Abstract

The present article analyzes the job market of nursing professionals, based on data obtained through the survey “Nursing Profile in Brazil” (Cofen – Fiocruz), showing that a significant portion of these workers, mostly nursing aides and technicians, live in increasingly precarious conditions of survival, with low wages, multi-employment and insecurity in the work environment, which prevents them from performing their work activities with dignity. It also analyzes the Nursing regulation process, having as reference the sociology of professions, from the creation of the Federal Nursing Council/Regional Nursing Councils System, in the 1970s, when the category started to have self-regulation autonomy, and currently, the profession shows a robust and highly regulatory legal milestone, considering the number of resolutions issued by Cofen, which have an impact on professional practice. The article points out that it is essential for the government to develop and improve job management and regulation policies, in order to contribute to overcome the problems faced by nursing professionals.

Key words
Job Market; Professional Regulation; Nursing Profile in Brazil

Introduction

The modern society has increasingly become a professionalized society, making a large part of human activities developed in it seek recognition and professional status, gaining social privileges and (almost always legal) labor market monopoly. Most of our actions and activities are based on or referenced by acts, criteria and professional standards. Contemporary society is characterized by the division of labor into different activities and specialized areas. Andrew Abbott's statement¹1 Abbott A. The system of professions. An Essay on the division of expert labor. London, Chicago: The University of Chicago Press; 1988. that professions dominate our world, our bodies, measure our profits and save our souls, summarizes how much we experience the myth of professionalism.

The domain and monopoly of knowledge constitute the core of the autonomy of the professions and their social prestige. They, in general, also appeal to the ideal of service in the pursuit of social credit and autonomy, which means that the patient's interest must take precedence over corporate interests. For Larson²2 Larson MS. The rise of professionalism. A sociological analysis. Berkeley, Los Angeles, London: University of California Press; 1977., the ideal of service and the code of ethics, different versions of the same idea of moral obligation to society, are the main ideological response of the professions to the contradiction between socially produced knowledge on the one hand, and its private appropriation in the form of expertise, on the other. Both are the justification and assurance that this knowledge will be returned to society as qualified services; which, however, present themselves as pre-capitalist or anti-market elements, which gives them an ideological connotation. These are elements that were incorporated into the organization of the professions because they support both social credit and public belief in the ethical character of the professions³3 Machado MH. Os médicos e sua prática profissional: as metamorfoses de uma profissão [tese]. Rio de Janeiro: IUPERJ; 1996..

A phenomenon that has been increasingly growing refers to a large number of legal suits by several technical activities seeking their recognition as a profession. And this is not restricted to the Brazilian reality, as it has a universal presentation, in a movement of increasing professionalization of these occupations. This demand reflects the “social need” that the services a given technical area offers to society comprise differentiated, specialized and good quality products. These professionals need to undergo specific training, be constantly peer-reviewed, and have norms and rules that guide them in their practice. Additionally, this activity requires government regulation to ensure the monopoly and exclusivity of the labor market.

Overall, there is a consensus among theorists of the area regarding the existence of two unquestionable attributes, namely, the existence of a specific body of knowledge and the orientation towards an ideal of services.

According to Freidson⁵5 Freidson E. Renascimento do profissionalismo. Trad. CM Paciornik. São Paulo: Ed. USP; 1998.:

This author also shows that the:

It is important to emphasize that the professionalized markets that exist today in the world emerged in the midst of the transformations arising from the Industrial Revolution and the consolidation of the capitalist system. These facts allowed the emergence of practices and new social functions, increasing the need for professionalism in all industrialized society²2 Larson MS. The rise of professionalism. A sociological analysis. Berkeley, Los Angeles, London: University of California Press; 1977..

On the other hand, as it occurred with several other professions, in nursing, the regulatory aspects required complex actions involving various actors.

For Moran & Wood⁶6 Moran M, Wood B. States, regulation and the medical profession. Buckingham: Open University Press; 1993., professional regulation scholars, there are three regulatory models. The first refers to Self-regulation, that is, the professionals themselves define the mechanisms of market entry and technical competency. The second is the Government-sanctioned Regulation, characterized by institutions in charge of formulating and implementing regulatory mechanisms with the government's consent and support. Finally, the Direct Government Regulation, exercised by specialized public institutions. For these authors, the regulatory model consists of the following elements: a) market entry mechanisms, including licensing and certification; b) control of professional competition; c) the structure of the labor market and; d) the payment mechanism.

