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Influencing factors in the nurses’ decision-making process in Ibero-American university hospitals

Abstract Objective: to analyze the factors that influence nurses’ decision-making process in Ibero-American university hospitals. Method: a case study with a qualitative approach and of the multicenter type, carried out with 30 Ibero-American nurses. The data were collected through semi-structured interviews, analyzed by thematic categories and interpreted according to the theoretical framework of Creating Effective Organizations. Results: it was identified that the decision-making process permeates the development of nurses’ own competencies, suffering influences from health management training and previous individual experiences. The following categories emerged: Technical-scientific preparation in decision-making; Hierarchization of the decision-making process; and Autonomous professional practice. Conclusion: the absence/presence of a rigid hierarchy, as well as technical-scientific preparation and autonomy, are factors that limit or expand the range of possibilities in nurses’ decision-making, with consequences in care management. Thus, discussions about this theme should be encouraged, in order to promote nurses’ autonomy for decision-making and favor a reduction of bureaucracy in the processes that prevent/hinder advances in these services.


Introduction
In the course of work-related activities, it is common for the nurse to have doubts about which management tools can be used for better decision-making and to favor autonomy and leadership (1)(2)(3)(4)(5) . Therefore, it becomes indispensable to understand which elements make up the decision-making process, as it is an instrument of managerial competence inherent to the Nursing profession, as well as to know its implications for work and for the quality of the services.
Nurses' autonomy depends directly on the work environment, so that cultural and organizational aspects of the institution can influence it, favoring or impairing the decision-making process of these professionals. In both cases, there are direct impacts on the health services and on the labor relationships (individual or collective) (6) .
By decision-making, it is understood the choice between two or more alternatives that enable the achievement of a given objective. An international study (7) describes decision-making in the Nursing practice environment as a dynamic conceptual process, capable of affecting the results in the services. Thus, in the course of the work activities, it is necessary that these professionals know how to identify and use resources that contribute to correct and self-reflexive decisions.
The settled organizational model can show both the presence of professional bureaucracy, characterized by democracy at the operational level, and of mechanized bureaucracy, which consists of an autocratic style. The presence of both models in the same organization can represent a hierarchical system of the work process (8) , which also applies to the hospital environment.
Institutions with mechanized bureaucracy properties are pointed out as limiting the communication between the different administration levels (9) , as they present a hierarchical, autocratic and vertical work mechanism, which provides the professional autonomy of a given category to the detriment of the work practice of another, in this case, of the nurse.
Moreover, in these institutions, nurses are not granted top management positions, due to lack of professional recognition, especially of their autonomy in the social, economic, political and legal instances (10) . However, considering that the main focus of these professionals' practice lies in the implementation of activities, to achieve maximum effectiveness and productivity, which also need to be valued, it becomes indispensable to make hierarchical relationships more flexible, in order to allow for the participation of these professionals in the actions and decisions, as well as the opening of a dialog between the various actors involved.
On the other hand, an organizational model with professional bureaucracy properties, implemented in health services, contributes to the development of managerial competences by nurses, such as leadership, communication and decision-making (9) , given the presence of less rigid protocols, which favor better working conditions. Thus, the focus of such bureaucracy is not related to the power struggle to obtain and predominate in a given professional category, but to the performance of actions thought, coordinated, integrated and shared with the group.
In this managerial perspective, an organizational culture is noticed that prioritizes professional improvement and quality of the care provided to the target population (11)(12) , due to recognition of the work performed, of the engagement and of the development of autonomy for decision-making by nurses. In addition to that, this culture favors changes in behaviors and performance scenarios; in this case, university hospitals. It is worth mentioning that these hospitals are recognized as spaces to support teaching, research and extension, linked to higher education institutions responsible for training health professionals.
In summary, given the importance of identifying how the decision-making process takes place in the hospital environment and its interface with the work of nurses, the question is: which factors influence nurses' decisionmaking process in Ibero-American university hospitals?
To answer this question, the objective was to analyze the factors that influence nurses' decision-making process in Ibero-American university hospitals. To support the analysis, the theoretical framework of Creating Effective Organizations (9) was adopted, which addresses the dynamics of the organizations. Influence was observed as a contingency factor in the authority flows, in the control of human behavior and in the information flows related to the decision-making processes; and decision-making, as an organizational characteristic in health institutions.
As for the relevance of the research, the intention was to encourage reflection on the Nursing management practice in the hospital context, in order to contribute to the development of studies in this area. It was also intended to boost the state-of-the-art on the theme and to subsidize the implementation or reconfiguration of the management models, in order to stimulate the role of nurses in such spaces.
In addition, it is intended to add knowledge in

Study design
A case study with a qualitative, descriptive and exploratory approach and of a multicenter character, having the think-see-do triad as theoretical framework (9) , where decision-making is related to rational, intuitive and improvised actions. In addition, in health, application of these concepts allows for a fresh perspective at the organizational configuration, in the presence of elements capable of interfering with the success of reforms in health systems.
The Consolidated Criteria for Reporting Qualitative Research (COREQ) instrument was used to structure the data (13) .

