The mobilization of nurses for the non-interruption of nursing residence

Objective: To analyze the strategies employed by nurses to maintain the nursing residence program at the Ophir Loyola Hospital and discuss the potential effects of this interruption on the state of Pará. Method: Social-historic research. Data were collected through primary sources, written documents, and oral testimonial; the secondary sources used were manuals and articles that approached the topic in question. The theoretical reference was based on the French sociologist Pierre Bourdieu’s ideas about the concepts of cultural, social, and symbolic capital, in addition to the habitus and fi eld concepts. Results: During the nurses’ mobilization there was a strong political infl uence on the development of the crisis and the interruption of the nursing residence Program at the Ophir Loyola Hospital, with implications for the nurses’ qualifi cations and the health care delivered to the societyof Pará. Conclusion: The analysis showed the prevalence of partisan political interests at the expense of social interests, culminating in the interruption of the nursing residency.


INTRODUCTION
Pará is the second largest Brazilian state in terms of territory.The capital is Belém, which is located in the Amazon metropolitan region, with about 1.8 million inhabitants, and is the second most populated city in the North (1) region of Brazil.
Health services in the state of Pará are not different from the remainder of the Brazilian North region.The health system is mainly public and comprises high and medium complexity hospitals (2) .However, it is insufficient to meet the demands of the population that longs for solutions to their health problems, from the most complex to the simplest ones (3) .
To that one should add the increasing complexity of health care allied to scientific and technological advances.This situation demands professional qualification (3) to make care practice in Pará comprise the technical and therapeutic possibilities available in the country and worldwide (4) , matching services offer to the care provided at the three health care levels.
However, despite the natural richness of Brazil, the territory is also marked by social conflicts, with highly capitalized agriculture that leads to increased intra-regional migrations of people seeking better working conditions (4) .All of this has contributed to the uncontrolled occupation of urban spaces that lack basic sanitation and increase poverty.This phenomenon is mainly observed in great metropolises such as Manaus and Belém do Pará, and is responsible, to a great extent, for the persistence of socio-political, economic, cultural, and sanitary imbalances in the region (5) .
Considering the relevance of the aspects approached and their correlation with the nurturing of well-trained professionals willing to work in the region, we should make reference to the much-needed continuity of a socio-economic and sanitary policy mainly focused on the fields of education and health.This need raises concerns regarding the continuity of nursing residence programs as an important way of health professional qualification in the state of Pará.
Nursing residence as a latu sensu post-graduation education modality for nurses emerged as a possibility of qualifying them to meet demands in the State of Pará.Nursing residence ensures the development of technical-scientific and ethical competencies resulting from on-the-job training that contribute to more qualified care and civic services (6) .
However, the rise of a new political group in the state led to a crisis that culminated in 2007 with the interruption of the nursing residence program at the Ophir Loyola Hospital (OLH), which was under the academic coordination of the Pará State University Nursing Course.The investment by nurses was not enough to ensure the expansion of nursing residences in that hospital, which is a reference for high-complexity treatments in the region.
In the face of this, this study has the following objectives: to analyze the strategies employed by nurses to maintain the nursing residence program in the Ophir Loyola Hospital; and to discuss the effects on the state of Pará resulting from interrupting the nursing residence program in that hospital.
The social relevance of this study lies in the possibility of disseminating the scientific production about the history of nursing in Pará, notably the mobilization of nurses for the noninterruption of nursing residence at the Ophir Loyola hospital.The rationale is based both on the pertinence of discussing the limits, on the possibilities brought by the actions performed by nursing professionals and the Pará state authorities, and on the recovery and appraisal of valuable oral sources.

METHOD
The time excerpt comprises the years between 2005 to 2007.In that period, political changes replaced the Pará State government leadership that ended up by closing the admittance of nurses for residence in the OLH.
As a theoretical reference, the study was based on the French sociologist Pierre Bourdieu's ideas about the concepts of cultural, social, and symbolic capital, in addition to the concepts of habitus and field.Bordieu's primary argument is that social practices are structured, that is, present the typical properties of the social status of those producing them.These practices are expressed through the habitus, which translates the intrinsic and relational characteristics of one's unique lifestyle, that is, in a unique set of decisions, goods and practices (7) .It works as a set of distinctive traits and differential separations that are part of a mythical-ritual system symbolizing individuals in social spaces.
