Professional insertion of registered nurses : a study with alumni

5 Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Psiquiátrica e Ciências Humanas, Ribeirão Preto, SP, Brazil. ABSTRACT Objective: To analyze the professional insertion of registered nurses, taking into account the current structure of work in the health area and in the training of technical workers, from the perspective of training of professionals who will develop their activities in the Brazilian Unified Health System. Method: Quantitative, cross-sectional, and exploratory study, with descriptive and inferential statistical analysis using Fisher’s exact test, carried out with 105 alumni of a nursing undergraduate course. An electronic questionnaire was applied. Results: The alumni worked as nurses (n = 59, 56.2%) or teachers (n = 18, 17.1%). The areas with the greatest absorption of alumni were hospitals (n = 37, 62.7%), the public sector (n = 35, 59.3%), and high-school level technical professional education (n = 16, 88.9%). Most participants were dissatisfied with their income (n = 56, 72.7%) and pointed out that the received values were incompatible with the work (n = 59, 76.6%). Conclusion: The alumni faced problems in developing their professional activities, especially because of the current policies, which establish limits on the recognition of healthcare workers and education as a public asset. Progress in the recognition of the profession of registered nurse is necessary, given the relevance of these professionals in the health and education systems and the nature of the profession’s practice of providing education and care, which have a transformative potential.


INTRODUCTION
In Brazil, the undergraduate nursing course oriented toward training professionals to develop teaching activities was created in the late 1960s by Higher Education Chamber Report No. 837/68. It grants the title of registered nurse, designating a professional who meets the social demand for high-school level professional training, and students who receive this training are able to work as nursing aides and nursing technicians once their training is completed. The creation of this course took into account the need for educational training of nurses who would work as teachers. This need remained in subsequent historical periods because of the increasing offer of technical courses in the area and their impact on health care. Currently, nursing courses of this type are based on the Brazilian Nursing National Curriculum Guidelines (1) and the Brazilian Nursing National Curriculum Guidelines for Initial Training for a Bachelor's Degree in Higher Education, as well as in pedagogical training for college graduates and a second degree course for the training of basic education teachers (2) .
Upon institutionalization of the Brazilian Unified Health System (SUS, as per its acronym in Portuguese) in the late 1980s, more emphasis began being given to the need to rethink the training of technical workers, given the perspective of the development of a new care model.
One of the commitments for the quality of training of nursing technicians, who currently number around 1.3 million professionals in Brazil (in addition to approximately 421,000 nursing aides) (3) , is related to the pedagogical training of nurses who work as teachers in high-school level technical professional education.
It is pertinent to mention that the origins of professional education in Brazil go back to, among other aspects, a strategy of employability of the children of the working class. This strategy considered the structural dualism in education that delimits the organization of the educational system by distinguishing high school training and professional education, with an implicit division between those who conceive and control the work process and those who execute it. These origins are also related to the need to fill gaps in the job market that result from increasing industrialization (4) . In Brazil, the policies for training of teachers for high-school level technical professional education are fragile and often lead to the professional practice of "teachers" with training in a specific area and some practical experience but who lack training to teach (5) .
Additionally, studies have pointed out, over different historical periods, the precariousness of work relations and the need to have two or more jobs (6) .
Regarding the specific work of nurses in healthcare facilities, the current reality has also been marked by conditions that have resulted from neoliberal political-economic policies: intense work rhythms; reductions in the number of employees; high employee turnover rates; precarious employment bonds; low salaries; and loss of labor rights. These characteristics negatively impact nursing care (7) .
In the current scenario, as a consequence of these neoliberal policies, health and education have been considered more as assets that can be used as bargaining chips on the market than as public properties, which has an impact and compromises work.
