Challenges of nurse leadership in the context of a health crisis in an international border locality^*

ABSTRACT

Objective:  To understand the challenges primary health care nurses face regarding their leadership exercise during periods of health crisis in an international border city.

Method:  Exploratory, descriptive, and qualitative study conducted in the Primary Health Care of a border municipality in the Southern Region of Brazil in 2023. In-depth interviews were conducted with 15 nurses and submitted to Content Analysis.

Results:  The analysis categories showed that, for nurses, the exercise of their leadership in times of health crisis is affected by the inefficiency of communication between management and the team, highlighting the gaps that compromise decision-making. There is an overload of responsibilities as nurses take on the roles of informal leaders. The difficulties in serving foreigners are due to the absence of clear protocols and the language.

Conclusion:  Leading in the international border region during health crisis pressures nurses to have the specific knowledge to lead their team.

KEYWORDS:
Leadership; Primary Health Care; Nursing; COVID-19; Border Areas

HIGHLIGHTS

Dependence on the nurse's leadership for service organization.

Inefficiency in communication between management and nursing staff.

Overloaded public health system in the border region.

Difficulty in attending to non-resident patients.

RESUMO

Objetivo:  conhecer os desafios dos enfermeiros da Atenção Primária à Saúde sobre o seu exercício de liderança, durante os períodos de crise sanitária em uma cidade de fronteira internacional.

Método:  estudo exploratório, descritivo e qualitativo realizado na Atenção Primária à Saúde de um município fronteiriço da Região Sul do Brasil, em 2023. Aplicou-se uma entrevista em profundidade com 15 enfermeiros, submetida à Análise de Conteúdo.

Resultados:  as categorias de análise mostraram que, para os enfermeiros, o exercício de sua liderança nos momentos de crise sanitária sofre as interferências da ineficiência da comunicação entre a gestão e a equipe, o que evidencia as lacunas que comprometem a tomada de decisões. A sobrecarga de responsabilidades, uma vez que os enfermeiros assumem os papéis de lideranças informais. As dificuldades de atendimento aos estrangeiros pela ausência de protocolos claros e pelo idioma.

Conclusão:  liderar, na região de fronteira internacional, em momentos de crise sanitária, pressiona os enfermeiros a deterem os conhecimentos específicos para conduzir a sua equipe.

DESCRITORES:
Liderança; Atenção Primária à; Saúde; Enfermagem; COVID-19; Áreas de Fronteira

HIGHLIGHTS

Dependência da liderança do enfermeiro para organização do serviço.

Ineficiência na comunicação da gestão com enfermeiros assistenciais.

Sistema de saúde pública da região de fronteira sobrecarregado.

Dificuldade de atendimento ao paciente não residente.

RESUMEN

Objetivo:  conocer los desafíos de los enfermeros de la Atención Primaria a la Salud sobre su ejercicio de liderazgo, durante los períodos de crisis sanitaria en una ciudad de frontera internacional.

Método:  estudio exploratorio, descriptivo y cualitativo realizado en la Atención Primaria de Salud de un municipio fronterizo de la Región Sur de Brasil, en 2023. Se realizó una entrevista en profundidad con 15 enfermeros, sometida al Análisis de Contenido.

Resultados:  las categorías de análisis mostraron que, para los enfermeros, el ejercicio de su liderazgo en momentos de crisis sanitaria sufre las interferencias de la ineficiencia de la comunicación entre la gestión y el equipo, lo que evidencia las lagunas que comprometen la toma de decisiones. La sobrecarga de responsabilidades, una vez que los enfermeros asumen los roles de liderazgos informales. Las dificultades de atención a los extranjeros por la ausencia de protocolos claros y por el idioma.

Conclusión:  liderar, en la región de frontera internacional, en momentos de crisis sanitaria, presiona a los enfermeros a detener los conocimientos específicos para conducir a su equipo.

DESCRIPTORES:
Liderazgo; Atención Primaria a la Salud; Enfermería; COVID-19; Áreas de Frontera

HIGHLIGHTS

Dependencia del liderazgo del enfermero para la organización del servicio.

Ineficiencia en la comunicación de la gestión con enfer meros asistenciales.

Sistema de salud pública de la r egión fronteriza sobrecargado.

Dificultad de atención al paciente no r esidente.

INTRODUCTION

Epidemics have accompanied humanity since ancient times, and as the great navigations and globalization increased people’s circulation, epidemics became pandemics. Examples of these include the Black Death in 1300, the Spanish flu in 1920, H1N1 in 2009, and recently, the pandemic of the new coronavirus¹.

