Abstract

This paper discusses the importance of the Nursing to the Unified Health System, considering its presence in all organizational health structures, in the 27 units of the Federation and all municipalities of the country, essential, therefore, for the provision of high-quality health care. Nevertheless, the profession faces many challenges, both in the field of education and in the job market, that must be addressed, aiming at the valorization of these professionals who, despite all the difficulties they are subjected to, are committed to the health of the Brazilian population.

Key words
Nursing; Job market; Brazilian Nursing Profile

Introduction

Talking about the Unified Health System (SUS) is bringing to light the process of establishing the most extensive and most efficient free health system in the world, created to serve all Brazilians, without distinction, and thus recognized by the World Health Organization (WHO).

Established as a public policy, having entered the policy agenda of the 1980s and finally being incorporated into the 1988 Federal Constitution, with the establishment of the SUS by Law Nº 8.080/90¹1 Brasil. Lei nº 8.080 de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União 1990; 20 set., Brazil took a decisive step that changed the formerly selective and centralized health care model.

Its principles of equity, universality, comprehensiveness, decentralization, and social participation have brought the possibility for all, but especially the poorest, the helpless and jobless to also have access to health. The SUS is inclusive and is in all areas of health – it performs the most straightforward and most complex procedures. Today, 30 years into its establishment, the SUS provides care to over 11 million people a day and performs about 127 procedures per second.

Interweaved with the existence of SUS is Nursing, which is a very significant contingent, representing more than half of all health professionals working in Brazil. One cannot think about the functioning of this system without the work of nurses, nursing technicians, and assistants present in each Brazilian city, in each unit and health institution.

The victories and challenges of the SUS are also interweaved with those of Brazilian Nursing. If SUS is underfunded since its inception, nursing professionals suffer from the lack of a national wage floor, which results in meager salaries, and in some areas of the country, professionals must resort to other activities outside health to supplement their monthly income.

SUS has survived government changes and was associated with reduced infant mortality, increased life expectancy, and the widespread improvement of key health indicators in Brazil over the past three decades. It is an achievement of the population that cannot be neglected. It has increased Brazilians' access to health as it was not thought possible 30 years ago. Today, seven out of ten Brazilians depend exclusively on the Public Health System. This is equivalent to 75% of Brazilians. Gateway to health, Primary care covers 50% of users today. Based on international evidence, the World Health Organization states that health systems based on strong Primary Health Care have better outcomes, lower costs, and higher quality of care. In the opinion of Santos²2 Santos NR. SUS 30 anos: o início, a caminhada e o rumo. Cien Saude Colet 2018; 23(6):1729-1736.:

Nursing and the SUS

Nursing is an essential profession and core in the structure of health professions in Brazil and worldwide. It is a professional category organized in a peculiar way, whose internal structure consists of three categories: Nurse, Nursing Technician, and Nursing Assistant.

It is a contingent of more than 2 million professionals, present in the 5,570 municipalities, the 27 units of the Federation, as well as in all organizational structures of the Brazilian health system, namely, hospitals, outpatient clinics, health centers, UBS, UPAS, SAMUs, ESF, among others.

Because it is a profession that acts in several realms of health, namely, care (very strong), public health, prevention, and health promotion, in all stages of our lives, from birth to death, it inherits the sociological notion of essentiality in the context of the professions.

Likewise, a feature of Nursing education, multifunctionality has enabled the expansion of practice spaces of professionals who are active in all SUS processes and procedures, including management, coordination of Programs such as the Family Health Strategy, management, and care. Nursing is the cornerstone of any health system – there is no way to get on with work without it.

As the SUS and the process of decentralized health actions and services were gaining in scope, especially for states and municipalities, an even larger and more specialized workforce for each area of activity was required. Nursing joined in and, throughout this history, has been contributing not only to the implantation and implementation of the various health policies (Family Health Strategy, SAMU, immunizations, control of endemic diseases, among others), but also the daily maintenance of this system, from major centers to the most remote locations in the country.

Brazil is a reference for any country that wants to learn about Primary Care, said Thomas Hone, a researcher at the Imperial College of London, and scholar of universal health systems. Nursing has an active role in PHC, and in the emergence of Advanced Nursing Practices, it provides a perspective of higher resolution, efficacy and efficiency.

Training

Matching training to the needs of the Unified Health System and regulating training by combating low-quality courses is another major challenge for the profession. The nursing staff is a young contingent – 61.7% are under the age of 40.