In this study the OLH, formerly the Hospital dos Servidores do Estado, stands for the social space where the dialectic links between agents (physicians, physiotherapists, psychologists, social assistants, nursing technicians, and other health team members) and the space structures are built.
The study's primary sources were obtained from seven nurses, among whom were one representative of professional class association (D1); two former students of the nursing residence (D2, D3); one who worked as a manager (D4); and two worked as teachers (D5, D6).These agents were included in the program because they participated in the OLH nursing residence from 1998 to 2007.The remaining members of the health team were excluded because they had no direct or indirect participation in the process.Subjects were identified with the respondent name, followed by the ordinal number, according to the use of interviews in the text.
Data were collected through semi-structured interview supported by an open-question script that allowed for speaking about the topic, having in mind the question asked (8) .Interviews were carried out from October 2009 to March 2010, having as the main question: "How do nurses organize in the face of the potential disruption of the nursing residence in the Ophir Loyola Hospital?"The date, time, and place were previously booked with the respondents that signed the Free and Informed Consent Form.
The secondary sources comprised articles, theses, dissertations, and books that supported the analysis of data obtained from the primary sources, making up the documentary corpus.These sources were found in public and virtual libraries such as the Dr. Orlando Costa Library; the Pará State Public Health Virtual Library; the Master's Degree Thesis and Dissertation Digital Library of the Pará State University (EPA); and the Paulo Freire Library-Social Sciences and Education Center-Campus I-UEPA.
As prescribed by the historical method, the study comprised three essential stages: data survey; critical analysis; and conclusions.After the stage of selection and classification of documentary sources, we analyzed the quality and relevance of that information to the historiographical work proposed.This process of validating sources is known as external criticism and internal criticism (8) .
The data analysis stage considered the set of political and social facts with which to construe historical data, allowing for an historical presentation based on the documents selected.
It is worth mentioning that, in compliance with Resolution 196/96 of the National Health Council, the study was submitted to the Committee of Ethics in Research of the Anna Nery Nursing School/São Francisco de Assis School Hospital and approved through protocol 087/2009 of November 30, 2009.

RESULTS
The Nurses' Fight to Maintain the Nursing Residence in the OLH On January 1, 2007 Pará State Governor Ana Júlia Carepa (Partido dos Trabalhadores-PT) took office, replacing Governor Simão Robson Jatene (PSDB).
The transition to the new state government led to several political arrangements involving public trust offices at different state levels, as the previous administration was headed by an opposition party.New agents took the field, replacing managers of several health units.
This was also true with the OLH, where General Director Nilo Alves de Almeida was replaced by the physician Laura de Nazareth de Azevedo Rossetti.As a result, many officers in charge of different services were replaced as well.At the heart of these internal rearrangements in the OLH Education and Research Board (DEP), Luís Cláudio Chaves, an OLH physician and UEPA professor, was replaced by Acácio Augusto Centeno Neto, who was also an OLH physician and UEPA professor.
In the same period, more precisely on January 24, 2007, Pará State University Dean Fernando Antônio Colares Palácios submitted letter #45 GAB/UEPA to the new OLH Board, whereby he informed the board of the impossibility of sustaining the financial execution of the agreement between the UEPA and the hospital, which was crucial to keeping the nursing residence.The argument employed was based on the recurrent questioning by the State Court of Auditors about what it considered to be double payment of services linked with the state, as some UEPA professors also belonged to the OLH staff.The dean posed his concern about the maintenance of the agreement terms, as this could lead to serious institutional and personal disruptions, including those involving reimbursement to the government treasury.
The solution found by the DEP/OLH director was to suspend all nursing residence-related activities that could entail expenses to the hospital.The impossibility of sustaining the residence was the object of deep discussions involving the DEP-OLH director, the head of the OLH Education Division, the nurse Zandra da Silva e Mota, and the remaining coordinators.
Thus, on August 29, 2007 the nurse Zandra da Silva e Mota, offended by the discussion, submitted a memorandum to the physician Laura de Nazareth de Azevedo Rossetti, the OLH General Director, whereby the nurse asked the OLH to start an auditing process on what she considered to be insults directed toward her by the DEP-OLH director.On September 2007 that culminated with Zandra's discharge from her office as the Education Division Head.
