Nursing workers: achievement of formalization, hard work and collective action dilemas

The singularity of the collective action of nursing categories in sociopolitical participation is the subject of our analysis. This paper attaches the compelling factors of social origin and aspects of the labor market to the political action of professionals. Based on the analytical association of the extended case method, we articulated the interpretation of the database of the Brazilian Nursing Profile Survey, specifically, in the light of socioeconomic identification, labor market, and working conditions, with an ethnographic study and semi-structured interviews in three hospital units. The bibliographic review shows the incorporation of these individuals without underestimating their particularity: the historical process of proletarianization in the Brazilian social formation, the inclusion of women in the labor market, and the relationship with unions. The history of workers based on inexperience in actions of resistance or union representation associated with the valorization of employment as a social ascent results in asymmetrical work regimes, a hindering element to coordinated actions, a fundamental aspect for the improvement of working conditions.


introduction
The reflection on the political performance of nursing categories in the literature is supported by several themes, including the union relationship with the 1980s Constituent Movement 1 , the establishment of parliamentary political representation of nursing for intervention in themes concerning the profession 2 , the historiography of the establishment of representative professional entities, the consequent debate about the representation model and the proposed professional political project of Brazilian nursing inspired by the 1980s social movements 3 .
The experience of political action of nursing workers is part of history, so one cannot think about the reality of these professionals, their impasses and challenges without locating them as a working class sector in Brazilian society.In our analysis, the historical characteristics of the proletarianization and wage-earning process in Brazilian social formation 4 are associated with the following axes of research on the Brazilian nursing profile: socioeconomic identification, labor market and working conditions 5 , fundamental aspects for understanding the theme.
This paper analyzes the political realm of nursing categories in the workplace, highlighting the collective action of nurses, technicians, and assistants from 2013 to 2014 in hospital units.In contrast to the particularist analyses, we correlate the reality of these workers with the dynamics of the increased health services through the Unified Health System (SUS) and expanded private market under the predominantly financial capitalist accumulation regime.The "non-public" sector (various forms of private contractual relationships) has at least 54.6% of the jobs of nursing technicians and assistants 5 .Thus, understanding the trend of the labor market from 1990 to 2010 is crucial and follows the movement of capital, intensifying the process, and deteriorating the working conditions.
The contemporary work dynamics are marked by the productive restructuring that, in health services, we find characteristics similar to "just in time", especially the production corresponding to market demand, "flexibility" of labor relationships, outsourcing and subcontracting.Thus, work is organized reactively to the high volume of user demand.The excessive pressure on professionals generating task overload and intensified work process, a fundamental characteristic in the dynamics of tensioned flow 6,7 , is established.
The sketch of the working conditions of nursing professionals is consistent with the general trend, as 64.2% of the assistants and technicians claim exhaustion in their professional activity, while this figure reaches 71.7% in graduated professionals 5 .Concerning the number of weekly hours worked, 40.8% of professionals work more than 40 hours in the public sector, while 38.5% are in this range in the private sector, culminating up to 80 weekly hours.We interpret from the data that the time range is similar in the public and private sectors, and the lower incidence in the latter is due to the higher non-response rate 5 .While these are different quantities, the number of hours worked can be associated with workload, a topic widely discussed in the literature.
These marks of contemporary working conditions develop mainly in the so-called Brazilian neo-developmentalist period.It is a political and economic bias of federal governments led by the Workers' Party (PT) (2006-2013) which, according to its proponents, prioritized job creation, minimum wage increases, social policies and strategies that drive economic growth by calling for increased domestic consumption of goods and services, a central aspect of neo-developmentalist ideas.However, such measures aimed at intensifying capitalist relationships and did not change the structural inequalities of Brazilian society, labor exploitation, and environmental degradation 8,9 .
