Brazilian nursing and the COVID-19 pandemic: inequalities in evidence

Abstract

Objectives

to reflect on the inequalities that affect Nursing in its historical trajectory and that are accentuated during the COVID-19 pandemic.

Methods

critical-reflective method based on historical-dialectical materialism. Positions of Nursing class entities, epidemiological bulletins and news about the work context of health professionals were analyzed since March 2020.

Results

issues about the inequalities and hierarchies specific to health teams were discussed, in view of the perspectives of class, gender and race/ethnicity that exert an impact on the Nursing profession and health work and that are accentuated in the context of COVID-19. The impacts of the pandemic expose the devaluation of the Nursing work, evidenced by the social invisibility of the category and the precariousness of the life of those who exercise it.

Conclusion and implication for the practice

It is urgent and necessary to recognize that the inequalities aggravated by the pandemic are part of a structural condition of society, and that it directly affects Nursing workers. Furthermore, it is opportune for Nursing to profile struggles with civil society in the egalitarian defense of justice, for universal social protection and in overcoming the structural drivers of inequalities.

Keywords:
Nursing; Unified Health System; Occupational Health; Coronavirus

Resumo

Objetivos

Refletir sobre as desigualdades que afetam a Enfermagem em sua trajetória histórica e que se acentuam durante a pandemia da Covid-19.

Métodos

Método crítico-reflexivo com aporte no referencial do materialismo histórico-dialético. Foram analisados posicionamentos das entidades de classe da Enfermagem, boletins epidemiológicos e notícias sobre o contexto de trabalho de profissionais da saúde, desde março de 2020.

Resultados

Foram discutidas questões acerca das desigualdades e hierarquias próprias das equipes de saúde, tendo em vista as perspectivas de classe, gênero, raça/etnia que impactam na profissão de enfermagem e no trabalho em saúde e que se acentuam no contexto da COVID-19. Os impactos da pandemia expõem a desvalorização do trabalho da enfermagem, evidenciada pela invisibilidade social da categoria e pela precarização da vida de quem a exerce.

Conclusão e implicação para a prática

Torna-se urgente e necessário reconhecer que as desigualdades agravadas pela pandemia fazem parte de uma condição estrutural da sociedade que afeta diretamente trabalhadoras e trabalhadores da Enfermagem. Ademais, torna-se oportuno a enfermagem perfilhar lutas junto a sociedade civil na defesa igualitarista de justiça e pela proteção social universal e na superação dos condutores estruturais das desigualdades.

Palavras-chave:
Enfermagem; Sistema Único de Saúde; Saúde do Trabalhador; Coronavírus

Resumen

Objetivos

Reflexionar sobre las desigualdades que afectan a la Enfermería en su trayectoria histórica y que se acentúan durante la pandemia Covid-19.

Métodos

Método crítico-reflexivo basado en el materialismo histórico-dialéctico. Se analizaron posiciones de entidades de clase de enfermería, boletines epidemiológicos y noticias sobre el contexto laboral de los profesionales de la salud desde marzo de 2020.

Resultados

Se discutieron cuestiones sobre las desigualdades y jerarquías propias de los equipos de salud, en vista de las perspectivas de clase, género, raza / etnia que impactan la profesión de enfermería y el trabajo en salud y que se acentúan en el contexto del COVID-19. Los impactos de la pandemia exponen la desvalorización del trabajo de enfermería, evidenciada por la invisibilidad social de la categoría y la precariedad de la vida de quienes la ejercen.

Conclusión e implicación para la práctica

Es urgente y necesario reconocer que las desigualdades agravadas por la pandemia forman parte de una condición estructural de la sociedad y afectan directamente a los trabajadores de enfermería. Además, es oportuno que la enfermería perfile las luchas con la sociedad civil en la defensa de la igualdad y la justicia, por la protección social universal y la superación de los impulsores estructurales de las desigualdades.

