Gender debate as a challenge in nursing training

El debate de género como reto en la formación en enfermería

ABSTRACT

Objectives:

to understand the challenges of introducing gender debate in nursing training from undergraduate students’ perspective.

Methods:

a qualitative, exploratory-explanatory study. Data were collected through a semi-structured interview applied to 12 undergraduate nursing students at a public university in São Paulo. For data treatment and analysis, the Discourse of the Collective Subject was used in light of Boaventura de Sousa Santos’ knowledge production paradigm theoretical framework.

Results:

nursing education remains centered on the traditional scientific model, neglecting gender and strengthening stereotypes aimed at the feminization of the profession.

Final Considerations:

nursing training has a challenge of implementing actions that deepen the gender theme. Therefore, some strategies are suggested, such as improving professor training and appropriating emancipatory pedagogical practices; reviewing pedagogical political projects; curriculum theorization and restructuring; problematizing gender issues for nursing leadership.

Descriptors:
Sexism; Nursing Education Research; Gender Equity; Curriculum; Health Education

RESUMEN

Objetivos:

comprender los desafíos de insertar el debate de género en el proceso de formación de enfermeras desde la perspectiva de los estudiantes de pregrado.

Métodos:

estudio cualitativo, exploratorio-explicativo. Los datos fueron recolectados mediante entrevistas semiestructuradas aplicadas a 12 estudiantes de enfermería de una universidad pública de São Paulo. Para el tratamiento y análisis de los datos se utilizó el método del Discurso Colectivo del Sujeto a la luz del marco teórico del paradigma de producción de conocimiento de Boaventura de Sousa Santos.

Resultados:

la formación en enfermería sigue centrada en el modelo científico tradicional, descuidando el género y fortaleciendo los estereotipos orientados a la feminización de la profesión.

Consideraciones Finales:

la formación de enfermeras tiene el desafío de implementar acciones que profundicen el tema de género. Para ello, se sugieren algunas estrategias, como mejorar la formación del profesorado y apropiarse de prácticas pedagógicas emancipadoras; la revisión de proyectos políticos pedagógicos; teorización y reestructuración curricular; la problematización de las cuestiones de género para el liderazgo de enfermería.

Descriptores:
Perspectiva de Género; Capacitación de Recursos Humanos en Salud; Educación en Enfermería; Enseñanza; Curriculum

RESUMO

Objetivos:

compreender os desafios da inserção do debate de gênero no processo formativo de enfermeiras(os) na perspectiva de estudantes de graduação.

Métodos:

estudo qualitativo, exploratório-explicativo. Os dados foram coletados por entrevista semiestruturada aplicada a 12 graduandas(os) de enfermagem de universidade pública paulista. Para tratamento e análise dos dados, utilizou-se o método do Discurso do Sujeito Coletivo à luz do referencial teórico do paradigma de produção de conhecimento de Boaventura de Sousa Santos.

Resultados:

a formação em enfermagem continua centrada no modelo científico tradicional, negligenciando o gênero e fortalecendo estereótipos voltados à feminilização da profissão.

Considerações Finais:

a formação das(os) enfermeiras(os) tem o desafio de implementar ações que aprofundem o tema gênero. Para tanto, sugerem-se algumas estratégias, como o aperfeiçoamento da formação docente e apropriação de práticas pedagógicas emancipatórias; a revisão dos projetos políticos pedagógicos; a teorização e reestruturação curricular; a problematização das questões de gênero para liderança de enfermagem.

Descritores:
Perspectiva de Gênero; Capacitação de Recursos Humanos em Saúde; Educação em Enfermagem; Ensino; Currículo

INTRODUCTION

Nursing, as a science and social practice that favors care, has historically constituted itself as a profession with the power to lead processes to face inequities in health in a world context of wars, social conflicts, violence and ethnic, gender, religious and political intolerances and sexual orientation, in addition to crises in public health and health systems, with epidemics and pandemics. In 2020, this power gained prominence and was intensified by the Nursing Now campaign, promoted by the World Health Organization (WHO) and supported in Brazil by the Federal Nursing Council (COFEN - Conselho Federal de Enfermagem) and Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo (EERP -USP), which highlights that the scientific body and the social practice of nursing are strategic in qualifying and valuing the profession globally.

