The American Nurses of the Special Public Health Service and the Formation of Human Resources in Brazilian Nursing^*

ABSTRACT

Objective

To historicize the changes in training human resources in nursing in Brazil during the period from 1942 to 1961 based on the presence of 35 American nurses assigned to work in cooperation with Special Public Health Service.

Method

The sources used for the study were reports written by American nurses who described their impressions, suggestions, and the activities they carried out in the country. These were analyzed based on the discourse analysis of Michel Foucault.

Results

The period mentioned was marked by an American presence in nursing projects developed by the Special Public Health Service. The discourses indicated that the period was marked by many changes in Brazilian nursing, particularly with respect to attracting and training human resources for the profession.

Conclusion

The results indicate that the American nurses, through what they said and their influence, were central to the consolidation of a new paradigm in the training of nursing professionals in Brazil.

Nursing; History of Nursing; Nursing Staff; International Cooperation

RESUMO

Objetivo

Historicizar as mudanças na formação de recursos humanos em enfermagem no Brasil, no período de 1942 a 1961, a partir da presença de 35 enfermeiras americanas designadas para trabalhar em cooperação com o SESP.

Método

O estudo utilizou como fontes relatórios redigidos pelas enfermeiras, que descrevem suas impressões, sugestões e atividades desenvolvidas no país, e foram analisadas a partir da análise de discurso de Michel Foucault.

Resultados

O período mencionado foi marcado pela presença americana nos projetos de enfermagem desenvolvidos pelo Serviço Especial de Saúde Pública (SESP). Os discursos indicaram que o período foi marcado por muitas mudanças na enfermagem brasileira, em especial no que diz respeito à captação e formação de recursos humanos para a profissão.

Conclusão

Pode-se afirmar que elas, através de seus discursos e influência, foram centrais para a consolidação de um novo paradigma na formação de profissionais de enfermagem no Brasil.

Enfermagem; História da Enfermagem; Recursos Humanos de Enfermagem; Cooperação Internacional

RESUMEN

Objetivo

Recrear la historia de los cambios en la formación de recursos humanos en enfermería en Brasil, en el período de 1942 a 1961, a partir de la presencia de 35 enfermeras americanas que fueron destinadas a trabajar en cooperación con el SESP.

Método

El estudio utilizó como fuentes los informes escritos por dichas enfermeras las cuales reportaron sus impresiones, sugerencias y actividades desarrolladas en el país y fueron analizadas desde el análisis del discurso de Michel Foucault.

Resultados

el período mencionado estuvo marcado por la presencia americana en los proyectos de enfermería desarrollados por el Servicio Especial de Salud Pública (SESP). Los discursos indicaron que el período mencionado fue marcado por muchos cambios en la enfermería brasileña, en especial con respecto a la captación y formación de recursos humanos para la profesión.

Conclusión

Los resultados indican que las enfermeras americanas, a través de sus discursos y por medio de la influencia, fueron fundamentales para la consolidación de un nuevo paradigma en la formación de los profesionales de enfermería en Brasil.

Enfermería; Historia de la Enfermería; Recursos Humanos de Enfermería; Cooperación Internacional

INTRODUCTION

Research in human resources in nursing has been expanding in Brazil over the years and has appeared in specialized magazines since the 1980s, revealing themes about not only nursing education, but also other nursing categories such as technicians and aides, as well as nursing attendants, a residual category still present in some health institutions even though it has been abolished by current legislation(¹). However, it can be said that concern about human resources in nursing is older than the publications indicate. Since the beginning of professionalism in the country, Brazilian nursing leaders have exhibited concerns about issues related to the training of human resources in this area, particularly with regard to their technical-scientific and ethical-political formation.

Prior to the health reform in Brazil that was led by public health physician Carlos Chagas between 1920 and 1924, the country had a small number of nursing schools that were linked to hospitals and trained staff to work in the institutions themselves, seeking to address the shortage of human resources in health. This was the case for the Professional School of Nursing, which was created as an annex to the National Hospice for the Insane in the city of Rio de Janeiro by Decree 791 of 09/27/1890(²-³).

