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Print version ISSN 1414-8145On-line version ISSN 2177-9465
Esc. Anna Nery vol.20 no.2 Rio de Janeiro Apr./June 2016
Sexist stereotypes in portuguese nursing: A historical study in the period 1935 to 1974
Gender may be understood as a historical construction, defined plurally and historically.
Historical investigation with a qualitative approach. The session diaries of Portugal's National Assembly and Corporative Chamber were used as a database for this study.
The findings configured the following analytical categories: the influence of the Armed Forces on the profession and military nursing, gender as a social formation, and nursing as a female area of work, exploitation of nursing work, gender as social formation and nursing as auxiliary knowledge, and nursing as a priesthood.
We assert the need to understand nursing as work, marked by historical and cultural contexts, such that it may be possible to think about paths towards the valorization and social recognition of the work of the nurse.
Keywords: Nursing; Gender identity; History; Feminism
Gender may be understood as a historical, social and plural concept, permeated by pre-definitions between the concept of female and male, socially and historically defined.It is the case that the idea of plurality regarding this concept would entail accepting not only that different societies have different concepts of male and female, but also that within a society such concepts are diversified, according to class, religion, race, age etc1.
In this sense, the concept of gender is influenced by social culture and the sexual roles established by the society, and it establishes how male-female, male-male and female-female relationships are to occur, and not only the male-female relationship, as the majority of studies have it. This corroborates the notion which postulates that social sex is the product of a permanent social construction which shapes, within all human societies, the organization of the social relationships between men and women2.
Gender, therefore, is the constitutive element of these social relationships based in the perceptible differences between the sexes, and is a first mode for giving meaning to the power relationships. In this regard, gender is not restricted to biological sexuated identity, but to the social construction as a male and female subjects, which are produced in relation, no longer fixed and immutable, but rather subject to all the historical-social transformations3.
In parallel, the action of caring for people has always been culturally linked more to women than to men, since the period before Christ, in ancient Rome and in the Middle Ages. The work of nursing was, in its origin, associated with female work and gender, was little valued socially, and was attributed to the role designated to women by the class society4.
Under this logic, thinking about socially and culturally defined gender, we can say that women have a series of experiences which "objectify" the construction of aptitudes and skills in the female field, caring for people being one of these. Girls receive dolls to care for, while boys receive cars to drive and balls to play with.
It is in this way that stereotypes are shaped, these are nonscientific generalizations regarding what is considered characteristic of each gender and are the product/producer of prejudices which often support the hegemonic interests. Due to their consequences, the stereotypes and prejudices related to gender stand out, and reverberate in sexist representations of women, which produce adverse effects in society and in women5.
In this social web, we identify the sexist stereotypes which occur since childhood and extend throughout life, with a series of predefined behaviors which apply to both men and women in a constant struggle for liberation6. In the present study, we have sought to deepen knowledge regarding the sexist stereotypes in Portuguese nursing.
In the theoretical field, this work is justified because it deals with a profession which is predominantly made up of women, who are little recognized or valued socially, and who routinely experience situations of work exploitation, prejudice, and low professional visibility.
Another question which adds to the justification is the low level of production on this issue. In research in the Virtual Health Library, eleven (11) studies were found which dealt with "sexist stereotypes", and only two (02) regarding "sexist stereotypes in nursing".
In the light of this, this article's guiding question is the following: What are the sexist stereotypes of Portuguese nursing in the period 1935 to 1974? The objective is to identify the stereotypes in nursing within the time limits indicated above.
In one time period, in the decades between 1930 and 1970, Portugal experienced one of the longest dictatorships in Western Europe, known as the New State, whose central figure was António de Oliveira Salazar. Some central characteristics may be emphasized: the censoring of means of social communication, and the creation of the 'Mocidade Portuguesa' (Portuguese Youth'),a young people's organization set up in 1936 with the aim of guiding youth towards the patriotic and nationalist values of the New State, and the removal of any and all 'demanding' character from the workers7.
