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Expansion of undergraduate courses in nursing: dilemmas and contradictions facing the labor market

La expansión de los cursos de pre-grado en enfermería: dilemas y contradicciones sobre el mercado laboral

Abstracts

We sought to analyze, from the perspective of professors and students, the reasons and consequences of the expansion of undergraduate courses in nursing, discussing the dilemmas and the contradictions confronting the labor market. It was a qualitative study with data obtained from focus groups, conducted in 18 undergraduate nursing courses in the state of Minas Gerais, during the period of February to October of 2011. The narratives were submitted to critical discourse analysis. The results indicated that the education of the nurse was permeated by insecurity as to the future integration into the labor market. The insecurity translates into dilemmas that referred to employability and the precariousness of the working conditions. In this context, employment in the family health strategy emerges as a mirage. One glimpses the need for a political agenda with the purpose of discussion about education, the labor market and the determinants of these processes.


En este estudio se buscó analizar, desde la perspectiva de los docentes y estudiantes, las razones y las consecuencias de la expansión de los cursos de pregrado en enfermería, discutiendo los dilemas y las contradicciones frente al mercado de trabajo. Estudio cualitativo con datos obtenidos de grupos focales, en 18 cursos de pregrado en enfermería en el Estado de Minas Gerais, en el período de febrero a octubre de 2011. Los relatos fueron sometidos al análisis crítico del discurso. Los resultados indican que la formación del enfermero está impregnada de incertidumbre en relación a la futura inserción al mercado laboral. La incertidumbre se refleja en los dilemas que se relacionan con el empleo y las condiciones de trabajo precarias. En este contexto, el empleo en la estrategia de salud de la familia aparece como un espejismo. Se considera necesario tener una agenda política que regule la discusión sobre la formación, el mercado laboral y los factores determinantes de estos procesos.

Educación en enfermería; Instituciones de Enseñanza Superior; Mercado de trabajo; Atención Primaria de Salud


Procurou-se analisar, na perspectiva dos docentes e discentes, as razões e as consequências da expansão dos cursos de graduação em enfermagem, discutindo os dilemas e as contradições frente ao mercado de trabalho. Estudo qualitativo com dados obtidos de grupos focais realizados em 18 cursos de graduação em enfermagem do Estado de Minas Gerais, no período de fevereiro a outubro de 2011. As narrativas foram submetidas à análise crítica do discurso. Os resultados indicam que a formação do enfermeiro está permeada por insegurança quanto à futura inserção no mercado de trabalho. A insegurança traduz-se em dilemas que se referem à empregabilidade e à precarização das condições de trabalho. Neste contexto, o emprego na estratégia de saúde da família desponta como uma miragem. Vislumbra-se a necessidade de uma agenda política que paute a discussão sobre a formação, o mercado de trabalho e os determinantes desses processos.

Educação em enfermagem; Instituições de Ensino Superior; Mercado de trabalho; Atenção Primária à Saúde


Introduction

After the implementation of the Unified Health System (SUS), the implementation of a policy that prioritized Primary Health Care (PHC) experienced in our country, with expansion of jobs for health professionals. Thus, it is a fact that the needs of the labor market influenced the establishment of schools and the orientation of professional education in Brazil(11. Oguisso T. Trajetória histórica e legal da enfermagem. Barueri (SP): Manole; 2005. ). We can infer that nursing education is undergoing a transformation, not only as to whether to expand the number of courses, but also as the focus of the education, the profile of graduates, and the labor market itself.

In relationship to the expansion between the years of 1964 and 1991, there was a 171% increase in the courses of nursing offered in Minas Gerais, reaching a total of 106 courses by the end of the period. On one hand, this expansion was recognized as a positive phenomenon among those who advocated the democratization of access to Brazilian higher education. On the other hand, one needs to ensure that it is designed and regulated in a consistent manner, establishing a dialogue with the labor market that will absorb future professionals.