This is the central topic of this article: the labor market and the regulatory process of the nursing profession in the light of the empirical findings of the Nursing Profile Survey in Brazil – PPEB (2017), which makes an accurate and detailed diagnosis of the situation of nurses, nursing technicians and aides, with nearly two million workers in the country's health system. The survey listened to these professionals in more than 50% of the municipalities, in the 27 units of the Federation and in the 5 regions of the country. Therefore, we have now the radiography of this profession, allowing a more accurate and reliable understanding of the local and national realities.

Professional regulation

The first regulatory measures of nursing were in the field of training, with the emergence of schools and vocational courses. However, even after the establishment of the National Department of Public Health in 1923, the supervision of Nursing activities was subordinated to Medicine⁷7 Kletemberg DF, Siqueira MTD, Mantovani MF, Padilha MI, Amante LN, Anders JC. O Processo de Enfermagem e a Lei do Exercício Profissional. Rev Bras Enferm 2010; 63(1):26-32.. Only with the creation of the Federal Council/Regional Councils of Nursing System, through Law N. 5.905/73⁸8 Brasil. Lei nº 5.905, de 12 julho de 1973. Dispõe sobre a criação dos Conselhos Federal e Regionais de Enfermagem e dá outras providências. Diário Oficial da União 1973; 13 jul., the profession became self-regulating, gaining autonomy.

This “rational-legal bureaucracy structure aims an efficient division of labor, forms of supervision that can effectively control and coordinate a complex variety of specialized tasks, and channels that can freely and fully pass orders, requests, and information up and down the hierarchy. (...) The organization personnel are chosen solely based on their competency to perform a particular type of work and are required to perform this work on their own. Their rights, duties and responsibilities are very precisely defined, as is their authority over others and their subordination to them”⁵5 Freidson E. Renascimento do profissionalismo. Trad. CM Paciornik. São Paulo: Ed. USP; 1998.(p.254).

Therefore:

The inspection by the Councils is the main action to ensure the effectiveness of Law N. 7,498/1986¹⁰10 Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei nº 7.498, de 25 de junho de 1986. Dispõe sobre a regulamentação do exercício da Enfermagem e dá outras providências. Diário Oficial da União 1986; 26 jun., which regulates the activity. In Brazil, Nursing accounts for most health care activities, totaling more than 2.2 million workers, represented by the Nurse, Nursing Technician and Nursing Aide. It is the nurse's responsibility to lead the care process, working in the management of nursing care, establishing the interrelationship between care and administering this care.

Based on the Law of professional practice, it is possible to observe that two types of Nurses are acknowledged: the generalist and the obstetric nurse, (Cofen Res. N. 581/2018¹¹11 Conselho Federal de Enfermagem (COFEN). Resolução COFEN nº 581, de 11 de julho de 2018. Atualiza no âmbito do Sistema Cofen/Conselhos Regionais de Enfermagem, os procedimentos para Registro de Títulos de Pós-Graduação Lato e Stricto Sensu concedido a Enfermeiros e aprova a lista das especialidades. Diário Oficial da União 2018; 18 jul., which regulates the specialties and N. 516/2016¹²12 Conselho Federal de Enfermagem (COFEN). Resolução COFEN nº 516, de 23 de junho de 2016. Normatiza a atuação e a responsabilidade do Enfermeiro, Enfermeiro Obstetra e Obstetriz na assistência às gestantes, parturientes, puérperas e recém-nascidos nos Serviços de Obstetrícia, Centros de Parto Normal e/ou Casas de Parto e outros locais onde ocorra essa assistência; estabelece critérios para registro de títulos de Enfermeiro Obstetra e Obstetriz no âmbito do Sistema Cofen/Conselhos Regionais de Enfermagem, e dá outras providências. Diário Oficial da União 2016; 27 jun., which establishes the competencies for working in the field of obstetrics)¹⁰10 Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Lei nº 7.498, de 25 de junho de 1986. Dispõe sobre a regulamentação do exercício da Enfermagem e dá outras providências. Diário Oficial da União 1986; 26 jun.. Another measure arising from the law is the institutionalization of its activities, with the inclusion of the planning and scheduling of care in organizational structures, as well as the obligatory position of the Nursing Service Direction and Supervision as the nurse's exclusive actions. Another important regulatory element is the consultation and prescription of nursing care. In this sense, the Cofen determines the institution of the Nursing Process and Nursing Care Systematization (Cofen Res. N. 358/2009¹³13 Conselho Federal de Enfermagem (COFEN). Resolução COFEN nº 358, de 15 de outubro de 2009. Dispõe sobre a Sistematização da Assistência de Enfermagem e a implementação do Processo de Enfermagem em ambientes, públicos ou privados, em que ocorre o cuidado profissional de Enfermagem, e dá outras providências. Diário Oficial da União 2009; 23 out.), in all health units.

