"To be a nurse": a professional choice and the construction of identity processes in the 1970s

ABSTRACT

Objective:

to analyze the factors that influenced the choice for nursing made by graduates from the first class of the Undergraduate Nursing and Obstetrics Course of the Federal University of Rio Grande do Norte in the 1970s and to understand the senses and meanings of being a nurse when choosing this profession.

Method:

a qualitative socio-historical study was performed, using oral history to collect data.

Results:

the analysis generated the following categories: "To be a nurse: a professional choice" and "The ideal of being a nurse: senses and meanings". The senses of "being a nurse" are associated with graduates' perspective of this profession and the meanings included the traditional conceptions that have historically affected it.

Conclusion:

professional choice was influenced by family and work expectations and the nursing course had an effect on the construction of nurses' professional identity.

Descriptors:
Nursing; History of Nursing; Professional Choice; Professional Identity; Qualification

RESUMO

Objetivo:

analisar os fatores que influenciaram a escolha dos egressos da primeira turma do Curso de Graduação em Enfermagem e Obstetrícia da Universidade Federal do Rio Grande do Norte pela enfermagem nos anos 1970 e compreender os sentidos e significados de ser enfermeiro no momento da opção profissional.

Método:

pesquisa qualitativa, sócio-histórica que utilizou a história oral para a coleta de dados.

Resultados:

a análise gerou as categorias: "Ser enfermeiro: uma escolha profissional" e "O ideário de ser enfermeiro: sentidos e significados". Os sentidos de "ser enfermeiro" dizem respeito à visão dos egressos sobre a profissão e os significados abrangeram as concepções tradicionais que permeiam historicamente a profissão.

Conclusão:

a escolha profissional foi marcada pela influência familiar e expectativa de trabalho, e o curso influenciou na construção da identidade profissional desses enfermeiros.

Descritores:
Enfermagem; História da Enfermagem; Escolha da Profissão; Identidade Profissional; Formação

RESUMEN

Objetivo:

analizar los factores que influyeron en la elección de los egresados de la primera clase del curso de Graduación en Enfermería y Obstetricia de la Universidad Federal de Rio Grande do Norte por la enfermería en los años 1970 y comprender los sentidos y significados de ser enfermero en el momento de la opción profesional.

Método:

investigación cualitativa, socio-histórica que se valió de la historia oral para la recolección de datos.

Resultados:

el análisis generado las categorías: "ser enfermero: una elección profesional" y "el ideario de ser enfermero: sentidos y significados". Los sentidos de "ser enfermero" se refieren a la visión de los egresados acerca de la profesión y los significados abarcaron los conceptos tradicionales que impregnan la profesión históricamente.

Conclusión:

la elección profesional estuvo marcada por la influencia familiar y expectativa de trabajo, y el curso influyó en la construcción de la identidad profesional de estos enfermeros.

Descriptores:
Enfermería; Historia de la Enfermería; Elección de Profesión; Identidad Profesional; Formación

INTRODUCTION

To think about the construction of identity in modern society is a sociological challenge due to structural changes inherent in the current stage of neoliberal global society. These social transformations have led to disruptions and conflicts in all institutions, causing a global crisis that has affected social relations and, consequently, creating a crisis in the construction of identify processes^(1-3).

Throughout one's life trajectory, individuals experience several socialization processes that reflect in their interaction with others in a certain socio-cultural context and enable the understanding of a concept of identity represented by the relationship of identity for oneself and for the other.

After the family, the first social environment for human beings is the school. In it, individuals experience social identity, provided by the institutions and social relations established with teachers and schoolmates. In this sense, the socialization process of school knowledge includes global historical aspects of social relations that are also influenced by conflicts inherent in social structures.

University qualification has an influence on the construction of one's professional identity for a long time after the school period, as it establishes active elements in the make-up of a professional group and follows all changes in work and employment⁽¹⁾.

The focus of university qualification as a foundation for the construction of nurses' professional identity is on both national and international literature. These publications are centered on the construction of such professional identity throughout their academic life from the point of view of models, professional choices, curricula, biographies and how essential identity is in the development of one's professional life^(4-14). Based on the studies analyzed, the construction of identity profiles as a social process has been an important debate in nursing worldwide throughout the years, seeking to understand how such processes occur.

Thus, the present study used Claude Dubar's theoretical framework, mainly his presuppositions on identity processes, prioritizing the professional dimension⁽¹⁾. According to this author, identity forms are constructed and/or reconstructed through socialization processes that individuals establish in the family and qualification and work processes.