In light of this, international border areas become a place of alert for the Federal Government due to the intense circulation of people. The border is a place of contact between the systems of countries, where spontaneous and everyday interaction occurs, often informally². This bond becomes even closer in relation to health care, as residents of other countries consider Brazilian health care to be of higher quality than that of other neighboring countries, and seek, especially during times of pandemic, health care services in Brazilian territory³.

Although the search for care can occur at various levels of attention in the network, Primary Health Care (PHC) stands out in this regard as the system’s entry point and plays a prominent role during epidemic moments⁴. In this challenging context, nursing professionals are the protagonists in facing health crises, in direct care of infected patients and in organizing workflows in health services⁵.

The management and leadership role of the primary care nurse enables the professional to care for interpersonal actions, complex relationships, and the organization of the work process. When leading, the nurse needs to deal with a situation that affects the entire team, such as the constant changes in workflows and protocols and the uncertainties that the situation imposes. That said, assertive communication, a supportive atmosphere, ongoing education, the coordination and care supervision are even more necessary in times of health crisis⁶.

This research is justified by considering pandemics as moments of crisis that will certainly arise again in humanity. So, it is necessary for the nursing professional to be scientifically and practically equipped to lead their team and face moments of health crisis. In this sense, this study aimed to understand the challenges faced by primary care nurses regarding their leadership exercise during periods of health crisis in an international border city.

METHOD

This is an exploratory, descriptive study with a qualitative approach based on the theoretical-methodological framework of Content Analysis. It was conducted according to the recommendations of the Consolidated Criteria For Reporting Qualitative Research (COREQ)⁷.

To identify perceptions about the exercise of leadership in the context of the health crisis, a survey was conducted in the PHC of the municipality of Foz do Iguaçu, Paraná, Brazil. This region borders Puerto Iguazú and Ciudad del Este, Argentina, and Paraguay, respectively. It is considered the busiest border in the country, with intense traffic.

Interviews were conducted with 15 nurses from 15 of the 29 health units that make up the five health districts of the city. The sampling was conducted for convenience, and the professionals were invited to participate by the researcher through a text message. The theoretical saturation strategy was considered for closing the sample, which was achieved when no new analytical information emerged and when the study provided the most information about the phenomenon⁸. Nurses were asked how it was to lead in the context of a health crisis in a triple border region.

Inclusion criteria were adopted: being a nurse, performing the assistance function in primary health care, and having at least three years of experience in the role. The professionals who were on vacation or away during the data collection period were excluded.

The study was conducted from May to July 2023. The data were obtained through a sociodemographic/occupational questionnaire and in-depth interview. The questionnaire was closed and included the variables: gender, age, level of education, and time worked in the PHC. In-depth interviews were chosen, as this is recommended for deepening the qualitative research objectives. Although there is prior planning with the questions in the instrument, this modality allows for other questions to be developed based on the interviewee’s speech, such as: “Explain your professional opinion on the subject”⁹.

The interviews were scheduled in advance with the professionals who agreed to participate in the study. They took place in a location that ensured privacy and at a time that each person deemed most appropriate, with only the audio recording made, and the content was used solely for data analysis purposes. The average duration was 18 minutes. The pilot study was conducted directly with a nurse from the PHC; after the evaluation of the transcript by the researchers, the quality of the material was confirmed, which was incorporated into the research, and there were also no sample losses. All interviewees had access to the material from their interviews for the conference.

The Thematic Categorical Content Analysis was carried out, which has the following stages: the pre-analysis, the exploration of the material, the treatment of the obtained data, and the interpretation. The pre-analysis corresponds to the first moment when the researcher begins to come into contact with the empirical material. Based on the recordings, a rigorous transcription was made of how the speeches were presented. Subsequently, a floating reading was carried out with the aim of delving deeper into the content. After reading and rereading the material, I refined and organized it according to the research proposal. Upon completing this stage, it was possible to organize the theoretical content so that the testimonies aligned with the study’s objective were highlighted¹⁰. In the treatment of the data and in the interpretation, attention was paid to the agreement and the foundation of the categories with the proposed theme.

After processing the data, three thematic categories emerged, resulting from the Content Analysis of the 15 participants’ interviews, totaling 79 Context Units (CU) (paragraphs/sentences).

To preserve anonymity, the excerpts of the testimonies were identified with the initial letter corresponding to the profession (E - nurse), and numbered according to the order of participation in the study. In the transcription of the CUs, […] were used for the long summaries without altering the meaning.

The study was approved by the institution’s Research Ethics Committee (REC) with opinion no. 6.028.890.