In Portuguese literature, this long period between the military revolution of 1926 and the Revolution of 25th April 1974, known as the Carnation Revolution, was characterized by the constant ubiquity of political and police repression, a half century of censorship of the media and productions, rigorous suppression of fundamental liberties through a police system (PIDE), and special tribunals and prisons whose principal aim was the violation of the citizens' rights8.
In relation to the evolution of the health system in Portugal, it was marked by the ideology of charity, which imprinted in legislation a concept of medical-health care. The hospital was considered the central element of the health system, with the Houses of Mercy predominantly managing these activities, with an underlying philosophy which called for the nonintervention of the State in health problems9.
At the beginning of the 20th century, there were, in Portugal, two types of nurses: the religious ones, also known as congreganistas , and the secular, or 'lay' nurses. Records from the literature point to the inferiority of the nursing practiced by the religious nurses, due to the fact that they had no scientific knowledge; did not use clothes which were appropriate to the practicing of care; considered themselves to be missionaries, and in this regard imposed their beliefs and provided differentiated treatment to those patients who did not share these; were hierarchically subordinated to the abbess or abbot; showed arrogance in relation to technique and showed greater concern with saving souls than with relieving the patients' suffering10.
Regarding the understanding of the care practices at that time, their concept was almost always associated with a practice of charity, centered on self-denial and the forgetting of the I because of favoring the other; furthermore, it was compromised by religious, political and economic interests11.
At another point, the model of training in nursing was based on the Anglo-American model, which stipulated that the female students should have higher cultural and educational levels, similar to those of the young people undertaking higher education courses; that the training should occur over a relatively long period (three to four years); and that the placement should be undertaken under the supervision of lecturers who were nurses12.
This is corroborated by other authors when they indicate that, at this time, the aspects of the general culture were important for the performance of the profession, asserting that: "besides the vocation, the charity for the ill and the general notions of nursing, the nurse also needs general culture which allows her to exchange impressions with the doctor and with the patients"11.
It is valid to emphasize that the first school of nursing founded in Portugal, in 1881, was an initiative of Costa Simões, and was named the Coimbra Nursing School. It did not aim to prepare personnel to substitute the sisters of Charity in the hospital services; in reality, the hospitals of the University of Coimbrahad never been staffed by religious nurses.According to him, this endeavor was to give better instruction to the nurses and to train the establishment's staff to apply for the places13.
In this regard, the nursing training passes through certain difficulties, as in the case of the failure of the school for nurses in the São José hospital in Lisbon: "The course for nurses has not given the results expected, mainly because the individuals accepted for the hospitals are, in the most part, illiterate"13.
Remaining in this historical period, the literature researched returns to emphasize the training criteriain order to enter nursing education, with emphasis on: considering the nurse as the doctor's assistant, or as an auxiliary element of medicine; as well as having religious and moral values11.
This is a historical study with a qualitative approach, characterized as a study concerned with the past of Man and which consists of locating, assessing and summarizing, objectively, the facts, so as to obtain conclusions referent to occurrences in the past, specifically, to identify these stereotypes in Portuguese nursing, in the period 1935 to 197414.
This research proposal was originated based on articulations between the School of Nursing of the Federal University of Bahia, and the Coimbra Nursing School, for the undertaking of doctoral internships, when the Professor of the Portuguese institution indicated the possibility of analyzing the database of the diaries of the sessionsof Portugal's National Assembly andCorporative Chamber, in the period 1935 to 1974.
It is appropriate to emphasize that this last already had undertaken searches in this database of legislative acts, on the site of the Assembly of the Republic of Portugal, using the following words: nursing, (female) nurse, (female) nurses, (male) nurses and (male) nurse. A total of 1687 pages were selected from the diaries of the sessionsof the National Assembly and the Corporative Chamberof Portugal.
