From stolen autonomy to the strengthening of the profession: connections between the Brazilian and African Nursing

Abstract

Aim

to characterize the challenges experienced by nurses in Portuguese-speaking African countries and discuss the potential of international cooperation in this context.

Method

qualitative and descriptive study. Data were collected through semi-structured interviews with nurses from Portuguese-speaking African countries and categorized through content analysis.

Results

nine nurses participated in the study. They were from the following countries: Angola, Cape Verde, Guinea Bissau, Mozambique and San Tome and Príncipe. Two categories emerged from the results, one focusing on the difficulties of Nursing in Portuguese-speaking African countries regarding the autonomy and appreciation necessary for the development and exercise of its competences. The second evidenced possibilities of connections based on networks for the integration and strengthening of Nursing, through international cooperation.

Conclusion and implications for practice

the study characterized as main difficulties the ones related to the work process, lack of autonomy, of human and physical structure. Therefore, international cooperation emerged as an important strategy for the capacity building of nurses from Portuguese-speaking African countries, as well as to deal with the huge challenges faced by nurses in their daily activities.

Keywords:
International Cooperation; Community of Portuguese-speaking countries; Nursing, Professional Autonomy; Human Resources, Nursing

Resumo

Objetivo

caracterizar os desafios vivenciados pela Enfermagem nos países africanos de língua portuguesa e discutir as potencialidades da cooperação internacional neste contexto.

Método

estudo qualitativo, descritivo. Dados obtidos por meio de entrevista semiestruturada com enfermeiros de países africanos de língua portuguesa e categorizados por análise de conteúdo.

Resultados

participaram nove enfermeiros, provenientes dos seguintes países: Angola, Cabo Verde, Guiné-Bissau, Moçambique e São Tomé e Príncipe. Foram desenvolvidas duas categorias: a primeira retrata as dificuldades da Enfermagem de países africanos de língua portuguesa acerca da autonomia e valorização necessárias ao desenvolvimento e exercício de suas competências. A segunda categoria evidenciou possibilidades de conexões a partir de redes para integração e fortalecimento da Enfermagem, em cooperação internacional.

Conclusão e implicações para a prática

o estudo caracterizou como principais dificuldades aquelas relacionadas a processos de trabalho, falta de autonomia, de estrutura humana e física. Nessa perspectiva, a cooperação internacional representou importante estratégia para o fortalecimento da formação dos enfermeiros de países africanos de língua portuguesa, assim como para lidarem com os expressivos desafios que se apresentam em sua prática cotidiana.

Palavras-chave:
Cooperação Internacional; Comunidade dos Países de Língua Portuguesa; Enfermagem, Autonomia Profissional; Recursos Humanos, Enfermagem

Resumen

Objetivo

caracterizar los retos vivenciados por la Enfermería en los países africanos de lengua portuguesa y discutir las potencialidades de la cooperación internacional en este contexto.

Método

estudio cualitativo y descriptivo. Datos recolectados por medio de entrevistas semiestructuradas con enfermeros de países africanos de lengua portuguesa y categorizados por medio de análisis de contenido.

Resultados

participaron nueve enfermeros de los países: Angola, Cabo Verde, Guiné-Bissau, Mozambique y San Tomé y Príncipe. Fueron desarrolladas dos categorías, una que retrata las dificultades de la Enfermería en los países africanos de lengua portuguesa sobre la autonomía y apreciación necesárias al desarrollo y ejercício de sus competencias. La segunda ha evidenciado posibilidades de conexiones a partir de redes para integración y fortalecimiento de la Enfermería, por medio de la cooperación internacional.

Conclusión e implicaciones para la práctica

el estudio ha caracterizado como principales dificultades las relacionadas a procesos de trabajo, falta de autonomía, de estructura humana y física. En esa perspectiva, la cooperación internacional ha representado importante estratégia para el fortalecimiento de la formación de enfermeros de países africanos de lengua portuguesa, así como para lidiar con los expresivos retos que se presentan en su práctica cotidiana.

Palabras clave:
Cooperación Internacional; Comunidad de Países de Lengua Portuguesa; Enfermería, Autonomía Profesional; Recursos Humanos, Enfermería

INTRODUCTION

The State of the World’s Nursing report points out that 81% of nursing professionals live in countries in the Americas, Europe and Western Pacific regions. On the other hand, there is a quantitative gap in nurses per inhabitant in the regions of Africa, Southeast Asia, Eastern Mediterranean and part of Latin America, highlighting the inequality related to the reduced economic power of these countries. It should be noted, however, that out of every eight nurses present in the most favored regions, one was not trained in the country where he/she works, demonstrating that high-income countries face a weakness in their nursing education system, forcing them to recruit professionals from neighboring countries or other regions that are already depleted.¹ In this sense, cooperation between countries emerges as an important strategy to deal with the mentioned inequalities in the context of the training of nurses, the number of professionals and working conditions within and between countries.