Regarding the expansion of the scope of practices, the law established prerogatives for nurses in the prescription of medications (Cofen Res. N. 195/1997), also guaranteeing the request for examinations established in the Public Health Programs and institutional routines¹⁴14 Conselho Federal de Enfermagem (COFEN). Resolução COFEN nº 195, de 18 de fevereiro de 1997. Autoriza a solicitação de exames de rotina e complementares pelos enfermeiros quando no exercício de suas atividades profissionais. Diário Oficial da União; 1997.. Therefore, the regulation of this practice complied with the care model based on the highly relevant activity of nurses in the public health context.

In the case of Brazil, other entities are also responsible for the regulation of nursing activity, especially the Ministry of Health (MOH), which establishes the main clinical guidelines for the Brazilian Unified Health System (SUS – Sistema Único de Saúde), through protocols. However, David et al.¹⁵15 David HMSL, Acioli S, Seidl HM, Brandão PS. O enfermeiro na Atenção Básica: processo de trabalho, práticas de saúde e desafios contemporâneos. In: Mendonça MHM, Matta GC, Gondim R, Giovanella L, organizadores. Atenção Primária à Saúde no Brasil: conceitos, práticas e pesquisa. Rio de Janeiro: Fiocruz; 2018. p. 337-367. mention that “nurses perform what is allowed in the field of political negotiations between categories, according to the needs and contractualization of local interests by the power management and micromanagement”. Therefore, these practices are under constant jurisdictional disputes with other health professions. In this sense, Cofen affirms and delimits, through resolutions and opinions, the jurisdictional questions related to clinical practice. It is noteworthy that these resolutions embody, in addition to self-regulation, responses to the jurisdictional attacks of other health corporations. This responsive capacity of Cofen is analyzed by Koster⁹9 Koster I. O exercício profissional da enfermagem no âmbito da atenção primária à saúde no Brasil [tese]. Rio de Janeiro: Ensp/Fiocruz; 2019., who highlights the exponential growth in the number of resolutions following the promulgation of SUS in 1988, with the expansion of health policies of the MOH from the 1990s and continuing to the present day. (Graph 1).

Among the set of resolutions, three stand out: a) the Code of Professional Ethics; b) the inspection system operation; c) the standardization of the Technical Responsibility, as a capillarization of the supervision of the professional practice as indicated in Chart 1.

According to Koster⁹9 Koster I. O exercício profissional da enfermagem no âmbito da atenção primária à saúde no Brasil [tese]. Rio de Janeiro: Ensp/Fiocruz; 2019.:

According to Koster's analysis⁹9 Koster I. O exercício profissional da enfermagem no âmbito da atenção primária à saúde no Brasil [tese]. Rio de Janeiro: Ensp/Fiocruz; 2019., the text of the current Code of Ethics, instituted by Cofen Res N. 564/2017¹⁶16 Conselho Federal de Enfermagem (COFEN). Resolução COFEN nº 564, de 6 de novembro de 2017. Aprova a reformulação do Código de Ética dos profissionais de enfermagem. Diário Oficial da União 2017; 6 dez.:

As for the phenomenon of specialization in nursing, the analysis points to issues related to the regulation of professional practice and the labor market. Some, involving public policies and models of health care, such as: Collective Health and hospital areas. Others meet the requirements of areas that are already regulated, such as worker's health and hemodialysis services.