The theoretical contributions of Joël Candau were essential to understand the dialectics between memory and identity⁽¹⁵⁾. For the author, memory is responsible for the strengthening of identity, both on the individual and collective levels.

Based on what has been described here, the present study aimed to analyze the factors that determined the choice of nursing made by graduates from the first class of the Undergraduate Nursing and Obstetrics Course of the Federal University of Rio Grande do Norte (UFRN) in the 1970s and to understand the senses and meanings of being a nurse for these graduates when deciding to choose a profession.

The period of time for this study was the 1970s, when two undergraduate nursing courses were created in the state of Rio Grande do Norte, Northeastern Brazil: the Nursing and Obstetrics Course of the State University of Rio Grande do Norte (UERN), created in 1968 and recognized in 1972; and the Nursing and Obstetrics Course of the UFRN, recognized in 1978.

The importance of preserving the memory and history of the Undergraduate Nursing and Obstetrics Course of the UFRN should be emphasized, due to its social significance in nurses' qualification.

METHOD

Considering the fact that the present study focuses on the socio-historical process of construction of nurses' identity profiles, the theoretical foundation is centered on the sociological field, according to conceptions developed by Dubar^(1,3). The methodological framework is comprised by theoretical foundations originated from the dialogue of several authors who deal with the historical method in their studies, developed from assumptions of the New History.

A qualitative study with a socio-cultural approach was performed. Data were obtained through a semi-structured interview, using the Thematic Oral History technique. This study is part of a doctoral thesis in nursing entitled "Qualification and identity processes of nurses in the state of Rio Grande do Norte: memories of graduates (1970s)"⁽¹⁶⁾.

The place of study was the Undergraduate Nursing and Obstetrics Course of the state of Rio Grande do Norte, created under the University Reform on August 13^th 1973, associated with the UFRN Nursing Department in the city of Natal, under Resolution 58/1973. It appeared at the height of the political and socioeconomic changes occurring in Brazil in the 1960s, which reflected on the increase in the number of undergraduate courses in this area in the 1970s, as the Ministry of Education encouraged more vacancies to be offered for the qualification of nurses in this country⁽¹⁷⁾.

The first class included 31 students, who began the course in 1974, of which 21 completed it on December 10^th 1977. Of all those who completed the course, four had already passed away, so there were 17 left. Of these, one was the author of the present study, thus not being included in the sample⁽¹⁶⁾.

As a result, study participants were these 16 graduates from the first class of the UFRN's Undergraduate Nursing and Obstetrics Course. The inclusion criteria were as follows: to be available for interviews; and to agree with the Informed Consent Form. They were identified by their last name as written on their graduation invitation, except for the male participant, so that this would not conflict with female participant with the same last name.

Data collection was performed between September 2013 and May 2014. The time and place of interviews were selected by participants, aiming to create more interaction between researcher and interviewees. Data were organized according to what is recommended by thematic oral history. Thematic Analysis was selected for data analysis⁽¹⁸⁾.

The present study was guided by the principles of Resolution 466/2012 and submitted to the Comitê de Ética em Pesquisa com Seres Humanos (CEPSH - Human Research Ethics Committee) of the Federal University of Santa Catarina, where it was appraised and approved in 2013. All participants were informed about the research objectives and procedures. The Informed Consent Form was read before interviews were conducted.

RESULTS

The analysis generated the following two categories: "To be a nurse: a professional choice" and "The ideal of being a nurse: senses and meanings".

To be a nurse: the choice for this profession

When asked about their "professional choice", some graduates reported that their aim was the area of health and that they opted for nursing because they could not be qualified for medicine, which was the first choice of many. As they were not approved, students chose nursing as a second option, as reported below:

I wanted to do anything in the area of health, so I first chose medicine and then nursing. As qualification was based on our grades, I could only go for nursing. (LOPES)

I had already taken university entrance exams to study medicine two times and couldn't pass. So, the third time [...] I chose nursing and this is how I entered university. (OLIVEIRA)

Family influence plays an important role in one' professional choice; at times, individuals project their social advancement, which they have not achieved yet. For some graduates, this parental influence was so strong that nursing was their second option, although still uncertain about continuing their course or not:

My father [...] had this big dream and thought I should study medicine. [...] I got excellent grades, but not enough to enter medical school. [...] So I took up nursing. After a while, I chose medicine again and I was approved, but I decided to continue nursing. (VILAR)

[...] nursing was my second choice because I wanted to please my father first. He really wanted me to study medicine, but I was in doubt because I preferred nursing. (CARVALHO)

Another factor that influenced professional choice was about the identification with nursing originated from the image of nurses projected by professionals or the literature.