Thus, considering that

education should seek to prepare the future health professional for the real world, globalized, and for the requirements of the labor market, so that the graduate can be prepared for the competition(22. Barbosa MA. Refletindo sobre o desafio da formação do profissional de saúde. Rev Bras Enferm. 2003;56(5):574-6.)
we must reverse the logic of the market that does not favor the critical and reflective education that is capable of impacting reality and stimulating local, social improvements in the medium and long term(33. Peres NA, Ciampone MHT. Gerência e competências gerais do enfermeiro. Texto Contexto Enferm. 2006:15(3):492-9.).

It is understood that the labor market is a space of socialization of the individual and an aspect of its importance

lies in the fact that it is where individuals transact, their prices are thus determined, its principal - and in most cases, unique asset is the ability to work"(44. Ramos LO. O desempenho recente do mercado de trabalho brasileiro: tendências, fatos estilizados e padrões espaciais [Internet]. Rio de Janeiro: IPEA; 2007 [citado 201 jan. 24]. Disponível em: http://www.ipea.gov.br/portal/index.php?option=com_content&view=article&id=4818
http://www.ipea.gov.br/portal/index.php?...
).
The market it is a space that suffers the influence of several social, political and economic factors, such as opening to a globalized world and the technological development that provides human development, as a result of more interaction between people(55. Baraldi S, Díaz MYP, Martins WJ, Carvalho Jr DA. Globalização e seus impactos na vulnerabilidade e flexibilização das relações do trabalho em saúde. Trab Educ Saúde [Internet]. 2009 [citado 2010 jan. 24];6(3):539-48. Disponível em: http://www.bvseps.epsjv.fiocruz.br/lildbi/docsonline/5/9/1195arquivo%5B6%5pdf
http://www.bvseps.epsjv.fiocruz.br/lildb...
).

The major vulnerability to which people are exposed in the labor market is the increase in unemployment and the consequent precariousness of employment, mainly in informal work. The area of health suffers the influence of productive restructuring, despite having increased positions in the sector with the implantation of SUS in the decade of the 1980s. However, the increase of positions was already accompanied, during the decades of 1990 and 2000, by greater flexibility in work relations leading the workers to have a multiplicity of linkages, with compromised labor rights(55. Baraldi S, Díaz MYP, Martins WJ, Carvalho Jr DA. Globalização e seus impactos na vulnerabilidade e flexibilização das relações do trabalho em saúde. Trab Educ Saúde [Internet]. 2009 [citado 2010 jan. 24];6(3):539-48. Disponível em: http://www.bvseps.epsjv.fiocruz.br/lildbi/docsonline/5/9/1195arquivo%5B6%5pdf
http://www.bvseps.epsjv.fiocruz.br/lildb...
). In the case of Brazilian nursing, employability in the category reached rates of 92.4% absorption in 1999, when most other professionals in the health sector faced crises of unemployment(66. Vieira ALS. Empregabilidade dos enfermeiros no Brasil. Esc Anna Nery Rev Enferm. 2002;6 Supl.1:S65-74.).

In the social representations of graduates, the transition from university to the labor market was identified as a difficult process. This began from the understanding of the university as a place distanced from professional reality(77. Gomes AMT, Oliveira DC. Formação profissional e mercado de trabalho: um olhar a partir das representações sociais de enfermeiros. Rev Enferm UERJ. 2004;12(3):265-71.). This creates anxiety, especially in the context in which this market is experiencing a reconfiguration, with rising unemployment, the increase in informality, and precariousness of working conditions(88. Carrijo CIS, Bezerra ALQ, Munari DB, Medeiros M. A empregabilidade de egressos de um curso de graduação em enfermagem. Rev Enferm UERJ. 2007;15(3):356-63.). Understanding the expectations of professors and students about the job market can reveal how they have developed education to prepare to meet the challenges of a competitive scenario.