As a result of technological evolution, Nursing specializes in areas of expertise. The first resolution on the subject is from 1998, regulating 8 specialties. In 2001, it increased to 37; in 2004, to 42, reaching 60 specialties in the year 2018, which represents an increase of 750% (Figure 1), as pointed out by Koster⁹9 Koster I. O exercício profissional da enfermagem no âmbito da atenção primária à saúde no Brasil [tese]. Rio de Janeiro: Ensp/Fiocruz; 2019..

On the other hand, data from PPEB (2017) indicate that:

The authors also analyze that this “specialization” of the activity reflects something new in the nursing labor market, since “of the 211,000 nurses who reported having a title of specialist, 47% obtained the title 5 years ago or less. Adding up the group of 6-10 years, the percentage rises to 65.7%¹⁹19 Machado MH, Wermelinger M, Vieira M, Oliveira E, Lemos W, Aguiar Filho W, Lacerda WF, Santos MR, Souza Junior PB, Justino E, Barbosa C. Aspectos gerais da formação da enfermagem: o perfil da formação dos enfermeiros, técnicos e auxiliares de enfermagem. Enferm Foco 2016; 7(n. esp.):15-34.. Similarly, and following the same process, 18 specialties have been registered for the Nursing technician, contained in Cofen Res. N. 609/2019²⁰20 Conselho Federal de Enfermagem (COFEN). Resolução COFEN nº 609, de 1º de julho de 2019. Atualiza, no âmbito do Sistema Cofen/Conselhos Regionais de Enfermagem, os procedimentos para registro de especialização técnica de nível médio em Enfermagem concedida aos Técnicos de Enfermagem e aos Auxiliares de Enfermagem. Diário Oficial da União 2019; 3 jul..

Regarding the regulation of care practice, Cofen has issued a series of norms that meets the needs and challenges in the category's daily life. The case of the autonomy for insertion of the Peripheral Intravenous Catheter (PIC); suturing/episiorrhaphy by the obstetric nurse; the collection of material for oncotic colpocytology as an exclusive activity of the nurse; authorization to perform the insertion of Intrauterine Device by nurses; the definition of the competencies of the team in the treatment of injuries, giving them the autonomy to open Nursing Offices, among others, have been defied, attained through judicial intervention by the Council, such as the recognition of the autonomy of nurses in the practice of acupuncture.

As an example, Cofen recently standardized the opening of nursing clinics and offices, through Res. N. 568/2018²¹21 Conselho Federal de Enfermagem (COFEN). Resolução COFEN nº 568, de 9 de fevereiro de 2018. Aprova o Regulamento dos Consultórios de Enfermagem e Clínicas de Enfermagem. Diário Oficial da União 2018; 20 fev. and N. 606/2019²²22 Conselho Federal de Enfermagem (COFEN). Resolução COFEN nº 606, de 5 de abril de 2019. Inclui na Resolução Cofen n° 568, de 9 de fevereiro de 2018, Anexos contendo modelo de Requerimento de Cadastro de Consultório e de Clínicas de Enfermagem e modelo de Registro de Consultório e de Clínicas de Enfermagem, no âmbito dos Conselhos Regionais de Enfermagem. Diário Oficial da União 2019; 9 abr., providing legal support to professionals for autonomous work; as well as resolutions on the regulation of the fees and the Technical Responsibility of the nurse.

Therefore, it can be observed that the profession establishes a regulatory legal framework of impact on its daily practice observed not only by the number of resolutions issued by Cofen, but also by the scope and amplitude of covered areas.

The Job Market

The Brazilian Unified Health System (SUS, Sistema Único de Saúde) , established in the Brazilian Constitution in 1988, is one of the largest public health systems in the world and has produced, in its 30 years of existence, major transformations in the health system, representing

However, as stated by Machado et al.²⁴24 Machado MH, Oliveira ES, Lemos WR, Lacerda WF, Justino E. Mercado de trabalho em enfermagem no âmbito do SUS: uma abordagem a partir da Pesquisa Perfil da Enfermagem no Brasil. Divulg Saude Debate 2016; 56:52-69.:

On the other hand, the labor market (LM) of the health sector will experience a strong expansion, which will have an impact on the dynamics of the sector. Machado and Ximenes Neto²⁵25 Machado MH, Ximenes Neto FRG. Gestão, da Educação e do Trabalho em Saúde no SUS: trinta anos de avanços e desafios. Cien Saude Colet 2018; 23(6):1971-1980. analyze that:

The structuring of LM is one of the bases of the Nursing professional project. Over the past few decades a solid market for complex services with social credibility has been built.