Palabras clave:
Enfermería; Sistema único de Salud; Salud Laboral; Coronavirus

INTRODUCTION

The pandemic of the new coronavirus (SARS-CoV2), which causes COVID-19, declared by the World Health Organization (WHO) on March 11^th, 2020, mobilized health professionals around the world to fight against it. Disease control significantly highlighted the essential role that these workers play in protecting people's lives and strengthening the health systems.

Nursing stands out among the professions that work to fight against the pandemic, with comprehensive care actions for infected people, prevention measures, and health education practices that involve technical-scientific and humanization aspects.

Prior to the pandemic, 2020 was declared the “Year of Nursing”, with the launch by the WHO of the campaign to value the professional category called “Nursing Now” ¹. In that same year, global Nursing puts itself to the test in the fight against the pandemic, not only because of its technical capacity, but also for being the largest health professional category, which is 24 hours a day managing and providing continuous assistance to people who present from mild symptoms to severe conditions resulting from the disease, acting at all levels of health care complexity.

Despite the significant number of Nursing professionals in Brazil, nearly 1.7 million among nurses, technicians and nursing assistants, this number was not sufficient in view of the population's care needs at this moment^2,3. The pandemic underscored that “nurses are the backbone of any health system”, as stated by the Director General of the WHO. With this, we witness the call of Nursing students and teams from other sectors of the services to contribute to urgencies and care in intensive care beds.

On the so-called front line, Nursing professionals are more exposed to the risk of infection by coronavirus, as evidenced by the percentage of the category affected in view of the number of infected health workers.

The epidemiological bulletin of the Ministry of Health (Ministério da Saúde, MS), referring to epidemiological week 11 (between March 14^th and March 20^th, 2021), pointed out that, among the confirmed cases of the COVID-19 Flu Syndrome in health professionals, the most recorded professions in descending order were nursing technicians/assistants, followed by nurses, physicians in sequence and other professionals such as pharmacists, community health agents and receptionists of health units. Of the deaths due to Severe Acute Respiratory Syndrome (SARS), the professional categories that prevailed most frequently, since the first year of the pandemic, were nursing technicians/assistants, physicians and nurses⁴. It is to be noted that these data reflect a selection of severe cases in these categories, and do not show the total number of people affected by the disease in the country.

An article published in a national newspaper presents the scenario of confirmed cases in Belo Horizonte, and points out that nursing technicians are infected three times more than physicians in the municipality of Minas Gerais⁵.

Regarding the mortality of nursing professionals due to COVID-19, the greatest preponderance of death records analyzed in Brazil until the first quarter of 2021 were mostly in the Southeast region, with nearly 28% of the deaths. Since the beginning of the pandemic, the states of São Paulo, Amazonas and Rio de Janeiro had the highest number of deaths. Female professionals and age group between 41 and 50 years old comprise the profile with the highest mortality, according to data presented by COFEN's Nursing Observatory.⁶ The data show that March 2021 was recorded as the most lethal month of the pandemic also for nursing professionals, with 83 deaths. However, there was a sharp drop, of nearly 71%, in the number of deaths among nursing workers in April this year, which can be attributed to the vaccination of health professionals, initiated in January 2021⁷.

Faced with such a disastrous context, we have the opportunity to publicize the debate on the situation of nursing workers and the possibility of reflecting on the professionalization of Brazilian Nursing, exposing the inequalities that the category is subjected to in its historical trajectory and which are accentuated in the fight against the COVID-19 pandemic.

We are faced with a scenario in which working conditions, low pay, insecurity, work overload, difficulty in accessing personal protective equipment (PPE), and precariousness in teaching and qualification of professionals are still challenges to be overcome.

Centrally, we face the need to formulate policies that are sensitive to care work, mostly carried out by women, recognizing their specificities and inequalities in society.

Therefore, the impacts of the pandemic also expose the devaluation of the Nursing work, evidenced by the social invisibility of the category and the precariousness of the lives of those who exercise it.