Therefore, it is necessary to examine this reality and find coping strategies to sort out these problems. It is thought that alumni studies contribute to this analysis, because they provide higher education institutions with resources that can help them strengthen ethical-political training that considers nursing beyond its technical dimension. In addition, this type of study allows higher education institutions to value, in the learning process and curricula, aspects cited by people who have already experienced the training under discussion, pay attention to the identified gaps, and maximize potentialities to guarantee high-quality training.
In view of this context, the authors posed the following questions: Are nursing alumni inserted in the job market? What are the main spaces for professional insertion of registered nurses? What challenges have they experienced during professional insertion? What are the relations between these challenges and the current structure of work in the health area and in the training of technical workers?
The objective of the present study was to analyze the professional insertion of registered nurses, taking into account the current structure of work in the health area and in the training of technical workers, from the perspective of training professionals who will develop their activities in SUS.

Study deSign
This was a quantitative, exploratory, and descriptive study, with cross-sectional design and non-probabilistic (intentional) sampling.

PoPulation
An invitation to participate in the study was sent to all alumni of the undergraduate nursing course at a Brazilian public university located in the state of São Paulo who obtained their degrees between 2010 and 2015, totaling 242 people. Contact with the participants was carried out by using the records of graduates, which were made available by the educational institution. However, it was necessary to carry out an extensive search in social media to update electronic addresses and make it possible to send the invitations.
The sample was 105 alumni who completely answered the study questionnaire.

data collection
Data collection was carried out by means of an electronic questionnaire designed in the free platform REDCap® (8) . The form had multiple choice closed-ended questions related to the characterization of the participants, insertion into the work world, working conditions, income, professional satisfaction, and undergraduate training. It is important to stress that the alumni could choose more than one answer option in most questions to better represent their reality. The participation invitation was sent to the e-mails of the alumni between June 2016 and April 2017 at three different times, aiming to increase the number of participants (8) . A minimum period of around six months between graduation and sending of the questionnaires was estimated so the professional insertion trajectory could be fully understood.

data analySiS and treatment
Descriptive statistical analysis was carried out, including measures of central tendency and frequency. Additionally, inferential statistical analysis was performed by means of Fisher's exact test.

ethical aSPectS
The proposal was approved by the Research Ethics Committee of the Ribeirão Preto School of Nursing at the Universidade de São Paulo as per report No. 920.125/2014, in agreement with Brazilian National Health Council Resolution No. 466/2012 (9) . Free and informed consent forms were sent electronically by using the mentioned platform. Regarding risks and benefits of the study, it should be emphasized that there were no direct risks. The participants were told there would be no loss if they interrupted completion of the questionnaire in case of discomfort. The researchers informed the alumni that they could ask for clarification about the study at any time.

RESULTS
The examined sample of alumni showed professional insertion by working as nurses (n = 59, 56.2%) or teachers ( n =18, 17.1%), and 28 participants (26.6%) selected the option "unemployed." It is important to stress that 75 alumni (71.4%) had two or three jobs when data were collected. Regarding professional trajectory, 31 participants (29.5%) declared that their current job was their first, and 70 (66.7%) stated that their current job was not their first professional experience.
Regarding gender distribution, 12 alumni (11.4%) were men and 93 (88.6%) were women. The participants' mean age was 28.8 years old at the time of data collection (minimum of 23 years and maximum of 35 years, with a standard deviation of 2.5 years).
The health system area with greater absorption of alumni was hospitals, with 37 nurses (62.7%). There were 35 nurses (59.3%) working in the public sector, a number higher than that recorded for the private and philanthropic segments. In the group of professionals who worked as teachers, five (27.7%) developed their activities at public institutions and 13 (72.2%) at private organizations. High-school level technical professional education was the main area responsible for employability, accounting for 16 jobs (88.9%) in the sample.