In the first decade of the XXI century, in which the expansion of the number of undergraduate courses in nursing in itself was evidence that something was happening in nursing education and in the labor market, it was necessary to investigate the elements that comprised this process, and analyze this phenomenon from the point of view of the profession, the organization of services, the current and future needs of populations, and their possible repercussions for the quality of care with which the nurse responds.

Considering this problem, this study had as its objective to analyze the perspectives of professors and students about the reasons and consequences of the expansion of undergraduate courses in nursing, discussing the dilemmas and contradictions faced in the labor market.

Method

This was an exploratory and descriptive study, with a qualitative approach, underpinned by the theoretical and methodological framework of Marxist dialectics. The choice of dialectic had as a criterion the fact that a current theory and method allows understanding and explanation of pedagogical practices, educational activities and, principally, the relationships of the school with all of society(99. Gamboa SAS. A dialética na pesquisa em educação: elementos de contexto. In: Fazenda ICA, organizadora. Metodologia da pesquisa educacional. 12ª ed. São Paulo: Cortez; 2010. p. 91-115.).

In order to understand objective reality, we sought to establish the relationship of interdependence between the singular (education of nurses in each scenario), particular (as evidenced by the analysis of the relationships between the curriculum guidelines and the regional needs of the health sector and demands of the labor market) and structural dimensions (the way in which health policies, education and regulation of the expansion of higher education are organized).

The state of Minas Gerais was chosen as the study setting. In January of 2010, 126 undergraduate courses in nursing were identified in the state, of which 18 were selected to be part of this research. Inclusion criteria were: location in different regions of the state, already recognized by the Ministry of Education, and having graduated at least one class by the time of data collection. We included 13 courses linked to private institutions, and five to public institutions.

In each course, two focus groups were performed: one with professors and one with students, for a total of 36 groups. The groups of professors were composed of representatives of the basic and the professional cycle; the student groups were formed by representatives of the different periods of the course. In total, 109 professors and 149 students participated in the focus groups.

The groups were conducted by one moderator and one observer, oriented by a discussion guide initiated by the following guiding question: Describe how you perceive that the formation of nurses in this institution prepares the students for the health labor market, considering the politics of the health force.

The focus group sessions lasted between 40 and 60 minutes, on average. For validation of the instrument, a pre-test was conducted in an institution that was not a part of the formal study.

The data were submitted to analysis using a critical discourse analysis perspective. A comprehensive reading of narratives contained in the transcription of the focus groups was performed to identify commonalities and singular experiences, by means of the meaning underlying the words. We sought to identify the common themes in conjunction with the interrelated material that permitted empirical categorization. Subsequently, in an interpretative synthesis, the points of view and the singular expressions of participants were discussed, comparing them, in a dialectical movement with the critical interpretation of authors confronting the analytical categories(1010. Fairclough N. Discurso e mudança social. Brasília: Ed. UNB; 2008.).

The project was submitted to the Committee of Ethics in Research of the UFMG and its approval was contained in protocol ETIC No. 435/08. The participants were informed about the objectives and purposes of the study, and signed the Term of Free and Informed Consent.

Results

The critical analysis of statements obtained from the focus groups revealed the following empirical categories: Possibility of entering the labor market: dilemma of the profession; Strategies for entering the market: individual alternatives; Public procurement and the Family Health Strategy: the mirage of work

Possibility of entering the labor market: dilemma of the profession

The results revealed that between professors and students of undergraduate nursing in the state of Minas Gerais, there was a feeling of uncertainty in relationship to the entry of future professionals into the labor market. From the perspective of the participants of the study, the labor market for nurses was “saturated”, requiring the development by graduates of some type of uncharacterized, differentiated ability, that would allow them to win the competition for employment positions.

The job market today is increasingly demanding, you understand. And I think the following: we are thinking about it, in the full market in our region, it is saturated, we have to go back and do the differential (Student focus group, Course 1).

Only the best even [will be absorbed by the market]. (Professor focus group, Course 3).