In this contradictory neo-developmentalist context, the consumption of private health services is being encouraged by expanding the number of private plan users from 31.5 million to 50.3 million from December 2012 to September 2013 10 , about 60% increase in demand.For example, the expanded healthcare consumer market led U.S. market leader United Health to acquire the national health insurance business group AMIL -Assistência Médica Internacional in 2012.This process was associated with higher industry revenues from 2003 to 2011 11 .Thus, the strengthening of the concept of consumption advocated by the neo-developmentalist ideology to the detriment of the concept of social right to health advocated in the principles of the SUS is noted.
This paper analyzes the growing trend of employment in neo-developmentalism and its characteristics, as well as discusses the roots of the insecurity of this working-class and its relationship with trade union organizations, to apprehend the object about the collective action of nursing categories.The reflections are based on the bibliography of the Brazilian social esta-blishment and case studies on the dilemmas of collective action of women and men and their hard working conditions in hospitals.

Methods
The detailing of the nursing categories profile in the Brazilian reality is a significant undertaking for comprehending the reality of these professionals.The national survey 5 fits into the theme of human resources and the sociology of professions associated with the labor market.The ethnographic approach is based on work sociology, the work process theory 12 developed in the field of public health, and the discussion of Brazilian social classes during the period characterized as neo-developmentalism.This approach covers different themes about the reality of nursing categories, and the approach to the political action of professional categories is absent in the public health bibliography.The methodological framework for the rapprochement of research with different methodological constructs is the application of the expanded case study methodology 13 , and linking ethnographic interpretation about local aspects to national realities is one of its postulates.
We worked from two perspectives to expose the object: the theoretical realm and the empirical realm.Regarding the first, we recognized that the social origin of professionals occurred through the analysis of data from the axis of socioeconomic identification of national research and previous work activities reported by respondents in ethnographic research.We built on the adaptation of the theorization of factory regimes 14 , keeping in mind the peculiarities of the original proposal and our application.We formulated the category work regime with a broad meaning, referring to the power relationships between peers and the boss, as well as their autonomy in the workplace in the service activity, highlighting the influence of employment relationship in the work regimes 15 .
We aggregated the literature about Brazilian workers and their relationship with unions, specifically in the neo-developmentalist period characterized by federal governments spearheaded by the Workers' Party.It is the general environment, that is, the background of any collective action.We sought to investigate the points in which the general determinations drive or restrict the (union) collective action of workers in nursing categories.
In the empirical research, we adopted the analysis of the database of the Brazilian Nursing Profile Survey, specifically regarding socioeconomic identification, labor market, and working conditions associated with ethnography and semi-structured interviews.This association correlated the trends identified in ethnography with the data found in the national survey, and both local and national surveys occurred at similar periods.
Ethnography focused on the analysis of the political action of nursing categories from 2013 to 2014 in three hospitals in the metropolitan region of São Paulo under different management types: direct administration, outsourced under the management of Social Health Organizations (OSS), and private enterprise.In the interview script, we addressed the educational background, career and professional prospects, labor market, remuneration, professional qualification, work process, outsourcing aspects, conflicts in the workplace, internal labor market, collective action, subjectivity involved in the worker's work and health.Some aspects are present in Brazilian Nursing Profile Survey 5 , others are aggregated and relate to the research with the ethnography resource.In line with the purpose of this text, we prioritized the discussion of the incorporation (formalization) of workers linked to the socioeconomic profile and relationships established in the labor market, and the consequent power relations and their collective action.

results and discussion
The neo-developmentalist economic and political strategy is known, among other things, for the significant creation of formal jobs, especially in the service sector.In the 2000-2009 period, an average of 2.1 million jobs was created annually, and 2 million were filled by workers up to 1.5 times the minimum wage.The tertiary sector generated 2.3 times more jobs than in the secondary sector.In other words, this period was marked by both a considerable increase in formal employment and the predominance of low wages 16 .This trend was manifested in the offer of nursing-related jobs, a majority category in hospital structures, and other care services.According to the Brazilian Nursing Profile Survey, 84% of nursing teams were employed in the last 12 months (referring to 2013) 5 .