The effort to enhance the profession in 2020 was accompanied by an unprecedented global health crisis leveraged by the Covid-19 pandemic. The extensive and intensive daily workload, exhausting work hours, low wages, psychological distress, among other problems⁽¹⁾, mark the reality of the profession, aggravated in the context of the pandemic. Nurses’ work is highlighted by society, key in combating the disease and highlighting the role of the profession in the organization of immediate responses at a global level; however, it brings up several inequities and highlights the lack of knowledge, the stigmas and even the contempt of layers of society regarding the work developed by nursing.

Despite presenting itself as strategic in tackling inequities, the scientific and social expansion of nursing is emerging, not only to improve care for individuals, families and communities, but to understand the career path and the paths taken, in addition to collaborating to the shift from the dominant training paradigm, characterized by the biomedical approach, to the emerging paradigm of transforming health practices⁽²⁾.

The hegemonic scientific order of overvaluing the natural and exact sciences, with over-specialization in medical sciences, has its origins in the scientific revolution of the sixteenth century, and is structured in the following centuries with the division of knowledge into “scientific” and “non-scientific”, fitting the social sciences and humanities into non-scientific. Named by Boaventura de Sousa Santos as dominant paradigm, in addition to reinforcing the rational and compartmentalized characteristic of the sciences, it denies a complementary understanding between human, exact and biological sciences, which would allow to know the object in its entirety, attitudes that are reproduced in the health field⁽³⁾.

Unitary, non-dialogical and based on natural sciences, the dominant paradigm is present in the current historical scenario of the teaching-learning process at all educational levels, especially in Higher Education Institutions (HEIs), with the replication of information given by an individual who “owns” the knowledge. In this process, the individuality of each “recipient” subject is ignored, simplifying themes that are, necessarily, complex. It is based on formulation of laws, with assumptions of order and stability, independent of scientific, critical and reflective advances arising from the dialogue between the sciences^(3-4).

The dominant paradigm goes through crises, since it does not contemplate the current complexity. From this crisis, a new paradigm emerges that proposes to converge knowledge instead of compartmentalizing it, identifying the existence of a science, whose biological, exact and/or social nuances are perceived in the object’s own knowledge process⁽³⁾.

This new paradigmatic direction contributes to reformulating the health and nursing curricula, with a view to developing knowledge and practices that contemplate people’s health care considering the relational aspects, among which gender issues⁽²⁾. Some historical milestones affirmed the need for changes in nursing education since the Brazilian National Curriculum Guidelines (Diretrizes Curriculares Nacionais) for the Undergraduate Nursing Course (CNE/CES 3/2001), updated in January/2018, which emphasized that training should focus on social needs of health, with an emphasis on the Unified Health System (SUS - Sistema Único de Saúde) and ensuring comprehensive care⁽⁵⁾.

However, there are several challenges to be overcome, one of which is to consider fundamental social categories for understanding the dynamics involved in the health/disease/care process, such as class, race/ethnicity, generation, sexuality and gender, overcoming professional training in nursing focused on generic and decontextualized subjects⁽²⁾.

Among the challenges mentioned, gender relations stand out and permeate nursing, being the subject of analysis in this study. Recent productions^(6-7) argue am urgent need to face and know the historical and structural roots of its construction as a way to overcome the hegemonic discourses that perpetuate social inequality, marked by discredit, monetary devaluation and a position of subordination that nursing historically faces it as a predominantly female profession.

