Unemployment and psychological distress in nurses

Objective: to assess psychological distress in nurses searching for their fi rst job, especially symptoms of depression, and identify the factors that caused mental suffering, and how these nurses cope with the situation. Method: this was a qualitative study carried out with unemployed nurses who had graduated less than two years before the time of the study, and were residents of the town of Assis in the Brazilian state of São Paulo. Data were gathered by means of semi-structured interviews, content analysis, and application of the Beck Depression Inventory psychometric scale. Results: of the 14 nurses that participated, three had scores on the psychometric scale indicative of depression. Participants reported psychological distress related to unemployment, poor university education, and surplus labor due to the large number of graduates and lack of jobs, as well as a culture of employment centered on professionals’ social networks. The unemployed nurses did not have effective ways of coping. Conclusion: unemployment promoted psychological distress among the new nurses, especially symptoms of depression, without effective means of coping.


INTRODUCTION
In cities in the interior of Brazil, it is difficult for nurses to find employment opportunities, due to the small number of vacancies, most of which have already been filled.Turnover in nursing rarely occurs, especially in public health care services that require public service examinations for hiring, and the creation of jobs depends on deployment of new health care services, which does not occur often.
This study evaluated psychological suffering in nurses searching for their first job in this profession, factors that led to emotional distress, and methods of coping.The nurses were found to have symptoms of mental illness, in particular depression.
In their search for education, adolescents and young adults have expectations regarding higher education as a means of upward social mobility.With the expansion of the number of private universities in Brazil in the 1990s, individuals from disadvantaged social classes were able to access higher education for the first time (1) .
According to one study undertaken in Rio de Janeiro, the choice for a degree in nursing is influenced by factors such as: interest in or affinity for health care; satisfaction in caring for others; identification with the profession; higher chance of entry into higher education; and influence of relatives and friends.Expectations regarding nursing as a profession included professional and personal achievement, financial return, helping others, acquisition of knowledge, and recognition and appreciation of nursing (2) .Another study in Minas Gerais pointed out that the demand for nursing courses is a result of ease of access, due to the increasing number of students accepted, admissions requirements, and higher earnings (3) .
However, today a college or university degree does not guarantee employment.This is a result of the restructuring of the labor market that began in the 1990s, and the global advancement of neoliberalism.Restructuring of the labor market led to outsourcing and temporary contracts, with a reduction of full-time jobs.Nurses have increasingly had to accept precarious and informal work; they are underemployed and have suffered loss of earnings (4) .
Experiences of suffering and feelings of emptiness, worthlessness, shame, sadness, hopelessness, devaluation, anger, low self-esteem, and social exclusion are present in unemployed workers, all of which influence the identities of these individuals, who end up looking at their life history for causes that led to unemployment.Unemployment generates suffering from the embarrassment of being unemployed, and the insecurity from not knowing how they will survive (1,4) .
This study confirmed that unemployed nurses experience psychological distress due to not being able to continue their professional development following graduation.
The need for this study is justified by the importance of identifying the factors that trigger emotional distress in unemployed nurses after graduation, and the possibility of generating knowledge that contributes to the professional category, considering the peculiarities of each scenario in the labor market.

OBJECTIVE
To verify psychological distress, especially symptoms of depression, in unemployed nurses seeking their first job in this profession, and to identify the factors that led to the situation of anguish, and nurses' coping methods.