The data were collected in the period 13th April to 27th August 2015, when all the pages were read, and the texts which dealt with nursing or the professional nurse were extracted.
For the analysis of the findings, the method of content analysis was adopted, in the technique of thematic analysis, defined as a method of textual analysis which reduces the complexity of this, covering statistical techniques and the qualitative analysis of the research materials. This method allows us to reconstruct indicators and worldviews, values, attitudes, opinions, prejudices and stereotypes15.
The data analysis passed through three stages, namely:
Comprehensive reading of the material selected: we undertook the reading of the legislative diariesand selected the excerpts which dealt with nursing, male nurses, the male nurse, female nurses and the female nurse. These were inserted in a spreadsheet containing the identification data of the diary, the topic in which it fit, and the transcribed text.
Exploration of the material: when we attribute meaning to the transcribed excerpts, going beyond the accounts and the facts, emphasizing the principle topic of the paragraph or its theme.
Elaboration of the interpretive summary: at the time in which we gathered transcribed excerpts based on the theme to which they related, the following categories of analysis emerged: the influence of the Armed Forces on the profession, military nursing, gender as a social formation and nursing as a female field of work, exploitation of nursing work, gender as a social formation and nursing as auxiliary knowledge, and nursing as priesthood.
In this regard, we present the results by decade, purely for didactic reasons, although we understand history in a perspective of the Annales School, a social history which correlates the past, present and future in a chain of continuous and discontinuous occurrences.
|1935||[...] In the health service, the length of service referred to in condition 2 (To have a minimum of one year of service, subject to being appointed to a rank, at junior NCO level) of the present article may be undertaken either entirely or partially by junior NCOs, nurses or pharmacy staff. [...]||Influence of the Armed Forces on the profession and military nursing|
|1938||[...] Regarding the importance of introducing in the schools the practice of manual work, with a program of female and male works. [...] For girls, the practice of sewing and others is suggested [...] Given that women, when housewives, will need to know something of everything, cooking, sewing, nursing, the decorative arts, etc. [...]||Gender as a social formation and nursing as female field of work|
|1939||[...] That foreign missions may possess exclusive hospitals and health clinics [...] Nurses [...] in good conditions so as to more efficiently obtain their aims.[...]||The exploitation of nursing work|
|1941||[...] It is said that the financial situation of the male and female nurses is very poor [...]The time taken by the nurse to arrive in a leadership position [...] in the best of cases is three years [...]The nurse will work, dedicated to serving his fellow man, risking his health amid unhappinessand subject to contagions for approximately 13 years in order to reach the position of chief nurse, earning the same amount – apart from deputy chiefonward - as a porter or some servants.[...]||Exploitation of the nursing work|
|1944||[...] Emphasizes that these women who undertake nursing in hospitals offer an example of self-denial which professionals rarely reach, even the best. [...]||Nursing as Priesthood|
|[...] the need to train more female nurses with severity of recruitment, the discipline and the moral environment of the corporation in which they entermay kindle within them the spirit of tender devotion [...]||Influence of the Armed Forces on the profession and military nursing|
|[...] A visiting nurse who, as well as social work and visiting, will assist the doctors of the various departments.[...] [...]A visiting nurse who will assist the doctors of the various departments[...]||Gender as a social formation and nursing as auxiliary knowledge|
|1945||[...] That in the female nursing services of this hospital, in the future, only single female candidates, or widows without children, will be admitted [...] Those who presently do not have children will have to cease hospital work [...] when in the future they come to have them [...] and when they marry.[...]||Nursing as Priesthood The exploitation of the nursing work|
|[...] There are male nurses who normally work 12 hours and sometimes up to 19 hours in 24 [...] This being because they are married and have two children and receive a[...] family allowance. In a ward with 120 – and sometimes more – patients, during the night there may be one assistant and one nurse, who receives generously two decilitersof coffee during the night, but nothing to eat, as this staff do not have the right to a meal.[...]||The exploitation of the nursing work|