Scenario and participants
This is a research study conducted in university  (14) .
In Spain and Portugal, university hospitals also follow a structural alignment, as is the case in Brazil.
They are public hospitals, managed by the National Health Services. However, there is a contractual relationship for the provision and consideration of services, supervised by the regional public sector, with internal administration and autonomous bodies in each of these countries.
We emphasize that, in line with the studies by these authors (15)(16) , it is necessary to clarify that, since the 1990s, the Iberian countries have implemented public policies and investments in excellence programs for the management of hospital services linked to universities. This investment is intended for the training of professionals to qualify in health management. The public policies referred to are focused on health protection as a citizens' right through public and universal health systems.

Thus, the legislation in force both in Spain and in
Portugal has principles and rules applicable to the health units, which calls on university hospitals to assume their nature as public business entities, made explicit in their strategic plan. In this case, they must strive to achieve the pre-established goals and to measure the results.

Participants
A total of 30 nurses participated in the research: eight from Brazil, nine from Spain and 13 from Portugal.
All of them developed managerial activities at the micro-, medium-or macro-organizational level in care and/or administrative areas.

Selection criteria
The study included nurses who had been working in the services for at least one year. Choice of these participants resulted from the significant experience they had with decision-making in the service, which enabled them to give a more accurate opinion in this regard. Nurses on leave or vacation or who did not attend three interview attempts were excluded from the study.

Instruments used for collecting the information
The technique chosen for data collection was individual interviews through the application of a semi- As for the tool used to select the participants, we opted for the snowball sampling technique (17) , which uses reference chains from a group called seed. Thus, the approach of these participants took place through a formal invitation to participate in the research, both in person and through telephone contacts and/or sending short messages and brief texts via cell phone or email, known as WhatsApp. This technique was chosen due to the difficulty accessing to the researched population, due to the work routine in the function performed and/or the positions held by these professionals. It is worth mentioning the adoption of the data saturation criterion for completion of the collection process, that is, the interruption at the time when there were no new contacts and the information was only repeated.
All interviews were recorded with the aid of a smartphone mobile device.

Data treatment and analysis
The data were treated and analyzed through content analysis (18) . Use of this technique enables replication and validation of the inferences about a given phenomenon, with application of specialized and scientific procedures.
It was initiated with the organization of the materials, the sorting stage, attentive and deep reading of the texts and references used to mark or complement the diverse information of the study, along with the notes described by the researchers and the transcripts of the interviews. The data were managed with the aid of the Nvivo ® 11 and WebQda ® software programs.

1) Technical-scientific preparation in decision-making
The results present an interface with the three fundamental decision models identified by the theoretical framework, namely: rational, intuitive, and improvised decisions. The rational model can be characterized by "thinking first"; the intuitive indicates "seeing first"; and the "improvisational" is justified by "doing first". Based on this approach, it is possible to synthesize the model for decision-making in the "think-see-do" triad.
Thus, scientific knowledge, management training and professional experience emerged as essential tools for good practices in decision-making by nurses, as evidenced in the excerpts from the following speeches:

3) Autonomous professional practice
According to the theoretical framework, the decisionmaking process represents a set of actions and dynamic factors that begins with the identification of a stimulus, which requires action and ends with a decision, that is, it requires the implementation of a decision-making process, either formal or informal, structured or unstructured.
The first stage of this process is the recognition and analysis of a problem or opportunity, which will guide the decisions. Subsequently, the objectives that will establish the alternatives are defined.

