFSC- Florianópolis (SC), Brazil, in 2012.
Conflicts of interest: none.
How to cite this article: Amestoy SC, Backes VMS, Thofehrn MB, Martini JG, Meirelles BHS, Trindade LL. Dialogic leadership: strategies for application in the hospital environment. Invest Educ Enferm. 2014;32(1): 119-127.
Objective. To analyze the strategies used by nurses to support the insertion of dialogic leadership in the hospital environment. Methodology. Qualitative study, case study type. Twenty five nurses working in three hospitals in the city of Florianopolis, in the state of Santa Catarina (Brazil) participated in the study. Data were collected from May to December 2010. For data collection, semi-structured interviews were performed, non-participant observation and dialogue workshops. Data analysis was performed through Minayo's operational proposal. Results. The strategies mentioned by the study participants were: dialogue, humility, setting an example, resoluteness, meetings and teamwork. It was observed that one strategy completed the other, which contributed to the nurses' leadership. Conclusion. The acceptance of dialogic leadership strategies in hospitals helps nurses strengthen the care provided in their workplace.
Key words: nursing; leadership; health services.
Objetivo. Analizar las estrategias que facilitan la inserción del liderazgo dialógico en el ambiente hospitalario utilizadas por los enfermeros. Metodología. Investigación cualitativa, del tipo estudio de caso. Participaron 25 enfermeros quienes trabajaban en tres hospitales de la ciudad de Florianópolis, Santa Catarina (Brasil). La información fue obtenida de mayo a diciembre de 2010. Para la recolección de los datos se realizaron entrevistas semiestructuradas, observación no-participante y talleres dialógicos. Los datos fueron analizados mediante la propuesta operativa de Minayo. Resultados. Las estrategias mencionadas por los participantes del estudio fueron: diálogo, humildad, dar ejemplo, solución, reuniones y trabajo en equipo. Se observó que una estrategia complementaba a la otra, lo que contribuía a la instrumentalización de los enfermeros para el liderazgo. Conclusión. El reconocimiento de las estrategias de liderazgo dialógico en ambiente hospitalario ayuda al enfermero a potenciar el cuidado en su ambiente de trabajo.
Palabras clave: enfermería; liderazgo; servicios de salud.
Objetivo. Analisar as estratégias utilizadas pelos enfermeiros que facilitam a inserção da liderança dialógico no ambiente hospitalar. Metodologia. Investigação qualitativa, do tipo estudo de caso. Participaram 25 enfermeiros que trabalhavam em três hospitais da cidade de Florianópolis, Santa Catarina (Brasil). A informação foi obtida de maio a dezembro de 2010. Para a recolha dos dados se realizaram entrevistas semiestruturadas, observação não-participante e ateliês dialógicos. Os dados foram analisados por meio da proposta operativa de Minayo. Resultados. As estratégias mencionadas pelos participantes do estudo foram: diálogo, humildade, dar exemplo, solução, reuniões e trabalho em equipe. Observou-se que uma estratégia complementava à outra, o que contribuía à instrumentalização dos enfermeiros para a liderança. Conclusão. O reconhecimento das estratégias de liderança dialógico em ambiente hospitalar ajuda ao enfermeiro a potencializar o cuidado no seu ambiente de trabalho.
Palavras chaves: enfermagem; liderança; serviços de saúde.
The work of nurses has been receiving great attention in hospitals due to the range of activities under the responsibility, among them: the management of the care and activities of the nursing staff, educational and research initiatives, conflict resolution and the performance of leadership. Given the plurality of activities performed by nurses, a differentiated leadership proposal based on the dialogue can be highlighted, with the purpose of strengthening their operations in the hospitals.1
Dialogic leadership is the leaders' ability to influence their staff and act in a critical and reflexive manner about their practice through the establishment of an efficient communication process. It is marked by the construction of horizontal relationships in the work environment, in which opportunities for knowledge exchange and collective improvement between leaders and their staff grow and there is room for autonomy and active participation of nurses, staff and users as social parties.1 Under Freire's perspective, the dialogue represents a human event which cannot be reduced to a simple deposit of ideas from one person to the other, since it is a meeting between human beings, as thinking human beings, to discuss situations with the intention of changing the reality they live in.2 However, it is relevant to clarify that the dialogue between people does not make them equal but indicates the democratic position between them. The dialogue is meaningful because the dialogue subjects do not only keep their identities but defend them, growing with one another; therefore, the dialogue does not make them equal, does not generate reductionisms, but instead encourages the respect between the interacting people.2
People often refuse to use the dialogue in their professional practice for the fear that this could affect their authority, since nurses have legal authority to perform the profession and coordinate the actions of the nursing team. Thus, the adoption of a democratic and participative position will not negatively affect their work but could rather bring the subjects involved closer and allow knowledge exchange and mutual growth. Leaders are not born this way, their development occurs throughout their personal and professional formation. In relation to the training of the nursing leader, it is important to emphasize that in 2001 the new Curriculum Guidelines for Undergraduate Nursing Courses were created with basis on the skills that define the preparation of generalist, human, critical and reflective nurses who have the ability to learn how to learn and meet the health needs of the population.
