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Revista da Escola de Enfermagem da USP

versión impresa ISSN 0080-6234versión On-line ISSN 1980-220X

Rev. esc. enferm. USP vol.53  São Paulo  2019  Epub 19-Ago-2019

http://dx.doi.org/10.1590/s1980-220x2018025503492 

ORIGINAL ARTICLE

Perception of nursing leadership on the fight against the precariousness of working conditions *

Midian Oliveira Dias1 
http://orcid.org/0000-0001-5378-736X

Norma Valeria Dantas de Oliveira Souza2 
http://orcid.org/0000-0002-2936-3468

Lucia Helena Garcia Penna3 
http://orcid.org/0000-0001-9227-628X

Cristiane Helena Gallasch2 
http://orcid.org/0000-0002-0823-0818

1Universidade do Estado do Rio de Janeiro, Faculdade de Enfermagem, Rio de Janeiro, RJ, Brazil.

2Universidade do Estado do Rio de Janeiro, Faculdade de Enfermagem, Departamento de Enfermagem Médico-Cirúrgica, Rio de Janeiro, RJ, Brazil.

3Universidade do Estado do Rio de Janeiro, Faculdade de Enfermagem, Departamento de Enfermagem Materno-Infantil, Rio de Janeiro, RJ, Brazil.

ABSTRACT

Objective

To describe and analyze gender and socioeconomic issues of category workers which interfere in the fight against the precariousness of working conditions within the perception of nursing leaders.

Method

A descriptive, exploratory study with a qualitative approach conducted at ABEn , Coren , Rio de Janeiro sessions and SindEnfRJ with leaders of work organizations, professionals in leadership positions, including directors or presidents. Individual interviews were conducted, and the data were treated using the content analysis technique.

Results

Seventeen (17) class entity leaders participated in the study. In the speeches, female predominance, double working hours, social and cultural origin, professional devaluation, reduced participation in spaces of struggle and bureaucratic labor issues were presented as justifications for the low involvement in labor disputes.

Conclusion

There is a need for partnerships between the category and the work organizations to mobilize and combat this perverse process through changes in legislation, which is essential to enable maintaining employment, the worker’s quality of life, and consequently excellence in the care provided to the population.

Key words: Nursing; Working Conditions; Gender and Health; Occupational Health; Labor Unions

INTRODUCTION

This study has the objective to identify the repercussions of gender and socioeconomic issues of nursing workers in coping with the precariousness of nursing work.

Nursing is a predominantly female profession, and due to cultural, socioeconomic, ethnic and other issues, it is little involved in the understanding and exercise of political struggles in seeking labor achievements, or the power relations which permeate work environments. The relationship between the number of men and women in the nursing profession was checked and updated in 2013 by a national survey requested by the Federal Nursing Council ( Cofen – Conselho Federal de Enfermagem ). The results show that 86.2% of nursing professionals enrolled in the Regional Nursing Council ( Coren – Conselho Regional de Enfermagem ) system are women. Such research covered 1,804,535 nursing professionals, with 414,712 of whom being enrolled as nurses and 1,389,823 as nursing assistants and technicians1 .

Society is mediated by struggles, whether symbolic or literal, hidden or clear, devastating or light. These struggles are often waged in search for power, recognition and/or material wealth across various dimensions of life such as politics, economics, religion, values and class2 . It is a fact that they are always present in society, both on an individual and collective level, hidden or evident.

In the context of the world of nursing work, it is relevant to understand issues involving power relations, class struggles and gender in order to subsidize critical positions and empower workers in the face of precarious working conditions and the weak social and professional recognition that permeate the profession.

The term empowerment is a complex concept which pass through the areas of democracy, political participation and deliberation3 , being considered a phenomenon in which people have control over resources, either physical or symbolic4 . In relation to the female population, empowerment is a transformation of society’s values and cultural positions, thus allowing women to escape poverty, have access to education, have a voice and social autonomy5 .

With regard to nursing, empowerment results in innumerable gains from safer work environments and better results in care6 , to contributions to overcome the adversities inherent in the work process, adversities which have been deepening with the advent of neoliberalism in the health sector7 .