Development of autonomy was evidenced in this
study as a process influenced by individual aspects and by the characteristics of the organization. In this case, predominance of a hierarchical management model was identified, which directly interferes in decisionmaking quality.
Based on the think-see-do triad (9) , which includes rational, intuitive and improvised actions for decisionmaking, it is noticed that, given the complexity of the services offered, skills development by nurses is linked to an eventual investment by the institution in health management training (19) ; applied in the services as a contribution to work performance, with the joint use of technical-scientific knowledge and experiences underwent by these professionals.
The possibility of achieving better and more significant results in the services managed by nurses is also reinforced by the presence of professionals with high know-how abilities to adopt critical thinking in favor of decision-making (19)(20)(21)(22)(23) .
Nevertheless, in professional bureaucracy (9) there is a decentralized and specialized structure, Thus, the presence of autonomy limiting factors is related to the institutional management model, and this will be decisive for the managerial actions in Nursing to be characterized as independent, interdependent or dependent.
Non-resolution for these demands will result in work overload, in the face of a context of personnel shortage, which, in turn, will compromise professional satisfaction and, therefore, the care quality offered (22)(23)(24)(25)(26)(27)(28) .
A research study carried out in Spain (27) revealed the impact of instrumentalizing health in the nurses' practice and in the presence of a management model with rigid and inflexible standards. Furthermore, a survey on the relationship between autonomy and moral distress in nurses working in emergency services from Iran (28) indicates that the reduction of professional independence impairs decision-making and the ability to implement appropriate interventions.
Such aspects are in line with the concepts of mechanized bureaucracy (9) , whose organizational structure follows normative standards for the work process and presents a formal chain for decision-making. In this sense, it can be asserted, as also verified in the current study, that this bureaucracy is still strongly present in hospital institutions. Thus, reflecting on their ties can be the first step to transpose rigid behaviors in these work environments.
In Brazil, these hospitals are maintained by the Federal Government, although labor relationships usually include two or more employment relationships (CLT contracted, statutory and outsourced). Thus, it is assumed that the decision-making process of the manager nurse and/or of the services meets the specific regime of the hired employee.
It is worth mentioning that the Brazilian Constitution does not recommend the use of outsourcing in core activities, due to the harms caused by the precarious relationship of health professionals, who, in general, earn low salaries and work long and exhausting hours. This is a situation that significantly compromises the work process (14,(29)(30) .
An international study (31) identified lack of recognition, salary inequality and distinctions between permanent and temporary nurses who perform the same functions.
In addition to that, it was found that, eventually, these professionals had some/no participation in the decisionmaking process. Such conditions impair the routine of the services that present this multiplicity of links and act as a demotivating element for the professional performance and compliance with the standardized routines, as there are disparities in the treatment modality offered to the professionals inserted in this context. However, in opposition to the structural model advocated by mechanized bureaucracy (9) , some organizations present professional bureaucracy characteristics (9) and, in them, the professionals enjoy certain autonomy and freedom for decision-making. In these environments, not only the quality of the services provided is favored, but also patient safety. Therefore, the health organization's responsibility to promote and provide means for nurses to act autonomously, through the establishment of roles, responsibilities and behaviors, is clearly emphasized (31)(32)(33)(34)(35)(36)(37) .
In line with the professional bureaucracy (9) , it becomes a priority to choose the development of leaders in Nursing as the institution's strategic objective. At the same time, www.eerp.usp.br/rlae 7 Silva GTR, Santos IAR, Conceição MM, Góis RMO, Santos AS, Amestoy SC, et al. union between nurses in the search for autonomy should be encouraged, as well as the commitment to assume the responsibilities resulting from such autonomy.
In summary, the results herein presented evidence similarities between the realities experienced by Ibero-American nurses. Therefore, transforming this reality is a common concern and needs to be discussed together with these professionals.
It is suggested to integrate these professionals through the creation of dialogical spaces (virtual/face-toface), in order to socialize experiences about the nurses' role/performance in these three countries. In addition to that, it is recommended to give these professionals a voice with the top management, in order to unveil the specificities inherent to each university hospital and their respective management models.
As contributions, the results of this research evidence the need to better understand the inclusion of Nursing in the health services. In this sense, although nurses' professional performance has been objectively and notoriously defined throughout history, through the development of skills and abilities, it is noticed that preservation of their autonomy for the full professional practice at the time of their institutional insertion requires further discussions in order to recognize, value and preserve the professional identity.
A limitation of this study lies in the fact that it was carried out only with university hospitals, as its results cannot be generalized or attributed to the category as a whole.

Conclusion
In this study, tools that influence the nurses' decision-making process were identified. They are as follows: Technical-scientific preparation, hierarchization and autonomy. It is noteworthy that the theoretical precepts about organizational structures were the basis for the analysis of this research, correlated with the thematic categories elaborated.
It was found that, many times, the decision-making process in the nurses' professional practice is constrained For the purpose of comparing the results obtained, it is suggested that this study be replicated in other active scenarios of the basic network (outpatient clinics, specialized clinics), as well as that futures surveys include the other social actors that work in care management. It is also considered valid to apply methods to carry out crosssectional and longitudinal studies that expand the range of observations and favor the compilation of answers to verify the phenomenon related to the decision-making process from a quantitative perspective.