With the advancement of the public health movement, doctors from the National Department of Public Health realized that there was a need for qualified nursing professionals to work in tuberculosis services at the time, especially in the capital city of Rio de Janeiro(⁴).

In the midst of the social changes that were taking place in Brazil during the first decades of the 20th century, the work of the American nurse Ethel Parsons stands out. She was from the International Health Board, linked with the Rockefeller Foundation. As part of that action, a survey on the nursing situation in the country was carried out in 1921; it revealed that the existing schools did not meet a minimum standard, and that it would be necessary to adapt the North American system to give a boost to Brazilian nursing(²-³,⁵).

With 13 other American nurses, Parsons proposed the creation of a nursing service within the National Department of Public Health, which rose to prominence because it was the first nursing service in the world to be created at the federal level. In its early years it was directed by Ethel Parsons herself. This service sought to insert nursing graduates into the activities of the Department, also aiding with their training(⁴).

In addition to this service, the Nursing School of the National Department of Public Health was created in 1922, based on the Anglo-American model; today it is the Anna Nery Nursing School. The main objective of the school was to remedy the problem of a nurse shortage in the field of public health in Brazil by facilitating training and standardizing nursing education. This standardization gained momentum beginning in 1931 when Decree No. 20,109 took effect; it called for all of the country’s nursing schools to comply with the Anna Nery School standards for their diplomas to be legally recognized(⁴).

Within the context of the 1920s, health visitors were healthcare agents who worked with doctors from the public health department, especially with regard to home visit activities. According to Ethel Parsons, these women were unable to represent the health authority (of the doctors) due to their lack of preparation to deal with the health issues seen in home visits. Due to this lack of qualification of the home visitors, Parsons sought to justify replacing them with nurses. It is worth pointing out that, at that time, “health visitors” was the name given to 44 women employed in the public health department by doctors. Before they could do their jobs, they attended 12 meetings held by the doctors to foster better understanding of what would be expected of them. Participating in these meetings was the only requirement for them to be considered suitable to carry out health and hygiene activities in home visits(⁴).

Since the number of registered nurses was limited, Parsons proposed that an emergency six-month course be prepared to better instruct the visitors who were already employed. After a first evaluation of the course, it was decided that it should be extended to 10 months, with an emphasis on the idea that the training of health visitors should remedy the lack of professionals at that moment, and that these women should work under the supervision of nurses until they could be replaced by trained nurses. This replacement was completed in December 1926(⁴).

To stimulate interest in the profession, it was decided that the women who took the course for visitors would earn 10 months of credit if they chose to continue their studies to become nurses(⁴).

In the first decades of the 20th century, from a historical and social point of view, Brazil was considered a backward country compared to the rest of the world, particularly with regard to industrialization. Much of the population was living in poverty away from the cities and surviving by subsistence farming. In this context women had few options. They could get married and stay under their husband’s guardianship or pursue a certain amount of emancipation in the work world as teachers or health visitors, and then become nurses. The woman/nurse was a binomial that brought social and economic disrepute, considering the low wages paid to this category from the beginning of professionalism in this area(⁶-⁷).

The period mentioned became known as the Parsons Mission (1921-1931)(⁴) and it marked the beginning of the American influence on nursing in Brazil. This influence intensified in the 1940s and 1950s.

Two major political reasons can be highlighted for this influence. In the 1940s, the US government sought ties with the countries of Latin America. One reason for this was the need for raw materials such as rubber, and another was to defend itself from war, in this case World War II. Through the Good Neighbor Policy, health agreements were established with 20 Latin American countries(⁸).

Meanwhile, Brazil was being led by President Getúlio Vargas, who based his political actions on the ideals of the New State, seeking development based on industrialization and State intervention, seeking to centralize, standardize, and organize public policies for sanitation and health in order to give value to what was Brazilian. Vargas saw in the agreement proposed by the United States the possibility of sanitizing and developing the country(⁸).

This was because the health agreement was part of a US strategy of allying itself with the countries in Latin America. Under the agreement, the US began to explore Brazilian natural resources and send staff to the country specializing in the development of projects in the area of health within the Special Public Health Service(⁹).