RESULTS

Of the 15 nurses who participated in the study, 12 (80%) were women, and the average age was 39.5 years. Of the 15 participants, 13 had a specialization; two were masters; three-spoke one or more languages in addition to Portuguese; five were natives of the city of Foz do Iguaçu (PR); three were from other cities in the state of Paraná, and seven came from other Brazilian states. The average working time in the PHC was 10.7 years.

The content of the interviews, guided by the proposed objectives, gave rise to the categories: inefficiency in workflow communication and workload overload, need for encouragement for the team in times of crisis, and difficulty in serving patients not residing in Brazil.

Inefficiency in communication of flows and workload overload

The inefficiency of communication between management and nurses regarding changes in workflows was pointed out as an issue that harmed the exercise of leadership, especially in times of crisis, when sometimes information was released to the media and only later to the employees.

There are many communication errors, the information does not arrive with precision in time or assertiveness, there are many gaps, many things are left hanging, we don’t know what we have to do, and the management itself becomes disoriented in these moments of crisis. You ask one thing, and everyone responds in a different way; there is no correct document link, and everything always arrives at the last minute. The flow starts tomorrow, the document comes today. We don’t have time to prepare, and we don’t communicate effectively with the team. (E04)

Nurses also pointed out that, in many situations, the local media had first access to information, which made it difficult to organize the work.

[...] there were things we knew because the patient arrived at the unit and said ‘no, but I just saw it on the news’ and then we would be like “how come you just saw it on the news and we weren’t informed?”, things changed very suddenly. Many times, especially during the COVID pandemic, many times, I was informed by the patient, because he had seen it on the news at noon, I would arrive to work in the afternoon and he would tell me that it had changed, there was a lot of delay in the information from the department for us. (E02)

Another point raised by the nurses is that they make most decisions within the health unit, even though administrative positions exist for that function.

The feeling is that, even if there is a manager, even if there is a supervisor, even if there is someone above to manage, the nurse should focus more on the care aspect [...] ends up doing much more than that, because if he doesn’t take the lead, nothing moves forward, everyone is kind of waiting for the nurse, like [...] asking the nurse: so, what’s up, nurse?, and this, in general, [applies to] all the people who work in the medical unit, NASF, reception [...] and it gets much worse in times of crisis. (E03)

They keep waiting for me to take the lead in situations, where it will be, what place is expected of us, this organization, and I, the manager, we try to share the decisions, where we will do it, we end up exchanging ideas to make it nice, both for the team and for the population. (E07)

There was also a greater demand on nurses in terms of leadership, both from management and from their own colleagues. This included knowledge of routines in constant change, patient management, and problem-solving.

We are always the most pressured to know, always more overloaded, always like a reference point even for things that are not exclusive to Nursing, but the nurse always has to find a way. (E05)

The whole time my leadership was required, I felt very pressured all the time to know all the answers, and to call on whoever needed to be called for support, and also to be there, alongside the team. (E02)

There was a lot of dependence regarding the flow decision-making, what to do with each patient, how to manage [...] we also attended to many patients poorly, which affects us a little [...] there is also the issue of dependence on leadership, indeed. (E04)

Need for encouragement for the team in times of crisis

In times of health crisis and uncertainty about how things would continue, nurses reported the need for team encouragement to keep it united and care for mental health.

I felt that I needed to give a word of affection, right? That was a period we were going through, trying to compensate in some way, sometimes, for a break that had to be taken at a time when I was overwhelmed [...] trying to negotiate something that would be good for that person who is going through that stress. (E09)

I needed to encourage, especially because we have colleagues who are older and were afraid of really dying [...], there are colleagues who have compromised immunity who stayed away, there were cases of depressed colleagues, in mental health we had to support each other. (E10)

Difficulty in attending to patients not residing in Brazil

In the nurses’ speeches, they expressed the difficulty in caring for non-resident patients, both Brazilians living in neighboring countries and foreigners crossing the bridge in search of care.

The team sought the nurse’s help resolving situations such as the service’s lack of flow and written organization and documentation.

[...] no matter how much we have relevant legislation regarding foreign individuals [...] it is different when you have the patient in front of you, who arrives with a health demand and comes to your unit seeking care. The municipality has some basic care units that are a reference for foreigners; however, emergency services are available for all basic care units, and there is no document that supports us in referring these patients to the reference basic care units, it is merely an “oral” guidance from the management. (E08)

There is no protocol for attending to these people, we are lost as to where to send this patient, what to do with them [and] many times the team is too. So, she comes to seek help with us, I think that here, at the border, it should be something very clear, [because] we get lost looking for information here and there, stitching together an appointment, especially if the patient does not have documentation. (E10)

Another point that the nurses expressed was that, to work in a border region, knowledge of a second language is extremely necessary to communicate with patients of various nationalities.