In a systematic study of international scientific productions, the authors⁸ indicate that the publications analyzed on health work in the pandemic “do not include the analysis of the inequalities and hierarchies of the health team”. This article intends to contribute to such analyses, considering the categories of class, gender, race/skin color/ethnicity that exert an impact on the Nursing profession and on health work.

Thus, the study proposes to reflect on the inequalities that affect female Nursing workers in Brazil in its historical trajectory and that are accentuated during the COVID-19 pandemic.

METHOD

This is a reflective-critical text, guided by the perceptions of nurse researchers and the understanding of social inequalities, as described by Santos⁹, as a result of the systemic articulation between capitalism, colonialism and patriarchy, which generate the society of classes and sustain the exploitation of the working class throughout the Brazilian history. The author states that “[...] the structural conflicts of our time result from the unequal and combined articulation [of these] three main modes of structural inequality in modern societies”.

The authors draw on theoretical frameworks of historical-dialectical materialism (HDM) to explain how gender, race and social class are interpretive categories that overlap in understanding the phenomenon of the socio-historical inequalities in Nursing.

An interpretive category allows capturing and interpreting a certain objective reality, defining operational axes or cuts of a phenomenon under analysis¹⁰. Thus, when we focus on the categories of gender, race and social class, we recognize the existing dialectic across these categories, that is, the social relations of race, gender and social class that determine the phenomenon of inequalities in Nursing.

As a procedure, the following was analyzed: the positions of the Nursing professional associations, epidemiological bulletins and news dealing with the work context of health professionals, which circulated in the main communication vehicles in the country since March 2020, when the pandemic began.

Based on the understanding that knowledge production is not separated from social reality¹¹, the experience of the authors, nurses, women, working in the field of teaching, research and direct health care, was used to support the discussion.

RESULTS AND DISCUSSION

Nursing and the historical and persistent conditions of inequalities

The Nursing team represents 59% of the human resources in health in the world, totaling 27.9 million professionals, making it the largest occupational group in this sector¹.

In Brazil, Nursing represents the leading workforce in the health sector, corresponding to 50% of the 3.5 million workers in the area, in addition to comprising the second largest workforce of all sectors in the country. In addition to that, it is a professional category with wide capillarity in different health fields and services, operating in the public and private sectors, present in all municipalities and strongly inserted in the Health Care Network of the Unified Health System (Sistema Único de Saúde, SUS) ².

Nursing is configured as a social practice, for developing an activity by and for people, meeting the needs of the social being; a profession, as a field of specialized actions in health, with qualified workers and mastery of specific knowledge; and a discipline, for producing knowledge that supports their care¹².

Historically, the Nursing knowledge framework was developed mostly by women, recognized as pioneers and responsible for the creation and systematization of the profession¹³. Women represent 85.6% of the total number of Nursing professionals in Brazil, according to the 2015 Nursing Profile. Another feature of the sociodemographic profile that stands out in the analyses of this workforce is that more than half are black-skinned people (black and brown), mainly among high school professionals^2,14.

The sexual division of work in health marks the profession, as care is attributed as a female activity, associated with “vocation”. On the other hand, the domestic and private nature associated with care contributes to the social invisibility and low remuneration of Nursing¹⁴. According to Silvia Federici¹⁵, even reaching the public work sphere, women still remain mostly in occupations that reproduce roles assigned to the female gender:

Everywhere we look, we can see that the jobs performed by women are mere extensions of the housewife condition in all its facets. Not only do we become nurses, maids, professors, secretaries — all the roles we've been trained for at home — but we're in the same kind of relationship that makes our struggle at home difficult: isolation, the fact that other people's lives depend on us, the impossibility of seeing where our work begins and where it ends, where our work ends and where our desires begin^15:50.

In the same context of the historical conditions of working women, especially in the so-called Global South, the Nursing professions, consisting of nurses, nursing technicians and nursing assistants, were consolidated under the influence of the practices of Colonial Brazil, in which black- and brown-skinned women fit the care and cure actions. Subsequently, it was institutionalized by a technical and social subdivision of work, based on the installment of assistance actions according to the levels of educational training and qualifications, and supported by the shield of elitization and whitening of the profession with the image of the white-skinned “Standard Nurse”, of an elite social class¹⁶.