In 1942, with the signing of the Bilateral Health Agreement between Brazil and the United States, Brazil began to receive specialized professionals, including American nurses, who were sent to the country by the Institute of Inter-American Affairs to work together on projects of the Special Public Health Service, the agency that was created in the same year as a requirement of the agreement. It had both administrative and financial autonomy, and received funds from the Institute and the Brazilian government to develop its activities(⁸). The objective of the projects was health education and professional training for doctors, nurses, health visitors, and others(⁸).

The purpose of this study was to assess the participation of the American nurses who were assigned to work in cooperation with the Public Health Service in Brazilian nursing schools and in projects developed by the Nursing Division during the period from 1942 to 1961. To this end, the aim of this research was to historicize and analyze the paradigm shifts in the formation of human resources in nursing in Brazil during this period. The intent was to understand how this American influence modified the training of human resources in nursing within the context studied, revealing the possible influences of these changes on nursing education up to the present day.

From this perspective, historical studies have the power to develop new ways of looking and thinking about social phenomena such as the field of education or the training of human resources in nursing, going beyond the events themselves and also examining how and when they happened and what influenced them(¹⁰).

The history of nursing reveals the training of its professionals, giving them the skills to deconstruct prejudices and myths, as well as expansion of the social role of nurses, consolidation of their actions, and legitimization of their professional identity, thereby opening up the possibility of understanding how understanding the roots of this profession can help in vocational training(¹¹).

METHOD

This was a historical-cultural study with a qualitative approach, evoking the memory of a group of women placed within a given sociopolitical context. We chose to work with cultural history because it concerns itself not only with the cultural objects or images produced, but also with the subjects who produce and receive the culture. It is interested in the subjects: their value systems, ways of life, social groups, conceptions of life, and the ideas spread among them⁽¹²⁾.

The study used document analysis, which consists of a set of techniques (guided by internal and external criticism) that provides the link between the data collected and the object proposed, extending the analysis based on the reading of a given historical process(¹³).

To this end, reports were collected that had been written in English and signed by the American nurses who were in Brazil, in which they reported their impressions, suggestions, criticisms, and the activities developed in the country. The reports described in the results were drawn from this pool of information.

The translation of the report sections presented here was initially done by the author of the study and subsequently validated by two other professionals, one with a Bachelor’s Degree in languages with a specialization and fluency in English, and the other a nursing professional with fluency in English.

Notes from the American nurses that had been published in newsletters of the agencies involved in the bilateral health agreement were also collected, as well as personal journals. These sources supported discussion of the findings.

The study is based on the genealogical analysis strategy proposed by Michel Foucault, whose trajectory requires three simultaneous steps: discursive practices, power strategies and techniques, and the forms of the subject’s relation with himself(¹⁴).

For Foucault, genealogy shows what is singular in events, seeking discontinuities, avoiding giving questions the same depth that they were given by the great thinkers, distancing the researchers from what they seek to analyze. For him, there are no hidden meanings that require interpretation(¹⁵). We opted for the discourse analysis of Michel Foucault to deal with the data because the historical analysis, in the view of this thinker, enables understanding not only the past, but also the present and, through them, the future.

Approval by a Research Ethics Committee was not necessary because only a strictly documentary research was required, whose sources were available at research centers and funds open to the public for consultation. However, the specific rules for each file and fund consulted were observed, thus complying with the standards they set with regard to the collection, storage, and dissemination of data.

RESULTS

The arrival of American nurses to Brazil was a joint effort of the Institute of Inter-American Affairs, the Special Public Health Service, and the Joint Committee on Inter-American Nursing, which was created in 1942 in order to provide advisory services in relation to cooperation with other American countries in the field of nursing. This Committee reaffirmed in its proposed activities the importance of promoting nurses in Latin America, who up to then had been viewed as unprepared professionals(¹⁶).

The Committee decided that to accomplish this, a few Latin American women should be educated in the US. And to remedy the lacks in the profession, a plan needed to be laid out to establish nursing schools in Latin America where young women would be trained who were well-qualified both academically and culturally(¹⁶).

