Nursing and society: Evolution of Nursing and of capitalism in the 200 years of Florence Nightingale*

Objective: to analyze the relationships between the development of the Nursing labor and of capitalism over the 200 years of Florence Nightingale. Method: a logical-reflective and theoretical exposition based on interpretations of historical facts and Marxist theories. The analysis categories were the following: the creation and expansion of the Nightingalean Nursing Teaching System; the subsumption of the Nursing labor to capital; imperialism and international health; and the flexibilization of the Nursing labor. Results: the expansion of the Nightingale Teaching System has trained nurses on a global scale. The capitalist system transformed the Nursing labor in the twentieth century, culminating in the twenty-first century with precarious and intense turnover of nurses in their jobs. Conclusion: the Nursing labor, made professional by Nightingale, has assumed in the last 200 years a dialectical relationship with capitalism in which it both determines and is determined by it. New challenges, such as the Industry 4.0 technologies, are constantly imposed on the profession.


Introduction
Florence Nightingale was born in Florence, presentday Italy, in 1820, into a wealthy family and with strong personal relationships with political and academic actors. In the 1840s, Florence sparked her interest in public health, a time when a health reform was being debated in the UK as a whole. The Nursing labor was part of her public health interests, including architecture and urban sanitation (1) .
At that time, the incredible expansion of production promoted by the Industrial Revolution increased the intensity of production and caused a relative reduction in the amount invested in the purchase of labor power available on the market by free workers (2) . Thus, the workers who left the countryside for the city in search of wage labor found themselves in the need to subject themselves to taking on unhealthy jobs and forcing their children into equally degrading situations, such as in the coal mines and in the workhouses (2) .
In Üsküdar, at the Barrack Hospital, Florence Nightingale found an environment lacking instruments and supplies for personal and environmental hygiene, for adequate food and for the comfort of wounded and sick combatants (1) . After strong resistance from direct superiors to improve the sanitary conditions at the Barrack Hospital, Florence Nightingale participated in the creation of a health commission, headed by physician John Sutherland, who, after arriving in March 1855, and with her support and that of her subordinates, transformed the health conditions of the hospital (3) .
Upon returning to England in 1855, Florence was a national heroine for her contributions to reducing mortality at the Barrack Hospital, having received several obeisances. To honor her, her friends came up with the idea of creating a care institution that would be a kind of "English Kaiserswerth" through a fund, the Nightingale Fund, established in 1857 (1)  Today, there is more than one work process in Nursing -administrative, teaching and research -all of them acting in function of the Nursing labor (4) . The Nursing labor, considered regardless of any determined social form, is characterized today by the labor act of caring for human beings that is performed by human beings in the role of Nursing laborers. They apply esoteric knowledge (5)(6) and set up interactions with their service users in a given environment.
When a work is subsumed to the capitalist mode of production, it ceases to be just a process of organic metabolism of the human being with nature in order to produce useful effects to be also a conservative, creative and multiplying value activity. The Nursing labor was no different.
Studies carried out on Nursing in Brazil (7) and with nurses and midwives from Australia, New Zealand and the United Kingdom (8) show that Nursing experiences similar