In this perspective, it is verified that there has been a deterioration in working conditions in health and nursing in recent years in Brazil which have been strongly influenced by neoliberal politics. The service sector has been suffocated by an intense reduction of material resources and a qualitative and quantitative shortage of professionals, in addition to having weak working agreements, leading to low wages and loss of labor rights7 - 9 .

The concern with the precariousness of nursing work is increasing, since it directly interferes in worker health, as they are exposed to intensifying work and to deteriorating working conditions, an extended working day, polyvalence and multifunctional adoption and to unemployment due to low wages in the category10 . This precariousness results in psychophysical suffering for the worker, as well as their commitment to quality and safety in care at any healthcare level11 .

Nor can it be ignored that this process has an impact on the group of workers by compromising the social value, organization and political power of a given professional category, reinforcing socially constructed inequalities expressed through unequal labor relations12 .

Workers consequently have difficulty in finding tools and strategies of social organization to face this situation. It should be stressed that there is a need for a union of different fields and knowledge, such as the scientific methods, trade unions, and associations, but also of the individuals who experience this phenomenon, aggravated by a policy of monetized health and risks, to impose respect for fundamental rights of workers against economic domination12 - 13 .

In addition to an unfavorable economic context for the working class based on the neoliberal ideology of labor exploitation and profit maximization, there are also gender issues which reinforce social and labor inequalities.

It is known that cultural and social heritage is androcentric, privileging men to the detriment of women. The sexual division of labor, discrimination and symbolic violence, especially against women, continue to devalue their professions14 .

In this perspective, one must refer to the nursing profession, which is eminently feminine, with an object of work (care), which refers to the domestic sphere, and which in turn is inscribed in the sphere of doing, of manual labor. In a synthetic counterpoint, it is emphasized that the medical profession, which represents the masculine universe and an intellectual work, holds great power in the health service context. This power has repercussions on nursing workers, from low autonomy in the health work process to failure of employers to ensure better working conditions15 .

In addition, it is necessary to mention the socioeconomic and cultural characteristics prevailing in the nursing profession. A study on this subject among workers in this professional category found that they come from less-favored economic classes, and are predominantly black and brown-skinned16 . Thus, unfavorable socioeconomic and cultural contexts are evidenced in empowering the category in face of political struggles for better working conditions.

Considering the previously discussed issues, the objectives of this study are to describe and analyze gender and socioeconomic issues of category workers which interfere in the fight against the precariousness of working conditions from the perception of nursing leaders.

It is understood that this study is relevant since it deepens reflection on deteriorating working conditions of the nursing category, such as the neoliberal policy, which has reduced formal employment, public service admissions, and the salaries, among other prejudicial aspects to worker health and the quality of care. In addition, it brings up the discussion of issues which have afflicted society and above all nursing, such as gender violence and social inequalities arising from socioeconomic configuration. Reflecting on these issues, it is hoped to contribute to building critical awareness and empowering the professional collective in order to elaborate strategies to cope with such an adverse context.

METHOD

STUDY DESIGN

This is a descriptive, exploratory study with a qualitative approach.

SCENARIO

The study had the headquarters of the Brazilian Nursing Association - Rio de Janeiro Session ( ABEn-RJ – Associação Brasileira de Enfermagem ), the Regional Nursing Council – Rio de Janeiro session ( Coren-RJ ) and the Nurses Union of Rio de Janeiro ( SindEnfRJ – Sindicato dos Enfermeiros do Rio de Janeiro ) as its study scenario.

POPULATION

The study participants were nursing professionals who held leadership positions in the aforementioned work organizations. To ensure that such leaders actually experienced political struggles against the precarious conditions and working agreements in nursing, the years from 2011 to 2017 was delimited as a temporal cut for selecting the leading participants of those positions. This temporal period was based on the fact that the Social Health Organizations appeared in Brazil in 1998 thanks to the possibilities created after the State Reform. These organizations are classified as “third sector” and emerged as a social management modality and of health services provision, linked to the model of public-private partnerships. However, these companies gained strength and coverage in the municipality of Rio de Janeiro from the year 2011 onwards, with a significant increase in the precariousness of relationships and work agreements in the health sector16 .