I think when you make the selection process [for employment] it is not only focused on the name of the college from which you graduated, but your specialization. If you have a post-undergraduate degree (“post”), it counts a lot (...). So what do they [employers] want? It is a different thing: if you have a post or you can do one. It weighs a lot when you have this differentiation (Student focus group, Course 18).

The participants of the study established a relationship between the saturation of the market and the expansion of nursing courses, identifying a growth not guided by planning that took into account the prospects of employability. That is,

It is increasingly difficult for you to find your place in the sun, even here in the region, which has many colleges. (Student focus group, Course 8).

The social rise and search for better salary conditions were presented as factors that determined the demand for undergraduate nursing courses and provide ease of access and flexibility as a means for obtaining a necessary opportunity.

The difficulty today is the issue of students who are arriving for us, with this huge facility of admission: it is the community agent, it is the nursing technician. (Professor focus group, Course 6)

And we have some students who talk to us, I'm a technician, I am going for education in order to retire in a better position. (Professor focus group, Course 2).

Paradoxically, the participants emphasized that, in the nursing field, in this historical moment, the mid-level professionals were not experiencing professional growth after completion of graduation, which was a dilemma experienced by the profession confronting the labor market:

There are a lot of assistants and technicians who are having the opportunity for education. (...) With a reality that will not absorb them, neither for the qualification, nor for the opportunity for vacancies. So she remains in the same job [occupation] but with a title (Professor focus group, Course 12).

I work in a hospital that has several nurses who continue to work as technicians because of the devaluation of the profession, because they earn much more as a technician than as a nurse ... (Student focus group, Course 13).

There is also the recognition of a vicious cycle with harmful consequences to nurse, when the expansion of courses, with a consequent increase in the number of graduates, is accompanied by an increase in the contingent in reserve, generating instability in the work conditions and degradation of wages. Thus,

Like it or not I think the greatest consequence of this devaluation in nursing is caused just because there are so many colleges launching professionals into the labor market. Because it has professionals who just graduated and accepted precarious wages to do the service of two, three professionals ... (Student focus group, Course 2).

I think that the labor market, with the installation of other colleges here, had an enormous loss for nursing. We are with our wages here in the chaotic cities. (Professor focus group, Course 5).

The salary of nurses today are so bad, why? If I do not get R$1000, you get R$600. So, to give you an idea, we have professionals nursing bidding. How much do you want to be paid? "Two thousand." And you? "A thousand" (Professor focus group, Course 1).

Another aspect of objective reality that was identified as problematic by the participants related to the contradiction between the jobs available and those needed for a consistent response to the health needs of the population. This applied to the relationship between the number of inhabitants of a given area covered by the family health team, with only one nurse, and to the relationship between the number of beds per nurse in hospitals in the municipalities :

The prefecture of XX has a project of 300 family health teams and does not pass 100, and it has 550 unemployed nurses in the city (Student focus group, Course 5).

We have, for example, the University Hospital, it is only a front, it has not expanded the other work fronts. The Family Health Strategy, I think it has 35 or Family Health teams, we have to have, I do not know how much [more] ... So the job exists, only that it was not activated, and this caused this issue in our graduates being unemployed (Professor focus group, Course 5).

What ws possible to affirm, therefore, was the unstable character, dynamic and adversarial labor market. In other words, there was a significant change between the demand for nurses and the increased supply of this workforce.

Strategies for entering the market: individual alternatives:

The findings of the study revealed that, both for the professors and the students, the entry into the labor market required choices and personal effort, before, during and after graduation. Thus, the opportunity of access to higher education by means of flexible alternatives offered by the private network, in the majority of cases without competition for vacancies, is the first “choice” that can define the employability of the professional. Factors were identified that had strong influence on the moment of entry into the labor market: the name of the university, and the devaluation of professionals educated in municipalities of small size. The fact of being a graduate of a renowned institution made a difference in the labor market, because of the expectation that this factor meant the acquisition of abilities that were positively differentiated.

Because like it or not, I think that, the XXX it is a very good institution (...) and it is that which will make a change there [On vacancy of employment] (Student focus group, course 12).