Therefore, Technical Cooperation among Countries (TCC) can result in development, strengthening, exchange of technical and scientific knowledge, in addition to the training of human resources.² Technical cooperation encompasses planning, development and implementation of coordinated actions aimed at achieving higher levels of development in key areas, such as health. The objectives of the international technical cooperation are moving towards modernization, bringing the proposal to level the quality of life, through joint actions in different areas, idealized and implemented by different international actors. In line with this complex mission, it is essential that States recognize the cultural and social bases of each nation, transforming economic and social axes and influencing the life of a society in a beneficial way.³

In recent years, the relevance of international cooperation between States has been noticeable, transforming technical cooperation into a guiding axis for the expansion of foreign policy. In this context, Brazil has been playing an important role, especially in the context of horizontal cooperation and in the area of health. This direction of the cooperation has resulted in important benefits for Brazilian foreign policy, especially considering the global health agenda and the awakening to health inequalities inside and outside countries.^4,5

In this way, the health sector has stood out with the south-south cooperation, or horizontal cooperation, implemented between developing countries, which was born in the mid-1970s, because of international movements for a new division of international labor, which encompassed the specific interests of peripheral countries. This cooperation is evidenced by the continuous exchange of experiences, knowledge sharing, learning and results, in addition to assuming joint responsibilities at national and international levels, shaped by strategic guidelines and based on democratic principles.⁵

Horizontal cooperation in health provides the dissemination of science and technology among countries, seeking to strengthen health policies in all areas and territorial instances.⁶ In this context, Brazil has been playing an important role in the South-South Cooperation, through technical cooperation in health in South America and with African countries, guided by horizontality and solidarity.⁷

With a lasting perspective, technical cooperation aims to plan and develop joint actions of a technical nature to benefit a specific area, such as health. It is bilateral or multilateral, with financial and human resources from everyone involved in the project. This type of cooperation differs from aid or assistance, usually of a humanitarian nature, which includes unilateral cooperation actions in cases of international emergencies.

In the context of Nursing, technical cooperation between Brazil and African countries is quite significant, with a special focus on the training of nurses. Thus, in the 1980s and 1990s, Brazilian public universities received a considerable number of students from Africa, many of whom studied Nursing. It can be said that the first Bachelors and Graduates in Nursing in Angola and Mozambique were trained in Brazil.

Considering its history of horizontal cooperation between Brazil and Portuguese-speaking African countries, this study aims to characterize the challenges experienced by nurses in Portuguese-speaking African countries and discuss the potential of international cooperation in this context.

METHOD

This is a qualitative, descriptive study, whose data were obtained through semi-structured interviews with nurses from Portuguese-speaking African countries, participants in the workshop: “Nursing in Brazil and in Portuguese-speaking African countries”. Nurses from Angola, Cape Verde, Guinea Bissau, Mozambique and São Tomé and Príncipe participated in the study. All nurses participating in the Workshop, organized in conjunction with the Ministry of Health of Brazil and the Representation in Brazil of the Pan American Health Organization, were invited to participate in this study. The participants of the workshop were nurses from Portuguese-speaking African countries who had partnerships with educational institutions and services in Brazil. Data collection took place under the responsibility of three of the authors who also participated in the organization of the workshop.

For data collection, the form prepared by the authors was used, structured based on the objectives of the study that considered, in this process, the concept and elements of horizontal international cooperation in health. The collection took place at the end of the workshop, in São Paulo, during an event that brought together the research participants.

For data treatment, the technique of content analysis by thematic categories was applied. In this sense, the data were encoded in units of record and aggregated into units of meaning, categorized by similarities. The analysis occurred repeatedly by two independent researchers; if there was a divergence in the analysis, a third researcher could be called; however, it was not necessary. The meaning units were grouped into subcategories and, subsequently, into categories. Thus, the categories were constructed according to the themes that emerged from the text, identifying what they had in common for their grouping.^8,9 Participants were identified by the letter P, followed by an increasing sequence of cardinal numbers, according to the order of the interviews.

For the conduct of the research, all ethical and legal aspects, related to the development of research with human beings, were fulfilled. As such, the project was duly assessed and approved by the Human Research Ethics Committee (Of CEP-EERP/USP – 157/2011. Protocolo n° 1290/2011).