In 1942, the American nurse Mary Elizabeth Tennant, a board member and nurse from the Rockefeller Foundation, came to Brazil to survey nursing conditions. Her survey indicated that the country had approximately 400 active nurses, which did not meet the health service needs at the time. Given this reality, creation of a central body of nursing was proposed; it became known as Nursing Division of the Special Public Health Service, and it would become responsible for various nursing projects around the country and for creating other nursing schools(¹⁷).

Thus, 35 American nurses were sent to Brazil. They were known as nurse advisors whose main objective was to assist the nursing schools and other projects of the Division, including the courses given to the health visitors, along with providing advisory services to hospitals and health centers and preparing candidates for scholarships abroad.

Much of the concern of the Americans, as presented in their reports, had to do with the training of human resources in nursing at both the higher education level and the technical level, as indicated below. The reports show that the Americans sought right from the beginning of their activities to modify the previous educational requirements for enrolling in nursing schools, since they thought that the requirements mandated by law were not sufficient for selecting good candidates.

It should be pointed out that these restrictions stemmed from Law No. 775 of August 6, 1949 regarding nursing education in the country; that led to other measures, as well as Decree No. 27.426 of 11/14/1949 approving the basic regulations for nursing courses and nursing aides. At the end of 1961, the enactment of Law No. 4024 of 12/20/1961 established the Guidelines and Bases of National Education.

This school has in the past accepted a number of students who had not completed the full secondary course. Sixteen applicants were registered for the March group but later it was decided, as a matter of policy, to accept only applicants who have completed the ‘ginásio’ or the normal course. This reduced the group to eight, which is a very small number, but it indicates that progress is being made to elevate the general educational level of the student body (¹⁸).

Another point noted in the reports of the American nurses refers to the issue of nursing education in Brazil. There was strong interest in strengthening the curriculum to specialize the teachers, and especially to extend the length of internships and opportunities for the students..

It is evident that action will soon have to be taken in order that the class scheduled to graduate in March 1948 may have the benefit of experience in the varied clinical services which a good school of nursing should have to offer(¹⁹).

Considering the lack of preparation of nurses in the specialty of psychiatry, which from day to day increases in importance in the field of medicine, we suggest that the schools of nursing provide for at least two months practice experience in a mental hospital, in addition to the usual theoretical instruction” (²⁰).

Below is another concern of the American nurses concerning the insertion of nursing in the Brazilian labor market, especially when it came to openings for nurses in state health services and the compensation given to the profession at the time.

The Brazilian committee was disturbed about the future which nursing presents to girls entering a school today. They felt that salaries were too limited and that ‘quadros’ in States and Federal Districts were too limited. Miss Hodgman suggested that States create large quadros (sic) and that it will be many years before they are able to be filled. She also has been suggesting that the Civil Service Status of the nurses be raised to higher levels, that hours of work for Public Health Nurses be increased, and that those nurses who teach and supervise in Schools be given higher rations than staff nurses(²¹).

In the following report it becomes clear that at that time there was a clash between the nursing categories, especially between nurses and health visitors since, as was pointed out earlier, the visitors were to be replaced with licensed nurses.

There has been much discussion about the health education program in Brazil and the use of subsidiary public health workers. It seems that the terms ‘Visitadoras’ and ‘Educadoras’ are used loosely and interchangeably. It appears that people are discussing two types of visitadoras one who does nothing but talk and the other who is trained to perform some nursing techniques. (…) we find the ‘visitadora’ used in the North of Brazil – an example of the ‘modified public health nurse.’ There should be clarification of these terms and the jobs these people are expected to do in a limited program. They should be kept within the confines of these definitions just as the Public Health Nurse is expected to keep within hers (²²).

Finally, the reports show that Brazilian nursing was taking a path to undertake different activities beyond the field of patient care in hospitals and primary health. This concerned the Americans, since at that time the profession still had a small number of trained nurses trained in the country.

In conclusion may I say that this attempt to care for Industrial Disasters, under graduate nurses is a step in the right direction. But how Brasil (sic) can manage to arrange for graduate nurses in the many new activities open to them, I don’t know. Several years of large graduating classes will be needed, and by that time, there will be many more avenues open to them(²³).