SELECTION CRITERIA

Inclusion criteria for the participants of this study was considered as those who were leaders of the selected entities in which they were either directly or indirectly involved with actions and interventions against the precariousness of working conditions during the selected period. As exclusion criterion, cognitive and/or physical impossibility of the possible participants to describe their experiences.

DATA COLLECTION

Data were collected through an individual semi-structured interview. The interviews were recorded in MP3 audio, listened to and transcribed accurately.

DATA ANALYSIS AND PROCESSING

Data analysis and processing were performed according to the Content Analysis technique17 , giving rise to the following category: Gender and sociodemographic characteristics: relevant aspects in the fight against labor precariousness, consisting of eight Units of Significance (US) emerging from 51 Registered Units (RU).

ETHICAL ASPECTS

This study observed the legal precepts of Resolution 466/2012, of the National Health Council, which deals with the guidelines and norms regulating research involving human beings, having been analyzed and approved by the Research Ethics Committee of the proposing institution, under Opinion No. 2.017.871 of April 17, 2017. In order to preserve the anonymity of the participants, codes beginning with the letter E with the interview accompanied by a cardinal number were implemented according to the order of the interviews.

RESULTS

Seventeen (17) representatives of nursing work organizations, aged between 33 and 70 years (mean 55 years) participated in this study, Six were Coren-RJ representatives (35.3%), five were from SindEnfRJ (29.4%), and six were from ABEn-RJ (35.3%). All of them held positions on the board of directors or in the presidency of these entities during the established time period, of which three (17.65%) were men and 14 (82.35%) were women.

All participants had more than ten years of experience in the nursing area. Thus, the professionals who composed the leadership of the work organizations were experienced and had mastery of their practices. Regarding academic training, only one participant was a nursing technician and was completing a nursing degree. Among the others, seven were specialists, two held Master’s degrees, four were nursing PhD, two were developing their Master’s degrees, and one was completing a doctorate in nursing.

GENDER AND SOCIODEMOGRAPHIC CHARACTERISTICS: RELEVANT ASPECTS IN THE FIGHT AGAINST LABOR PRECARIOUSNESS

Participants were encouraged to speak freely about the characteristics of nursing and their relationships in coping with the precariousness of working conditions and relationships through political struggles. They emphasized that female predominance associated to double shifts is a justification for the low involvement of the category in labor struggles, as exemplified below:

We are a female majority, mothers, wives, and because of the salary issue we have more than one job (...), so it is difficult to put this worker on the street (E1).

Women who include the condition of mother, wife, housewife, and worker, do not get involved in political matters because of this overload (E10).

Another characteristic of nursing which joins previous ones and corroborates the justification for the low adherence to the struggles is the social and cultural origin of the profession, as observed in the interviews.

Most of the people who migrate to nursing are middle class or low middle class (...) they end up giving up the precarious employment due to a lack of conditions to maintain it (E2).

I attribute this non-political insertion of nursing to the eminent feminine composition (...) and the cultural question that women do not discuss politics (E8).

Other aspects that have emerged from the speeches historically refer to the devaluation of this professional, the reduced participation in spaces of struggle and issues related to bureaucratic work as aggravating elements.

Today we have nurses managing health units, we are increasing space, but there is almost no social visibility (E11).

The difficulty of social recognition has to do with the construction of nursing. We have the doctor as reference. Nursing is not well defined, the object of our practice is care, and care is very broad, linked to doing, not to thinking work (E12).

Participants view nursing as a depoliticized and accommodated category, without understanding the power relations existing in corporate environments of professional action.

Nursing does not fight for political space. And so we let them weaken us. Numerically we are many, but disunited and fragile. Nurses are very accommodating against the fights (...) I don’t think they see the real value of the fight (E5).

The nursing professional is very unrelated to everything that is happening, we are a category with a very high level of alienation, for being a woman and burdened with responsibilities (E10).

Regarding nurses’ behavior, they continue to talk about more passive and less articulated attitudes in the search for their rights.