To identify, know and face these social inequalities is also to understand that such inequalities have a strong mark on gender relations, defined according to cultural attributes imposed on men and women since birth and that place women as “second class citizens”^(8-9). Gender debate is also the object of contemporary feminist intellectuals, nationally⁽¹⁰⁾ and internationally^(11-12), which emphasize the need to expand women’s actions on the oppressive structure, bringing women enhancement as a strategy for transforming historically established power relations.

The institution of these power relations in nursing can be observed throughout its historical trajectory. Built on Florence Nightingale’s legacy (white woman, religious and from an English aristocratic family), modern nursing establishes a new professional profile that should obey the principles imposed by that time, mainly moral and religious, in contrast to the negative image that nursing carried until then. In Brazil, modern nursing is established from a hygienist discourse of the beginning of the 20^th century, a period in which the Church and Medicine are united in women control, reducing them to mothers, wives, and educators⁽¹³⁾.

Nowadays, the movement for transforming nursing is growing and constant, which can be observed, for instance, in the commitment of institutions to change the curricula of undergraduate courses, intensifying the concern with philosophical and pedagogical aspects, in contrast to reductionist teaching, fragmented and technical that still prevails^(5,14-16). When thinking about curriculum, there is an explicit difficulty in theorizing it caused by divergences about concepts of education and the function of education, making the process of curricular restructuring changes in content and form, without reaching the intentions of the educational process⁽¹⁷⁾. In this reality, the issue of gender, which is directly related to social power relations and revolutionary movements, has little scope for inclusion.

Considering the history, the importance of critical education and the emerging need to deepen debates on the complex network of social inequalities of gender, race and class, it is essential to understand how gender debates take place in the education of nurses.

OBJECTIVES

To understand the challenges of introducing gender debate in nursing training from undergraduate students’ perspective.

METHODS

Ethical aspects

The study was approved by the Research Ethics Committee of Universidade Estadual de Campinas (UNICAMP) and complied with all current ethical and legal precepts of research conducted with human beings that are contained in Resolution 466/2012 and 510/2016 of the Brazilian National Health Council (Conselho Nacional de Saúde).

Theoretical-methodological framework and type of study

This is a qualitative, exploratory-explanatory study^(18-19), which aims to understand the interpretation of human beings through history, relationships, representations, beliefs, perceptions and/or opinions, in light of Boaventura de Sousa Santos’ knowledge production paradigm theoretical framewoek⁽³⁾.

Study setting

The study was developed at a public Brazilian university located in the state of São Paulo from August 2018 to June 2019.

Data source

Twelve nursing students participated voluntarily, ten women and two men, aged between 17 and 28 years and from all years of an undergraduate course (1^st to 5^th year).

Data collection and organization

Data collection was performed in the second semester of 2018 by the first researcher, a graduate student in nursing. Aiming at the methodological rigor of the study, the Consolidated Criteria for Reporting Qualitative Studies (COREQ) was used during the process. Open-ended interviews were conducted based on the triggering question: “for you, what does it mean to be a woman in nursing?”, supported by other questions during the interview, such as “do you recognize any stereotypes in nursing? Have gender issues ever been addressed during your graduation? Do you believe that this content should be addressed? Do you believe that gender issues interfere with your professional life? Do you think there is a relationship between feminism and nursing?”. The interviews were conducted with volunteer nursing graduate students from all years of a course in a private room on the Faculty premises. The interviews were recorded and transcribed in full, lasting between 22 and 68 minutes.

Data analysis

The method of qualitative analysis chosen, consistent with the need to achieve understanding of the studied population, was the Discourse of the Collective Subject (DCS). It consists of the representation of collective thought, aggregating similar manifestations of different people in a synthesis discourse, written in the first person singular. It is based on Theory of Social Representations (TSR) to rescue shared ideas and cover the different conceptions and ideas contained in the discourse of a given social representation⁽²⁰⁾.