METHOD
This was a qualitative, descriptive, cross-sectional study performed with nurses who had graduated less than two years before the time of the study, who lived within a radius of 50 km around the town of Assis (São Paulo), and who were graduates of universities located in the municipality: namely Universidade Paulista (UNIP) and the Educational Foundation of the Municipality of Assis (FEMA).According to data reported by coordinators of nursing courses within these institutions, in 2011 there were a total of 43 nurses trained in both schools; these nurses were the study subjects.
The sample number was defined due to the difficulty in having the participation of additional professionals.The inclusion criteria were: 2011 nursing graduate; alumnus of one of the universities of Assis; no working experience as a nurse since graduation; and residing in Assis or another city within a radius of 50 km.
The institutions authorized the study and provided the data on the students.During the initial meeting with the study subjects, a high rate of unemployment was identified among the study subjects, which emphasized the psychological distress caused by having been searching for their first nursing job for 18 months.
The project was approved by the Research Ethics Committee of the Federal University of São Paulo (UNIFESP) under opinion No. 203,144.The unemployed nursing professionals were contacted and informed about the study, and then signed a free and informed consent form.
Data collection took place during 2013 by means of semistructured interview that included questions on social, demographic, and educational data, and guiding questions related to job search, the psychological distress generated by unemployment, and methods of coping with this problem.The Beck Depression Inventory (BDI) was also applied.The BDI is a universal psychometric scale of self-evaluation used to assess the presence and severity of symptoms of depression in adults.The BDI is easy to apply by nurses, and is recommended for use in clinical research.The interview was recorded, transcribed, and analyzed by means of thematic content analysis (5) using the theoretical framework of Marxist theory.
The scores used for the BDI with no prior diagnosis were between 15 and 19 for dysphoria, and the term depression was used for scores above 20.With prior diagnosis, scores of 9 or less were considered absence of depression, mild depression from 10 to 16, moderate depression 17 to 29, and severe depression 30 to 63 (6) .
Participants were asked to respond to the IDB items based on how they felt in the past week, including on the day of the interview.

RESULTS
Study participants included 14 female nurses who self-identified as being white or mixed race, most of whom were Catholic, single, childless, aged between 23 and 34, with a mean family income between R$1,000.00 and R$2,500.00.Nine participants were graduates of the Educational Foundation of the Municipality of Assis (FEMA), and five were from the Universidade Paulista (UNIP)-Assis Campus.
According to content analysis, the data obtained in the interviews were grouped into four categories with their thematic units.
1. Feelings about not working as a nurse and search for employment in the field

Feelings
The participants were asked how they felt about being unemployed in their field of training.They expressed feelings of frustration, sadness, helplessness, hopelessness, and economic dependence.Few respondents reported not having negative feelings and feeling secure in their jobs, including those working outside their field of professional training, showing that they had not adapted to their situation.Others reported not being concerned about employment, but about studying or concerned with personal issues.When asked to define their feelings about their search for employment, the respondents said they were discouraged, hopeless, frustrated, and disappointed:

Mechanisms for seeking employment
When the participants were questioned about their search for their first job in their field of training, they reported that they had submitted their résumés and participated in public selection exams and processes.Some responded that they were looking for jobs in fields other than nursing, and that they had given up hope of finding employment as a nurse.

Difficulties finding their first job in nursing
The nurses' search for their first job was imbued with difficulties, such as a lack of experience when this was required for employment, taking public service exams for vacancies that had already been unofficially filled, and high competition for few openings in these exams.
[...] the public service examinations are very relative.Sometimes you study, study, study, and a person who sometimes did not even go to school is placed in the position.You get angry with things, because it happens.(E1)

I took public service exams [...] I was disillusioned with some of them because I found out that the position had already been filled [...] I interviewed, everything, took company exams [...] I failed all of them because of the experience [requirement]. I always wonder, if I don't get my first opportunity, how will I get experience? (E2)
The search is very big, there are a lot of trained nurses, so the competition is very big [...]

Choice and education in nursing 2.1 The choice of nursing
The reasons the study participants chose the nursing profession were primarily to help people, followed by interest in the field and curiosity.Participants also mentioned ease in obtaining employment, influence from other people, and secondary choice on the college entrance exam.

Education
When asked to evaluate their academic education, most participants responded negatively, with complaints about failures of coordination and teaching, lack of training internships, and a lack of professional preparation.In regard to professional preparation, most participants said that they did not feel prepared professionally after graduation.Fear was the most common emotion, due to their perceived unpreparedness, usually justified by their lack of experience in supervised internships.