To cope with the aforementioned conflicts, the resident nurses mobilized to seek support on different fronts such as the Regional Nursing Council (COREn), the Prosecutor's Office, and the Pará State University.The following testimonials illustrate this: The discussion about nursing residence started with some residents who resourced to the COREn to express their dissatisfaction with the path of the Nursing Specialization Course in the Residence Modality, […] this cry for help started with the resident nurses and ended up by affecting the Institution.(D1)

[...], by the time the residents gathered, everyone was angry […] and some students joined [them] and went to the COREn. (D2)
Moreover, among other implications, it is worth emphasizing that the change in the board membership was dreaded.There are evident disagreements between those dealing with education and research in that institution, notably regarding the development of the nursing residence:

Impact of the OLH Nursing Residence Interruption on the State of Pará
When the new state government decided not to prioritize nursing residences, it put at risk the continuity of the project in the hospital.This had a strong impact on the people leading the process such as coordinators, teachers, former nursing residents, professional class entity representatives, and the society of Pará at large.
[...] The blow was in the care provided to our oncology patients.Because by the time of the Residence we were really compelled to study; like it or not we had to build our capacities.I believe there were significant losses for care in detriment to the cessation of the Residence Program.(D5) [...] it was really painful when we saw we had gone back in time, this sad feeling of having lost something extremely valuable […].That not to mention the damages related to the lack of specialized human resources to work in the state strategic areas, where the presence of those professionals is increasingly demanded.(D6) As can be inferred from the testimonials above, many participants in the study mentioned that the nursing residence programs' suspension was mainly for political-partisan reasons, with countless implications, mainly to Pará society's health.
To show the impact of this context on Pará State's health, we have consulted the Caderno de Informações em Saúde Publicado of July 2007, published by the Ministry of Health.The document clearly shows that Pará State accounts for 25.7% of the deaths from undefined causes in the Legal Amazon region, disclosing failures in the completion of death certificates and poor medical care resources.
If we consider only the nine states comprised by the Legal Amazon region, we will see that Pará state has very disturbing health indicators that place the state in a disadvantaged position in the region.As main diseases related to this we can mention: respiratory tract diseases (second place); infections in the perinatal period (second place); malaria (second place); infectious and parasitic diseases (third place); Hansen's disease (fifth place); external causes (sixth place); and neoplasias (seventh place).The nurses participating in the nursing residence project used to study some of those health conditions.
These indicators disclosed the critical health status in the state of Pará.Disregarding these means contributing to their persistence.The nursing residence interruption contributed to the shortage of specialized nursing human resources to cope with complex health issues in the state.

DISCUSSION
The OLH nursing residence continuity was at risk.By means of a letter, the Pará State University Dean recommended the OLH to adopt alternatives to the financial execution of the nursing residence as happened with other bodies, by celebrating agreements with similar foundations or institutions, but keeping partnerships of an academic nature (9)(10) .
In the view of the professionals engaged with the nursing residence project, the crisis was more strongly influenced by ideological and partisan issues than by reasons related to the residence course itself.They believed it was partially due to the lack of appreciation of the nursing residence by the group that took on decision-making offices in the OLH administration.
In this study, the OLH, which is the setting for the nursing residence, is a scientific field that represents a field of powers and, thus, a social space of struggles between agents to conserve it or change it (11) .Then, the protesters join forces and define their strategies of fight to roll back an advanced movement to cease the nursing residence in that institution.
Nursing was obstinate and adopted important strategies that strongly contributed to the "qualification of nurses, considering among other aspects the strengthening of professional identity; the political expression of knowledge through the coordination of professional and their insertion in several civil society movements [...]" (12) .
It is worth mentioning that in public or private administration the change of holders of institutional power is followed by changes in administrative actions.This can bring about a problem known as discontinuity of planning and one of institutional policy.This phenomenon becomes even more important when it is added to political-partisan fights, even more when it means the rupture of a model that has been deeply contested for a long time.To be successful, one must be careful when submitting political projects and filling the so-called public trust offices.
This care, however, should be based on specific criteria, because it could restrain the administrative flow and, thus, jeopardize the work of the different public administration sectors, including some activities that are crucial for social well-being.Despite the different understandings about growth exclusively associated with economic aspects and development associated with growth committed to social aspects, today this last has "multiple and differentiated" dimensions.This reinforces our view about the complexity involved in dealing with this matter (13) .
Social interest should count on actions capable of meeting the demand of vulnerable groups, going beyond superficial measures for political-partisan purposes (14) .This way, it can effectively contribute to producing real effects on the social area, mainly in the field of health, where the scientific discourse is sometimes disregarded.Neglecting the damage caused by political actions, losing sight of the potential direct or indirect impacts on the nursing care delivered to the society of Pará, would not be wise.