Method
This is an original, discursive, logical-reflective and theoretical production based on interpretations of historical facts that represent turning points in capitalism and that determine the ways to perform the Nursing labor, as well www.eerp.usp.br/rlae as on Marxist theories that assist in the interpretation of these historical facts. It is organized into analytical categories, created from the method of scientific dialectics as described by Karl Marx (9) , in which the economic categories function as ideal expressions of historical relations of production and, therefore, correspond to a certain level of development for the productive forces. The model lasted three years, as in Kaiserswerth.
The first year was devoted to theoretical classes and, in the following two years, hospital and home services were performed (1) . Working class apprentices were considered to be ordinary apprentices and the costs of maintaining them in the first year of the program were financed by the Nightingale Fund (1) . Upon graduation, the so-called nurses were directed to assume regular obedience positions.
The apprentices of the bourgeois classes, referred to as lady nurses, paid for their maintenance costs in the first year of the program and, upon graduation, were directed to assume leadership positions on an international scale (1) .
In addition to the prestige of adopting an education system associated with the image of a UK heroine, the adoption of the relatively inexpensive labor of apprentices www.eerp.usp.br/rlae was introduced in the country by that institution (1) . The education systems started disconnected from the hospitals but, due to the lack of donations to finance them, they were integrated into hospitals. In Canada, in 1874, the St. Catharine's General and Marine Hospital brought two trained nurses and five or six students from England to set up a teaching system that would last three years (1) .
In 1875, the Montreal General hospital sought help from Florence Nightingale to set up her education system and five nurses were sent from St. Thomas' Hospital to establish the school in the institution (1) .
The hospitals in these two countries did not have good working conditions for the nurses. After completing their training in the hospitals, the nurses sought to sell their workforce to families who hired them to provide their services within their homes (10)(11) . With the arrival of the education system in these countries, the time in which students were trained, on average, tripled, keeping hospitals with more employees on low salaries (with a mean of $10 a month in 1874 in the USA) for longer time (10) . The result of this equation was a rapid growth in the number of nurse training schools. Between 1900 and 1929, the number of nursing schools in the USA rose from 432 to 1,885 (10) . In Canada, the number of nurses between 1901 and 1921 rose from 280 to 21,385, including the students (11) .
The process of formal subsumption of labor to the capitalist mode of production is characterized by the conversion of the work process into an instrument of the process of capital self-valorization, although this conversion does not necessarily alter the work process itself (2) . This process begins to affect the Nursing labor in the USA with the sale of health insurance, which started in the 1920s, gained popularity in the 1930s, helped in the economic recovery of the hospitals, and boosted the capitalization of these services (10) . From 1934 to 1938, the Blue Cross, which was selling insurance for hospital care, went from 100,000 to 1.5 million insured clients, and to 22 million in 1946 (10) . The Nursing labor already served the capital indirectly by improving workers' productive capacity, keeping workers and bourgeois healthy or recovering their health. However, from this process of capitalization of the health services, it is also directly exploited by capital.
While in the process of formal subsumption, the work process only becomes a process of self-valorization of capital, in the process of real subsumption, capital acts in the work process, intensifying it and making it more efficient to produce profit (2) . It is characteristic of the real subsumption of labor to capital that the conscious application of sciences to the immediate production process in order to produce more relative value (2) . Formal subsumption is a precondition for real subsumption of labor in the capitalist mode of production, since it is necessary to accumulate a minimum of capital in order to invest in the development of new methods of work and in the improvement of its means.
In the Nursing labor, the real subsumption of capital happened pari passu to formal subsumption. As soon as the hospital services were being capitalized, the production of absolute surplus value generated by the excessive increase in daily working hours, the technical division of labor, the loss of ownership of the means of production and the production of relative surplus value generated by application of the Taylorist and Fordist models of work management plagued this in a short period of time.
In the 1930s, the American Nurses Association (ANA) defended the application of Taylorism in hospital care and the consequent technical division of the Nursing labor (10) .
The ANA proposed that hospitals could hire workers without formal qualifications to perform maintenance services, secretaries for administrative tasks and attendants for routine activities, in order to rationalize the work of registered nurses and reduce labor costs applied to simpler tasks (10) . In this way, the ANA promoted an intensification of the separation between manual and intellectual work.
Not only was Taylorism applied to Nursing care, Fordism also influenced the structural changes in Nursing care in the 1930s in the USA (10) , as well as the hospital architecture (12) . During this period, Functional Nursing emerged, which acted as an assembly line with an intense division of activities into small tasks, and time and movement studies were applied to operations performed in the Nursing labor, which led to a significant increase in the working pace on an industrial scale (10) .
Under the pretext of an alleged "shortage" of nursing professionals caused by the Second World War, American hospitals reversed many previously-achieved advances. for admission to the Nursing courses, so as to reduce the training time for Nursing students, reintroduce Nursing students to conduct direct assistance in wards and regulate the position of the Licensed Practical Nurse, trained from a one-year technical program (10) . Although thousands of nurses left their countries to take part in the war, they represented a small number of the available nurses and governments and private hospitals refused entry to male nurses, black-skinned nurses and people over 40 years old to take up positions in hospitals (10) .  (13) .
The technologies of the First Industrial Revolution and imperialist interests deeply expanded the production capacity and demanded a greater supply of raw materials, labor instruments, workers and consumer markets (13) . In this way, means of land and sea transportation, as well as commercial routes, were developed to move goods and workers to meet the demands of production and capital accumulation, generating large intra-and international migratory flows and eventual contacts for the purchase and sale of goods. In addition, the First World War imposed the movement of large troops in foreign lands. Such elements, combined with the growing population concentration in urban centers, contributed to the population being exposed to microorganisms, for them new, and for the rapid spread of communicable diseases (14) .
In the meantime, potential or actual epidemics in one part of the globe came to affect the profits of large international corporations headquartered in other locations (15) . Therefore, general health conditions,  (16) . The Rockefeller Foundation in its creation had the International Health Commission (1913)(1914)(1915)(1916), later named as the International Health Directorate (1916)(1917)(1918)(1919)(1920)(1921)(1922)(1923)(1924)(1925)(1926)(1927) and, finally, as the International Health Division   (16) .  (17) , replacing or diminishing the influence of religious Nursing assistance and existing traditional practices where the Foundation had advanced (16) . In Brazil, the Rockefeller Foundation played a fundamental role in Nursing and Public Health as a whole, creating schools for the training of nurses and health visitors throughout the national territory (18) and, subsequently, the Special Public Health Service (19) .
Crises are the natural mode for the existence of capitalism and, therefore, since its initial stage of development at the international level, the capitalist mode of production has faced several crises (20) . The socalled cyclical crises, which took place every 7 or 10 years, occurred within longer periods, around 50 years, which are called long waves (21) .
Until the 1950s, there were four long waves in the history of capitalism: (i) between the end of the 18 th century and the 1847 crisis; (ii) between 1847 and the beginning of the 1890s; (iii) between the 1890s and the Second World War; and (iv) the last one that started in the mid-1940s (20) . Each was initiated from a technological or industrial revolution and all were composed of two phases: an initial expansion, marked by accelerated capital accumulation, and a final one with a tendency to stagnation, marked by gradually decelerated accumulation (20) .
The stagnation phase of this last long wave, called the Golden Age of Capitalism, was marked by recessions in imperialist economies in western Europe (capitalist) and Japan between the 1960s and 1970s that culminated in the 1974/75 world recession (20) . This phase was also in the international labor division. In Brazil, contradictorily and due to its quality as a country with a dependent economy, the Unified Health System is built as an element of a universal social security system in the midst of this international setting and, consequently, suffers from pro-market reforms, underfunding and deepening competition between public and private institutions since its inception (22) . The 1970s were crucial for capitalism, marking the end of the Social Welfare State guided by Keynesianism, starting the implementation of neoliberal rationality, and marked the beginning of a crisis of another nature: the structural crisis of capitalism (20) .
Capital has three fundamental dimensions: production, distribution/circulation/materialization, and consumption.
These dimensions, although they have relative autonomy from each other, are fundamentally interdependent and tended to be strengthened, expanded and made increasingly complex through their interactions. When one of these dimensions met a limit, another compensated and gave the feeling that this contradiction had been overcome. With the structural crisis, this triad that leads to the self-expansion of capital's suffers more and more disturbances to the point of presenting flaws in its mechanisms for displacing contradictions from one dimension to another (20) .
Unlike the long waves that happened until the 1970s, with the structural crisis there is a situation of cumulative, endemic and chronic crisis on a global scale (23) .
A productive restructuring was necessary to generate a more flexible pattern of accumulation and to be better able to overcome the contradictions within this crisis (23) .
This restructuring, which is still under development until the present day, had the Toyota Production System as its main reference (24) .