There is no insertion, there is no political understanding, then they have no instruments to fight for space (...) We live in a very serious situation in progress of loss of rights, and we see an ignorance in nursing, and therefore, a reproduction of the understanding passed on by the media (E8).

Nursing has difficulty articulating in the struggles, which ends up leading to precariousness. We are subjected and subordinated, professionally speaking (E12).

Participants note that the category is not organized to give visibility to the sufferings and precariousness of the class and sometimes transfer the responsibility of fighting to the work organizations.

We are not making any political moves to deprecarization. I see a passive category, waiting for organizations to do everything (E9).

We often talk about our conditions, our precariousness, but we are not careful to make them visible, seeking to join forces in the fighting organizations (E15).

DISCUSSION

The speeches of the participants refer to gender issues and their influence on the low political participation of the nursing category. The historical and cultural feminization of the profession is recognized1 , 18 . According to data from a study which investigated nursing professionals enrolled in the Cofen and Coren system in 2013 conducted by the Oswaldo Cruz Foundation ( FIOCRUZ ), it is evident that 13.8% of professionals are men and 86.2% are women15 .

The number of men in nursing has increased significantly since 2005. However, this figure is still much lower than the female number, and if this growth pace continues, the Brazilian tendency is that it will take some decades for men and women to support themselves in this profession1 .

The gender view of the participants refers to the distinction of social roles between the genders; they believe that the predominantly feminine composition in nursing relates to the historical and cultural construction of the category. The term gender has undergone several conceptual transformations throughout history. From the 1970s onwards, “the biological perspective of gender – implied only in the distinction between the genders – was counterposed by new looks considering the gender category permeated by cultural, historical, social, race, ethnicity and generation”19 .

In a broader analysis, gender is now understood as a means of classifying phenomena, socially-agreed upon distinctions, rather than an objective description of inherent traits in a group. Gender is taken as synonymous with “women” in research and publications, a simplification and superficialization of a complex concept20 - 21 .

However, gender issues involve an economic, political, social and historically constructed perception, as well as adding attributes and functions which demarcate differences and interrelations between the genders, transcending the biological definition. These are questions which cover the differences in roles, statutes, responsibilities and places in society, in the characteristic behavior and attitudes of men and women20 - 21 and the “establishment of rules and configuration of the social place that each subject or group occupies in the productive and reproductive system”1 .

Women have historically and socially placed themselves in subservient positions, which widens with the sexual division of labor separating men’s and women’s work and values; the so-called “masculine activities”. The devaluation of domestic work and child raising is observed, since it does not produce monetary wealth21 . Thus, the professions culturally considered as female are devalued if compared to male ones.

Professions are social constructions which form part of an existential basis of the social phenomenon. The way a profession is perceived and valued is determined by its historical context of creation21 . Nursing is permeated with stereotyped and primitive images, misperceptions originating from the profession’s history, but which remain to this day. The lack of recognition and appreciation is not discussed with importance in the education and training spaces with the purpose of transforming this context, to create a critical and combative collective for such questions.

Valuation of the nursing professional directly interferes in their professional performance, because due to the low valuation and social recognition, the salaries are low, and the working conditions are inadequate. Thus, job dissatisfaction and demotivation are generated, impairing the quality of care and the workers’ health22 .

The depoliticization of nursing (in the view of the participants) is directly related to its composition, historical-social origin and inheritance of gender social functions. The relationship between gender and low political involvement has a multicausal origin. Added to this analysis, the symbolic nature of women’s political participation stands out. Situations of inequalities and social injustices marked by the inheritances of domination relations persist. In this perspective, male symbolic power promotes a representative effect of reality in a hegemonic way. Therefore, a logical feminine conformism is produced23 .

The reduced number of women in power and decision-making spaces continues to be marked by symbolic power. In spite of the transformations that have taken place in the contemporary world in the sense of increasing access to different levels of education and entering the labor market, these are insufficient to ensure equal participation between men and women at different levels of social and political life. The political participation of women is still limited by material and symbolic factors.

The current scenario of female participation in power spaces is not the result of individual processes, but of collective and deliberative processes. Such processes are important instruments of social transformation, but there is still a need for greater ideological transformations24 - 25 .