|[...] Regarding the training of the nurses, it is very complex; it involves principally two trainings: the technical training and the moral training [...]It is asserted that not having morals causes inconveniences which are immensely greater than not having technique. [...]||Nursing as Priesthood|
|[...] Such that each rural boroughmay possess at least one first aid station, under the leadership of an honest and competent male nurse, directly subordinate to the council doctor. [...]||Nursing as Priesthood|
|1951||[...] They impede marriage for the hospital nurses, stating that nurses who are wives or mothers will sacrifice to the heavy schedules of the hospital work [...] The legislator does not judge this to be compatible with the duties of the wife and mother [...] Promotion is prohibited to these nurses whose work is mitigated due to their being married. [...]||Nursing as Priesthood|
|[...] argued in favor of revoking the law which prohibited nurses from marrying and those who have children, such as widows, from exercising the profession. He judges the law to be anticonstitutional, wounding the family institution, and leading to abortions and that not even the Church itself agrees, as there have been cases of nurses marrying illegally. [...]|
|1952||[...] Yet again, in the debate, emphasis is placed on the positioning of the nurse-manager, who is always forbiddingthe attending of these patients. [...]||Influence of the Armed Forces on the profession and military nursing|
|1954||[...] The main homage made is directed to D. João de Deus, a notable figure as priest and missionary [...] who, in the hard hours of the war, was a selfless nurseof souls and bodies.[...]||Nursing as priesthood|
|[...] as dedicarted nurseswho care for bodies without forgetting the souls. [...]|
|[...] An appeal was made through the press, radio and television for unoccupied girls and women to help the nurses in the hospitals which are short of staff.[...]|
|1955||[...] The orator continues to discuss the right of the womanto exercise any function outside the family, such as education and teaching, social services and nursing [...]||Gender as a social formation and nursing as a female field of work|
|[...] A nurse, who will help the doctor and undertake his instructions for the treatment of the patients [...]||Gender as a social formation and nursing as auxiliary knowledge|
|1956||[...] In effect, the nurse needs to have knowledge of anatomy, physiology, pharmacology, pathology, hygiene etc.[...] so as to understand well the reach of the doctor's instructions [...]||Gender as a social formation and nursing as auxiliary knowledge|
|[...] Relationship of nursing with Self-denial. According to the orator, lay nursing, in the French Revolution, drove awaycharity [...]||Nursing as priesthood|
|[...] The importance of the Nursing actions, the history of Nursing based in charity and the priesthood.[...]|
|[...] The reason for this shortage of nurses: The lack of schools and the paywhich does not correspond to the intellectual level and the sacrifice required. [...]||Nursing as priesthood The exploitation of the nursing work|
|[...] Psychiatric nursing, said to be essentially specialized, continues to require virtue, civic-mindedness and, increasingly, a high professional level and high moral training of its professionals. [...]||Influence of the Armed Forces on the profession and military nursing Nursing as Priesthood|
|1967||[...] (speaking of the shortage of staff and overloading of work) making the profession harder and, certainly, the care for the patient less efficacious [...]||The exploitation of the nursing work|
|[...] In dealing with voluntary female military service, it is foreseen in the proposal that women also may be admitted to undertake military service, as volunteers. [...] It is suggested that women may be called to care work in the rearguard with the wounded and ill [...]||Influence of the Armed Forces on the profession and military nursing|
|1968||[...] Does not understand that women may kill, but understands that they may relieve suffering [...] as nurses. [...]||Gender as a social formation and nursing as female knowledge|
|1970||[...] The position of deputy chief nursewas being undertaken by an auxiliary nurse, and in other cases these jobs were empty [...] It was revealed that the lack of professionals is caused because many go abroad, others marry and leave the profession, retire, and move to private healthcare centers, because these pay better [...]||The exploitation of the nursing work|
|1971||[...] The lack of nurses for providingcare necessary to the patient [...] removal of general nursing staff to management roles [...]||Gender as a social formation and nursing as auxiliary knowledge The exploitation of nursing work|
In didactic character, we shall discuss the thematic topics in sequence from the greatest to the least in occurrence.