In the countryside, the Sesp Foundation was very strong and Sesp nurses [...] said good things about nursing and [...] I was very excited about it all. [...] I had this dream of being a nurse. [...] I was very happy when I was in grade 11 in high school and the nursing course began to be offered at the UFRN [...] so I chose nursing. (GOMES)

I decided to take up nursing after I read a book by John Crown, an American physician [...]. Nurses played an important role and I began to want to be that type of nurse, even though I wasn't sure what that was like... The more I read, the stronger I felt about it and my decision was based on this, as incredible as it seems. (SILVA)

The analysis of professional choice also indicated an interest aimed at the inclusion in the health work process. Being a new course, nursing was viewed as a profession with a greater chance of inclusion in the job market.

As this was a new course and there were stories in the papers about the work perspective, I chose nursing. (ARAÚJO)

Additionally, there was the possibility of social advancement, as reported by one of participants:

I was already working in the area of health, so I chose nursing because it was a new course and it could lead to social advancement. (ASSIS)

The ideal of being a nurse: senses and meanings

The theme "Being a nurse" generated reports that showed graduates' low level of knowledge about this profession, some of which associated it with a conception of profession geared towards care as a synonym for "performing", in the sense of help and development of techniques, although there are signs showing the need for scientific knowledge in some reports.

I thought about the idea of being a nurse over and over, working at a hospital, giving injections, applying dressings to wounds, and really caring for patients. I didn't see myself in primary care, where I am now. (FREIRE)

I imagined being a nurse meant performing simple actions [...] especially in hospitals. I never thought of nurses in primary care. I always thought about nurses being inside hospitals and what they would do, performing these actions as techniques, maybe a little more, because I'd have to study and have a scientific basis, but also performing these procedures and supervising a team. (JALES)

Another aspect reported by graduates was the invisibility of being a nurse. According to them, this profession had no social recognition; thus, it was easy to meet the challenges of selecting a profession recognized by oneself and society at the moment of such choice.

I didn't know what it meant to be a nurse. I think this was because of the lack of general knowledge, nobody knew what this profession was in Rio Grande do Norte [...]. We had no idea what the role of a nurse was; someone was dressed in white, but it wasn't a doctor, it was a nurse, although it was a stretcher bearer (NICOLETE)

I think people couldn't understand what it meant to be a nurse. You had to explain. Was she an assistant? No, nurses have to take an undergraduate course like other health professionals. It took people a long while to understand this. (CERVEIRA)

The fact that nurses' identify profiles are also influenced by the history of nursing, according to the different historical contexts in which it is included, cannot be disregarded. Thus, being a nurse in the social imagination of that time also involved many prejudices which, in a way, made an impression on course students. Consequently, some of them maintained this distorted conception of the profession that had been created worldwide.

People thought that a nurse was a doctor's lover or employee, this view was very strong at that time. So, if you as a nurse got closer to a doctor professionally, people would think: "Oh, this one must be having an affair with the doctor!". (SILVA)

It was frustrating for me later on [...] after I began to get involved in that environment I knew that wasn't my path [...] The course made me change the romantic view of nurses I had. (BRITO)

When I was going to start my specialization and because I was a woman and had never left home, my dad came to me and said, 'my daughter, you can quit your job!'. I had already passed the exams and all, but he said, 'Stay here, I can support you!'. In his view, women didn't have to work, travel, or stay away from their family and father. (BARBOSA)

However, prejudice was not only present around this profession; it was also in the minds of certain students who, throughout the course, felt undervalued and frustrated due to the actions performed by nurses. Another aspect regarding the view of nurses was associated with the sexual stereotypes involved with women's history and their roles in patriarchal societies. Thus, a predominantly female profession could not be unaffected by sexist-based relations.

DISCUSSION

Professional choices represent a landmark in the construction of one's professional identity and inclusion in the job market. In modern society, young adults have been forced to choose a profession earlier and earlier. When entering secondary school, family and society in general create expectations about their choice of higher education course, as the possibility of entering university, recognized as a space for developing science and a bridge for professional inclusion in the job market⁽¹⁾.

Therefore, one's professional choice represents a personal and professional life project whose decision can be associated with several factors. In the present study, family influences, representations about nursing and positive expectations about the job market were important for this choice. The social recognition of this profession is among such factors as it interferes with the construction of identity profiles.