Language can become a barrier to providing care, as communication difficulties can lead the professional to make a mistake and make it difficult to convey information and care to foreign patients.

We have a lot of difficulty with this because most people of other nationalities speak another language, and because it is very close, also being near UNILA, we serve many patients who are students, who are Colombian, Venezuelan, Chilean; sometimes colleagues ask for help with these patients, especially the assistants. (E04)

I find it difficult because there are some who speak English, [there are] many Arabs who bring their husbands to translate, there are Chinese as well, so I say that we are encouraged to try to learn a little of other languages, language is fundamental, right? Then, we use Google’s resource when it doesn’t work [...] I already understand Spanish better, but the service time increases. (E07)

Professionals also need greater knowledge regarding federal legislation on the SUS, which indicates a lack of awareness of the rights of care for foreign patients, in addition to a better approach to these legislations in the academic environment.

The nurse who works at the border must be aware of the regulations of the SUS, as the right to health is a right of everyone. Even residents of neighboring countries cannot be barred when they need urgent or emergency care, and this must be clear to the team that he [the nurse] leads. (E13)

[...] I see a lot of lack of information about the rights of individuals living on the border and, whether we like it or not, this impacts the guidance that this nurse will provide to their team. (E15)

DISCUSSION

In light of the above, it is essential to recognize that communication plays a fundamental role in the context of health and is important to ensure the continuity and quality of the care provided. In times of crisis, such as during a pandemic, changes occur at an accelerated pace, and uncertainty prevails. When communication is not clear and precise, there can be confusion, which hinders the nurse’s ability to make decisions¹¹.

When analyzing the statements of the interviewed professionals, it is clear that the pandemic period was a time when there was a great communication noise between the PHC nurses and management, as the information presented was contradictory or incomplete. These cases of information gaps, which resulted in inadequate or delayed actions, in addition to the lack of alignment and internal understanding, contributed to a tense and demotivating work environment, especially when crucial information for the smooth progress of the service arrived late¹².

This inefficiency in communication within the workflows directly affected the team’s trust in the nurse’s leadership, as it was in this person that they found a reference during a time of uncertainty. However, due to the difficulty of communicating the flows through management, the nurse often did not have the correct answers in situations where he would need to have them⁶. The complex dynamics of health units, especially in times of crisis, have assigned the nurse the role of leader and decision-maker. This reality was evident in the expressions of the nurses themselves, who made visible the notorious dependence on the decisions they made regarding emerging situations in the health unit¹³.

As crises set in, challenges like these are exacerbated. With the intensification of demands, reduced available time, and increased pressure, the tendency to trust the nurse to lead becomes even more pronounced during critical moments. This entails an additional burden of responsibility and expectation on the nurse¹⁴. The excessive dependence of the nurse in decision-making situations can be seen as a reflection of the lack of clarity in the assignments and responsibilities of the other team members. To mitigate this excessive dependence and the overload that arises from it, redefining the unit’s assignments and responsibilities is imperative. Managers and supervisors should play a more active role in the equitable distribution of tasks, with the aim of encouraging collaboration and shared decision-making¹⁵.

It was noted that during times of crisis, nurses felt more overwhelmed with the leadership role, especially regarding the previous topic, where the entire team saw them as a support point to know the necessary procedures and flows for the functioning of the basic care units (BCU) during this period. However, the nurses had difficulty accessing the information to support their teams¹⁶. In this sense, although this approach sought to enhance the nurse’s skills, it resulted in an unsustainable overload for this professional, as it highlighted an excessive dependence and pointed out the gap in the execution of responsibilities by the unit managers¹⁷.

The overload of responsibilities that fell on the nurse exceeded their primary role of assistance, which caused significant reflections on their leadership capacity and decision-making. In practice, the nurse took on an informal leadership role; however, this stance resulted in unfolding a series of tasks that exceeded the expected scope¹⁸. Upon closely observing the context, it was noted that the nurse’s role goes beyond their usual responsibilities within the Primary Health Care. The need to express empathy and understanding towards colleagues demonstrates an intrinsic recognition of the importance of emotional well-being in the workplace¹⁷.

The nurse’s role as an emotional support point is not limited to just mitigating stress and workload, as it extends to understanding the individual anxieties of each team member. The granting of time off during critical moments and pursuing more favorable conditions are not just operational strategies but tangible expressions of solidarity and emotional care¹⁹. Furthermore, recognizing the diversity of challenges faced by the team, such as the fear of contracting the disease from older colleagues and cases of healthcare professionals being away due to immune compromise, reinforces the complexity of the work environment in the healthcare field. By becoming an emotional support point, the nurse emerges as a vital link in the cohesion and resilience of the team in the face of these adversities¹⁷.