In the thematic axis exploitation of the nursing work, the quotes tabulated reveal a team of nurses who are subjected to poor working conditions, low salaries, overloading of work and a subhuman work schedule, resulting in the marginalization of the profession.
In relation to this, we observe that the work in nursing first appears as essentially female and, as such, in a patriarchal society, suffers oppression, domination and marginalization. The situation is expressed in the conditions of work in nursing, grounded in the enormous fragility of the struggle for better working and living conditions, in the low rate of trade union membership among women, in the alienation, in the lack of a political tradition among women, in elitism, submission, lack of class awareness (female nurses do not consider themselves to be workers), acceptance of the situation and ignorance16.
More recent studies have emphasized that Portuguese nursing, like nursing worldwide, is marked by many of these shortcomings: poor housing conditions, food, salaries, education and instruction, in which our male and female nurses live, it being necessary to promote a campaign for greater and better recruitment of nursing staff, improving the worker for exercising the profession11.
In the data found in the category 'influence of the Armed Forces on the profession and military nursing', we observe that the insertion of the woman in the military service occurred with the aim of obtaining voluntary and charity work, considering the expansionist and economic interests, expressed in the value of the social corpus of a soldier.
However, it is considered that the military organization emphasized the most elementary contributions of nursing, placing emphasis on the action of supervising patients. On the other hand, it marked this profession in a singular manner, in particular resulting in the social division of the work, and the separation of the knowledge and the doing, resulting in the devalorization of the nurse's care.
Other authors corroborate this in asserting that nursing is heavily influenced by the military organization, in particular with the principal of the unit of command, found in the linear organization, whose origins are in the Army and in the medieval period, being reflected in the dichotomy between thinking and doing in nursing17.
In this regard, for some authors, the social division of the work begins in this period. The work of nursing is provided by a matron (the female element to direct the nursing work) and the sister (for the women in charge of the ward), a division inspired in the military organization and the religious hierarchy, a reference dating from the colonial period.
Another relevant aspect was to emphasize the military nursing school, termed here as military training in Nursing. Many records dealt with the contribution of the military institutions to recruiting and training nurses to work in the wars or help in the colonial role of a country - in the case of Portugal, there are these two records.
Of the aspects found in this analytical category, gender as a social formation and nursing as auxiliary knowledge, we observed that nursing is seen as an auxiliary and collaboratory practice which can be molded at the mercy of the interests and gaps of the service.
Some authors assert that, regarding nursing, as well as being seen as a secondary structure, the inequality with medicine is accentuated by the fact that it has a history linked to doing, de-articulated from theorization and a systematic and scientific training and, as a consequence, the strongest result is the devalorization and lack of prestige of the profession in relation to medicine18.
However, the work of nursing, demanded by the advance of technology in hospitals and epidemics, needed its own technical-scientific knowledge, and the appropriation of this knowledge allowed the State to understand the impact of this professional on the health services and systems, so as to meet the population's health needs.
It is worth emphasizing that, in spite of this understanding, the legislative acts sought to assure the medical hegemony and the submission of nursing, having this last as an auxiliary practice, exploited by the medical category, so as to ensure its economic and professional interests.
Regarding the thematic axis of gender as a social formation and nursing as a female field of work, we note that the call for workers was always geared to the female, as well as to the induction of the woman to actions held as "domestic", for example, for care.
Some authors hold that the identification of nursing with these activities, held as feminine, is a fallacy, as is also its explanation that it results from an "impulse" of the woman who identifies with a "maternal instinct", as an instinct for conservation of the species present even in animals18.
She - the author - says that this assertion is a myth. Women are not born mothers but, rather, human beings of the female sex, and the roles that they occupy in society are constructed dialectically based on their own historical-social conditions18.