Some points regarding education are worth highlighting in the study by Machado³3 Machado MH, coordenadora. Pesquisa Perfil da Enfermagem no Brasil: Relatório Final. Rio de Janeiro: Nerhus-Daps-Ensp/Fiocruz; 2017. on Nursing, namely: first, the private initiative dominates the training of these professionals, which means that 57.4% of nurses and 72% of technicians and assistants derive from private educational institutions; second, there is an apparent Southeastern hegemony with regard to professional training (50%); third, one-third of the nurses were previously nursing technicians or assistants. Concerning post-training qualification, data portray a very uneven situation within the staff: among nurses, 4.7% are Ph.D., 14.5% are have a masters' degree, and 72.8% have some specialization; among the assistants and technicians, only 23% have specialization and 45.8% have attended a refresher course during their professional life. Finally, 60% report that they have not pursued any qualification in the last 12 months.

However, the desire to qualify is a goal of Brazilian nursing professionals, who seek to improve their position in the job market – 80.1% of nurses report having taken postgraduate courses, and most (72.8%) in the specialization modality, as per data from the Brazilian Nursing Profile Survey³3 Machado MH, coordenadora. Pesquisa Perfil da Enfermagem no Brasil: Relatório Final. Rio de Janeiro: Nerhus-Daps-Ensp/Fiocruz; 2017.. Most, 78.1% of the mid-level workers (technicians and assistants), want to enroll in undergraduate courses and many already have education above the required for the performance of their duties, with 22.8% reporting incomplete higher education and 11.5% completed an undergraduate course (Table 1).

However, there is still a low rate of professionals with postgraduate residency and high specialization level, often disconnected from what the country's health system needs. Machado³3 Machado MH, coordenadora. Pesquisa Perfil da Enfermagem no Brasil: Relatório Final. Rio de Janeiro: Nerhus-Daps-Ensp/Fiocruz; 2017. says that:

Nursing is becoming a university profession. On the other hand, technical and higher education private schools without education quality are proliferating. COFEN's data⁴4 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... in 2018 evidence that 149,425 new professionals were registered in the Nursing Councils, of which 36,359 were nurses, 24 midwives, 94,676 nursing technicians, and 18,366 nursing assistants graduated at the 6,719 existing schools in the country (819 undergraduate nursing courses, 3,877 technical training schools, and 2,023 nursing assistant courses), without considering distance learning hubs⁴4 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... .

This course upswing followed the growth trend in all areas, resulting from an expanding education process to create educational opportunities, often without following an orderly criterion.

Also, with the advent of distance learning (DL) in nurse training and the implementation of distance learning centers, mainly in small and medium-sized municipalities without the necessary infrastructure, besides the dramatic expansion of the number of vacancies for nurse training contributes to the deteriorated training quality. Also, the municipalities cannot absorb this contingent, a mismatch between courses' offerings and the lack of public policies for the inclusion of graduates in the labor market.

The Labor Market

Research data evidence that the nursing labor market points to an unequal composition throughout the country, i.e., 77% are technicians and assistants, while only 23% are nurses. These are concentrated in the Southeast Region, while the North and Northeast suffer from a lack of these professionals. Likewise, an apparent concentration is also seen in the large urban centers, especially in the capitals, where more than half of all contingents are living and working³3 Machado MH, coordenadora. Pesquisa Perfil da Enfermagem no Brasil: Relatório Final. Rio de Janeiro: Nerhus-Daps-Ensp/Fiocruz; 2017..

It is essential to know where they work and how is this massive health contingent. Searching data from the Nursing Profile Survey in Brazil³3 Machado MH, coordenadora. Pesquisa Perfil da Enfermagem no Brasil: Relatório Final. Rio de Janeiro: Nerhus-Daps-Ensp/Fiocruz; 2017., one can have the following radiograph of the category employability (Table 1).

Work in the public sector accounts for 58.9% of the entire workforce, becoming the largest and most crucial nursing employer. However, data are not encouraging, since half of them are in poor work conditions, 62.5% earn up to three thousand reais, and 14.4% earn substandard salaries (≤1,000 reais).

The private sector is also a significant employer, accounting for one-third of the contingent; that is, 31.6% work in the private sector. On the other hand, 40% are in poor work conditions, 68.2% earn up to three thousand reais, and 22.1% earn substandard salaries (≤1,000 reais).

Another important sector in the states and under the SUS is the nonprofit, which gathers 15.4% of this contingent, 40% of which are in poor work conditions, 70.1% earn up to three thousand reais, and 23.7% earn substandard salaries (≤1,000 reais).