Of 16 registered nurses inserted into professional education, nearly all chose this professional trajectory because of personal satisfaction with the teaching activity (14 or 87.5%) or interest in the education field (13 or 81.2%). Additionally, no participants opted for this activity because they found the salary adequate, and five (31.2%) had this job because of their need for income. However, none took the job because they considered the salary adequate or thought that their insertion in the activity took into account growth prospects or career plans. Still in the group of participants who worked in the high-school level technical professional education field, five (31.2%) declared that they found their working hours adequate to their needs, four (25.0%) had career growth prospects, and five (31.2%) stated that their work as teachers was valued and acknowledged.
Of the sample of 105 alumni, 79 (75.2%) had a mean individual monthly income of R$ 3,549.34 (Brazilian currency Reais), with a minimum value of R$ 600 and a maximum value of R$ 12,000. Ten income values (12.6%) were lower than two minimum wages (minimum wage in force during data collection: R$ 937) and 19 participants (24.0%) stated that their income was the sum of payments from two or three jobs. In this case, the mean monthly value was R$ 4,931.57.
The null hypothesis that the alumni had the same probability of being dissatisfied with their income regardless of the number of jobs proved correct according to Fisher's exact test (p = 0.55), indicating that even alumni with more than one job were not pleased with their remuneration.
Of the 18 alumni that worked as teachers, nine had two jobs (50.0%), two had three jobs (11.1%), and seven had only one job (38.9%). This piece of information must be examined in combination with salary data from the perspective of having a job as a teacher, specifically in the highschool level technical professional education field, in which most participants were inserted, to complement monthly income. In this context of summing jobs, the hypothesis test confirmed that the chances of an alumnus getting a monthly income lower than the mean value received by their peers were greater among those who worked as nurses (p = 0.01) than those who worked as teachers (p = 0.07).
Twenty-six participants (24.8%) did not state their income, of whom eight declared that they were employed. This corresponds to 30.7% of missing data regarding the monthly income of the portion of the sample that surely had a paid occupation. In the subgroup of alumni who had income, 11 (13.9%) stated that they did not have a job but indicated a value in the personal earnings field. It is likely that this portion of the sample was made up of graduate students who were receiving scholarships, as shown in Figure 1.
Of the 77 participants who had a paid occupation when data were collected, 56 (72.7%) were not satisfied with their income, and 59 (76.6%) believed that their remuneration was not compatible with the executed work. This stressed a marked perception that payment is lower than what is considered reasonable for health workers and teachers responsible for training future SUS professionals.
It is necessary to emphasize that several alumni selected the option "unemployed" but said they had income, whereas some considered their graduate scholarships and the time dedicated to their graduate courses as the equivalent of a job, which limited analysis of satisfaction with current income among scholarship holders. Despite this limitation, it was found that for a subgroup of 17 alumni who referred to themselves as graduate students and scholarship holders, 12 (70.5%) reported dissatisfaction with their income and 15 (88.2%) declared that their remuneration was insufficient, taking into account their work effort.
Another interesting finding that may translate into numbers the context of the economic crisis in Brazil was the fact that the chances of having a salary lower than the mean were higher among alumni who graduated more recently (between 2014 and 2015) (p = 0.05). The data indicated a higher mean monthly income among those who graduated between 2010 and 2011 (p = 0.01), whereas the difference was not significant for the group of alumni who graduated between 2012 and 2013 (p = 0.63). It is important to emphasize that this finding may be a consequence of both the economic situation of the country and the possibility of career progression and increased remuneration that results from time working in the same job.
Regarding insertion into the job market, 58 respondents (56.3%) mentioned having experienced at least one difficulty. The main obstacles were: lack of practical experience (58 or 55.2%); lack of positions compatible with the profession in the city of residence (36 or 34.3%); perception of lack of qualification (15 or 14.3%); salary incompatible with the position (12 or 11.4%); and personal problems (5 or 4.8%).
Although 72 participants (69.9%) indicated insecurity in entering the job market, 84 (80.0%) judged that their course prepared them satisfactorily or very satisfactorily to work in health services, and 97 (92.4%) had the same opinion regarding training to develop teaching activities in nursing.