In the area of health, with the development of modern medicine, which used to be a predominantly male profession, the hegemony of the medical profession and knowledge was established in the health work process and submitted the remaining professionals to its medically-oriented logic, constructing what came to be known as the paramedic identity throughout the years. An example is the area of nursing which, although having become a profession in the late 19^th century, was considered to be a paramedic profession as it had been a discipline from this area for a long time.

Historically, medicine has ranked first among those competing and willing to be health professionals. This great demand has led several students to choose other professions as a second option, as observed in studies conducted in 2009 and 2010^(19-20).

The uncertainty of professional choice has forced certain students, although with some frustration, to rethink their professional perspectives and choose a profession similar to their desires, thus guaranteeing the possibility of being included in the job market and fulfilling their project of social advancement. This fact has been a landmark in the path of young adults when feeling impelled to seek their financial independence in the job market.

When choosing a profession, individuals identify with idealized images (identity for oneself) and social identity (identity for others) of certain historically constructed professions or professional areas⁽¹⁾. This fact has marked the trajectory of the majority of young adults when forced to seek their professional independence in the job market. A study on the construction of nurses' professional identity performed in 2006 also reveals such option⁽²¹⁾.

Consequently, when entering the Undergraduate Nursing Course, some students bring meanings and identifications about this profession, which can be confirmed or not throughout their qualification trajectory. The romantic view about such profession that one of the students had is associated with the "lady lamp" view, inspired by feelings of charity and selflessness, causing her to perform her work in a submissive and selfless way. According to Florence Nightingale, nursing was understood as a vocation as much as a profession and any woman could become a good nurse as long as they associated obedience and respect with hierarchy and humility⁽²²⁾.

However, when coming closer to the concrete particularities of performing nursing, students deconstruct this romantic identity, which can be replaced by a more coherent view, closer to reality, of a profession that has peculiarities of caring for others.

In some cases, the initial repercussions of family members of students for their choice for nursing were not very positive, but rather negative at times, due to lack of knowledge about this profession and to its stereotyped image that has been present since its beginning.

Regarding women, this family interference, especially from fathers, used to be much stronger, especially in the 1970s, when women's professional choice was historically influenced not only by their family, but also by society. This influence was greater as they chose a profession full of stigma and prejudice at that time.

The fact that historically this was a predominantly feminine profession did not guarantee that nursing would be socially recognized, thus receiving little visibility, which would interfere with its social status and professional identity^{(10,14,23-24)}.

While the male identity was constructed through productive work and recognition from society, the female identity only achieved private forms of recognition. "Women were socially placed in the home environment in a submissive position and with the status of objects"⁽³⁾.

However, this lack of knowledge about nurses present in society in the 1970s was not accidental. Nursing was recognized as any non-medical profession, but nurses were still a rare professional in the health work process. In fact, until the mid-1970s, nursing as a higher education profession was the least increasing one in the area of health.

Thus, nurses' identity processes, especially in their professional dimension and regarding achievements and developments in nursing, have been influenced by impositions resulting from a certain vulnerability inherent in this profession that cannot be visible or recognized by society^(16,23-25).

Moreover, in terms of idealized images, the identification with nurses from the Fundação Serviço Especial de Saúde Pública (Sesp - Special Public Health Service Foundation) originated from their contribution to the expansion of health services in impoverished areas in Brazil, as part of a unique model that included nursing as one of the foundations for its actions. Sesp's contribution to nursing was based on several strategies such as: training, continuing development and praxis founded on technical and scientific knowledge⁽²⁶⁾.

However, the identification that led to the professional choice does not end when entering the course that one selected. At the beginning of their academic trajectory, students keep constructing or deconstructing their basic professional identity, so they can reaffirm or question their choice, as observed in some interviews. Thus, identities are neither innate nor immutable, they are constantly changing in the destructuring/restructuring dynamics. Some identity trajectories are marked by continuity (recognition) and others by ruptures (lack of recognition), thus implying confirmation or questioning of identities previously acquired or constructed⁽¹⁾.

Therefore, the construction of a basic professional identity is not only represented by an identity in the workplace, it is rather "a projection of oneself in the future, the expectation of a career trajectory and the development of a logic for learning, or better yet, for qualification"⁽¹⁾. Participation in professional qualification and the academic trajectory, especially when students are dealing with the action of nurses in the field of practice, stand out as a privileged space of identification and contribute to students' adherence to their profession and construction of professional identity.

The second thematic focus of this study involves the senses/meanings attributed to the profession by students, before being included in the qualification process. The meaning of care was associated with healing in a technical/hospital-centered way, only aimed at simple procedures performed in the hospital environment.