SUS underfunding is aggravated by Amendment 95/2016, which limits spending and freezes investments in health, education, and social assistance for the next 20 years, and will also affect, in the medium term, demand and salaries of nursing professionals.

Also, the Brazilian Nursing Profile Survey points to a phenomenon resulting from the imbalance between labor supply and demand, in which, due to the nursing schools' boom and, consequently, the unbridled supply of new professionals in the labor market, as mentioned above, leads to open and structural unemployment.

Machado e Ximenes Neto⁵5 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. argue the following:

Contradictorily, another phenomenon is observed: the shortage of nurses throughout the national territory, especially in the inland region of the country, that is, 56.8% live and work in the capitals, leaving the inland regions with a shortage of professionals to serve the population. The idea that there are plenty of nurses in return is untrue, such is the deficit of health care to the population in the country. All this leads to a common denominator: low growth in employability among nurses portrayed throughout the structure of the SUS, whether in the public, private or nonprofit sphere, in which the policy of keeping low percentages of nurses in the composition of the nursing staff is adopted, generating a clear burden for nurses. Machado³3 Machado MH, coordenadora. Pesquisa Perfil da Enfermagem no Brasil: Relatório Final. Rio de Janeiro: Nerhus-Daps-Ensp/Fiocruz; 2017. says:

It is a fact that work in health generates wear, stress, and illness. The Brazilian Nursing Profile research sought to identify how nurses, technicians, and nursing assistants stand. The data also show that 65.9% declare professional wear. The increase is rampant, generating depression, obesity, extreme fatigue, a feeling of devaluation, with alarming rates of sick leave.

Reinforcing the statement that Brazilian Nursing shows signs of exhaustion is because 56.1% have fallen ill in the last 12 months, requiring medical attention; the high rates of occupational accidents, i.e., 10% (mean) in the public, private or philanthropic sector, which means that more than 180,000 professionals have been injured in the last 12 months, according to survey data. They also report that they feel unattended, that is, when they get sick, only 40.6% of them are treated at their workplace, and often die in the work routine. Physical inactivity is another triggering factor of illness, and in the case of nursing, 66.2% are sedentary, do not practice sports regularly, claiming tiredness, lack of time and opportunity.

Finally, it is necessary to mention the assessment of nursing in the work environment of these 2 million workers. Survey data show that 71% feel unprotected in their work environment because of the violence in most hospitals, outpatient clinics, health centers, among others, nationwide. A significant portion (52.8%) report being mistreated and disrespected by the user population, especially the patients' relatives, and 19.7% have already suffered physical, psychological, or institutional violence.

There is also no minimum comfort in the workplace for those on duty and in need of a break, so less than half report that there is rest infrastructure where they work.

Final notes

The most recent nursing challenge is Pension Reform, which will overly affect nursing professionals. A mostly female category (85%) is exposed to intense physical and psychological wear, as well as biological risks. The Brazilian Nursing Profile Survey shows that the demands inherent to the profession are reflected in the labor market: only 2.1% of professionals working in Brazil are over 60 years of age. Six out of ten professionals are under 40 years of age. Therefore, it is imperative to adapt the proposal to the specific nursing working reality.

Nursing professionals seem invisible to the eyes of politicians, entrepreneurs, and managers of health institutions and, often, of the population. They are invisible even to themselves, who have low self-esteem. The largest health area, with more than two million Brazilians, cannot see approved the indispensable claims for the improvement of their work, their health, and the entire population of the country. It is curious how they do not realize or pretend not to realize this bottleneck in health.

Even with the technological and innovative advances in health, the human being is still the most critical input. It is the look, touch, presence, precise care, technique, and loyalty of the nursing professional who, despite all difficulties, spearheads the main procedures, at the entrance and in all stages and processes of a call. When hospital managers and public officials say this is a vast category and it is, therefore, difficult to approve a decent wage floor, a journey commensurate with their work because health will collapse. They deny these rights, which are already proven not to affect economically; on the contrary, these will bring more health gains, with healthier care by happier, more fulfilled, restful professionals. They do deny, because they are sure of the commitment of each of these workers to health, to the population. They are sure that they are not irresponsible; on the contrary, they are committed to life, to each other.

A debate on the training, functions, working conditions, and directions of Nursing is, therefore, (re)thinking the Health System. It is looking, and yet looking again at the commitment to the population and the conditions to which these professionals who are in charge of health for Brazilians are subjected daily.

References

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