When asked whether their current job was their first, 70 answered negatively, which accounted for 69.3% of the valid answers. In the group of alumni whose time since graduation ranged from one to five years, 61 (58.1%) had already considered abandoning the profession for one or more reasons, which were indicated 143 times in the data: lack of acknowledgement and appreciation (42 or 40%); payment incompatible with the job (35 or 33.3%); exhaustion caused by excessive working hours (31 or 29.5%); nonexistence of career plans (25 or 23.8%); and new professional choices (10 or 9.5%). There was no relationship between gender (male or female) and intention of abandoning the profession (p = 0.55).
It was analyzed whether there would be a higher probability of considering abandoning the course among the participants whose monthly income was lower than the mean value calculated for the sample. This hypothesis was refuted statistically (p = 0.63), which reinforced the multifaceted nature of this phenomenon and will require in-depth analysis in future studies. The main reason to keep the job was the personal satisfaction achieved with the profession (68 or 64.8%), indicating the importance of institutional incentives to guarantee the permanence  of these workers in the mid to long term, especially if the impact of the actions of nurses and teachers on the structuring of SUS is taken into account. Among the alumni who had a monthly income lower than the mean of their peers, there was greater demand for lato sensu graduate courses (p = 0.03). For stricto sensu graduate courses and residence programs, this hypothesis was rejected (p = 0.09 and p = 0.48, respectively). It is necessary to consider that the motivations to join a graduate course in any area go beyond the financial aspect and are related to professional interests regarding career advancement, personal aspirations, and opportunities, which can be examined in further detail by future studies.
Regarding gender, four out of the five highest incomes (between R$ 5,500 and R$ 12,000) were male alumni's (40.0%). This result did not correspond to the gender distribution in the sample (9 women: 1 man). It is also important to take into account the existence of multiple jobs, which was reported by 60.0% of the respondents and equally prevalent among men and women (Figure 2).

DISCUSSION
Although most participants of the present study were inserted in the job market, in health services or high-school level technical professional education, they pointed out the difficulties encountered during their insertion process, with lack of experience and lack of job vacancies standing out. A Brazilian national study also showed that 78.9% of the consulted nurses faced problems in finding jobs, but that only 12.4% were unemployed (10) , numbers similar to those found in the present study.
Lack of experience has also been mentioned by nurses as a professional insertion difficulty in recent studies (10)(11) that showed results similar to those described in the present investigation, followed by low levels of job offers or reduced numbers of public offers. Consequently, there is an ongoing pattern of challenges experienced by nurses seeking professional insertion.
Although the alumni of the undergraduate course under discussion mentioned the professional insertion difficulty of not having experience, they also reported that they felt adequately prepared as nurses and teachers by their course. It was noteworthy that the nursing course in question has a curricular proposal that values coordination between theory and practice in many subjects, and insertion into settings of professional practice starting in the first year. The curriculum also provides for extracurricular internships at several health and education institutions. Therefore, it must be considered that the first professional experiences, construed as socialization processes, are challenges to be faced, which includes the need to continue training in the world of professional work, with the initial training received during the undergraduate course as a starting point.
In a study that addressed professional insertion of new teachers in basic education, it was mentioned that socialization processes imply searches, constructions, anxiety, choices, frustrations, and quitting, but also achievements and adherence to the profession (12) .
In the results, it is possible to highlight views of registered nurses about working conditions, encompassing, among other aspects, having multiple jobs and unsatisfactory salaries, characteristics that have been pointed out in other studies (7,13) .