Aspects of unemployment that caused distress
The following were cited as aspects of unemployment that cause depression: lack of employment in field of academic training; steady job search met with negative responses, which generate lack of motivation and frustration; unsatisfied expectation of working with a university degree; desire to have their own income; need for recommendation in order to be hired; not being hired due to lack of professional experience, which will not happen as long as they cannot get their first job opportunity; the possibility of earning more money if they could work as a nurse; the unfulfilled desire of wanting to work as a nurse.3.3 Suffering proven by the BDI scale and unemployment as the primary triggering factor of suffering Of the total number of participants, four had previous diagnoses of depression.Of these, one did not attain a score indicative of depression on the BDI, while three attained results indicative of moderate depression.The 10 participants who did not have previous diagnoses of depression did not attain a score indicative of depression on the BDI scale.
For the majority of participants, the reasons provided to justify their answers on the BDI included unemployment, and many also cited personal problems.
The respondents reported some psychological distress, although only three showed symptoms of depression.The researcher provided guidance based on the symptoms presented, and referred the participants to specialized evaluation; one participant who obtained a result indicative of moderate depression and signs of suicidal behavior was immediately sent to the emergency room.

Coping with psychological distress
The participants engaged various methods to cope with their psychological distress: relationships with family and friends; religion; work in other fields; psychological therapy; use of herbal medications; recreation and leisure activities; and dedication to studies.This study found that these activities did not provide a solution to the participants' depression, because the coping method was characterized as being temporary and pointed, and did not have lasting effects because it did not act directly on the essence of the problem of being unemployed.

My first decision was to seek the professional help of a psychologist. I tried to act alone, but there came a time in my life when I said "No, I'm going to [seek help] because I think I can't do it alone." Seek help from a professional and [...] look to God to help [...] pray, go to church [...]. (E7)
Immediately I want to eat.If I can't immediately cheer myself up, I go talk to some friend who is not in the field, because it makes me more sad if I talk to somebody that's working [...] and I try not to think too much about my situation.Change the focus from my sorrow, in order to not just think about it, because it's stressful.(E9)