The comparison of job offers in the general labor market over decades is enlightening.In the 2000s, 20.8% more jobs were generated than the 1990s in the range of up to 1.5 minimum wages 16 , which in our case is linked to the reality of mid -level professionals.In the national profile survey of nursing categories, in the public sector, 45% of nursing team professionals and 55.2% of mid-level professionals have a monthly income of up to R$ 2,000.In the private sector, 54% of team professionals and 62% of assistants and technicians fall within this range 5 .
Complementarily, data from subscribers provided by the Regional Nursing Council of the state of São Paulo (Graph 1) can serve as a mirror of job growth over the decades, as the progression of registered professionals is not expected to grow considerably without the correlational increase of jobs.Data from the Council show that the number of registered professionals grew from 73,360, in 1993, to 445,693, in July 2014.This increase of approximately 600% is due to the predominantly relational composition of the nursing work process and economic expansion of service provision.
Probably, these jobs were filled by women and men who had other informal occupations and substandard occupations previously, as per statements of the workers in the hospitals analyzed by the ethnography.We refer to the categories of relative overpopulation that is disqualified and subject to systemic unemployment swings.Marx makes four distinctions of this overpopulation.The first group would be the mobile reserve of the workforce, that is, workers who would move across productive sectors with momentary unemployment; the second group is marked by the "latent" feature in which people would be made available to the market by capitalist development, such as rural workers towards the city; the third group is the most relevant to our characterization, spelled out in Marx's words: "The third category of relative overpopulation, the stagnant one, is part of the active army of workers, but with completely irregular occupation.It thus provides capital with an inexhaustible reservoir of available labor power.Its living conditions fall below the average normal level of the working class, and precisely that makes it a broad base for certain branches of capital exploitation".The fourth group refers to the lumpen proletariat as the most impoverished segment 17 .
We characterized these professionals as deriving from relative overpopulation, that is, they were not inserted in the formal labor market, because domestic work, informal activities or the various types of "filler jobs" were their reference.Thus, they were a sector of the workforce rooted in neglected rights and informality.
The concept of precariat 18,19 was coined in the analysis of this segment of workers in the Brazilian reality, and this sector is highly exploited and underpaid.Among these individuals are young people seeking their first job, lacking professional qualifications, subjected to high turnover in the labor market, and who move across formal and informal occupations as the labor market swings.
In the Brazilian reality, the social origin of the nursing workforce that underpinned this cycle of capital appreciation presupposes an understanding of the forms of collective action and the relationship with unions.The incorporation of impoverished sectors into the labor market in Brazilian society refers to the development of a population contingent with lower living standards than subsistence and unemployment.Fernandes says: "Basically, whether it is metropolises, cities or the countryside, social classes themselves include social circles that are in one way or another privileged and could be described relatively as "integrated" and "developed".Such sectors coexist with the mass of the destitute, condemned to lower than subsistence living standards, systematic, partial or one-off employment, poverty or misery, socioeconomic marginalization, cultural and political exclusion, and the like 4 ." The social origin of nursing workers is elucidated in the national survey with the approach to the education of the mother or significant person who replaced her; concerning the nursing staff, 64% achieved elementary education, while 69% of assistants and technicians reached the same rate 5 .In general terms, the relationship between educational background and social stratification has a clear correlation in contemporary societies.Concerning "nursing lineage", 46.6% of the team professionals had a close relative who previously worked in the segment, showing the social class relationship hardly reached by any other professional segment, except for regional realities with a predominance of a particular economic activity.
Understanding the fundamentals of this process helps us analyze contemporary situations of incorporation into the labor market.In the ethnographic study, subjects from informalization and poor remuneration, while in the national profile research, the presence of a set of professionals with a family relationship with the profession is considerable.In ethnography, the relationship of these workers with the achievement of employment is characterized by the valoriza-tion of wage-earning as a "privilege" and not the reality of work itself.This scenario results from the Brazilian social construction, and also implies the political organization and the awareness of the performance of newcomers in the formal labor market.This characterization is highlighted in the establishment of the Brazilian urban proletariat: "[...] Migration to other regions, seeking salaried employment in traditional occupations; attempting penetration into the urban world, to classify oneself within it and gain access to its privileges; positive identification with proletarianization, seen as social ascent and also a privilege; the overestimated workers' lifestyle, and the like, are the mechanisms by which the reconciliation of the "damned of the system" with their socioeconomic order occurs" 4 .