RESULTS

Nine nurses participated in the workshop, mostly female, aged between 31 and 54 years old, one from Angola, three from Cape Verde, two from Guinea-Bissau, two from Mozambique and one from São Tomé and Príncipe. Regarding training, only two participants had a master’s/doctorate, and 66.6% held academic functions. When asked about the knowledge of any cooperation project (help or technical assistance) developed in their country, in cooperation with any foreign country in the field of Nursing, 55.5% replied having knowledge – 55.5% on technical cooperation or 44.4% on aid or assistance. The participants also mentioned that many projects, previously in force, were stagnant; 22.2% answered that there were logistical difficulties and 44.4% stated that they observed difficulties related to the lack of financial resources for the development of projects.

Two categories emerged from the thematic analysis, described below.

Nursing in Portuguese-speaking African countries: differences and similarities with Brazilian nursing

According to the participants, the difficulties encountered were eminently due to lack of motivation, as a reflection of their “stolen autonomy”, definition taken from the essence of the testimonies. For them, the difficulties experienced paralyze the entire human and functional structure. They are characterized by the difficulty of working with the multidisciplinary team, especially with doctors, resulting in the lack of recognition of their professional autonomy.

[...] Difficulty working in the multidisciplinary team and recognition of the quality of professionals (P1).

Difficulty in entering the National Health System as an autonomous professional with decision-making power. Lack of professional autonomy due to strong intervention by professionals in the medical field (P2).

[...] Lack of autonomy, which is stolen by other professionals [...] low remuneration that implies lack of motivation (P4).

The devaluation of the contribution of Nursing by the team and health leaders reflected in low remuneration, absence of progression in the academic level and promotion of nurses, lack of autonomy to exercise the profession were key points in the participants’ discourse.

Little integration of nurses in health activities (P2).

[...] The non-implementation of the career (P9).

[...] Prevention of progression and promotion of nurses (P6).

[...] Non-participation of nurses in health activities due to lack of authorization from the Ministry of Health (P4).

The main obstacles to access to continuing education and the lack of investments in specialized training, such as specialization courses, continuity in graduate studies, deficit in higher education institutions for specific nursing training were also reported:

The difficulties are of the following order: in the areas of training nurses and midwives about a nursing/obstetric degree, there is no specialization/nursing course (P8).

[...] Lack of Higher Nursing Schools (P6).

[...] Low number of professionals with higher education and continuity in graduate studies (P1).

The results of the aforementioned category reveal, therefore, difficulties for the practice of nursing professionals with the necessary autonomy for the broad performance of their skills. This reality, however, presents elements that touch the reality of Brazilian Nursing. Despite this, the second category reveals possibilities for strengthening nursing, in a perspective of networks that articulate and connect strengths and possibilities for the development of the profession in these different countries.

Potential for collaboration among Portuguese-speaking countries

Collaborative alternatives provide investment in the human capital of Nursing, based on technical and human training and, mainly, the appreciation of the specific contribution of this profession and science. In addition, it encourages the development of partnerships in research and for the training of qualified nurses through collaboration between universities and organizations.

Exchange in scientific research. Exchange and training of nursing staff at a higher level including postgraduate (master's and doctorate). Opening of a regional academic nursing school. Strengthen exchanges in search of funding sources for nursing development in countries (P6).

More communication of activities between countries. - Participation in more international events where everyone participates. - Exchange of experiences between nursing teams in the countries. - Supervision of the professional’s profile in several countries (P1).

Exchange of knowledge and experiences that could improve activities. Partnerships between representative countries to develop some projects, considering that we have many problems and potential in common. Cooperation in terms of training and participation in activities developed at the Pan American Health Organization (PAHO (P2).

Creation of the Order of Nurses in the Portuguese Speaking African Countries (PALOP). Creation of higher education institutions for the PALOP nurses. Creation of joint research projects/centers. Strengthening of mobile libraries. Organization of scientific meetings on a rotating basis in the PALOP (P5).

The potentialities can be acquired through the development of common knowledge and experiences, within the scope of science, through evidence-based Nursing research.

Cooperation in formation. Exchange of experiences in the practice of professionals in the area of ​​management of health or primary care programs, teaching and research. Help in finding financing for development projects (P6).

Partnerships for specializations and postgraduate courses in general. Promote our country better and learn more about the other countries that participate. More knowledge: conditions to make better professionals (P4).