DISCUSSION
Admission into an institution of higher education brings with it a belief in personal growth and the possibility of social mobility.Starting with the increased number of students accepted into private universities during the 1990s, individuals from disadvantaged social classes gained the possibility of access to higher education.Several factors led to this, including modernization and globalization, the increased number of young people who completed basic education, market demands that professionals have increased qualifications and education, and cultural changes caused by information systems.These transformations in higher education are part of complex and profound social changes (1) .
In the past 20 years, the federal government of Brazil has significantly increased the number of students enrolled in institutions of higher education, with no concern for the quality and massive sums of resources spent on the profitability of this private initiative.In the census of higher education in 2012, it is notable that there were 908 college-level nursing courses in Brazil, of which 192 (21.1%) were public (90 linked to federal institutions, 66 to state, and 36 municipal) courses, while 716 (78.9%) were private (7) .
It is necessary to go beyond the quantitative expansion of students enrolled, and establish parameters of quality, so that this expansion is also in investments in professionals who are empowered to intervene in health care models (3) .The possibility of quantitative expansion of institutions and the number of course vacancies for students resulted in a model of professional training with neither a stimulus for new and critical ways of thinking nor construction of new knowledge, due to the lack of support for research and extension, as well as the proliferation of courses and institutions which, for the most part, fall far short of minimum standards of quality (8) .While the number of college-level nursing courses has increased, this growth has been unplanned, and there has there been no policy for growth accompanied by the much-touted triad of teaching, research, and extension (9) .
Challenges of the nursing profession include: the quality of vocational training; a quality work environment with conditions that provide dignity in terms of working hours, salary, and retirement that is compatible with work in unsanitary conditions, employability, and job positions (10) .
Factors that facilitate or hinder insertion into the labor market are related to the individual's education, including both the reputation of the college and professional experience gained during work towards a degree; personal characteristics such as professional profile or attitude; being proactive; time to carry out work; performance in selection processes; age; preferences by area of practice and location preferences; among others; and finally social capital, including a good network of people for job recommendations.In addition to current market demands, there are factors such as lack of practical experience due to being recently graduated, few jobs compared to the large number of graduates, lack of previous professional experience, and not having contacts or recommendations.Obviously, due to the large supply of workers, those most qualified, with more experience and better training, are selected (11) .
Although we know that the low quality of training in the field may be one reason for unemployment, this was not the main factor found in this research as the cause of suffering.This study found that the main cause of suffering was the lack of vacancies and jobs.This study found that health care jobs in Assis and the surrounding region are almost all in public service.Even when added to jobs in private institutions, the number is insufficient to absorb the demand.The number of job vacancies falls short of the number of graduates.These data corroborate one study that points to the damaging relationship between expansion of the number of courses and employability, and how the labor surplus creates a reserve and fosters precarious working conditions and wage losses (12) .
Capitalism promotes social injustice.Individuals become rich and amplify their wealth through the exploitation of other people's labor.Capitalists use workers to obtain assets by increasing the duration and intensity of work, with a focus on increasing productivity and reducing costs, with guaranteed profits and consequent accumulation of wealth (13) .
Today, capitalism exerts its power in the endless pursuit of profitability, as it discards part of the workforce and increases the number of part-time, outsourced, and informal workers, leaving millions unemployed.Capitalism is decreasing stable employment, and promoting a wave of structural unemployment on a global scale (14) .
In Brazil, on average, there are four workers for each available vacancy in the national labor market.When the eight million currently unemployed workers are added to the 2.3 million new entrants into the labor market per year, there are more than 10 million unemployed workers competing for employment in 2.5 million open jobs (15) .
Health is an important sector of the labor market, and the largest number of working and reserve professionals is in nursing.In 2011, nursing professionals corresponded to 64.7% of the workforce in health care (9) .The distribution of these workers is not homogeneous.Regions that are more economically developed have more health care facilities and, consequently, more professionals.
Although in Assis employment in public services is hegemonic, the number of vacancies is insufficient to meet regional demand by nursing graduates.
The vacancies in these institutions are filled and, in cities in the interior regions of Brazil, turnover is rare, especially in public service positions filled by exam.The creation of job vacancies in nursing depends on the deployment of new health care services, which does not often occur.The offer of job vacancies in the region of Assis does not meet the demand of new graduates every year, generating an increasing number of unemployed nurses.
The reality shows that the qualifications of the workforce do not translate into guaranteed employment.Research shows that most graduate students (master's level) surveyed had paid activities without a contract, data that show the level of unemployment among young professionals.This study highlights the disjuncture between workers' level of education and the complexity of their work.Reality demystifies education as a solution to social problems such as unemployment.It must be asked whether education is really the most effective strategy for social mobility, an assertion that is not supported in the research for this study (16) .
Many workers believe that the main obstacles imposed by the labor market are within their control, such as low qualification and levels of education, and lack of experience.The inability to secure employment is internalized as a personal failure (17) .Individuals feel guilty and blame themselves for being unemployed.For example, some respondents in this study blamed themselves for being unemployed due to not having studied more.
One study on mental health among unemployed workers found positive relationships between being unemployed and mental suffering, and shows that the main feelings related to the situation of unemployment were depression, suffering, frustration, anguish, irritability, worry, and devaluation.Study participants also referred to feelings of shame for not being able to help with household expenses, feeling very sad, and increased anxiety due to being unemployed (18) .
These data corroborate our study, in which participants reported feelings of guilt due to unemployment in their field of training; lack of dedication to their undergraduate studies and public service exams; hampered efforts due to discouragement caused when efforts were made to compete in public service exams for positions that had already been filled; wrong choice of profession; and the mistake of not leaving their home region to obtain employment elsewhere.The situation is not perceived by the mass of workers who internalize guilt due to their unemployment.
There was a sense of failure and low self-esteem resulting from feelings of guilt generated due to being unemployed.There are several psychological consequences due to the feeling of personal failure, causing personal insecurity, depression, and isolation.These are due to the exclusionary economic model (19) .
The psychosocial consequences of unemployment lead to feelings of humiliation, shame and guilt, discrimination, worthlessness, low self-esteem, and sometimes despair.Reactions such as irritability, aggression, despondency, and insomnia are common.Social influences occur as concrete situations such as hunger, family problems and conflicts, use of alcohol and other drugs (20) .
This study verified that a significant number of participants (21.4%) in this study had symptoms of depression comppared to the prevalence of this clinical picture in the general population, with a variation of 11.1% to 18.4% (21) .
Among the difficulties reported in gaining their first employment experience were lack of experience when this was a requirement for hiring, demonstrating the hypocrisy and cynicism of the system to require experience in order to gain their first job.
Professional experience as a requirement for recruitment of nurses was verified in one study conducted in a teaching hospital in Sao Paulo, due to lack of technical and scientific knowledge and appropriate practical experience, a consequence of poor education (22) .
This study verified that the situation of unemployment caused intense psychological distress, and the participants' frustrated attempts to be hired increased this suffering.
Some strategies used by participants to cope with unemployment are classic and enshrined in the literature.Although participants cited leisure activities, the authors of this study conclude that this is not an effective coping strategy, because these activities may provide instant relief, but do not eliminate the cause of suffering.
To minimize the impact of unemployment and maintain continuity of the job search, religion and sports proved ambiguous or frustrating (20) .
As a strategy to cope with unemployment, participants stayed occupied, as much as possible, with activities not related to their field of training, or even with recreational activities, in order to remain productive and shield themselves from their suffering.This is also a way to explain the situation to oneself and others, showing the world that they are not standing still, and avoiding the risk of being accused of giving in (23) .
One of the main strategies used for replacement of professionals in the labor market is social capital and networks of interpersonal relationships.Through these networks, unemployed professionals are recommended to companies with vacancies.Yet, for the participants in our study, these networks did not help and there was no one who could recommend them.This situation was cited by participants as a cause of suffering, knowing that others used social capital to find a job, and they felt abandoned by the system and powerless to reverse the situation.This refers to the situation already mentioned of jobs and influences, including policies for employment, a situation very common in interior regions of Brazil.
Despite the high technological levels attained globally, the market maintains its structure by the accumulation of capital and profit, which does not contribute to the health of those involved (24) .
This study observed that the suffering of the nurses came from the system of accumulation of capital, and the association with the lack of political and critical training of workers caused guilt and suffering among them, as a result of the deleterious action promoted by the capitalist system itself.
Study limitations included the small sample size and nonlongitudinal tracking of respondents.