A genesis of low female participation in the political dimensions and power spaces is also highlighted as a direct correspondence between socioeconomic development and female political participation. Therefore, the degree of the country’s development directly influences this insertion. However, it is necessary to reflect on the cultural aspects present in the different regions and localities, and with this to understand the image that women have of their own representativeness and self-esteem24 - 25 .

The participants attribute their withdrawal of the political dimension to the overload of tasks, demands and responsibilities. Nursing does not understand the broad process of relationships in which it is embedded. In addition, it is known that this is a stratified professional category and comes from poorer social strata of the population1 .

Regarding the double employment relationships in nursing cited by the participants, the permanence of the professional in their work environment for an extended period distances them from social and family life, which can weaken their mechanisms of healthy coping and make them vulnerable to pathological stress and other physical and mental illnesses. It is known that a significant number of Brazilian nursing professionals exceed 40 hours a week, which is assumed to have more than one employment relationship15 , thus contributing to burnout, since the nursing work environments are mostly unhealthy. In addition, this professional intensely experiences the suffering, sickness and death of clients, which potentiates their psychological suffering.

Nurses usually experience a double working day, associating the housework, caring for family and children, in addition to their actual working day, causing an overload of tasks to be performed. On the other hand, one of the justifications for the multiple employment relationship is low wages, and with the weakness of the contracts in addition to low wages/salaries, there is no guarantee of social security26 - 27 .

Another additional fact that aids in understanding the permanence of professionals in precarious employment relationships and low salary is the law of supply and demand. There is no homogeneous distribution of nursing professionals in the national territory. The Southeast has a larger number of vacancies for the nursing team, but also concentrates the largest number of professionals and nursing schools, which increases market competitiveness15 . This situation results in forming a reserve army of labor, whose labor supply is greater than demand for the labor market. Consequently, the value of wages falls, and the devaluation of the professional in general work terms is accentuated.

In analyzing the nursing profession, one must take into account that the biomedical model and the logic of capitalist labor organization have resulted in fragmenting the body, division and hierarchization of work. Nursing opposes this model, preaching the holistic view of being and the interdisciplinarity necessary to guarantee providing comprehensive and efficient care. Therefore, one can perceive the existing conflict and the consequent relationship of power between the precepts of nursing and the other professions, society and employers.

Nurses are important in planning, developing, implementing and organizing the health work process, but are not recognized by society. This fact can be intensified by the social and technical division in the nursing team composed of professionals with different training and functions, which hinders delimiting professional roles and responsibilities by society28 .

Nursing has advanced in the search for action spaces and has ascended in science and research over the years. Nevertheless, little has evolved with regard to social recognition. In addition, as mentioned by the interviewees, the profession’s job is care, which is not exclusive, or defined and clear in society’s view, leading to some impairments in strengthening the professional identification of the nurse’s value10 , 29 . Regarding the bureaucratization of nursing work, ways are generally discussed to deal with the issue in the work field10 , 30 , but not to favor participation in political struggles.

Participants also discussed the nurses’ posture of being accommodating in the face of adversity faced by the profession. Nurses’ accommodated and often apathetic positioning in the face of political struggles may be related to the fragmented composition of the category, to its social origin, to the overload of professional and domestic functions that many female workers need to assume, in addition to the relatively common dual employment relationship in the profession. In addition, the labor market demands for professional qualification intensifies this overload of activities that nursing professionals have to attend21 .

Organizing politically enables the nurse’s social performance to be expanded. However, there is little incentive in teaching environments for student political participation; therefore, the nurse’s accommodation and political apathy may be reflexive to this sum of factors. A depoliticized professional misunderstands the power relations that permeate social environments, and are therefore easily manipulated by those who hold power. Political action is fundamental and mobilizes the collective transformations of the working world21 .

Nurses are consequently losing confidence in the powers of democratic transformation, which for the most part do not meet the profession’s demands. The news of corruption by public agencies, including some nursing leaders, is becoming more frequent30 .