This image of nurses as professionals responsible for simple actions, associated with technical actions performed under doctors' orders, without its own scientific knowledge, somewhat characterizes one of the identity traits of nurses at that time. This view was legitimized by the need for technical competence efficacy to contribute to technological development, based on a fragmented conception of the health work process where doctors control health knowledge and actions in hospital institutions, leaving the "performing" to nurses and other health professionals.

In Spain, this conception also existed in the 1970s. Spanish nurses should be concerned about their clothing and physical appearance to draw patients' attention, while doctors were responsible for technical-scientific questions⁽¹⁴⁾.

With the advent of the Modern Age, the scientific revolution contributed to the success of medicine as a profession, strengthening with the expansion of universities and hospitals. However, nursing did not develop in the same way. The first identity of nursing was associated with religiosity of charitable actions performed by orders of nuns and laymen in hospitals/monasteries at that time. With the Protestant Reform, this identity was deconstructed, causing an identity crisis when their activities started to be performed by individuals without qualification, from low social and moral classes; consequently, unprivileged. This stigma led to repercussions that have affected nursing until now^{(14,19-20,23,25)}.

Individuals become social by internalizing values, ideas and dispositions that contribute to their identity, especially the principle of recognition and acceptability; however, the conception of being a nurse that students saw projected in society was that of total lack of knowledge about this profession, which also included them.

In contrast, when asked about the meaning of being a nurse at the time they took the university entrance examinations, students sought to recall memories of individuals and positive experiences, showing that identity construction is a socio-relational and cultural process, as identity is always comprised of a certain relationship between oneself and the other based on where one is situated; through this relationship, one recognizes oneself and is recognized socially. This relationship with oneself and the other is an identity form that can result from a commitment to a project that implies an identification with others who belong to the same idealized project⁽¹⁶⁾.

Despite the entire organization of nursing to overcome this crisis and reconstruct a social identity (self attribution) that portrays how society recognizes its achievements, this seems not to have included such society as a whole.

It should be emphasized that other more recent studies on the choice for nursing courses indicate the same aspects found in this study, especially with regards to the influence of traditional values, cultural and social norms, distorted and prejudiced gender conception and professional status^{(10,14,19-21,23-24)}. It could be inferred that family context influences, social representations about professions and positive expectations about inclusion in the job market still remain as part of the personal and/or social identification.

One of the limitations of this study was the fact that researchers did not interview students who began their course, but who, throughout their qualification process, chose other courses and/or failed certain disciplines, thus being unable to conclude the course with the first class. Consequently, it is recommended that other studies should be performed to consider this limitation.

The importance of studies that preserve the memory and history of the UFRN's Undergraduate Nursing Course should be emphasized due to its social significance in the qualification of nurses. This is an innovative study that will certainly contribute to the understanding the history of nursing in this particular region of Brazil. Additionally, it will enable the archives of the history of nursing school is Brazil to be improved and the professional identity of Brazilian nursing to be constructed.

FINAL CONSIDERATIONS

Through the narratives, we could observe that the professional choice for nursing made by the majority of students from the first class of the UFRN included a certain amount of frustration for an unfulfilled dream - the medical course, the closeness to the medical profession, the expectations about the job market, and the desires of social advancement. Participants' opinions about professional choice were almost unanimous, especially regarding nursing as a second choice.

In this sense, the professional choice of nursing students was influenced by family members, positive expectations about inclusion in the job market and social advancement, and identification with positive experiences of professionals from this area. These elements can be considered as the foundation of the social identification of the profession by such students.

The theoretical framework for identity conception, from the sociological perspective, contributed to grasp the subjectivity of participants through memory recall, in terms of senses and meanings about the ideal of being a nurse that comprised the professional identity of this group. These meanings represent the particular view of students, their individual (re)construction of nursing, which included the following aspects: dreams, romantic view of this profession, the influence of literature, the possibility of inclusion in the job market and social advancement. The meaning of being a nurse encompassed traditional conceptions, especially the understanding of care as a synonym of "performing", distorted images, stigmas and social prejudice that historically affected this profession.

Considering the fact that the present study was conducted according to the memory of students from the 1970s, it is recommended that other studies on this theme should be performed, seeking to reveal the construction of nurses' identity processes in the current context.

Finally, it is also recommended that those responsible for the qualification of nurses should have a debate on the construction of their professional identity as this is important for students to identify with their profession and for their social recognition.

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Publication Dates

• Publication in this collection
  May-Jun 2016

History

• Received
  27 July 2015
• Accepted
  20 Nov 2015