And much better, they get [in employment] a student of an institution that it is renowned, that is old, that has good teaching ... (Student focus group, course 12).

In a demonstration of a more dialectical movement, at the same time in which recognition of merit of the academic institution was identified as a facilitator to entry into the labor market, because of real or potential quality of the education, it was frequent in the discourse that the student was co-responsible for his education. Namely, the responsibility of the institution about the quality of the professional educated was minimized, and, at times, in an uncritical and deliberate manner, it was transferred to the student. Therefore, the guarantee of employment depends, also, on his effort during the educational experience. Thus,

The student takes the course knowing that, if he does well, he will be employed. (Professor focus group, Course 15).

(...) it's up to you to be that good professional that the market is needing, it is up to your effort. So, if it is oversaturated, if you are a good professional you will have a job, you will be able to arrange something with certainty (Student focus group, Course 8).

If you make the right “choice” of course and strive a lot during undergraduate studies and, even still, you do not get a job, there is still the “option” for graduate education latu sensu, considered strategic in the fight for a job. For some,

If the nurse does not do the specialization, if he does not have a differential, he will not be able to enter into the market. (Professor focus group, Course 8).

To finish graduate education today has become a requirement. The people know the institutions only admit you if you have completed graduate education (Professor focus group, Course 12)

The search for large urban centers was also a characteristic that marked the discourse of professors and students when questioned about the expectation of entry into the labor market:

If it was an option I would not choose to leave my city but we know today that the labor market for nursing is a little tighter, more saturated. So, sometimes we need to go where we will be able to practice the profession (Student focus group, Course 6)

(...) because much employment exists, much work, but in other municipalities. There is a salary much better than here (Professor focus group, Course 8).

The search for major urban centers depicts a perspective of overcoming the precarious work conditions offered in the regions in which schools that were the scenario of the study were located, expressed by the deficiency of resources in the local community. Thus, the participants revealed a sense of hope that there would be a place where it is possible to be and do the best:

The only certainty that I have it is that I want my specialization and not to stay in a small city; I think in São Paulo, Belo Horizonte; I think in a big city; I think in a structure for work; I intend to specialize. So I want a structure that I can play my role, to practice my profession (Focus group student, Course 2).

No critical analysis about the lack of a national policy of human resources consistent with the needs of the country was emphasized, in any statement, nor about the lack of control and monitoring of the geographical distribution of undergraduate nursing courses that were created.

Public procurement and the Family Health Strategy: the mirage of work

The current organization of health care on the Brazilian population with a focus in primary health care, operationalized by means of the Family Health Strategy (FHS), was recognized by the participants as responsible for a great part of the expansion of the labor market of the nurse.

The relationship established by those between the development of a course, the labor market, and the expansion of work positions as a result of the advance of the FHS was evident. Thus, the possibility of employment in public health, with a focus on family health, was highlighted as a great opportunity, independent of profile or of more aptitude for the area:

The labor market, the people know that where there is much growth in nursing in the Family Health Strategy. So, many of us here already think ... for example, I never thought of working in this area, but what happens? As it is opening vacancies, it is a risk. Already changed my idea of thinking and working, adapting to working in this area (Student focus group, Course 5).

The great attraction to the people that enter the nursing course is the question of being educated to work in the Family Health Strategy. (Professor focus group, Course 6).

Also there were those students that ideologically adopted the proposed transformation of reality and believed that they could make a difference. For some, this expectation broke down rapidly, seduced by a comfort zone contained in the known, in the traditional, or vanquished by challenges common to large movements of transformation:

Yesterday I met with a graduate who came here with the idea that family health was the solution; he worked for two years and surrendered, surrendered and is working in the cardiology department of a traditional hospital. He said it is less costly, less stressful, to work in clinical cardiology. He only gets heart attacks, but at least he has a routine to be followed, he does not need to be working on a knife's edge, he only has to do what is prescribed, and voila! (Professor focus group, Course 5).