According to data from PPEB³¹31 Machado MH, coordenadora. Pesquisa Perfil da Enfermagem no Brasil: Relatório Final. Rio de Janeiro: Nerhus-Daps-Ensp/Fiocruz; 2017., there were 1,804,535 professionals, of which 414,712 were nurses and 1,389,823 were nursing technicians and aides. In 2019, the number reached 2,169,402 professionals, of which 527,842 were nurses and 1,641,560 were mid-level professionals, of which 1,230,182 are technicians and 411,378 are nursing aides³²32 Conselho Federal de Enfermagem (COFEN). Enfermagem em números[página na Internet]. [acessado 2019 Jul 15]. Disponível em: http://www.cofen.gov.br/enfermagem-em-numeros
http://www.cofen.gov.br/enfermagem-em-nu... .

Table 1 shows data from the Nursing LM, in which the public and private sectors (for-profit and nonprofit – philanthropic subsectors) are the major employers, with the public sector accounting for 55.6% of jobs and the private for 44.4% of the total.

Public sector

This sector has continental dimensions, consisting of more than 75,000 health facilities, incorporating more than 1 million Nursing workers, which is equivalent to more than half of the employability of the category, whether at the municipal, state or federal level (Table 1).

Their insertion in the market has different types of employment bonds. The statutory workers, ruled by the Single Legal Regime, comprise half of the workers (49.9%), while the CLT-type constitute17.7%, service providers, 8.5% and temporary workers, 8.4%. The OSCIPs, OS and Co-ops amount to 15.6%.

Regarding the types of institutions in the sector, it has been recorded that 68.7% of the professionals work in Hospitals and Urgency/Emergency Units, amounting to more than 976,000 professionals. Basic Health Units (BHUs) and similar health services concentrate the second largest number of workers, with 18.4%, or more than 261,000. The outpatient units and polyclinics nits employ 6.2%, about 88,000. And the SADTs employ more than 19,000 professionals (1.4%). As for the teaching, research and management activities, they are performed by more than 75,000professionals (mostly nurses), equivalent to 5.3%.

On the other hand, working shifts is the most often used work regime in this sector, with 57.1% (more than 593,000, with daily work showing 42.9%, which totals over 445,000 professionals.

As for the working hours in this public sector, the majority (63.8%) work between 21-40 hours a week and 34%, more than 41 hours. A total of 2.2% of workers has a “sub-number of working hours” (equal to or less than 20 hours a week), that is, almost 21,000 professionals.

In practice, the working hours of nursing professionals are not regulated by law, and a free negotiation is allowed. In general, the federal government, most states, and large municipalities adopt the 30-hour /week system, while the private sector, 40-44 hours/week.

Income distribution in this sector shows the following pattern: 1) 55.7% have a monthly income of up to 2,000 reais; 2) 39.4% receive salaries between 2,001-5,000 reais; 3) only 4.8 have income above 5,001 reais (in August/2019, 1 dollar = 3.96 reais).

The private sector

This sector comprises more than 60,000 health facilities, with more than 840,000 professionals, which corresponds to 44.4% of the total number of workers (Table 1).

Regarding the types of employment bonds, the private for-profit sector has more than 571,000 professionals, or 29.9% of the total number. Two types of bonds predominate: CLT with almost 299,000, or 56.1% and service providers, with 30.5%. Private non-profit has 278,000 professionals, 14.5% of the total, of which 61.3% are CLT workers and 30.3%, service providers. The private non-profit sector employs 278,000 professionals, 14.5% of the total, of which 61.3% are CLT workers and 30.3% are service providers.