Searching for a better classification in the labor market, considering wage labor as a privilege, among other points cited by the author, results in the denial of rebellion and consent to the established order.
Subsequently, the incorporation of women into the labor market follows the script of this conditioned proletarianization and is related to the declining purchasing power of the "head of the household" identified in the male figure in the 1970s 20 .This consideration is relevant, given the significant feminization of the workforce of health professionals in the nursing categories.Furthermore, working women have currently a leading role in household income 21,22 .In the na-tional profile survey, the massive feminization of nursing categories is expressed in 85.1% of the teams 5 .
The theoretical interpretation of the poor situation of this segment of workers in Brazil helps us to reflect on the reality of work and employment of nursing categories.Implicitly, in the case study, the report of the professionals corroborates the decision to join nursing, mainly motivated by the formalization obtained in two ways: 1) guarantee of employment supported by CLT (Consolidation of Labor Laws); 2) entering public services via public examinations.The national profile survey shows the relationship between nursing job stability and in the public sector, 42% under the statutory regime, and 17.2% by CLT, while 10.8% are via fixed-term contracts.In the private sector, 56.1% are CLT, and 30.5% are service providers, although CLT hiring prevails in the private sector, other forms of labor relationships emerge without the established labor rights.However, due to increased job offer and high employability of the category previously shown, from the viewpoint of the interviewed professionals, taking the technical course guarantees employment, despite considering work as exhausting and underpaid.For these workers, being employed with formal employment is an advance compared to previous work activities.
Regarding the first formalization related to the guarantee of CLT employment, the formalization by the employment record card is signi- ficantly relevant, in line with the higher levels of formal employment in the country in the neo-developmentalist period.Informalization represented 43% of the economically active population in 2012 16  Strictly about nurses: The outsourced hospital professional worked in another informal sector and later migrated; the others joined in as attendant and medical secretary.We draw attention to the professional career of nurses in the public hospital.His life story will condition his stance in work relationships and the appreciation of the nurse profession.He worked in pottery at the age of nine in the inland region; subsequently, he was an informal salesman.His transition to healthcare occurred when he was an office boy at a hospital.This type of internal transition was reported as typical, as per the nurse at the outsourced hospital: Some people who were from the cleaning service here and are technicians today.Other people were receptionists and are technicians today (Nurse 2).The public hospital technician was a cook at a nonprofit institution that also provided health services, and made this transition.We noted that most reported occupations are characterized by high turnover and non-formalized activities.Coherently, all respondents report coming from poor households.
The centrality of the formal relationship by most respondents is confirmed with the information of not knowing unemployment after training as a nursing technician, although, contradictorily, graduates report moments of unemployment.According to the data gathered, only a mid-level professional worked as a home-care worker informally.
In this sense, the valorization of formal employment is clearly expressed in the nursing categories.This is confirmed in the reports of our investigation, as well as the reports of workers in previous research 23 about the category of nursing attendants (extinct category).The workers' statements in the referred paper about their social origin, professional life, and entry in the nursing area by training courses are very similar to those expressed by the workers interviewed in this research.The professional qualification processes trained attendants and assistants, guaranteed jobs and labor rights, as well as progressive changes in the living conditions of these workers.
The description of the situation before the workers' professional training also converges with the informality situation observed in the investigation, including the mention of some identical informal occupations.Thus, professional training and employment become access to previously nonexistent citizenship rights.In the paper's examples, the internal transition of the attendants was achieved through the implementation of a technical training program provided by the municipal health department.The assurance of formal employment, either through the CLT or entering the public service, was also shown 23 .