Therefore, for nursing performance, it is necessary to develop some professional abilities, leadership among them.3 Nurses who wish to succeed as leaders of the nursing team need to develop and improve some characteristics, such as: communication, grasp of knowledge, responsibility, common sense and self-awareness.4 These skills might support the performance of a critical and conscious leadership based on the dialogue and respect for human beings. Based on the strengthening of the leadership, this study was aimed at analyzing the strategies used by nurses to support the adherence to dialogic leadership in hospitals.
This is a qualitative study with a descriptive approach, in which the case study was chosen as the research strategy, since it represents a method used in situations in which the object of the study is a singular event that has value in itself.5 Therefore, new perspectives concerning the preparation of leading nurses were investigated, with focus on the need to recognize the strategies used by nurses in their practice, which may support the performance of a leadership based on dialogue. Twenty five nurses, who were interested in discussing and reflecting about leadership in nursing, participated in the study. From these, ten work at the University Hospital Polydoro Ernani de São Thiago, 10 at the Imperial Hospital de Caridade and five at the Hospital Governador Celso Ramos. These hospitals were chosen for being reference in healthcare in the city of Florianopolis, in Santa Catarina state. It is noteworthy that nurses who perform their practice in the above mentioned hospitals and had up to six years of study were invited to participate in the study. This period was chosen with the purpose of including those nurses trained according to the New National Curricular Guidelines. The subjects agreed to participate in the research, allowed the recording of the interviews and dialogue workshops during data collection, the observation, and authorized the release of the data analyzed in the scientific resources.
For data collection, the following techniques were used: semi-structured interviews, non-participant observation and dialogue workshops. The data were collected from May to December 2010. The interviews were performed individually at the site of the study, with pre-established date and time, according to previous contact with the participants. A guide to direct the collection was developed. The interviews were recorded and transcribed soon after their conclusion. The statements of each subject were identified by the letter E for interview and the ordinal number that corresponded to their completion by the nurses E1, E2,,, E25. The non-participant observation corresponded to the second technique for data collection. It was observed, in average for four hours, the work routine of each participant, totaling 100 hours of observation, which allowed better recognition of the elements of the professionals' work process, especially the work tools used by them. The observations were identified by the letter O for observation, followed by the ordinal number by nurse O1, O2…O25.
Three workshops were held, one in each hospital, in order to provide group discussions about the topic. It can be highlighted that the nurses participated in the workshops held in the hospital where they worked and it was not possible to hold a workshop with all the research subjects in the same place due to the difficulties in gathering them. Each dialogue workshop lasted in average one hour and a half and they were recorded in audio. The statements resulting from the dialogue workshops were identified with the letters OD, plus the ordinal number representing each nurse OD1, OD2…OD25.
In order to analyze the data, the operational proposal of Minayo was used,6 and marked by two operational stages. The first includes the essential determinations of the study, which is mapped in the exploratory phase of the investigation. And the second stage is called interpretative, since it is the starting point and the arrival point of any investigation and it represents the meeting with empirical facts. The interpretative phase presents two stages: the collation of the data and the classification of the data, which includes the horizontal and exhaustive reading of the texts, transversal reading, final analysis and the development of a report presenting the results.
During the research, the ethical principles established by Resolution 196/967 were respected, with approval by the Research Ethics Committee of the Federal University of Santa Catarina, under registration number 658/10.