In 1950, Eiji Toyoda visited Ford's Rouge plant in
Detroit to study the plant and its modes of production and management (24) . Upon returning and discussing what he had found in Detroit with Taiichi Ohno, they understood that Fordism would not serve Japan and developed an alternative that would be called the Toyota Production System and, later on, Lean Production (24) .
One of the main features of Lean Production is the search for eliminating wastes through processes that promote continuous improvement of the capital accumulation process (24) . In Lean Production, wastes are results of operations that do not add value to the product developed (25) . To eliminate wastes in the Lean Production, therefore, it is necessary to define what is and what is not value according to the view of its consumer -be it the final consumer or some intermediary in the production chain -, trace the value chain, that is, define the set of absolutely necessary actions for the production of a certain product or service, and ensure that the entire production process of the product or service reaches the necessary fluidity to meet the needs and desires of the consumers in less time, with fewer errors and with the lowest competitive price (24)(25) .

With the transformations generated by
Lean Production, the intellect of the workers, previously rejected, started to function as an intellect of capital, based on the valorization of value and on the devaluation of work (26) . Thus, unproductive work performed by assistants, such as maintenance, monitoring and quality control, are now performed by productive workers (26) .
Such modifications in the production process generated spaghetti diagrams, Gemba walkarounds, root cause analysis and rapid process improvement workshops) and Lean improvement activities (such as 5S or the "6S" variation which includes safety (33) , level production, visual management and standardized operations) (25) .
A key concept for applying the Lean Production principles in the health field is waste. The NHS currently recognizes eight health wastes: (i) Defects: rework caused by failed processes or lack of access to correct information in the first attempt; (ii) Waiting: when the individuals cannot perform their work due to the absence of people, equipment and information at the appropriate time; (iii) Transport: unnecessary movement of materials; (iv) Over processing: performing unnecessary stages that do not add value; (v) Inventory: characterized by excess stocked materials and patients waiting to be discharged or waiting for procedures; (vi) Motion: when people move unnecessarily and for things that are difficult to access; (vii) Over production: the act of producing more than necessary or when it is not necessary; and (viii) Skills: not making the best use of people's abilities (34) .
Nursing laborers, mainly in England, have suffered from the so-called zero-hour contracts (43) . In this contemporary model of hiring, the employer does not settle a minimum number of hours worked, and can serve both to fill the void left by job abandonment or by medical leave, and for hiring professionals to work from their homes in a situation of flexible demand for health care (26,43) .

From 2016 to 2017, the British National Health
System recorded a total of approximately 325,000 workers employed in the zero-hour contracts for adult care, representing almost a quarter (24%) of the entire workforce employed in this sector, with the most affected workers being registered nurses, with 55% of the workforce subjected to this precarious hiring regime, and caregivers, with 56% of the workforce (43) . This same report points out that the turnover of these workers is higher in all the scenarios (43) . In Brazil, there is currently a trend to intensify the precariousness of the health work, either due to the deterioration of the working conditions or of the contractual employment ties (44) .
The area still needs to invest more in studies on the increasing precariousness of the Nursing labor but, from what it has produced, wear out and work overload are verified as consequences, with negative impacts on the physical and mental health of the workers (45) . In this sense, for the Nursing labor to produce health care for the population, in the light of the Nightingalean ideas, Nursing laborers need decent conditions to safely exercise their professional practices.

Conclusion
The Nursing labor, which becomes professional under