The strong political-partisan bias that would have spillover effects on the future of the nursing residence in the state of Pará caused impacts, notably on the health of the society of Pará.This meant denying "thinking [of] the building of citizenship and political subjects in the process of teaching health care based on the education process" (15) .This way of thinking comprises macro-structural and micro-structural spaces that influence both the health and the educational worlds.
Health indicators for the state of Pará were considered disturbing, including the categories of respiratory tract diseases, external causes, and neoplasias (16) .These health conditions were the objects of study of nurses in the OLH nursing residence project.
Likewise, data also showed that the population epidemiological profile was marked by the overlapping of indicators of different natures.On the one hand, among the causes of death, non-transmissible chronic diseases and health disorders such as external causes, typical of the epidemiological transition and the increasing urbanization process prevailed.On the other hand, it reveals diseases resulting from poor living conditions and limited access to preventive and control measures and to health services (17) .
That is the social context where the crisis regarding the maintenance of nursing residence came about.The professionals engaged in the creation of the nursing residence knew the health epidemiologic indicators in the state of Pará and in the North region of Brazil, which enabled them to envisage the medium-term impact of the nursing residence cessation in the OLH, justifying their feeling of rejection.
Moreover, the nursing residence interruption would put an end to the possibility of updating the professional habitus of the newly graduated nurses, as it limited the expansion of theoretical-practical knowledge based on regional epidemiological indicators.The specialization of newly graduated nurses would then be restricted to financing a limited number of specialization courses in the state.Yet these would serve much more to incorporate theoretical knowledge than practical skills in some fields of knowledge.
Therefore, it is worth mentioning that the insertion of new agents into the OLH board and the education and research board unveiled a game of power where political capital played a decisive role in the nursing residence interruption, opening a gap in the specialization of nurse professionals in the state of Pará.
The symbolic power enunciated by the newly appointed leaders to the OLH main offices prevailed over the remaining agents in the institution, mainly those involved with the residence project.That happened upon the imposition of a new order to the holders of the legitimate symbolic violence represented by the new OLH leaders.In this game, gestures and words were used as symbolic tools to extort recognition from those who did not hold power positions in the same space.That was so because the bywords had the power to maintain or subvert the order thanks to the belief in the legitimacy of the manifestations of those uttering them, that is, who speaks and from where they speak (7) .
The official appointment of public authorities is favored by the collective power, consensus, common sense, because it is done through a state representative and, as such, is a holder of legitimate symbolic violence.This way, the appointed officer can influence or set internal policies capable of interruption political actions such as the nursing residence project that are highly relevant to the resident nurses, teachers, and representatives of the professional class entity, among others (7) .
On the other hand, one should not disregard the fact that interrupting the possibility of qualifying nurses implied preventing that group from having access to a professional title that, in the social perception, would be a right.Such title serves as a social distinction that entails other kinds of symbolic gains (7) .This aspect partially explains the objection of those who had a lot to lose with the interruption of that course.In a different light, the group reaction could also be explained by the awareness built during the nursing residence about what social policy consists of, as it was not limited to help, mercy, or voluntary work.It was a social process through which "individuals in need could manage the political awareness about their needs."Because of that, they emerged as subjects of their own destinies, having their own organized work as a crucial condition to cope with inequality.The "emancipating social policy" is that where the organized citizenship of stakeholders is built, where subjects are co-participants and co-decision makers (13) .
The discontinuity of political projects in Pará, mainly those of a social nature, could worsen the critical scenario in the state.The health indicators for 2007 show that the main causes of mortality among the circulatory system diseases were: cerebrovascular accident; myocardial infarct; high blood pressure; congestive heart failure; and intra-cerebral hemorrhage.
All of these conditions demand highly specialized treatment intervention and rehabilitation units of high technological complexity and high financial cost.Once again is evidenced the need for trained professionals with scientific knowledge and technical skills soundly incorporated during their academic life.
To that we should add that the circulatory system diseases mainly affect the population in older age groups.Because of this, we should consider the aging population in Brazil, which is expected to be ranked the sixth largest elderly population in the world as of 2025.This phenomenon brings important changes to the society that can worsen in the future and have impact on the economy, the labor market, and the health system, demanding the adoption of social policies responsive to the demands resulting from population aging (18) .Some measures have been adopted in this sense, such as the National Elderly Policy governed by law 8842 of January 04, 1994 Chapter IV, Article 10, which provides for health care to this population group, and the Elderly Statute, Law 10741, of October 1, 2003 which prescribes guidelines on care aimed at prevention and maintenance of health in that same group.
