From Discredited to Heroines: COVID-19 and the year that would be Nursing Now

The year 2020 was nominated as Nursing Now by the World Health Organization (WHO, 2019). Many nurses and midwives around the world were mobilized to advocate for the recognition of the profession and to promote fellowship events. However, in March, the WHO declared that the COVID-19 epidemic had become a pandemic – managed with physical isolation so as not to collapse the healthcare system – which generated an international health, economic and social crisis.

In this context, health professionals received a lot of attention from the media and the public. Instead of having a year of celebrations and planned awareness, in 2020, a virus unexpectedly made nursing visible and the responses ranged from applause and references to the heroic work of nurses¹ to violence against people in uniform in public transportation and lack of protective equipment to work. The crisis generated by COVID-19 has been described as a “magnifying lens”, as it exposes the problems of the neoliberal logic (competition and profit) applied to health, such as the cracks in the Brazilian hybrid healthcare system, fragmented between public and private institutions that do not work together, lack of public investments to serve the entire population, and precarious working conditions for health professionals.

Bearing in mind this new understanding that the crisis revealed, we reflect below on the future of nursing as the backbone of the public and private healthcare systems, where more than 2.2 million nursing professionals work, so that it is able to face the customaryBrazilian calamities and also the eventual crises that exclusionary neoliberal capitalism and climate change will continue to present. We believe that such professional stature will only be possible if three Rs are incorporated into the way nursing works as a team and how it is treated institutionally and socially; a NURRRSING profession with Recognition, Respect and fair Remuneration will be able to face the future, offering quality care. Using our professional trajectories as a background to make such considerations, we propose that 2020 should be the year that inaugurates a decade of transformations for nursing to be celebrated and for Brazil to have the nursing it deserves within a cohesive and sustainable healthcare system.

Recognition: The majority of the Brazilian population and health professionals themselves do not know the nature of nurses’ work. The centrality of biomedicine and medical treatments in the collective imagination often ignores or disqualifies nursing prevention, care and treatment. When we started our undergraduate education, we both heard “oh, what a pity, if she had studied more, she could have been admitted to Medicine”. After 12 years of higher education, not considering postdoctoral fellowships, we were still “just nurses”. In Brazil, nursing is still seen as a female occupation, performed predominantly by mixed ‘race’ andblackwomen or homosexual men, almost an intuitive practice, which does not require much knowledge (“anyone can give an injection”), where the prestige of everything done by the team is traditionally assigned to physicians.

To Recognize, our first R, means to carefully examine the professional category of nursing, to know its workers, the power dynamics and the dominant discourses that govern it in society and within the healthcare system, as well as the stigmas internalized by the professionals, analyzing their capabilities and limitations to seek a new professional and social order. Recognizing also means, for the multi-professional team, asking the different nursing professionals jobs related to their competences and sharing the merit of promoting or recovering health among all who performed the therapeutic work.

We believe that nursing is a profession of great value, the main source of life for the healthcare system, which is in contact with users 24 hours a day, requires high scientific training and continuing education, but whose fragmentation interferes with its recognition. In Brazil, few patients and family members are in contactwith a nurse, who does a lot more human and material resources management than caregiving, leaving the technicians and assistants (77% of the category)² to do what in other countries is done by those who have four years of university education. Nursinglabour division into three professional levels (behold – teams have already been divided into four professional groups) and its subordination to medicine is derived from colonialism, patriarchy and the Taylorist capitalist model applied to health, where one segment of the hospital sector aim at profits, in the case of the private system, and the other tries to contain costs, in the case of the public system.

As if this fragmentation that reflects social classes and racialization in Brazil was not enough, there is still the stigma internalized by the nurses, technicians and assistants that structure the relationships within the nursing team itself. A few decades ago, in order to distinguish nurses from other members of the nursing team, they were called “standard nurse”, what raises the question: Are the technicians and assistants “out of the standard”? Unfortunately, the “standard” of Brazilian nursing is classist, accompanied by low autonomy and remuneration, difficult working conditions, and little understanding of how such oppressions are reproduced in daily work relationships.

For example, in 2019, in a tense meeting with nursing and medical colleagues at the UFPel teaching hospital, one of the authors heard a head nurse express her frustration and unpreparedness to deal with institutional conflicts, complaining of minimal collaboration by the nursing team (nurses and technicians) with management. She said with conviction: “Nursing is all about trashy^a [in Portuguese someone who cannot afford to buy shoes]”. For those who are unaware of the social and cultural context of the city of Pelotas, regrettably we have to recognize the persistence of slavery cultural traces, patriarchal and elitist past, in fact, aligned with Brazil as a whole. Metaphorically, “trashy nursing” is poor, mixed ‘race’ or black and has no money to wear shoes in this chic city in southern Brazil, where the head nurses differ from “trashy” workers, accusing them of being “non-collaborative poor”.

Recognizing is being critical, but it is not victimizing or creating heroes. The recognition thatnursing professionalsdeserve requires discussing how the complexity of teamwork is permeated byneoliberal, elitist, racist, homophobic, sexist perspectives and other forms of discrimination that permeate society and the healthcare sector in Brazil. From our point of view, recognizing nursing means, for the nursing and the multidisciplinary teams, to understand the power relationships that are established inside and outside them, on what these relations are based and how they are reproduced in the daily work, inevitably affecting the population that needs nursing care.