The technical division of work in Nursing took place in a context of racial hierarchization, in which black-skinned women, when necessary to expand the care work in hospital institutions, were given access to professional training based on technical education. On the other hand, “white-skinned and family” women were granted access to higher Nursing education, as shown by historiography, since the first school in Rio de Janeiro, in the late nineteenth century.¹³

Since its genesis as a profession in Brazil, racial division was unveiled in the selection processes of who should be aspiring to be a “qualified nurse”, whose profile described privileged the entry of young white-skinned women from urban and educated middle classes, with black-skinned women, who wished to exercise the profession, in the role of health visitors¹⁷. Such questions make clear the relationship between race, gender and social class that determine the oppression experienced in health work and, especially, in Nursing.

It is important to recognize that the division of work in Nursing is determined by production relations in which different social classes occupy different positions in the explorer-explored dialectic. In these relationships, Nursing as a social class carries within itself the marks of inequality with workers who occupy exploration places. However, Nursing also lives with an internal bipolarization¹³, a cleavage that arises from the distinct position of white- or black-skinned women within work. In this cleavage, we have social agents who occupy themselves (in the sense of doing) and occupy (as a consequence of this doing) positions of lesser appreciation, greater subordination and, therefore, greater exploitation, even though there is a hierarchy within the profession. Thus, we can argue that this is an apparent hierarchy since, from the social class point of view, they are agents subjected to the exploitation of the workforce, which, ultimately, is determined by the capitalist production mode.

Given the rescue of such historical processes, it becomes evident that ethnic-racial and gender issues are at the base of the way in which the maintenance of relations of exploration, oppression and the erasure of the struggles of workers in the field of Health and Nursing is determined. Thus, it is understandable that the consequences of the social and sexual division of work and structural racism determine the composition of Nursing as a workforce.

In recent years, in the global labor market and in Brazil, we have experienced a marked precariousness of formal work, with new forms of hiring, lower wages, flexibilization of labor rights, extension of working hours and increase in unhealthy and dangerous working conditions, among other ways¹⁸. More recently, we have experienced the dismantling of the labor laws in Brazil, the permissions for new forms of hiring and providing services, especially the so-called uberization of labor relations¹⁹.

In the context of Nursing, there is also the risk of this uberization of the profession. A number of studies show that there are signs of underemployment in this category, characterized by the presence of professionals who work with no regularity or a few hours a week, without an employment contract, or even those who receive income far below what is due for their functions established by the labor market, configuring subwages. In addition, there are the heavy and extensive workloads, with shifts of over 40 hours extending up to 60 hours a week^20,21.

Historically, the entities representing the category seek measures that can guarantee the protection of professional performance with quality and safety, including equal remuneration conditions and regulation of the working hours.

For nearly 20 years, Nursing has been struggling for the approval of bill No. 2,295/2000, which provides for the regulation of the workday to 30 hours a week, as recommended by the WHO and the International Labor Organization (ILO) for the health area. This struggle is due to acknowledging that long periods of work are associated with illness in the professionals and compromise the provision of safe and quality care. It is noteworthy that the reduction in working hours has already been achieved by other professionals in the health area, such as physicians (20 hours a week/four hours a day, since 1961), physiotherapists and occupational therapists (30 hours a week/six hours a day since 1994) and social workers²².

Additionally, the definition of weekly working hours must be accompanied by adequate remuneration, so as not to increase the need for more than one professional contract, as is already the case among most Nursing workers. Thus, the regulation of the working hours and the definition of the wage floor were configured as needs for the protection of the workforce of this professional category²³.

Quality educational training is also a challenge for Nursing. From 2001 to 2011, there was a 393% growth in the offer of Nursing courses in the private sector and 122% in public education, which was accompanied by a process of precariousness in teaching with intensification of the teaching work and damage to the organizational and didactic practices^24,25.