The DCS is based on three operators: key expressions, extracted directly from interviewees’ discourse and that reveal the essence of the testimony content; central ideas, featuring a summary of the contents of a category of key expressions, with their real meaning; DCS, which brings together the key expressions grouped by categories or central ideas, summarizing the social representation⁽²⁰⁾.

RESULTS

From an analysis of the transcribed interviews, three central ideas were identified from the most prevalent key expressions in the collected speeches, as shown in Chart 1. This article addresses and deepens the last central idea, related to nursing training in higher education.

Chart 1
Central idea based on key expressions extracted from the interviews

Main key expressions	Central idea
•    Stereotypes permeating the profession •    Mostly female profession •    Florence Nightingale's influence •    Devaluation related to gender	The profession suffers from gender discrimination, mainly due to historical factors.
•    Professional empowerment inseparable from feminism •    Unfavorable political environment •    Students as potential for change •    Lack of political involvement	Optimism in students' potential for change as they demonstrate greater political engagement, despite the unfavorable political situation.
•    Unpreparedness and denial of the professor for gender debate •    Importance of cross-cutting theme •    Perpetuation of feminizing stereotypes of the profession •    Training focused on leadership and management •    Traditionalism permeating the course	Traditional training and focused on management and leadership content, with professors unprepared to address gender issues.

After understanding the central idea highlighted from key expressions, it was possible to build the following DCS:

Every time we talk about gender in college, it was never focused on the profession, but on the patient we would care for. Even so, this approach was superficial. The most we have seen about gender and the profession is that historical thing about Florence. But everything this is given fact, and never debated critical reflection [...] because it is not nor that is not said of the subject [...] it seems that the people simply deny that it exists. It is easier to ignore the issue than to face it. The impression that it gives is that the college does not care about the harassments that we suffer in the internship because we are women and do not want to awaken this critical sense. The places where I found this debate have always been external to the college, such as the Academic Center, Leagues [mainly Obstetrics], conversation circles, in moments outside of graduation [...] the faculty is simply not able to deal with the matter, nobody is prepared to talk about it and forms a vicious circle of denial. In addition, instead of deconstructing stereotypes, professors end up favoring them. How many times have I seen professors criticize students for wearing relatively short shorts in college? And it wasn’t even in the hospital! If it were, fine. I’ve been criticized for having a piercing. What does this have to do with my technical and relational skills as a nurse? For me, this is camouflaged traditionalism [or not so much] [...] it seems that the nurse can never get out of line. It has to be perfect all the time, flawless. [...] here, training is to be a leader and manager, as everyone here likes to talk, but no one debates that management positions will often be male nurses and not women. How are we going to train leading nurses if we don’t know all the variables of the process? And gender is one of them. That is why this training has to be addressed in all subjects. The theme could be defined in some specific subjects, but it has to be addressed in all, whenever the need arises [...].

DISCUSSION

Nursing students’ DCS brings important aspects about the way teaching is structured: fragmented, technical and disconnected from social reality.

Students stated that professors, in addition to not including gender debate in subjects, end up denying it when the subject comes up. The speech points out that they prioritize technical content over social debates. It is not a question of devaluing traditional scientific knowledge, but of recognizing the need to incorporate other knowledge that dialogues with complex phenomena present in society and human subjectivity⁽²¹⁾.

In addition to the unpreparedness and denial of the theme, professors end up perpetuating gender stereotypes in their relationship with students. Situations experienced during graduation were reported that reinforce the social imaginary of nurses’ impeccability, even outside the environment of practical activity, such as body control, clothing, and attitudes.

The perpetuation of these stereotypes has historical origins, built mainly, though not in isolation, from the discourse of modern nursing. In her book, “Notes on Nursing: what is and what is not”⁽²²⁾, Florence Nightingale indicates attributes such as honesty, sobriety, trust, respect for hierarchy, religiosity, fidelity and delicacy as indispensable for the construction of what is idealized of a nursing professional. The permanence of male supremacy in science and in the world of work reflects unequal power relations in the consolidation of these present stereotypes.