With the intention of changing this framework of reduced political participation, demotivation and political disinterest in the category, the interviewed nursing leaders jointly or individually develop actions according to their legal competencies in defense of the professional. Coren is a public authority dedicated to controlling and supervising the nursing category, acting on legal fronts which legally seek to support the professionals in developing their duties, in the private activities of each stratum of the category, as well as in the minimum conditions and safe and quality care. As examples, denunciations and prosecutions can be cited with the Public Ministry against degrading state hospitals and delays in paying the professionals’ salaries.

ABEn is a private, cultural, scientific and political association that acts in a non-partisan manner, without distinction of gender, race, ethnicity or religion. It promotes actions and spaces for discussions among professionals, highlighting the integration between care and academia. ABEn develops forums, congresses, symposiums, among other meetings, participates in the formulation of curricular guidelines for nursing education, in addition to publishing letters with its political positioning, influencing important political decisions.

SindEnfRJ has the objective to defend the interests and the professional rights of the category, giving voice to the worker against their employer. The union is concerned with the social conditions of workers and acts through grassroots meetings, negotiations, strikes and acts to demand solutions to the problems experienced by the category.

Together, the work organizations carry out activities together with the universities to approach the future professional, granting them a space to seek support and discussion, as well as contesting calls for public service positions and selective processes when they have below-average wages or incompatible workload with the labor market; in short, to promote actions for valuing and recognizing nursing.

Theories of participatory democracy argue that “the political apathy of citizens is a pathology of the rise of representative democracy, because political participation is vital to democracy properly functioning”30 , as well as being an important instrument that authenticates and strengthens democracy, ensuring cohesion and equity. It can be noticed that the change in the interest and participation pattern in political issues occurred among Brazilians, generally not particpating in formal environments with political discussion visibility31 . Therefore, it is verified that this apathy is not exclusive to nursing, but a phenomenon of the current society, however, forceful in this category. According to the participants, there are no significant movements of struggles that give visibility to the causes of the category coming from practicing nurses.

Nurses do not see themselves as being necessary for the desired changes to occur, often attributing the responsibility to fight to the work organizations, and therefore are not mobilized. Engaged with their individual issues, they do not realize the potential for change that the union of the category enables. Great achievements are possible from adhesion to political movements, which leads the holders of the institutional power to perceive the strength of the professionals.

CONCLUSION

It is possible to consider that the gender and socioeconomic issues of nursing professionals negatively influence their participation of the category in the political struggles for labor accomplishments, from the perspective of these category leaders who were interviewed herein. The depoliticization, accommodation and social apathy are described as consequences of a sum of unfavorable characteristics which promote removal of the nurse-woman from the struggle movements and demands, favoring labor precariousness intensification.

The reduced participation of these women in political struggles is a multicausal and multifactorial phenomenon which crosses different areas of knowledge, covering collective and individual aspects. Understanding these relationships and interrelations is necessary to develop actions aiming to interrupt this cycle.

There must be partnership and mobilization of the category and of the work organizations to combat this perverse process via changes in the legislation, which are necessary to improve the quality of life to the worker and consequently excellence in the care provided to the population.

It is considered that strengthening the relations of the work organizations with the nursing workers, as well as developing actions in training and in-service education environments are capable of breaking this perverse and alienating system, as well as to promote changes in the appropriate legislations for reducing or extinguishing the precariousness of the working contracts/relationships and working conditions, giving security and labor guarantees for maintaining employment and quality of life at work.

The limitation of this study lies in the fact that it only occurred within the scope of Rio de Janeiro, and with only three nursing work organizations. However, it is understood that these limitations may serve as an incentive for new research, which could cover the entire national territory and investigate the other work organizations which fight for the rights of nursing workers and for better working conditions.

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*Extracted from the dissertation: “Lideranças da enfermagem e as lutas políticas contra precarização das condições de trabalho”, Universidade do Estado do Rio de Janeiro, 2018.

Received: June 19, 2018; Accepted: November 26, 2018

Corresponding author: Cristiane Helena Gallasch Boulevard 28 de Setembro, 157, 7º andar. CEP 20551-030 – Rio de Janeiro, RJ, Brazil cristiane.gallasch@gmail.com

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