A large category was obtained after data analysis, which was called Strategies used by nurses that support the inclusion of the dialogic leadership in hospitals, being this composed of the following elements: dialogue, humility, setting an example, resoluteness, meetings and teamwork. Thus, the main strategies listed by the nurses during this research are presented in a sequence. The first strategy refers to the dialogue, which was highlighted as the key element in the development of relationships in the workplace. This result strengthens the adoption of a democratic and horizontal leadership style, capable of bringing the dialogue subjects closer: I think that the dialogue is the main one. Like doing things talking to both the patient and to the person providing care, to the doctor. I think this is very important, developing a leadership based on dialogue, conversation, I think that this is imperative for everyone's satisfaction (E5).
It is noteworthy that, through observation, it was possible to see the insertion of the dialogue in hospitals put into practice, supporting the communication and relationship process between nurses and other professionals who perform their activities in this environment, aimed at improving the quality of care. This aspect is shown through the following observation: a doctor arrives at a nursing station and has a dialogue with the nurse concerning the health condition of a patient who had undergone vascular surgery. Both of them take the opportunity to discuss relevant aspects relating to the health needs of this patient. After that, they both go to the patient's bed to make, together, a bandage (O13).
Humility also emerged as a strategy that supports the relationships between the nurse and the nursing staff. Based on this position, the leader will be able to gain the trust, because this is not humility meaning subordination, but it is related to the intellectual, since the apprentice will always have something to learn, and therefore the professionals should be accessible and open to new training possibilities: […] if I don't know, I say that I don't know, that I have never done it, how it is done, teach me. I think that this is the way we have to learn, we don't know everything (E4). Taking into consideration that leadership is the leader's ability to influence people, it was noted that the professionals who are actually able to influence their staff will be viewed as example for the team. Thus, setting the example is another relevant strategy to be developed by the nurses who wish to take on leadership positions: You conduct the procedure using the correct techniques, then the technician watches you and reproduces this procedure also using the correct techniques. I think that this is the example (E6).
In the dialogue workshops, the participants emphasized that, to set an example, there must be coherence between the actions and the speech: You should act in the same way you speak, there is no point saying one thing and acting in another way. We have a lot of responsibility to be fair and to set the example, always! (OD, 21). To be resolute on the face of the problems which occur in the workplace is another important aspect that was valued by the participants of the study. Thus, nurses stand out within the healthcare area for their capacity to promote changes, overcoming the limiting situations that may arise in health services: I think that leadership means resoluteness […] the fact of being a leader does not mean that they are the savers, but I think it is resoluteness in relation to obtaining support to improve a situation, to improve a routine, to improve a scale (E12).
Holding regular meetings was also seen as a strategy that supports the adoption of dialogic leadership in hospitals, as they are characterized by appropriate opportunities for discussion, reflection and proximity among professionals: […] I really like having meetings. I think that meetings bring up things that need to be improved, corrected, things that need to be changed. Then, I think that the fact of having a meeting at least, I don't know, every three months, would be of upmost importance (E20). This last statement is consistent with what was observed, since it was verified that the nurses are used to enjoying informal moments with the team such as the break and lunch, as well as the on call shift changes, to act in an informal manner in order to talk about their actions. Working as a team is the last strategy emphasized by the participants, since they understand that the work in nursing is a collective process: An essential thing is also that there is no point in having an excellent scientific knowledge, an excellent idea if you have no support, if you don't have the support of the group […] if you don't have the support of your staff, then there is no point. That will be stagnated, nobody will perform it (OD21).
The statements collected at the dialogue workshops, among other findings, show that teamwork was expressively mentioned among the subjects and the researched scenarios.