As one of the central subjects of nursing training, professors and their training stand out. Being a professor and educator requires being theoretically prepared and knowing how to make the connection between theoretical content and social reality; however, the training of university professors does not prepare for teaching, but for research and specialization. Considering that graduate qualification enables professionals to be professors, with the complexity of the educational system, teaching-learning relationships and so many other aspects that involve education are, at least, inconsistent with the current reality⁽²³⁾.

In addition to the current scenario of training higher education professors, it is necessary to add to the reflection that this training is carried by the trajectory of nursing. It is not uncommon for professors, at the beginning of their practice, to rely on natural trends and/or models of professors that they internalized as students⁽²³⁾. In this context, it is necessary to disentangle from principles rooted in traditional education, as well as in fragmented care, focused on biological aspects and disease. However, for effective curricular changes to take place, it is necessary to incorporate new knowledge⁽⁵⁾, including gender debates that are disconnected from the perpetuation of unequal and stigmatizing relationships.

Learning how to teach is a process that must take place throughout teaching career and educational structure must provide incentive to participate in continuing education to build and expand the knowledge necessary for teaching, among them the complex discussions of social inequality relations, with emphasis for the gender relations that permeate nursing⁽²⁴⁾. The approximation of training to gender discussion regarding the historical construction of the profession^(6-7) and the current challenges of overcoming inequality relations are a global need towards training empowered professionals capable of sustaining autonomy and social relevance of nursing.

According to the collective discourse, one of the few approaches to constructing the profession takes place in the subject of the first course’s semester, which aims to address the historical construction of nursing as well as the work process in its ethical, political, and cultural dimensions. Although it was approached that nursing is mostly female, students’ discourse states that there is no critical debate on how this fact influences professional performance today. The discourse points out that the gender theme, in its multiple implications for the subjects involved in nursing care, is seldom addressed during the course and, when addressed, is rarely deepened.

According to Resolution 569/2017 of the Brazilian National Health Council⁽²⁵⁾, it should be considered that training requires political skills in establishing relationships and that it must aim at integration and interdisciplinarity, seeking to articulate the different dimensions including the gender dimension. Furthermore, it provides that learning opportunities are needed throughout the undergraduate course, with human and social sciences as a transversal axis in professional training, with a generalist profile.

Students argue that the theme of gender should be approached in a transversal way during the course, crossing it, in addition to being included in some subjects that may provide further discussion. Some of the subjects mentioned were in the fields of women’s health, social sciences, anthropology and administration.

When expanding the look at the schools curriculum, with a focus on nursing, it is possible to perceive that the curriculum construction is loaded with a tradition that represents a socially validated selection in a vertical process, which highlights the interests of a group, to the detriment of a portion of the social body⁽²⁶⁾, excluding gender debate.

Although it is important to include the gender theme in the syllabus of specific subjects, it cannot be thought that it is the same as incorporating it into curriculum theory. When the curriculum is reduced to the syllabus, the intrinsic dialectical component of curriculum theory and materialization is lost, focusing on a simplistic perspective in which the curriculum mistakenly becomes curricular subjects listed⁽²⁶⁾. When reducing the curriculum in school subjects and goals, it is not possible to contemplate the real needs of emancipation to be promoted at school, since specific activities do not promote the desired critical and reflective capacity to act with ethical and social commitment in health-disease of individuals and collectivity⁽¹⁷⁾.

In order to achieve the proposal for the transversality of the theme and the promotion of an integrated curriculum, it is necessary to review university plans. An important instrument in the organization of undergraduate courses is the Pedagogical Political Project (PPP), which consists of a set of collective actions aimed at making structural changes in the organization of pedagogical work. Its elaboration requires reflection on the purposes, its social role and the clear definition of the paths and the operationalization of the actions that will be undertaken⁽²⁷⁾. Therefore, it makes sense that the commitment to the debate on gender is explicit in PPP, since changing paths in education implies breaking crystallized practices and facing challenges in search of training that addresses population’s social demands⁽²⁷⁾.