According to a survey of the income of alumni of engineering and medicine undergraduate courses and those who got a degree in undergraduate courses oriented toward providing training for educational activities in several areas, there are considerable discrepancies in remuneration. In the cutout of courses with an intermediate score in the Brazilian National Student Performance Test (score 3 on a scale ranging from 1 to 5), the remuneration per working hour of newly graduated physicians was R$ 58.60 on average, with the value dropping to R$ 22.30 for newly graduated engineers and R$ 7.14 for new teachers (several fields of knowledge included). Assuming an average of 40 working hours per week for all analyzed categories, including nursing with the numbers found in the present study, the monthly income would be R$ 9,376 for physicians, R$ 3,568 for engineers, R$ 1,142 for teachers (several fields of knowledge included) (14) , and R$ 2,892 for registered nurses. Similarly, a study that aimed to understand the migration situation of nurses reported that the mean monthly income of these professionals in Brazil was R$ 2,341.17 (15) .
Working conditions, in addition to being related to the development of activities in health services, are connected to high-school level technical professional education in health technical schools, a scenario that shows some fragilities, especially in the private sector.
Most alumni who were teachers worked in the training of nursing technicians. Technical schools have become an expanding professional field for nurses who work in the education area. Nursing currently occupies the first place among professional education courses with the highest number of enrollments (5) .
Despite the qualified training available in the field of high-school level technical professional education, the working conditions faced by professionals when they enter the job market still fall short of what would be desirable and compel nurses to adopt education as a second or third job, as illustrated in the examined sample.
The reality of extended working hours has been reported in other studies focused on teaching in basic education (16)(17) , specifically on high-school level technical professional education in nursing (6) . This situation indicates the lack of appreciation of the work of basic education teachers in Brazil, especially regarding training of technical professionals This is connected to the historical-social structuring of high-school level technical professional education in the country.
Regarding salary differentiation by gender, discussion has been growing about power relations in the job market that place men as the main providers and women as complementary providers, which reinforces inequalities in the incomes reported in the present study. A similar result was found in a recent study carried out with Brazilian nurses (18) .
Considering that the workforce in nursing is mostly women, as it has been since the emergence of the profession, this social factor seems to play a role in the low remuneration of these professionals. The results of the present study reinforced that even when the nursing category is examined in isolation, differences between the income of men and women are found. This strengthens the hegemonic situation of the job market regarding gender, as shown in Figure 2. This scenario configures a gender relation.
The intention of abandoning the profession had a frequency of 60% among the consulted alumni. The reasons are multifaceted, and the main ones corroborated results of another Brazilian study: dissatisfaction with working conditions, employment bonds, and salary, and the resulting need to have more than one job (10) .
International studies have also shown the intention of abandoning the profession among newly graduated nurses. The cited motivations for that were, among others, work overload (especially over the five first years of professional work) (19)(20) , low level of satisfaction with the work environment, and low quality of the environment, including interprofessional relationships with colleagues (19) . One of these studies (20) , similar to the present one, indicated no relationship between risk of abandoning the profession and gender, a result corroborated by the data gathered in the present investigation.
The evasion aspect is worrying in many countries that are currently experiencing an increasing need for nursing activities, mainly because of population ageing and growth in health demands. Some examples are Canada and European countries (21)(22) . Brazil is becoming part of this group of countries, since the top of its demographic pyramid is widening, and the projection is that this phenomenon will remain steady over the coming years (23) .
In Brazil, the Work Management and Education in Health Policy, which is under the Ministry of Health, focuses on the participation of workers as an important dimension for SUS. This demands the guarantee of certain basic aspects if the appreciation of workers and their work is taken into account: positions, careers, and salary plans; employment bonds involving social protection; and perspectives on negotiation spaces at work, among others. These basic aspects received more attention between 2003 and 2015 by means of public policies that considered health and health workers as a public asset. At present, these aspects are being neglected, and essential rights are being threatened (24) .
A study of basic education new teachers (12) pointed out experiences marked by dissatisfaction and related to contradictions in the economic, institutional, pedagogical, relational, and social spheres. These contradictions are also present in the high-school level technical professional education modality, in which some of the alumni consulted in the present study developed their activities.