FINAL CONSIDERATIONS
The nurses proved to be under psychological distress, with symptoms of depression, a consequence of feeling worthless due to being unemployed as nurses.
The experience of having graduated and invested time, money, and energy to study is extremely taxing, given that the participants had not received even minimal return work as a nursing professional which caused intense psychological distress in these individuals.
In general, the participants' coping methods were based on subjective and palliative actions that brought palliative relief and subliminally prolonged their psychological suffering.
The root of the problem is the capitalist mode of production which, through its mechanisms to maintain profit at all costs, does not value workers, their needs, and their lives.This is part of the capitalist system of profiting from education, based on the unbridled expansion of higher education institutions that do not guarantee the quality of training of future professionals, thus exacerbating unemployment.
The lack of critical policy formation of professionals reveals one of the forms of control of the system, a mechanism to maintain both hegemony and simultaneous suffering.
There is a need for social intervention measures that are long-term and broad reaching, but they must be initiated by the individual's training in political acumen in order to understand the context into which s/he is inserted, and how to seek collective means to change the means of production, so that nursing professionals can live their lives in a proactive manner and not be manipulated by the all-powerful capitalist labor market.
Powerless.Disheartened.Frustrated.(E4) I feel frustrated because it is very complicated.Because in college you have so many dreams.I also get sad because every day I think, I need, I want to work in my field [...] although I like what I do, it's not the same thing.(E9) I don't like it one bit [...].I feel dependent on him, and I like to be independent.(E13) For now I'm okay because I'm in graduate school in the field.Since I have a steady job, I have my salary, I'm not so worried [...] and also with the arrival of the baby, I'm more focused on this [...].(E11)