Finally, participants emphasized that nursing training focuses on leadership and management as essential skills (also mentioned in DCNs), but reinforce that these skills are not so simple to acquire when it is a woman.

In a research to verify the effectiveness of female and male leadership styles, it was concluded that the female style is more efficient than the male one, because it is essentially more participatory, more people-oriented, while the male one has a more autocratic style, being more oriented to tasks and results⁽²⁸⁾.

Although women have better leadership styles, there are problems in accessing these positions and difficulties faced throughout their careers, described as: prejudice, motherhood, personal appearance, resistance to women’s leadership, problems with leadership styles, life demands family, division of tasks in childhood, little investment of social capital, option of women for positions, need to “be better than men” to get the same position, lack of ambition and lack of confidence⁽²⁹⁾. In this context, it is not enough just to train students for leadership and management, but to train students with these competences equally, considering the different variables of individual and collective processes for men and women.

We highlight as priority and urgent strategic actions:

• Improvement of professor training regarding the appropriation of educational philosophies and pedagogical didactics, with an integral and constant movement of changing educational paradigms;

• Untying pedagogical practices that influence the consolidation of unequal power and gender stigmatizing relationships, seeking emancipatory practices;

• Review of PPP with a focus on the transversality of gender discussions, and here the categories of race and social class can also be added as structuring forces in the perspective of the intersectionality of contemporary feminism;

• Emphasis on curriculum theorization and restructuring, considering the concepts and objectives of higher education and creating spaces for debates for further study;

• Questioning the obstacles to management and leadership faced by women in the world of work, as well as incorporating debates about the reflexes of the patriarchal structure in guaranteeing the rights of health professionals, focusing on nursing.

Study limitations

Regarding the study limitations, it is important to highlight that, despite contemplating the chosen method of analysis, the sample is limited to a public university and the approach of students’ perceptions, without involving professors and educational management, being possible that some aspects of the debate did not merit the necessary deepening.

Contributions to nursing, health, and public policies

It is expected that the results of this study, by revealing the interlocution of gender debate with nursing education, will support the expansion of the approach to the theme and the implementation of strategic actions in the training process of HEIs, in order to generate changes in teaching-learning process and increasingly qualified and empowered professionals personally and professionally.

FINAL CONSIDERATIONS

According to participants’ perceptions, nursing education remains traditional, observing deep gaps in gender debate and perpetuation of stereotypes of feminization of the profession.

In this process, professors are unprepared for gender debate even when the social problematization of reality is structuring. Professor education is supported by traditional models of the history of nursing, so it is necessary to overcome teaching and care centered on fragmentation and biological aspects and disease.

This means expanding the look at the pedagogical project of nursing, giving a new meaning and reconstructing training, with a cross-cutting gender debate. Nursing education of the present times - Nursing Now! - has a challenge of mainstreaming the complex social dimensions to face health inequities, which requires the dismantling of the dominant knowledge paradigm. To this end, changes in training are urgent through strategic actions that broaden and deepen gender debates, with regard to the historical and critical construction of the profession, in the current scenario of these issues in the country and in the world and their direct influences on professional performance.

• FUNDING / AKNOWLEDGEMENTS
  We thank Unicamp for providing the possibility to conduct the study and National Council for Scientific and Technological Development (CNPq - Conselho Nacional de Desenvolvimento Científico e Tecnológico) for funding the research. We also thank the participants who made this work possible.

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Edited by

EDITOR IN CHIEF: Antonio José de Almeida Filho

ASSOCIATE EDITOR: Fátima Helena Espírito Santo

Publication Dates

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

History

• Received
  13 Oct 2020
• Accepted
  02 Dec 2020