In order to guarantee an adequate level of teaching in Nursing, the opening and creation of new courses must be regulated by an assessment by the Ministry of Education (MEC), as is the case for the Dentistry, Medicine and Psychology courses. In addition, the training process of the profession must be rethought, not only to meet the needs of the labor market, but to be able to prepare professionals with indispensable skills and abilities for safe care and for the transformation of the work reality of their category. For this, the articulation between teaching, research and extension should be the guiding axis of the Nursing educational training process²⁶.

Nursing Inequalities in Confronting the Pandemic

In the current context of the pandemic, the inequalities faced by Nursing workers are even more aggravated, especially when compared to other professional categories in the health sector^27,28.

Until December 20^th, 2020, in its observatory of Nursing professionals infected with COVID-19, the Federal Council of Nursing (Conselho Federal de Enfermagem, COFEN) reported more than 45,000 confirmed cases and 469 deaths due to COVID-19. In addition to that, there is also underreporting, due to the scarcity and lack of access to tests to diagnose the disease^6,7.

The characteristics of comprehensive care in the work process of this category, such as the volume of procedures, longer contact with infected people and contaminated surfaces, including the handling of hospital equipment, admission of patients to the service, and even body care after death and long working hours increase exposure and, consequently, the infection risks^29,30.

Safety conditions at work should be guaranteed through institutional measures to help fight against the new coronavirus. However, problems such as the chronic underfunding of the SUS, freezing of spending in the sector in recent years, deterioration of services and precariousness of the workforce, point to the challenges that are presented to health work management, given the necessary expansion of services in a pandemic context⁸.

The inequalities currently experienced by Nursing are related to poor access to personal protective equipment (PPE), to the scarcity of human resources for the correct sizing of teams, and to the presence of professionals over 60 years old or with chronic diseases. These are exposed to contagion, in line with the Ministry of Health's recommendations, with a need for labor lawsuits in several cases across the country for the distancing of professionals in this category belonging to the risk group³¹.

In a publication in its official organ, the COFEN released more than 4,000 complaints since the beginning of the pandemic in the country. Reports and complaints are mainly related to the rationing and hierarchization of the distribution of PPE, shortage of professionals, lack of testing and professionals belonging to risk groups in direct patient care, among others. These conditions, present in the daily lives of Nursing professionals, are frequently reported in the media, such as the reality of a Brazilian municipality where the professionals in the vaccination room used homemade masks at the beginning of the pandemic, due to lack of adequate PPE, and whose situation was only reversed after a complaint to the union and the category council³².

In view of the wage distances, health professionals with greater purchasing power were the first to protect themselves by purchasing their own PPE, unlike the situation in Nursing, which had to wait for the provision of supplies by the employers. There is also insufficiency and poor quality of PPE, when they are distributed, leading to a longer use period than recommended. Added to this are the difficulties of timely preparation of the team regarding the proper use of these PPEs and the inadequate infrastructure of the health services, increasing the possibility of infection during degowning³³.

The segregation faced by this category is also visible in the physical spaces of the health services intended for Nursing professionals to rest, which are not suitable for distancing measures. In addition to that, nurses in the pandemic are more exposed to stigmatization, physical and psychological violence⁸.

It is noteworthy that Nursing professionals are responsible for the management, coordination and assistance of the health services and are even more necessary in a pandemic. However, they suffer from the flexibilization of labor laws and low pay, also at this moment, in emergency hiring processes, with a glaring wage inequality, for example, between physicians and nurses. Therefore, these low wages are compensated with professional connections in different health services, which lead to exhausting working hours and increased exposure to the virus²⁰.

Another point to be highlighted refers to the chronic problem of human resources development, such as lack of permanent education programs, which leads to an increased risk of infection and the teams' lack of preparation to deal with suspected and confirmed cases.

According to the World Health Organization, worldwide, up to 15% of the health workers may be infected with the SARS-CoV-2 virus. Brazil is the country with the highest number of recorded deaths and absences from work due to COVID-19, surpassing the United States, which was the most affected by the coronavirus pandemic³⁴.