In our analysis, the professional path and origin in the impoverished sectors considerably influence labor relationships.However, we characterize as distinct in the three hospitals investigated.The type of employment is a constitutive element in the contrasting labor relationships and functioning of the studied hospital units.The different relationships are a considerable aspect for nursing workers concerning the types of management.Public servants are part of statutory regimes, with more rights compared to CLT employees, namely, the provision of absenteeism allowances, attendance premium leave, and, mainly, stability in which sanction or dismissal would occur after the definition of the administrative disciplinary process with the worker's right to a full defense.
The instability of the CLT regime underpins the management of the workforce based on insecurity and influences the daily lives of professionals.In private and outsourced hospital units, the power asymmetry between workers and company management leads to despotism permeated by arbitrary relationships, such as the dismissal of a union director worker and the Internal Accident Prevention Commission (CIPA) component.Workers' autonomy is more significant in the public sector, and the foundation is the stability that stems from the statutory regime.This situation facilitated the outbreak of a strike for better working conditions in the city studied.
Regarding the political organization of workers, union representation in the public hospital studied is fragmented.Three entities compete for the representation of mid-level professionals (municipal servants' union, recognized by the municipal administration, specific health servants' union, and association of health servants).However, none of the entities has a significant weight in labor relationships.In 2011, a mobilization gap was observed at this hospital.The union representing the category, as opposed to the municipal administration that shared the federal government's neo-developmentalist ideas, organized a strike in the municipal network for salary issues and better working conditions.The administration did not negotiate with the strikers, and the mobilization had no immediate results; the administration subsequently gave in on salary aspects, changed contested commanding officers, reversed strikers' downtime discounts and administrative sanctions of the leaders, but did not recognize the strike union, which lost its momentary relevance and was discontinued.The national context is relevant to understanding the nature of the strike.The period claimed as neo-developmentalist (2006-2013) experienced an organic evolution of strikes, in which the main reasons for the outbreak come with the strike: better salaries, career plans, meal tickets, and working conditions 24 .
The neo-developmentalist period witnessed a high impulse of the strike movement reaching, in March 2011, a significant number of 170 thousand striking workers, including national strikes such as bankers and postal workers.The strikes also continued in 2012 in several categories: The Belo Monte Plant, the Rio de Janeiro Petrochemical Complex, and various stadium constructions for the 2014 Football World Cup 19 .Thus, the strike uprising in the public hospital is part of a broad wave of discontent with the neo-developmentalist model, even if limited and unable to overcome the political inertia characterizing the category.
Workers at the private and outsourced hospital are represented by the same union.In the former, the reference is negative concerning the union and characterized by the interviewed assistant, who is union director, as little active and distant from workers.Contradictorily, some of his colleagues have a positive reference in the union, precisely because of the performance of this director.In the outsourced hospital, the references are positive because of union intervention in the recurrence of salary arrears.In the words of the establishment's technician: Look, I didn't believe much in the union, but now, in January, when I went on leave, and my leave allowance (deposit) was never paid, the union solved the problem (Téc./Aux.2).Regarding the nurses' union, the graduates are unaware of their performance.
Besides the limited union action, regarding the political profile of nursing, the private hospital assistant and union director considered: Yes [...] I believe it is different, people even put a different pressure on women, because they know they will give in easily by the very characteristic of women, of nursing, which is an exhausting, submissive category, right?People command, and we obey (Téc./Aux.3).
Despite the understanding of those involved, we consider this position based more on the chauvinistic characteristic of society than on the practical action of the subjects.This is because, in the example of the public hospital strike, most of the strikers, and especially leaders, were women.The issue of an employment relationship is more relevant than the predominance of women because any attempt to mobilize in private and outsourced hospitals, whether women or men, is sharply curtailed by the boards.