DISCUSSION

The difficulties encountered by Nursing, in relation to the lack of autonomy, as a reflection of the lack of recognition of its value and importance for the health sector are characteristics present in several countries, from virtually all regions. Challenges faced, for example, by nurses in India demonstrated the existence of a strong mismatch in the link between the other professional categories, characterizing a great challenge for a productive relationship between these teams. In this sense, nursing professionals carry the burden of enduring the pain of being at the forefront in the health systems and not being recognized.¹⁰

Factors that generate physical and emotional exhaustion and interfere with nurses' motivation in the hospital environment are frequent, indicating the lack of autonomy, as well as the influence of the doctor's authority on their work, hierarchy, work overload, shortage of human resources and inputs, generators of physical and emotional exhaustion.¹¹ These wear and tear directly impact their lives and their work process, leading to the demotivation found in the statements of the participants in this research. In this perspective, some participants mention that they feel their “stolen autonomy” by the current structure and considering the relationship with other members of the health team.

This scenario of difficulties in the recognition and (in)visibility of nursing work has been reported in several studies; it is noted that when the nursing professionals are not valued, the expression of their professional identity is lost, de-characterizing the importance of their professional performance.^12-15 The results of the present study point to the clear demotivation of the nursing professionals who participated in the research, due to the feeling of professional devaluation.

The prejudice experienced by nursing is analyzed in the social relations that corroborate the experience of the nurse’s exclusion, who often accepts this condition because he/she is inserted in a social context in which this limited concept is crystallized. Under these conditions, nurses devalue themselves and others, with low self-esteem and even aversion to their colleagues.¹⁶ Many conflicts experienced by nursing result from the predominance of the biomedical model, in which the professional is unable to exercise his/her profession autonomously, being subordinated to the orders/approvals that doctors impose.¹⁷

The precariousness of the nursing labor market was recorded in a cross-sectional study carried out between 2005 and 2018 in 32 states of Mexico, which has increased as a consequence also of major labor reforms, affecting nursing professionals, mostly salaried. In that country, there was an increase of 8.6% in admissions of nurses without a contract, 53.4% with low salaries and another part of this population is working underemployed.¹⁸

On the other hand, interprofessional integration in health teams occurs in some countries. A study carried out with nurses from England revealed that some nurses are able to exercise their autonomy through teamwork, in their daily practices sharing their knowledge and skills. Thus, nurses reported that the hierarchy of health systems, as well as policies and guidelines, are determinant for their performance in an autonomous manner,¹⁹ which is essential for their motivation and satisfaction in the context of the work environment.

In the field of professional training, a study with managers of public and private institutions in a state of northeastern Brazil showed that although there has been over the years an expansion of private institutions focused on the training of nurses, there has been no growth in the hiring of health professionals in health institutions, resulting in a large number of unemployed professionals.²⁰

In Portugal, a survey of the nursing workforce has been carried out in the last 40 years – since the creation of the National Health Service, with advances in technical and scientific knowledge in the years investigated. It is noted a change in the educational framework aimed at the specialized training of nurses.²¹

Despite the difficulties reported by the participants, collaboration between nurses from other countries, especially the Portuguese-speaking ones, was pointed out as an alternative strategy for their strengthening.

In this sense, the potential for collaboration among Portuguese-speaking countries, constituted by the Community of Portuguese Speaking Countries (CPLP) is highlighted. But, especially with regard to the African continent, considering identity aspects common to the Portuguese-speaking African Countries (PALOP) initiatives are suggested such as the organization of more events for the exchange of experiences and even the creation of an Order of Nurses in the PALOP. Another integrative initiative of nursing in these countries, endorsed by the respective Ministries of Health and Foreign Affairs of each country, so that common programs can be developed frequently, according to the needs pointed out by the nursing professionals themselves and agreed upon in this integration instance. In this way, once the demand is identified, institutions from Brazil and Portugal are activated that can jointly and sequentially develop each strategic program in different themes. If in the 20th century there was a strong limitation due to the geographical distances and the fragile digital infrastructure that would favor the creation of between nursing in the countries that are members of the PALOP,^22,23 in this second decade of the 21st century we can no longer accept that we are not using the advancement of the internet and applications on mobile devices to advance in search of integration through knowledge.

As already highlighted in the nursing literature, it is important to recognize the trend of the new postmodern order that through technology it is possible to foster the development of human resources - “the most valuable asset that societies have to care for, promote and educate in health. There is no use in technical, financial resources, power, if there are no health systems that work, that guarantee free accessibility with productivity, quality, equity and social justice”.²⁴ In this perspective, knowledge represents the power that participants in the present research most resent to rescue and assert their autonomy.