Regarding the types of institutions where they work, the private for-profit, the Hospitals and Urgency/Emergency Units concentrate the absolute majority, i.e., 70.1%, which is equivalent to more than 533,000 professionals. Outpatient services comprise 10.3%; Diagnosis and Therapy Support Units – SADTs, 8.8%; BHUs only 2.5%; and in the Teaching, Research and Management activities, 8.3% (the absolute majority performed by nurses).In the non-profit private sector, the Hospitals and Urgency/Emergency Units also concentrate the majority, with 73.6%, almost 260,000. SADTs comprise 13.3%; Outpatient Units, 12.2% and in the Teaching, Research and Management activities, the participation is minimal, only 0.9%. There is no record of nursing activities in BHUs.

The most common work regime in the for-profit private sector is the shift work, used by 56.2% of the staff, whereas daily work accounts for 43.8%. As for the working hours, half of the professionals (50%) work 21-40 hours a week and 45.4% work more than 41 hours. On the other hand, 4.6% work 20 hours or less a week, that is, more than 21,000 professionals, which characterizes the existence of a “sub-number of working hours” in the sector.

As for the private non-profit sector, the shift work is also the predominant work regimen, with 54.8%; daily work represents 45.2%. More than 50% of the workers (52.6%) work 21-40 hours a week and 44.4%, more than 41 hours. And 3% of the workers declare they work 20 hours or less a week, which characterizes a “sub-number of working hours” in the sector.

The distribution of income in the private for-profit sector shows that: 1) 69.4% have a monthly income of up to 2,000 reais; 2) 28.3% receive a salary between 2,001-5,000 reais; 3) and only 2.3% have incomes > 5,001 reais. In turn, the nonprofit private sector has the worst income distribution compared to the others, considering that: 1) 73% of the staff have a monthly income of up to 2,000 reais; 2) 25.8% receive a salary between 2,001-5,000 reais; 3) and only 1.2% of them have an income > 5,001 reais³³33 Machado MH, Oliveira E, Lemos W, Lacerda WF, Aguiar Filho W, Wermelinger M, Vieira M, Santos MR, Souza Junior PB, Justino E, Barbosa C. Mercado de trabalho da Enfermagem: aspectos gerais. Enferm Foco 2016; 7(n. esp.):35-53..

Considering data from the PPEB it is possible to state that:

Still considering information from Table 1, it can be observed that 10.7% of the nursing staff experienced unemployment in the last 12 months and 70% reported difficulties in finding a new job. What is noteworthy is the team's occupational accident rate of 11% in the public sector and 10.9% (average) in the private sector, which is equivalent to more than 199,000 injured workers in the health work environment. On the other hand, even more serious is the rate of 22.5% of sick leave among the nursing staff working in the public sector and 15.6% (average) in the private sector.

Final considerations

Traditional professions, such as lawyers, doctors, nurses, engineers, priests, have experienced transformations regarding their technical and scientific aspects, as well as the designing of a political-ideological reordering of the “ideal of service”. Corporate interests increasingly seek to meet economic demands and respond to technological needs. It can be said that these professions undergo a process of radical changes altering their essence, with ruptures in self-perception and their professional project.

In the last two decades, nursing professionals in Brazil have experienced important changes in the world of work. The job market has shown clear signs of wage earning, with the wages being linked to several different types of work regime: by shift, by hour worked, short and temporary contracts, lack of institutional bonds, generating precariousness and multi-employment, with insecurity at the work environment becoming increasingly more frequent. The discussion about decent work has become a recurring theme among trade unions representing workers.

The technological advances registered in the last decades have required the nursing profession to obtain more prestige, status and a great capacity to demonstrate its resolutive capacity regarding the population's health problems. However, these advances also have negative effects, generating competition, jurisdictional disputes in the field of professional regulation, jeopardizing achievements and even loss of space in the labor market.

The managerial bureaucratic control implemented in health organizations (public or private) has been pointed as a sign of new times regarding the types of health work regulation, which represents the imbalance of government regulation among the professions. It is a fact that the Brazilian health system has not responded to these new demands from both health professionals and users. Both feel dissatisfied with the results of these advances and the ways in which the state has responded to them.

If, on the one hand, the pressures of the professions on the government to achieve their autonomy and market control are definitely legitimate, on the other hand, the government should seek to promote a balance between them, to guarantee the constitutional principles and guidelines for health and develop health policies for its workers.

References

Publication Dates

History