However, the participants also mentioned motivations to remain in the profession. The main one was the personal satisfaction experienced with being a nurse or teacher. Regarding teaching in high-school level technical professional education, 31.2% of the participants declared that they were satisfied. Therefore, the core of the problem continues to be low salaries, which are also found in health services.
It is important to emphasize the commitment of nurses and teachers to their social roles, indicating that they are aware of the impact of their work on society. A qualitative study with Brazilian and Portuguese nurses showed that the participants had strong bonds with the care delivered, the patients and their relatives, counterbalancing the alreadymentioned difficulties related to working conditions (25) . Regarding working as a teacher, taking into account the work process, it is noteworthy that, at the current stage of development of capitalism, the teaching profession is not as marked by pedagogical creation but by the alienation that is associated with the flexibility and precariousness of/in the work process (26) . This idea can probably be extended to the work of professionals in health services. That is, in work processes (those used in both nursing and education), there is tension between alienation and humanization, bringing professionals closer or moving them away from their work's meaning, beyond its function as livelihood. This phenomenon should be explored in future studies.
Therefore, despite the feelings of satisfaction expressed by some participants, professional insertion difficulties related to working conditions limit creative potential in the work of nurses and teachers. These professions are construed as oriented toward human development, and are consequently indispensable in coping with economic and social inequities and improving life conditions. In this context, public policies must implement effective initiatives to strengthen and support professional appreciation.
By considering the convergence between demands of society and their potential fulfillment and the strengthening of nursing and nursing education, the authors emphasize the need to increase the visibility of the profession in Brazil. Among other professions in higher education, the discrepancy in financial acknowledgment reflects the need for changes and the importance of actions such as Nursing Now, which was created in the heart of a time of global acknowledgment of nursing and its importance in consolidating health in the future (27) .
It is pertinent to consider that the United Nations 2030 Agenda includes targets (28) oriented toward promoting health to increase the life expectancy of all populations, and inclusive, equitable, and quality education, including technical and professional context. This would allow full participation in social life to meet the need to strengthen the social acknowledgment and appreciation of nursing and teaching in high-school level technical professional education.
Professional insertion of registered nurses has been occurring in health services, mainly in the public sector, as well as in high-school level technical professional education, mostly in the private segment. This insertion is characterized by conditions related to the current structuring of work in health services and technical schools.

CONCLUSION
A general overview of professional insertion and working conditions of registered nurses who are alumni of a nursing undergraduate course exposed social, political, and economic challenges. There has been progress in the training of this type of professional for the work world. However, in both health and education in the SUS context, after obtaining their degrees, alumni are faced with difficulties in inserting themselves professionally and getting incomes that are compatible with the efforts made routinely and the investment made in their studies at college. This needs to be related to the structuring of work in health services and high-school level technical professional education. That is, the double training to work as nurses and as teachers in technical schools faces challenges caused by current policies and health and education scenarios, which impose important limits on the appreciation of workers and the idea of construing health and education as public assets.
Therefore, although both activities show potential to develop actions oriented toward decreasing economic and social inequities and promoting quality of life, they are likely to end up being weakened when confronted with the issues that require multiple jobs, work overload, and unsatisfactory salaries.
It is concluded that it is necessary to make progress in the appreciation of registered nurses and high-school level technical professional education teachers, in order to clearly perceive positive impacts in health care in Brazil, considering the numeric relevance of this type of professional in the health and education systems and the nature of the profession's practice of providing care and education with transformative potential.
The present study contributed to a little-explored area, especially regarding nursing undergraduate courses. Its main limitation was being exclusively quantitative, which allowed some characterizations and analyses. Therefore, future studies with qualitative or mixed approaches could increase knowledge about alumni. The authors recommend the development of longitudinal studies with this population to monitor the trajectory of registered nurses in the work world over the years and its impact on the training of nursing technicians who will work at SUS and on the development of their activities in the health system.