It is important to emphasize that the systematization of information about the working conditions has the potential to provide tools for coping with the inequalities experienced since before the pandemic and which were incited by such a situation. Such information must be produced in order to consider the characteristics of gender, race/skin color/ethnicity, territorial distribution and work modalities in which the category is inserted.

Therefore, it is urgent and necessary to give visibility to the complaints about the working conditions, as well as to encourage the participation of representatives of the category in public policy management instances such as health councils, intersectoral commissions, negotiation tables and other spaces that were necessary.

Thus, it is necessary to formulate policies and adopt measures that are capable of ensuring safe Nursing work, a greater workforce in the health system, essential for fighting against the pandemic, consequently reducing the social and economic impacts caused by the distancing of these professionals. After all, “[...] health care quality also depends on the way in which the system faces the workers' needs and subjectivity in the performance of their tasks”^35:473.

FINAL CONSIDERATIONS

In view of the inequalities suffered by Brazilian Nursing workers, herein described and analyzed, we understand that there is an urgent need to formulate historical reparation policies such as:

1. 1

   Establishment of a wage floor and regulation of labor relations with guarantee of a contract and basic labor rights;

2. 2

   Approval of the 30-hour weekly workload Regulation project;

3. 3

   Conduction of public tenders to eliminate precarious work contracts in the public sector;

4. 4

   Implementation of effective actions of the National Occupational Health Policy, with the establishment of these policies at the state and municipal levels;

5. 5

   Adequate ambience in spaces for the care of people and also in spaces for these professionals to rest and eat;

6. 6

   Appropriate sizing of the teams, according to each sector's needs.

However, facing the historical and persistent inequalities, aggravated by the pandemic, requires that we recognize them as part of the Brazilian socioeconomic conformation that directly affects Nursing. This recognition must allow us to highlight the causes and fight for a fairer society in which Nursing workers have their rights to work and to live with dignity preserved.

Thus, the health crisis we are experiencing can and must be an opportunity to give visibility to the structural inequalities of our society. In this aspect, it seeks to recognize that social inequalities are based on the capitalist production mode and that the reality of the category is a product of the existing class society.

It is also noteworthy that Brazil has its roots in a colonial, patriarchal and slavery social structure, which results in the oppression of the working class, especially for groups historically in unequal conditions, such as women, black-skinned people, indigenous and quilombolas. It is these social groups that face asymmetrical power relations, suffer discrimination due to their sociocultural forms of expression, and still find themselves under precarious living conditions, subjected to exhausting working hours, in occupations considered to be subordinate³⁶.

It is noteworthy then that the Nursing struggles must go through the position of social justice in defense of actions to overcome the structural drivers of inequalities and to promote better working and living conditions. In the first aspect, it includes, for example, the defense of the Unified Health System, which currently means fighting for legislation changes in its financing, which went through fiscal adjustment measures such as Constitutional Amendment 95/2016, which froze health spending for 20 years; gender, race, ethnicity and creed equality; and the guarantee of broad participation and social control. In the second, which reflects on fair employment and combating precarious work and unemployment; healthy living conditions and access to health promotion; access to the services, promoting universal, public and free systems, based on primary care and guaranteeing equitable access and universal social protection.

Finally, it is no longer possible to deny that the strategy of struggles for rights of this group of the Brazilian health workforce involves the anti-capitalist, anti-racist struggle and the historical struggles of Latin American women.

This reflection enabled the immersion in the universe of the theoretical basis that guides the inequalities that affect Nursing. However, we recognize the limits of this study for understanding the multiplicity of theoretical approaches that encompass this theme. Furthermore, it allowed for a better understanding of the phenomenon under study.

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Edited by

ASSOCIATED EDITOR

SCIENTIFIC EDITOR

Publication Dates

• Publication in this collection
  27 Aug 2021
• Date of issue
  2021

History

• Received
  11 Feb 2021
• Accepted
  12 July 2021