Respect: Our second R, in Latin “respectus”, means to look again, “it is a positive feeling, and it means action or effect of respect, appreciation, consideration, deference”³. Usually the lack of respect for nursing work comes from the false perception that we only follow medical prescriptions, without intellectually contributing to the work; that manual labour is unworthy; that caregiving is predominantly disgusting and dirty; and, when done as a team, it is impossible to measure the results of nursing work for health promotion, rehabilitation and improving the quality of life of communities or patients and their families. Although in the individual experience of many assistants, technicians and nurses, there are many expressions of gratitude from patients and family members, socially and institutionally, the expressions of appreciation and consideration are limited. Most commonly, the experiences are disrespectful treatment, minimal value to nursing work, perceiving it as a cheap and disposable workforce, similar to the interchangeable gears of an industrial machine that works 24 hours a day.

The language used to refer to nursing often reveals disrespect for the profession. In the south of Brazil, the second author heard for the first time the expression “peniqueira”, which means a person who carries a bedpan for patients to urinate. To her amazement, she discovered that it was the habit of some physicians, teaching in a public university, to use the term when describing nurses and nursing technicians to medical students, causing laughter and reinforcing the inferiority of all nursing professionals.

The low prestige of nursing generates disempowerment, making assistants, technicians, and nurses unable to advocate for their own rights and those of the users of the healthcare system. The lack of respect with the know-how of a professional category can have harmful effects, as journalist Suzanne Gordon shows in the case of Korean airline co-pilots who did not have the power to differ from the pilots' opinion, resulting in more accidents than in other companies.⁴ If the opinions of the members of the nursing team are not respected by management and other professionals, how to prevent errors, iatrogenic practices or improve care for vulnerable patients? If you do not want an airplane co-pilot without a voice, why would you accept to be cared for by a nursing technician who cannot question the excess of patients assigned to her by the head nurse or question medical orders that do not seem consistent butadminister such medication? However, the population, in general, is still unaware of the concrete effects of lack of respect and what is behind nursing work, where there are many practices required to make healthcare safe.

In summary, respect for nursing work is closely related to professionals’ capacity for assertive discussion and change of the status quo, making their actions visible using judgement to reject the toxic hierarchy present in obsolete institutional management, as is the case of many healthcare institutions in Brazil. Collaborative interprofessional practices in healthcare teams and management can be an antidote to this toxicity, generating quality, effective and safe care.⁵

Remuneration: Our third R, means to reward for a job done but, as we know, the reward tends to be lower in mostly female professions, where work is not considered economically productive. In Brazil, in general, a woman receives 30% less than a man with the same qualification and experience. The mean salary for nurses, the best paid professionals of the team, varies according to the Brazilian region, but it is approximately R$ 3,500.00 per month, while other professional categories with a similar level of education and responsibility earn 3 to 4 times this amount (for example, engineers).

The rewards for preserving and promoting human life can include personal satisfaction and professional recognition, but are seldom accompanied by profit sharing, paid training opportunities, quality continuing education, user satisfaction awards or the creation of positions where professional development is valued and rewarded, among other formulas of remuneration in addition to salary. To attract and retain qualified professionals in nursing, it is necessary to improve salaries and job benefits given that nursing is such a demanding occupation.

CONCLUSION

In 2020, it was a virus that “made the party”, not the nursing professionals. Until the beginning of September, more than 350 nursing professionals in Brazil have died. In an unusual way, the year of nursing is being a year with expressions of appreciation. But, in addition to applause, we need recognition, respect and better remuneration for Brazilian nursing. To start, tensions within nursing teams and internalized prejudices must be discussed openly and strategies of humiliation and exploitation must be confronted.

If Brazil wants to promote health, care for and treat the population in an equitable manner, we will need a decade of investments in health and collaborative work among all who make up the national healthcare system, and its interfaces with the private system. Neither trashy “peniqueiras” nor heroines can offer what users and their respective communities need. NURRRSING is what the country and its healthcare system need if we are to achieve quality of care and sustainability.

• a
  Regional slang from Rio Grande do Sul of a derogatory character. It denotes something vulgar, uneducated, and crude.

REFERÊNCIAS

• ¹
  Einboden R. SuperNurse? Troubling the hero discourse in COVID times. Health (London). 2020;24(4):343-7. http://dx.doi.org/10.1177/1363459320934280 PMid:32538181.
  » http://dx.doi.org/10.1177/1363459320934280
• ²
  Machado MH, Aguiar Fo W, Lacerda WF, Oliveira E, Lemos W, Wermelinger M, et al. Características gerais da enfermagem: o perfil sócio demográfico. Enferm em Foco. 2016;7(N. esp.):9-14.
• ³
  Significados. Significado de respeito [Internet]. [citado em 2020 ago 10]. Disponível em: https://www.significados.com.br/respeito/
  » https://www.significados.com.br/respeito/
• ⁴
  Gordon S, Mendenhall P, O’Connor B. Beyond the checklist: what else health care can learn from aviation teamwork and safety. New York: Cornell University Press; 2013.
• ⁵
  Miró-Bonet M. Práctica colaborativa en salud: conceptos clave, factores y percepciones de losprofesionales. Educación Médica. 2016;17(Suppl 1):21-4.

Publication Dates

• Publication in this collection
  16 Dec 2020
• Date of issue
  2020

History

• Received
  08 Oct 2020
• Accepted
  15 Oct 2020