DISCUSSION

The standard criteria required that candidates admitted to Brazilian nursing schools have a high school diploma or be approved by a selection test before they could enter(⁴). The reports of the American nurses reflect their efforts to try to raise the educational level of the candidates in the nursing schools. However, reports also made it clear that the country’s educational realities hampered these efforts, forcing schools to make concessions in relation to the educational level of their candidates or open classes with a very small number of students. So one of the main functions of the cooperation was impaired, which was to increase the number of qualified personnel in health. In the case of nursing, it was to increase the number of licensed nurses.

However, there was resistance, especially from the directors of nursing schools, to requiring a higher level of education of candidates for nursing courses. It was feared that the career was not attractive enough, due to low wages and working conditions, to interest middle-class women with high-school educations and the financial resources to take the courses(²⁴).

The reduced number of professionals available could be solved in two ways: increase the number of schools in the country, but according to the author, that would not be possible because of the low number of trained human resources to fill the positions of teachers; or fragment the profession with the insertion of the position of nursing aide, regulated by Law no. 775 of 1949(²⁵).

Regarding the nursing curriculum in Brazil, one of the main contributions of an American nurse during the period is reflected in comment about the discipline of psychiatric nursing. This pioneering spirit is assigned to Ella Hasenjaeger who, early in her role as advisor to the USP School of Nursing, set up at the Central Hospital of Juqueri in São Paulo an internship for students in the specialization of psychiatry. Hasenjaeger was also initially responsible for teaching the theory of this discipline(²⁶).

A membership system was created at the time so that all students in training could get experience in different specializations. This system allowed students from different nursing schools around the country to do internships in areas that were not offered by their home schools at other institutions such as at the USP Nursing School and at the Anna Nery School of Nursing, which offered internships for all the specializations listed on their resumes(⁵). This allowed expanding knowledge in nursing so as to prepare students to work in the various fields of health.

The fact that some subjects were taught by doctors also concerned the American advisors, for two distinct reasons. First, there was a shortage of nurses to work in all the fields of the profession, including education. Second, the curricula at the time included newer disciplines that the licensed nurses at the time were not prepared to teach. Therefore, training was also sought to strengthen trained nurses so that they could take on the teaching of their profession and be able to better prepare new students, allowing the profession to gain greater legitimacy and scientific backing, along with other already consolidated professions.

Another evident concern was in regard to the number of job openings for the profession. With nursing gaining ground and becoming more specialized, it was necessary to educate other professionals and the public at large about the work and importance of nurses on health teams. To do this, nursing sought its place by using the Brazilian Association of Graduate Nurses, today the Brazilian Nursing Association, to fight for this space in both the public health and in hospitals.

In addition to efforts to strengthen the training of nurses, the Americans were concerned about attracting human resources to nursing. To this end, the nursing schools, with support from the Special Public Health Service, invested in advertising to promote both the schools and the opportunities that nursing could offer to women at the time, and publicize nursing as an established profession(²⁷).

As previously noted, the Public Health Service had other projects to train human resources in nursing, among which were courses for health visitors, hospital assistants, and to train the “curious,” the name given to midwives of the time who had no formal education. The American nurses also served as advisors in these areas, and often even taught these courses despite their difficulty in understanding Portuguese.

The course for the health visitors was to train staff to work at the health clinics that were being funded by the Public Health Service. Initially, both the creation of the positions and the implementation of the courses for the visitors took place in the Amazon Program(²⁸).

These courses especially benefited the north and northeast regions of the country; the Special Public Health Service realized early on in the activities of the Amazon Program that there was a lack of trained personnel to carry out visits in the homes of the region to spread to the population basic concepts of hygiene and sanitation. The visitors were envisioned not only as remedying the lack of personnel to carry out home visits, but also as working through aspects of hygiene within the family circle(²⁸).