Other concerns involve public policies such as, for example, regarding the increased rate of cardiovascular diseases that cause more than 40% of deaths in Brazil.In less than 40 years Brazil moved from a mortality profile typical to a young population to a profile characterized by complex and more expensive diseases associated with older age groups (19) .
We can also include neoplasias in the context of degenerative chronic diseases.To better understand the magnitude of this pathology, we have emphasized some aspects approached in an event held between March 12 to 13, 2009 in the city of Rio de Janeiro: the 2005 Neoplasias Notice Final Evaluation Seminar supported by the Science and Technology Department (DECIT).On that occasion the representative of the INCA Prevention and Surveillance Coordination, Cláudio Noronha, provided relevant clarifications about epidemiological data for cancer in Brazil, presenting estimates, incidence, and mortality from the disease.According to him, Brazil is considered a country of medium to high cancer incidence.In 2008 alone, for example, 352 new cases were registered in the country, and the most developed cities reported the highest rates (19) .
These indicators reinforce the enormity of the challenge of coordinating public policies in all areas and the changes in the demographic profile of the Brazilian population and its effects, notably, on the health of the elderly.
This is yet another argument to reinforce the huge drawback that interrupting nursing residence would mean, because it qualified nurses to work in this specialty at a hospital that is a reference of oncology care in the North and Northeast regions of Brazil.
Another mortality indicator in the state of Pará referred to external causes.In an article published in the O Liberal newspaper in February 25, 2011, entitled "Pará is ranked fourth in terms of violence in Brazil," the journalist Thiago Vilarins describes the Brazilian map of violence.Supported by data from the Ministry of Justice, the article shows that the Belém Metropolitan Region recorded 97 homicides per month; that is, a rate of 47 homicides for each 100,000 inhabitants.An in-depth analysis of the information found that among the six most violent cities in Brazil, three are in the state of Pará (Itupiranga, first place; Marabá, fourth place; and Goianésia do Pará, sixth place) placing the state as the fourth most violent in the country (20) .
These indicators should be considered in the analysis of the causes of death in Brazil, mainly because in some areas or regions violence has become a general phenomenon, mainly affecting male youth and young adults (15 to 39 years of age) (19) .
The aforementioned clearly supports the importance of maintaining a nursing residence in Pará.Disregarding these indicators is evidence of the prevalence of political interests in detriment to the social interest of that population.

FINAL CONSIDERATIONS
Despite the investments made in the last years, the North region of Brazil still needs measures to hasten its development.
Here we would emphasize increasing technical-scientific elements in the training of health human resources, where residence courses stand out as an efficient strategy.
The nursing residence created in the Ophir Loyola Hospital was a great achievement for nursing, as it provided nurses in Pará with an additional training level, giving them the opportunity to acquire a specialization that is already consolidated in other regions of Brazil.
The impact of disrupting the OLH nursing residence on health care is evident when we correlate the health needs in Pará and the need for in locu professional qualification, considering regional specificities that interfere in the population health-disease process.
The democratic political movement should try to provide continuity to social development based on the maintenance, transformation, and improvement of projects implemented by previous administrations.These historic facts involving the OLH nursing residence presented herein make us think about the political movements that promote rupture and cause damages to the population, as these hinder progress in the nurturing of health human resources.
The health picture in the Amazonian region shows sharp inequalities resulting from a historic, economic, and social process with strong impacts on its forestry resources, culminating in an epidemiological situation where we observe the increase of endemic infectious-parasitic diseases and other diseases considered to be eradicated: yellow fever; dengue; and leishmaniosis.Moreover, the advance of mining activities favored the emergence of occupational diseases with important clinical manifestations.Because of all that, disregarding the importance of nursing residence at the OLH for politicalpartisan reasons also means neglecting the social, sanitary, and epidemiological context typical of the North region of Brazil, notably in the State of Pará.
Interruption [...] was due to political issues.[...] it was the change of government, change of party, then came another Director to the hospital who had a critical view about Residence, so these political issues had negative influence on the area of health.(D3) [...] I believe there was a lack of commitment, lack of commitment by managers, lack of political commitment with the cause, and it is really a pit to see it, because Residence courses were not the only ones abolished […].(D4)