An understanding of the public sector as the major employer of nurses, and the public tender as the modality recognized by the respondents as providing more employment stability was evident in the statements:

We try to give the most possible return for what the open tender for positions require (...) we saw this in other periods of the SUS, but now we are having classes on health promotion and social control.

So, everybody is just watching every word of the professor because it may be part of the tender... (Student focus group, Course 14).

There was a very large devaluation, for people to find a job, work, with due valuation, we will have to run far behind, struggle to pass a public tender (Student focus group, Course 13).

Discussion

The results enabled the identification that the labor market was a theme that provoked insecurity in the professors and, mainly, in the students of the undergraduate nursing courses studied. The insecurity translated into dilemmas that referred to employability and the precariousness of working conditions.

Despite not being critically analyzed by the participating subjects, there was a contradictory relationship evident between the expansion of undergraduate courses in nursing and the prospect of nurses entering into the labor market. The major employer mentioned was the Unified Health System, as the locus of political strategy of strengthening primary care.

The reflection of this uncritical stance in the educational process was the finding of the phenomenon without highlighting elements that signaled a movement for change. On the contrary, the feeling of impotence and accommodation were evidence of the contradiction expressed in the construction of a “savior” perspective of the nursing labor market. There was also a responsibility of the students, who must ensure their employment through individual effort, since, in a competitive environment due to the large supply of professionals, it is up to the market to select the most adept.

The personal effort of each student to make a difference, in an individualistic view, reinforced the market perspective influenced by neoliberal logic in a process of deregulation(1111. Varella TC, Pierantoni CR. Mercado de trabalho: revendo conceitos e aproximando o campo da saúde: a década de 90 em destaque. Physis Rev Saúde Coletiva [Internet]. 2008 [citado 2011 out. 10];18(3):521-44. Disponível em: http://www.scielo.br/pdf/physis/v18n3/v18n3a09.pdf
http://www.scielo.br/pdf/physis/v18n3/v1...
). Similarly, the migration movement, presented in this study, revealed the neoliberal face of competition for the labor market, in which, individually, each professional graduate seeks, by their skills and individual differences, to gain a place in the market.

This study highlights the need for collective processes for clear positioning and struggle of nursing staff through transformations that impact the labor market, such as: the creation of new jobs, expansion of those that exist, reduction in working hours, and salary conditions. Added to this, the urgency to discuss the adequate nurse/nursing professional relationship to respond to the health needs of the population.

The employability of nurses can not escape the rationalizing measures that have been practiced by the government and, in the statements of the participants, a dilemma was identified: unemployment was recognized, demotion in the value of remuneration, and the precariousness of labor relations, including less stable linkages and the extension of working hours per week. However, as this was still a recent phenomenon, there did not seem to be an accumulation of reflections by the participants to enable them to unravel their determinants and pinpoint strategies for overcoming them.

Concerning the FHS, there was a "mirage of employment"(1212. Demo P. Miragem do emprego. Bol Tec SENAC [Internet]. 2005 [citado 2011 out. 10];31:5-17. Disponível em: http://www.senac.br/BTS/311/boltec311a.htm
http://www.senac.br/BTS/311/boltec311a.h...
), as the scenario of primary care that could ensure adequate remuneration and all legal protections, especially stability. Paradoxically, the findings also revealed the recognition that the work in the FHS was “costly”, that is the deregulation of working conditions or failure to present, in the context of the study, the expansion required to meet the the health needs of the population without a consequent increase in jobs.