For example, the interviewed assistant from the private hospital was fired when he was a member of the Internal Accident Prevention Commission (CIPA) because he was not considered cooperative (the assistant was readmitted after a court decision).Another aspect observed is the resigned commotion of workers about the reverberation of procedural errors as individual responsibility, but which is not channeled into practical solidarity actions.Most workers empathize with the professionals involved, as all workers have reported witnessing error situations.
Also, we understand that the significant appreciation of formal employment is an obstacle to joint action.Workers hardly view their working relationship collectively, but much more individually, therefore, not as a hierarchical contractual relationship between employees and employer.Personal conflicts predominate over conflicts inherent in labor relationships.We cited four examples of the relationship between employment dependence manifested in personality and collective action: i) In the example mentioned of the public sector strike, the strikers did not mobi-lize some colleagues because they "owed favors" to the nursing supervisor who appointed them for jobs in private enterprise; ii) Mention of private hospital owners is always made in a personal tone; iii) The nurse of the outsourced hospital interviewed reports having suffered bullying, but in another sector and under a different leadership, however, the professional does not see responsibility of the social organization, because this gave her the first opportunity for employment; iv) Another aspect of understanding about the category itself is the false awareness that the fact that the sector mainly consists of women means that the category is submissive and docile.
These characteristics fragment the collective ideas of working individuals.The pressure of daily life also isolates the worker from his peers and possible confrontations for better working and living conditions.While in the labor regime, understood as the power relations in daily work, employers' decision has precedence over labor claims.However, some gradations depend on the type of management and the employment relationship.

Final considerations
The economic and social scenario boosted by neo-developmentalism enabled high levels of employment for nursing categories in the national scenario and the entry or relative improvement in the incorporation into the formal labor market of the interviewed workers.However, after joining, they continued to experience severe working conditions and work regimes, typical of contemporary capitalism, aspects signaled by the manifestation of overwork and the number of hours worked, in line with the tendency exposed in the research of the national nursing profile.
In this scenario of formal employment with intense and stressful work pace associated with low pay, collective action and politics refer to the essential aspect of how women and men work and build their resilience to workflow dictates and overwork, low financial benefits, among other factors.
In the ethnographic study, professionals showed the diffuse notion that nursing categories are submissive to hospital management.This understanding of respondents regarding nursing is pointed out as an inhibiting factor of collective action and resistance capacity.All three hospitals show rare mention of unions or organized mobilization efforts.Also, the instability of the CLT contracts of private and outsourced hospitals are asymmetric work regimes that hindered collective action, which is why the example of the reported strike occurred in the public hospital.Indeed, the specific reports in the ethnography point to elements that will be distinct due to the heterogeneity of other realities, the link with the national reality serves to reflect on how the configuration of nursing categories are linked to their political activities in the workplace.
Aspects that result in the inhibition of collective action are found in the expanded case study of nursing categories.Firstly, we highlight the social origin of health workers, specifically mid-level professionals.Having their past linked to conditions of extreme vulnerability in the face of capitalism swings, wandering between "filler jobs" and instability at work, having a signed portfolio or statutory bond is understood by these individuals as "privilege".They thus tend to avoid situations that compromise their jobs, including engaging in collective actions, especially trade unions.Another impediment refers to the characteristics of the health workers' organizations, linked to government spheres and little combative.The neo-developmentalist model proved ineffective in reversing impediments to collective action.If, on the one hand, it inserted a large contingent of workers in formal relationships, on the other hand, the predominance of job insecurity created was not considered.
Finally, we considered that the professional history of nursing workers, in which they did not experience actions of resistance or proximity to union representation, associated with personality, build the incipience of coordinated actions, besides interpreting the union as something unrelated to their working condition.

collaborations
HS Souza contributed to the elaboration and design of the research, data collection, analysis and interpretation, drafting of the manuscript.AN Mendes contributed to the critical review of the manuscript for relevant intellectual content.AR Chaves contributed to the elaboration and design of the research, data analysis and interpretation, and drafting of the manuscript.

Graph 1 .
Progression of Registered Professionals of the Regional Nursing Council of São Paulo.