These findings reinforce that nursing appears first as a female profession, determined by a series of economic and social interests, such that it was held as a devalorized, submissive and exploited practice, so as to meet the interests of the economic and political system in power at that time.
Finally, we find as an analytical category nursing as a priesthood, with great occurrence of citations which reported nursing as a dedicated, charitable, moral and selfless practice. For example: the demand that women contracted to work as nurses should be single and without children, excluding those married with children, and widows.
This determination resulted in the occurrence of abortions and illegal marriages among nurses, and on the other hand served as an agent of vulnerabilization of the women exploited by the state and health services.
We perceive that, to the extent that it is prohibited to constitute a family due to the rationale that it is impossible to conciliate the work as a nurse with the condition of being a wife, to some extent, this denotes the high degree of exploitation of these workers, there being similarity with slave labor.
We observe in the legislative findings that a significant number of women interested in exercising nursing had, in reality, interest in the benefits linked to the training period, such as a home, the provision of meals, and the possibility to study.
These influences are impacted by the training itself;in Portugal, many of these schools were supported by religious orders or private foundations, with training centered on mastering the practice in the first part of the Course. Emphasis was placed on manual dexterity and expertise, and the nurse was to be a mix of kindness, skill and obedience13.
However, in Portugal, there was the juxtaposition of two types of nurses: the religious or congreganistas and the lay or secular nurses. Academics have warned regarding the inferiority of the nursing practiced by the religious nurses, given that they did not have scientific knowledge; did not use clothing appropriate to the practicing of care; regarded themselves as missionaries, and in this regard imposed their beliefs and provided differentiated treatment to the patients who did not share these; that there was incompatibility between their duties as religious persons and as nurses; that they were hierarchically subordinate to the abbess or abbot, which impeded the selection of the most competent nurses and the maintaining of stability and quality of the care in the wards; that they revealed arrogance regarding techniques; exercised the profession without qualification; showed greater concern with saving souls than with relieving patients' suffering, and worked out as more expensive than the lay nurses10.
All these questions are linked to the sexist stereotypes, to the social role stipulated for the woman and for the man, and determine and contribute toa professional practice in nursing which is alienated and subjugated by economic interests of domination, oppression and marginalization.
In this regard, identifying the nurse with the stereotype of 'Angel' is a way of reaffirming an identity which, distant from the professionalism and from a position of political engagement, keeps her as a being exercising a sacred occupation and serves to distance her from the professional aspect. This attitude, moreover, serves to justify and/or maintain the low salaries and inferior social status which has marked nursing throughout its history18.
Once more taking up the research question, what are the sexist stereotypes in Portuguese Nursing in the period from 1935 to 1974? We observe that these stereotypes permeate the social and cultural construction of the woman, and, in particular, mark nursing as an auxiliary and exploited practice, represented in the figure of the angel.
We perceive that this study's findings corroborate the existing studies, however, they revealed specific characteristics of Portuguese nursing between the 1930s and 1970s, which are important for understanding and overcoming the historical trajectory of nursing.
We assert the need to understand nursing as work, marked by historical and cultural contexts, such that we may think about paths for the valorization and social recognition of the nurse's work, it being evidenced that the history of women in society may overlapwith the history of nursing, and that the parts constructed were demarcated by political, economic and cultural interests.
Thus, we perceive that nursing was first appeared as auxiliary work, without a scientific basis; this became a profession which is essential to the health services and systems, shaping a complex and distinct body of knowledge, bringing together knowledges from various areas, impacting on the populations' health needs.
Finally, we express our thanks to the Coimbra Nursing School, in the district of Coimbra, in the Central Region of Portugal, which provided the opportunity and encouraged the undertaking of this study, and to the Coordination for the Improvement of Higher Education Personnel (CAPES), which financed this study through the Doctoral Program with Sandwich Abroad (PDSE).
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Received: October 06, 2015; Accepted: January 19, 2016