The focus of the FHS may mean that the trend of growth in the jobs of nurses since the 1990s, with a predominance of formal and salaried employment, continued to modulate the participants’ expectations regarding entering the market. However, one must consider that the linkage to the municipal public administration, state or federal, was the principal workplace for nursing professionals, mainly due to the decentralization of health services and the deployment of the FHS(1313. Varella TC. Mercado de trabalho do enfermeiro no Brasil: configuração do emprego e tendências no campo do trabalho [tese doutorado]. Rio de Janeiro: Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro; 2006.). In the current context, this was a scenario with signs of precariousness represented by temporary contract work, the three-tier system, and transfer of operation of services to the private sector by outsourcing,(1414. Girardi SN, Carvalho CL, Wan Der Mass L, Farah J, Araújo JF. O trabalho precário em saúde: tendências e perspectivas na Estratégia de Saúde da Família. Divulg Saúde Debate. 2010;(45):11-23.), especially of medium and high complexity.

Associated with this context of deregulation and greater flexibility of labor relations, the current scenario of expansion of undergraduate courses in nursing was among the determinants, in a particular dimension, of variable conditions of employment, multiple job contracts, diversified , multiple jobs and differentiated rights(55. Baraldi S, Díaz MYP, Martins WJ, Carvalho Jr DA. Globalização e seus impactos na vulnerabilidade e flexibilização das relações do trabalho em saúde. Trab Educ Saúde [Internet]. 2009 [citado 2010 jan. 24];6(3):539-48. Disponível em: http://www.bvseps.epsjv.fiocruz.br/lildbi/docsonline/5/9/1195arquivo%5B6%5pdf
http://www.bvseps.epsjv.fiocruz.br/lildb...
).

Therefore, the perception that the public sector was seen as an objective image and public procurement as a strategy to achieve job security(1515. Varella TC, Matsumoto K. O trabalho do enfermeiro no Brasil: analisando oferta e demanda no mercado. In: Pierantoni CR, Viana AL. Educação e saúde. São Paulo: Hucitec; 2010. p. 82-97.) pointed to the need for collective discussions bringing together the public policy agenda of the health care organization for the public policy agenda of education of the health professionals and the regulation of the labor market and employment. In this case, the consolidation of the health system and the expansion of FHS demand that the education of professionals incorporate the principles and methods of work in the territory and communities, understanding their determinants. However, this can not be understood as the only option for market access, without considering the profile and the initial desire of students to enroll in undergraduate courses.

A reflection about the labor market should consider that part of the structure of the competitive globalized economy is growth without increasing employment, because the production and the intensive use of knowledge provide the logic of relative surplus value, to the point that, with obvious exploitation of human labor, it can “easily” produce more and better with less labor cost of the workforce(1212. Demo P. Miragem do emprego. Bol Tec SENAC [Internet]. 2005 [citado 2011 out. 10];31:5-17. Disponível em: http://www.senac.br/BTS/311/boltec311a.htm
http://www.senac.br/BTS/311/boltec311a.h...
). It should also be considered that it is within the process of work, to transform nature, that the human being is also transformed(1616. Mishima SM, Pereira MJB, Fortuna CM, Matumoto S. Trabalhadores de saúde: problema ou possibilidade de reformulação do trabalho em saúde? Alguns aspectos do trabalho em saúde e da relação gestor/trabalhador. In: Brasil. Ministério da Saúde. Observatório de recursos humanos em saúde no Brasil: estudos e análises. Rio de Janeiro: FIOCRUZ; 2003. p.137-56.), characterizing the possibility of conforming and being conformed by a socio-historical situation(1717. Pereira MJB, Fortuna CM, Mishima SM, Almeida MCP, Matumoto S. A enfermagem no Brasil no contexto da força de trabalho em saúde: perfil e legislação. Rev Bras Enferm. 2009;62(5):771-7.).

Despite the lack of more precise data, different studies indicate that unemployment in nursing is a worldwide problem(1818. Spetz J. Unemployed and underemployed nurses. Geneva: International Centre for Human Resources in Nursing; 2011) that coexists, paradoxically, with the scarcity of these professionals. It is estimated that one in every four nurses in the United Kingdom is not employed in nursing,(1919. Buchan J. International recruitment of nurses: policy and practice in the United Kingdom. Health Serv Res. 2007;42(3 Pt 2):1321-35.),although there is a shortage of nurses in the country. It has been verified that 81% of Canadian nurses and 85% of American nurses are employed in nursing positions(2020. Murphy GT, Birch S, Alder R, Mackenzie A, Lethbridge L, Little L, et al. Tested solutions for eliminating Canada's Registered Nurse Shortage. Ottawa: Canadian Nurses Association; 2009. ). Yet there are deficits of professionals in these countries, that has been confronted with immigration(2121. Aiken LH. US nurse labor market dynamics are key to global nurse sufficiency. Health Serv Res. 2007;42(3 Pt 2):1299-320.).