The current digital health policy, highlighted by the World Health Assembly in 2018, approved a strategy to promote global collaboration to boost the transfer of knowledge by digital means. This proposal advocates the alignment of countries and collaborators so that, together, they explore global opportunities and achieve goals using digital technologies to improve health and enable universal coverage – the heart of the Sustainable Development Goals related to health.²⁵ Universal health coverage is the biggest challenge facing health systems worldwide, especially in developing countries; in this challenge lies a potential for visibility and appreciation of nurses through their interventions consolidating the principles of this health policy.²⁶

In this scenario, all countries must advance their investment in digital technologies and health, so that it is now possible to bring together Portuguese-speaking countries and, in fact, to put in place programs that have long been presented as a common desire, but previously prevented due to the technological barrier present in African countries. Therefore, it is essential that nursing entities and leaders make efforts to technically and politically manage to advance proposals for sharing solidarity of content, data, experiences, challenges, barriers and successes achieved by nursing. Affirmative action will have a power that generates self-confidence and self-realization, reinforcing the purpose of fighting for the autonomy that African nurses feel and define as stolen, and rescuing it through the power of updated knowledge. In the current era of intense appeal for instant social communications and for digital health, there is no lack of vehicles and formats that allow the operationalization of programs designed and capable of solving the distancing of human resources in the nursing area, which are united by the same language in African, American and European continents. Thus, through this bridge it is possible to promote equality.²⁵

And in line with the window of opportunity opened by the Nursing Now movement in the International Year of Nursing, global awareness of the value of investing in health as a public good and the representativeness and precious potential of nurses and obstetricians in improving health grows, creating gender equality and strengthening economies. In this wave of visibility and appreciation, more and more nurses are encouraging themselves to “break the silence” and take ownership of their right to spread their voice on decision-making tables and contribute to the definition of health policies.^27-29 Finally, successful lessons show that in the presence of political and strategic posture of institutions and leaders capable of developing and enhancing the exchange of experiences in the horizontality of the South-South cooperation with the PALOP, with instruments that are better suited to each need and potential of the cooperating institutions, we will be able to overcome a challenge that we have seen for decades as urgent. Perhaps, with the validity of the digital health strategy, global cooperation is promoted, so that the south-south effort receives contributions from the north-south direction and that, together, these contributions achieve and are inducers of strengthening, agility, equity and solidarity in the aggrandizement of nursing human resources. And that, taking advantage of the vigorous movement for the valorization of Nursing and Obstetrics, they gain visibility^13,14 in their country.

CONCLUSION

The present study characterized the growing challenges faced by nursing in Portuguese-speaking African countries and the expectation of nurses from those countries regarding the potential for international cooperation, specifically involving Brazil.

Thus, the statements about the difficulties related to the work processes experienced, lack of autonomy and human and physical structure emerged as a major challenge to be faced by nurses in their daily activities. To deal with this adverse context, the participants reinforce the existing collaboration history, within the scope of the south-south cooperation in the area of ​​health, involving Brazil and these countries. The data demonstrate the potential, from the perspective of the research participants, of cooperation between African Countries of Portuguese Official Language in terms of collaboration in technical and human training, exchange in scientific research, training of nursing staff at a higher education level, including post-graduation, aiming to promote sustainable development for nursing.

In this scenario, the use of digital technologies is highlighted as fundamental resources for the construction of lasting collaborations, especially for the training and qualification of human resources among Portuguese-speaking African countries.

The convenience sample centered on workshop participants is considered as a limitation. However, despite involving a small number of nurses from the five countries, the study points to important directions aimed at strengthening collaboration in nursing between the countries involved. Therefore, it is suggested to develop studies that deepen this theme and systematically evaluate different experiences of international cooperation in the health area and with a focus on nursing.

The valorization of international technical cooperation relations in health is fundamental for the improvement of nurses’ practice. In the case of professional nurses from Portuguese-speaking African countries, cooperation was essential for their professional training and acts as a support tool for their strengthening and improvement. International cooperation can be considered strategic so that nurses from Portuguese-speaking African countries can deal with the constant challenges experienced in their performance scenarios.

ACKNOWLEDGMENTS

The authors thank Dr. Maria Auxiliadora Trevizan for the organization and development of the Workshop “Nursing in Brazil and Portuguese speaking African countries”.

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Edited by

ASSOCIATE EDITOR

Cristina Rosa Baixinho

Publication Dates

• Publication in this collection
  12 Feb 2021
• Date of issue
  2021

History

• Received
  04 Aug 2020
• Accepted
  03 Nov 2020