I
feel like I'm swimming, swimming, swimming and dying on the beach.(E2) [...] frustration [...] I invested in a college degree, invested in a graduate degree, now I am going to invest in another and I'm worse off than six years ago.I was a lot more successful because I had my own money.I was not a nurse, I wanted to help, but [...] I feel horrible.(E4) [...] A certain hopelessness starts rising up, desperation, you think you can't do it, that you are never going to be able to make it; it is very complicated.(E5) [...] I am about to throw in the towel and move to another field, because it is very difficult.You keep hoping, hoping, hoping and nothing happens [...].(E10) [...] I submitted a lot of résumés; I'm participating in various public service examinations, both here in our region, and in other places as well.I'm busting my ass, but it is really hard.(E1) As soon as I graduated, I submitted my résumé [...] six here in town [...] 20 outside of town [...] lately I've been studying for public service examinations.(E6) I have given up already.(E14) of a team [...].(E3) I'm not ready.I'm totally unprepared.(E6) 3. Unemployment as a factor in psychological distress 3.1 Unemployment and psychological distress Most of the participants stated that unemployment caused psychological distress and feelings of sadness, discouragement, uselessness, disappointment, failure, despair, frustration, hopelessness, and distress.[...] It makes me very sad, I cry a lot [...] I think because of this frustration [...].I'm a person frustrated about, hopeless sometimes, what a year ago for me was a dream, today is no longer [...] I cry because it's very complicated.(E2) [...] I'm frustrated because I expected to have a profession and so far I haven't been able to [...] you want to fulfill a dream and get frustrated because you are unable to.(E4) [...] discouragement, serious discouragement.Sometimes I don't feel like [...] I don't do things that I'm excited to do because I get discouraged.The urge to stay at home.(E7) Sometimes I get sad; we feel a little useless.(E8) It is hard [...] for most positions [...] there's that one detail: they want more specialization, six months experience, experience for one year.How can you have experience if you can't get your first job?In fact, sometimes in some exams, sometimes it's like they already know who they are going to hire, and it's just a way to make money.(E13) in relation to the selection exams [...] I have already competed with three of my teachers [...] sometimes I feel at a disadvantage.(E5) [...] I think the internship was very little time.The internship that we did [...] the real practice.I thought the theory was good, but I did not like the practice.Because it was a very short time, we did not leave prepared.(E6) [...] lack of internships, internship placements, they were very limited [...].We could only do[the internship]in public health, and nurses work in all areas, we need to experience what the field is like at least a little bit [...] and I felt very frustrated about it.(E10) I think the theory was very good, but I think the practical experience [...] lacked a lot, especially in terms of training internships.I think we did not have [...] as much opportunity as we would have liked.It's possible that [...] you get a training internship and are still not able to get a job [...].But I think the practical internships could have been better, especially in the last year, which I think is what we most needed, especially in the emergency room [...] so it was really weak.(E13) [...] there is going to be some lack of employment.Because if I worked as a nurse, I wouldn't need two jobs [...].Thus, I wouldn't need to be away from home so much.And I could lead a normal life.(E1) My problem today is just financial, professional, more professional than financial, honestly, because I want to have a profession, and I don't have the opportunity.I think this is the reason for all the anxiety I have today, since I have no other problems; it's this urge to work as a nurse, and also [...] the personal desire to be financially independent [...].(E4)