The cycles of professional nurse shortages, that alternate with times in which there is a "surplus" of professionals, are characterized by periods of increased demand for nurses to confront new health programs and practices, generating support for the expansion of nursing education by government agencies during these periods of shortages(2121. Aiken LH. US nurse labor market dynamics are key to global nurse sufficiency. Health Serv Res. 2007;42(3 Pt 2):1299-320.).

In Latin America and in Asian countries, recessions and the programs of fiscal control reduced the public sector opportunities for employment and salaries, leading many professionals, including nurses, to underemployment and/or to procure other occupations to complement the income necessary for subsistence(2222. Malvárez SM, Castrillón C. Overview of the nursing workforce in Latin America. Washington: Pan American Health Organization; 2005.-2323. Ding Y, Tian J. Annual review of HRH situation in Asia-Pacific region, 2006-2007. Geneva: Health Human Resources Development Center Ministry of Health, P.R. China; 2008.). The persistence of this cyclic pattern indicates the ineffectiveness of policies of workforce planning.

In countries in which the technological composition of the nursing workforce was stratified into categories with a technical division, the phenomenon of shortage of professionals and of unemployment and underemployment takes different shapes and dimensions. In the case of Brazil, in 2002, studies indicated a significant increase in jobs for nursing assistants and, to a lesser extent, a decline in employment of other categories of nursing personnel(2424. Brasil. Ministério da Saúde. Mercado de trabalho em saúde: dimensões setoriais, jurídico-institucionais e ocupacionais: um estudo a partir da RAIS/MTE: relatório de primeiro estudo. Belo Horizonte; 2002.). These numbers can have a relationship with what was identified by the research subjects, when they said that those in professional nursing education at the secondary level - technicians and nursing assistants - even after graduating, remained in their original occupations because, in these positions, the compensation was better when compared to the nurse, or due to the lack of opportunity for career advancement by not creating "new" positions for nurses.

The fact is that, in this historical moment, there is a technological recomposition of the nursing team with the qualification of technicians and auxiliaries, that could and should be used to favor the qualification of care(2525. Silva KL, Sena RR, Silveira MR, Tavares TS, Silva PM. Desafios da formação do enfermeiro no contexto da expansão do ensino superior. Esc Anna Nery Rev Enferm. 2012;16(2):380-7.). However, the findings of this and other studies revealed that these changes have not yet been used to their potential, to permit overcoming dialectically the devaluation of the profession, the technical division and the entry into the labor market.

Conclusion

It was concluded that, from the perspective of professors and students, there was a feeling of insecurity about the possibility of choice in the area of practice, with social and economic-financial constraints, with professional valuation, and the material conditions for achieving ideal health care quality.

The results contributed to the understanding that the expansion of the courses had not been able to bring about qualitative changes, in a movement of negation of the negation, namely, to overcome the contradictions, that would indicate the conformation of a new reality with the expansion of positions of work, in the equitable relationship to meet the health needs of the least developed regions. We must think about setting strategies of the professionals, valuation and stimuli for professional growth to overcome the dilemmas facing the labor market.

The study also contributed to the critical reflection about the consequences of disorderly expansion and unregulated of undergraduate courses in nursing, both with regard to the impact on the employability of the worker, as with respect to the need for collective movements for better qualifications in the educational process

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Publication Dates

  • Publication in this collection
    Oct 2013

History

  • Received
    16 Feb 2012
  • Accepted
    24 June 2013
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