Given the results, the need to use the dialogue as a strategy to support communication in the workplace, as well as to strengthen the leadership of nurses, was evident. Firstly, when addressing the dialogue, it is relevant to highlight that there is no true word but praxis, that is, reflection and action of human beings about the world in order to change it, and without this, overcoming the contradiction between oppressor and oppressive becomes impossible, that is, overcoming inflexible and authoritarian relationships. The true word means the transformation of the world. Thus, it is not in silence that human beings are constituted but in words, work and action-reflection. Speaking the word cannot be a privilege of a few, but a right of all; thus, nobody can say the true word in isolation, or say it to others as a prescriptive act.2
For this reason, the dialogue means the meeting between human beings, mediated by the world, in order to express it, and does not end with the relationship between I-you. It is an existential need of the human being based on the meeting in which the reflection and action of the subjects sympathize in order to change and humanize the world, and cannot be reduced to subjects' simple acts of depositing ideas on one another. It is noted that the dialogue cannot be considered as a strategy used by a subject to dominate the other. Through the dialogue subjects, this domination covered by the dialogue is related to the world, it is not from one subject to the other, that is, it is the domination of the world for the release of human beings.2 It is also reinforced that the dialogue, since it represents a relationship between I-you, involves the relationship between two subjects. However, every time that the you of this relationship is reduced to a mere object, the dialogue action will have been perverted.8 By extending the attention from the nursing education to the professional practice, it can be seen that the dialogue authenticity helps the interpersonal relationships, besides making the subjects to feel valued and conscious of the importance of their social role.
By bringing back the professionals abilities established by the New Curricular Guidelines for the Nursing Undergraduate course, it can be noted that, for the professional practice, the development of the following skills becomes necessary: healthcare, decision making, communication, administration and management, permanent education and leadership.3 Therefore, the dialogue is viewed as a strategy that can support, in addition to the leadership, the nursing professional practice, taking into consideration its multiplicity of actions, obligations and responsibilities. In the healthcare scenario, it is up to nurses to manage the care, the performance of administrative, educational and research-related activities, in order to improve the professional practice.9 Their working process involves the act of caring and educating, without the transfer of knowledge and its passive uptake by the subjects which, in Freire's perception, is called banking education.2
Then, the importance of inserting Freire's dialogue in the daily lives of nurses comes to light, concerning interpersonal relationships with nursing staff members and with users of the health service. These are authentic dialogue relationships A with B and not A over B, which can benefit the professionals who are aware of their importance, in the sense of providing a horizontal relationship through the open expression of ideas, focused on the nursing care. Concerning the activities of healthcare education, nurses have the responsibility to value the knowledge resulting from common sense, given that nobody educates anybody nor does anybody educate themselves, but rather, the human beings educate themselves mutually, mediated by the world.2 Based on this, it is sought to make people more aware of their actual reality in order to overcome the educational practice based on a vertical model of communication, that is, a monologue, in which a person speaks "to" the other and not "with" the other.10 Whilst construct of dialogue, humility was also recognized as a strategy for providing proximity between the leader and the staff, because there is no dialogue when there is no humility. The pronunciation of the world through human beings cannot become an arrogant action, since the human beings who do not have humility or those who have lost it, distance themselves from the others, becoming incapable of acting as beings through whom the world speaks.
Based on Freire's position, it can be stated that humility is manifested as a precious certainty: that nobody is superior to anybody. Due to this, the lack of humility showed in the arrogance and false superiority of one person over another expresses a transgression in human condition.11 It is in the power relationships built in the workplace that the lack of humility can often be observed.
Humility is a virtue that should be cultivated mostly by people who wish to take on leadership roles. Being humble is a sine qua non condition for leader nurses who wish to be trusted in and have a positive influence in their practice. It is these professionals' responsibility to accept new opinions, since the human being is an unfinished and inconclusive being in constant transformation and learning, as well as to promote the participation of the staff with the purpose of promoting a horizontal decision making process, being open to true dialogue; otherwise they become a dictator with solid and inflexible attitudes and not a transformation agent inserted into the world and capable of creating and recreating it.
For the participants, leader nurses who seek to influence their staff through their attitudes, being the first to set the example in their workplace and adopting an impartial position based on justice, receive the respect and the trust from the staff. The subjects associated the setting of an example to the active participation of nurses in the care, acting with the team in a participative way and being available to assist the group when needed. Professionals having this understanding position and who also have technical scientific skills are quite valued by the staff members. With this in mind, nurses who wish to positively influence their staff need to set the example and use their words and actions coherently. People who cannot establish a harmonious relationship between speaking and doing may end up losing their staff's trust and credibility, consequently undermining their own leadership.12
Establishing trust relationships also represents a prerequisite for the establishment of dialogic relations between the various social parties. Trust enhances partnerships between the dialogue subjects, and because of this it suggests genuine intentions in the statements that a subject transmits to the other. Therefore, false love, false humility and human beings' disbelief cannot bring trust.2 It is known that interpersonal relationship problems are one of the main issues faced by nurses in their workplace, and this is an aspect that brings even more attention to the importance of maintaining relationships based on the example, trust and dialogue.