One highlighted point in the analysis is the complexity of attending to patients who are not residents of Brazil. The absence of an established protocol to guide where and how these patients should be treated in the BCUs creates uncertainty, which directly impacts the leadership exercised by nurses. The lack of clear guidelines results in a constant demand for guidance, as other professionals often turn to nurses for direction on how to proceed with these patients¹⁶.

This situation became even more pressing during the COVID-19 vaccination period. With the limited availability of doses and restrictive guidelines that prioritized vaccination only for city residents, the nurses found themselves confronted with a complex ethical and operational dilemma20. The leadership that naturally falls on the nurse plays a crucial role in resolving the conflicts generated by this situation.

The protocols must be clear and consensual to establish guidelines on how to deal with specific scenarios. When these guidelines are not available, professionals often find themselves at a crossroads without guidance to follow. This not only compromises the effectiveness of care but also puts at risk the safety of patients and the integrity of professionals²¹.

In an environment where decision-making requires technical knowledge and discernment, professionals rely on clear guidelines to support their actions. Without this guidance, leadership is compromised, as nurses and other team members may feel disoriented and insecure regarding the decisions to be made²².

Furthermore, regarding the care of foreigners, a survey conducted on the care of migrants in the SUS revealed that the language barrier has adverse effects on understanding health conditions, treatment follow-up, and interaction with health professionals. These circumstances contribute to instilling a sense of insecurity in patients regarding the expression of the symptoms they experience and in relation to the understanding of the information conveyed by professionals²³.

The language barrier becomes even more pronounced when the disease is more severe due to healthcare professionals’ widespread use of technical terminology when providing clinical guidance. Additionally, the complexity of understanding the instructions during procedures that require the active collaboration of patients contributes to this difficulty²⁴. In this way, it is imperative that nurses have proficiency in a second language to facilitate more effective communication with their patients.

In the context of regulations and guidelines for assisting migrants within the SUS, a gap in knowledge emerges, both on the part of professionals and managers, regarding the rights to assistance for this population²⁵. It is essential that professionals not only receive and welcome these individuals but also be adequately trained and educated from undergraduate studies to provide more effective care based on respect, comprehensiveness, and equity. This approach aims to ensure the fulfillment of your rights and preserve or recover your health²⁴.

Another relevant aspect concerns the communication of accurate information to SUS users, including migrants. It is crucial that these individuals, who have the right to access health care, are aware of this right and understand how they can benefit from the services offered by the public health system²⁶.

In this way, it is evident that nurses widely use leadership to organize work in primary health care and as a support tool for overcoming challenges arising from the locality and the epidemiological situation experienced during the period.

The limitation is in the chosen professional category: PHC nurses in BCUs. Other professionals from the Nursing team and managers from other areas who could provide relevant perspectives were not included.

FINAL CONSIDERATIONS

From the interviewees’ perspective, leadership is present in their daily lives. Organizing the work process in primary health care is even more necessary in times of health crises, even if this causes an overload. Leading in the international border region pressures nurses to have the specific knowledge to lead their team.

The analysis of the speeches highlighted a scenario in which the lack of clear guidelines and specific procedures led to difficulties in managing the team, which the nurse needed to solve the problems assigned to the municipal management.

The research strengthened nursing practice and encouraged the creation of specific protocols and investment in leadership training. In addition, it pointed to the need for policies that promote emotional support and better structure PHC services, with the aim of valuing the nurse as the central piece in team management and problem-solving. Thus, this study provided important subsidies for advances in management and training in nursing, which directly impacted the quality of care provided to the population.

• HOW TO REFERENCE THIS ARTICLE:
  Silva GK, Scherer KES, Almeida ML. Challenges of nurse leadership in the context of a health crisis in an international border locality. Cogitare Enferm [Internet]. Ano [cited “insert year, month and day”];30. Available from: https://doi.org/10.1590/ce.v30i0.98187
• *
  Article extracted from the master’s thesis: “Liderança dos enfermeiros que atuam em um município de tríplice fronteira do sul do Brasil, frente à crise sanitária de COVID-19”, Universidade Estadual do Oeste do Paraná, Foz do Iguaçu, PR, Brasil, 2023.

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• Associate editor: Dra. Juliana Balbinot Reis Girondi

Publication Dates

• Publication in this collection
  24 Feb 2025
• Date of issue
  2025

History

• Received
  05 June 2024
• Accepted
  20 Nov 2024