The courses for the health visitors were taught over a six-month period, with only one month fully dedicated to supervised internships in health clinics. The selection of candidates focused on young women 16 to 28 years old, preferably single or widowed, who had finished junior high school and passed Portuguese and math tests given at the time of the their admission. Those interested who were married could only attend the course by presenting their husband’s consent, and all candidates had to be able to purchase the materials required for the course and stay in the boarding school during the course period(⁸,²⁸).

The need to create new courses and nursing categories was also related to the displacement of the activities of nurses, which became predominant in management and supervision, and involved the training of other professionals at the expense of direct patient care. One reason for this change may have been related to a shortage of nursing staff to work in health care services and the long period for training nurses. Another explanation may be associated with the training of head nurses, a topic widely discussed in nursing publications, especially in articles written by the American nurses who worked in Brazil, and discussed in the Nursing Congress, as was the case at the First National Congress(²⁹). With this paradigm shift within nursing, nurses took on a prominent place of on nursing teams(²⁹).

Although considered a successful strategy, the training of health visitors and other subsidized public health agents, as they were called, presented conflicts. There was difficulty, especially in the general populace, understanding the differences between the categories and their roles, which continues to be experienced up to the present by nursing professionals.

It becomes clear from this study, however, that there was great concern in relation to human resources in nursing. This became more evident when, with the support of the Rockefeller and Kellogg Foundations and the Pan-American Sanitation Workshop, a survey was begun entitled “Survey of Nursing Resources and Needs in Brazil,” which was conducted between 1956 and 1958 in order to identify the human resources available in nursing in Brazil(⁵,³⁰).

The study was divided into five parts: active and inactive nurses; hospital nursing; public health nursing; nursing schools and nursing aide courses; and nursing schools. It described the nursing scenario at the time. The study also detailed its methodology and it is considered a landmark in Brazilian nursing research(⁵,³⁰).

The results were published as mimeographed copies in English only in 1960 with cooperation from Special Public Health Service. This publication included some results of the study and recommendations made during the 11th National Nursing Congress in Recife in October 1958, which is where the data was discussed(⁵). In 1963, the Rockefeller Foundation published a book, Survey of Needs and Resources of Nursing in Brazil , containing the final report on the study. National publication occurred only in 1980 and was carried out by the Brazilian Nursing Association(³⁰).

This study brought about a rethinking of the profession and sparked an interest on the part of some authorities of setting up the Nursing Association as the main forum for dialogue with the Ministry of Education on matters related to nursing and nursing education. As a corollary to this process, a national campaign was promoted to recruit candidates, promote the profession, and provide discussions and changes in the curricula of schools of nursing, and assisting them in the replacement of the category of nursing aides with that of nursing attendants(⁵).

CONCLUSION

The period studied was marked by many changes in the field of nursing in Brazil, especially as regards the training of human resources in nursing. It can be observed that in addition to increasing the number of nursing schools across the country, the curriculum and nursing standards to be followed were also changed, strengthening the profession.

Moreover, this time was also marked by concerns about raising nursing to the level of a respected, recognized, and independent profession; a search for new candidates who were better educated and prepared to fight for better wages and working conditions; and efforts to clarify to health teams and the populace the importance of nursing professionals for carrying out health practices.

This was possible due to a focus on human resources training for the profession; once better prepared, they could be inserted in the different spheres of health, which also underwent changes during the period, taking on a more caring and hospital-centered character.

The influence of the American nurses was undeniable. They had been given nursing knowledge that was legitimized in their country of origin and in the structure of nursing services and schools, allowing them to make achievements in various spaces to advance the profession.

However, it is not possible to determine which of these suggestions and changes were in fact the fruit of the beliefs and values of the American nurses and which were influenced by the politics of the time or by prior discussions with Brazilian nurses. It is difficult to discern their personal motivations when taking into consideration the political context in which they were inserted and the influence of this context on the relationship between Brazil and the United States, particularly with regard to their actions with the Special Public Health service, In the Brazilian Nursing Association, and in nursing schools throughout the country.

It is worth noting that studying the history of a profession, nursing in this case, not only allows us to recount the events of the past, but also to rethink the present and plan for the future.

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Publication Dates

• Publication in this collection
  Dec 2015

History

• Received
  30 Nov 2014
• Accepted
  21 May 2015