Resoluteness was another strategy emphasized by the nurses. In the view of the participants of the study, to be resolute does not exactly mean to solve the problem, because they are aware that the solution is not always in the hands of the nurses, that is, within their reach, but that it relates to the willingness of these professionals to expose themselves, to search for things and not to be passive waiting from the solutions to "fall from the sky". Resoluteness is part of nurses' work. However, it is necessary that these professionals promote proactive attitudes that refute inactivity, strengthen changes, choices and new views when facing reality.
The meetings also emerged as strategies, being viewed by the participants as formal and informal meetings, which can occur through previously scheduled date and time or even through quick conversations during shift change. he meetings significantly help to establish professional relationships and should be interpreted as a moment to provide feedback to the staff concerning their performance, a forum for claims and complaints, as well as a privileged moment for interaction among staff members, supporting the improvement of interpersonal relationships and minimizing conflicts.13
Based on Freire's views, it is suggested that the workplace meetings could be organized according to the principles of the Culture Circle, in which people are placed in a circle in a way that nobody has a prominent place. The circle usually makes people comfortable to participate and also be seen and heard. In addition, the meetings represent a space to meet and discover other people as a social party who has aspirations, feelings and experiences that need to be revealed through group dialogue, participation in the discussions, exchange of knowledge and experiences.14 Although highlighted as strategies, some people relate them with the existence of problems. Similar result was found in another study, in which the meetings still cause fear and some uncertainty, since they are associated to arguments and conflicts in the workplace context. However, it should be noted that the meetings are not only held to resolve conflicts, but also to avoid them through a horizontal communication process. Thus, regular meetings may help to improve trust within the team and consequently strengthen the nurses' leadership.15
The team integration is promoted when its members are satisfied with what they do and are open to work as a team through sharing information and developing activities in partnership and mutual support.16 Being able to work as a team is an essential ability for nurses, even because the nurses' work is governed by the collectivity. It is relevant to highlight that during data collection it was not possible to gather the participants of the study from the three hospitals in a dialogue workshop, since some of them had other employment relationships. It is believed that a dialogue workshop with the participation of nurses from the three institutions could have contributed to a more open and conscious discussion about the topic and partly shows a weaknesses of this study.
However, the aim of this study is to contribute to the development of others, in order to make the various social parties aware of the need to provide healthcare focused on the users, with the purpose of promoting health and preventing diseases, which are challenges especially found in the work of hospitals covered by the Unified Health System (SUS). It is believed that the strategies raised in the study can provide conditions to leader nurses and strengthen dialogic leadership. This proposal represents the breaking up with authoritarian and stagnant practices that hinder the actions and relationships. It is noteworthy that the hospital environment, in its essence, is still governed by hierarchical power relationships and often by the individual and divided professional action. Therefore, it is seen in Freire's dialogue a possibility to destroy these work arrangements and bring the subjects closer, in order to improve hospital care.
Final considerations. The development of this study allowed the analysis of strategies used by nurses to support the insertion of dialogic leadership into hospitals. By accepting them, nurses will be able to put them into practice in their workplace, strengthening care and nursing staff management and supporting a better care quality. The link between each strategy was identified and it was recognized that one complements the other, which gave more conditions to nurses to be leaders. This leadership is still challenging and appears in the context of the SUS as strengthening its principles, especially in the hospital environment where the biomedical practice tends to be followed.
The importance of this proposed nursing leadership is defended, since it is through dialogue that human beings show they are different from one another, becoming unique and capable of innovating, overcoming limits and changing the social context. Based on the above, dialogic leadership is understood as a strategy connected to the autonomy of all the participants in the nursing working process, and can help and set the example for other professionals in the health area.
To strengthen leadership as a professional skill, according to the curricular guidelines that govern the preparation of new nurses, is a challenge also for higher education institutions. It is believed that, for nurses to be able to use the strategies listed in this research, they need to undergo training that promotes their leadership, dialogue and autonomy, since the beginning of their course - an education capable of overcoming social, economic, cultural and many other inequalities, and which awakes in the students, regardless of their reality, a critical view and the potential to intervene in the world, being aware of their power to change things.
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