Abstract

Introduction

The Covid-19 pandemic was particularly tough for the health systems of the different countries affected. These systems were required to restructure in order to prevent and treat cases of infection, especially to prevent deaths. In the front line of this challenge, nurse workers play an indispensable role, as they represent the largest health care workforce in the world¹1. Llop-Gironés A, Santillan-Garcia A, Cash-Gibson L, Benach J, Zabalegui A. Covid-19 and the global need for knowledge on nurses’ health. Int Nurs Rev. 2022; 69(2):196-200. doi: 10.1111/inr.12722.
https://doi.org/10.1111/inr.12722... .

To a large extent, success in confronting the Covid-19 pandemic relates to the performance of nursing work under adequate conditions. However, it was possible to observe global difficulties in the structuring of work in this area, which left workers unprotected, suffering serious impacts on their health, as was found in some countries, such as Italy, the United States of America (USA), Brazil, India, Mexico, among others²2. Llop-Gironés A, Vračar A, Llop-Gironés G, Benach J, Angeli-Silva L, Jaimez L, et al. Employment and working conditions of nurses: where and how health inequalities have increased during the Covid-19 pandemic? Hum Resour Health. 2021; 19(1):112. doi: 10.1186/s12960-021-00651-7.
https://doi.org/10.1186/s12960-021-00651... .

Illness and death of nursing workers has gained social importance, being the object of study in several studies³3. Ran L, Chen X, Wang Y, Wu W, Zhang L, Tan X. Risk factors of healthcare workers with coronavirus disease 2019: a retrospective cohort study in a designated hospital of Wuhan in China. Clin Infect Dis. 2020; 71(16):2218-21. doi: 10.1093/cid/ciaa287.
https://doi.org/10.1093/cid/ciaa287...

4. David HMSL, Rafael RMR, Alves MGM, Breda KL, Faria MGA, Neto M, et al. Infection and mortality of nursing personnel in Brazil from COVID-19: a cross-sectional study. Int J Nurs Stud. 2021; 124:104089. doi: 10.1016/j.ijnurstu.2021.104089.
https://doi.org/10.1016/j.ijnurstu.2021....

5. Okechukwu EC, Tibaldi L, La Torre G. The impact of Covid-19 pandemic on mental health of nurses. Clin Ter. 2020; 171(5):e399-e400. doi: 10.7417/CT.2020.2247.
https://doi.org/10.7417/CT.2020.2247...

6. Rahman A, Plummer V. Covid-19 related suicide among hospital nurses; case study evidence from worldwide media reports. Psychiatry Res. 2020; 291:113272. doi: 10.1016/j.psychres.2020.113272.
https://doi.org/10.1016/j.psychres.2020....

7. Fernandez M, Lotta G, Passos H, Cavalcanti P, Corrêa MG. Condições de trabalho e percepções de profissionais de enfermagem que atuam no enfrentamento à covid-19 no Brasil. Saude Soc. 2021; 30(4):e201011. doi: 10.1590/S0104-12902021201011.
https://doi.org/10.1590/S0104-1290202120... -⁸8. Rezio LA, Oliveira E, Queiroz AM, Sousa AR, Zerbetto SR, Marcheti PM, et al. Neoliberalism and precarious work in nursing in the Covid-19 pandemic: repercussions on mental health. Rev Esc Enferm USP. 2022; 56:e20210257. doi: 10.1590/1980-220X-REEUSP-2021-0257.
https://doi.org/10.1590/1980-220X-REEUSP... . Some of these studies have revealed the high incidence and mortality due to Covid-19 among nursing workers³3. Ran L, Chen X, Wang Y, Wu W, Zhang L, Tan X. Risk factors of healthcare workers with coronavirus disease 2019: a retrospective cohort study in a designated hospital of Wuhan in China. Clin Infect Dis. 2020; 71(16):2218-21. doi: 10.1093/cid/ciaa287.
https://doi.org/10.1093/cid/ciaa287... ,⁴4. David HMSL, Rafael RMR, Alves MGM, Breda KL, Faria MGA, Neto M, et al. Infection and mortality of nursing personnel in Brazil from COVID-19: a cross-sectional study. Int J Nurs Stud. 2021; 124:104089. doi: 10.1016/j.ijnurstu.2021.104089.
https://doi.org/10.1016/j.ijnurstu.2021.... , as well as mental health repercussions, developed in the face of such a challenge⁵5. Okechukwu EC, Tibaldi L, La Torre G. The impact of Covid-19 pandemic on mental health of nurses. Clin Ter. 2020; 171(5):e399-e400. doi: 10.7417/CT.2020.2247.
https://doi.org/10.7417/CT.2020.2247... ,⁶6. Rahman A, Plummer V. Covid-19 related suicide among hospital nurses; case study evidence from worldwide media reports. Psychiatry Res. 2020; 291:113272. doi: 10.1016/j.psychres.2020.113272.
https://doi.org/10.1016/j.psychres.2020.... . Most of these studies were developed from the typological mosaic of epidemiology or traditional clinical practice, providing precious but insufficient findings. They called attention, however, to the innovative character of some of these studies, when they proposed to analyze the health of workers based on their experiences at work. In these studies, even though they start from the subjectivity of the subjects, objective repercussions are highlighted, such as conflicting feelings, like the feeling of duty and professional pride, mixed with fear and anguish⁷7. Fernandez M, Lotta G, Passos H, Cavalcanti P, Corrêa MG. Condições de trabalho e percepções de profissionais de enfermagem que atuam no enfrentamento à covid-19 no Brasil. Saude Soc. 2021; 30(4):e201011. doi: 10.1590/S0104-12902021201011.
https://doi.org/10.1590/S0104-1290202120... ,⁸8. Rezio LA, Oliveira E, Queiroz AM, Sousa AR, Zerbetto SR, Marcheti PM, et al. Neoliberalism and precarious work in nursing in the Covid-19 pandemic: repercussions on mental health. Rev Esc Enferm USP. 2022; 56:e20210257. doi: 10.1590/1980-220X-REEUSP-2021-0257.
https://doi.org/10.1590/1980-220X-REEUSP... .

This research bears a resembling character, through an analytical-qualitative approach, whose focus is also on the diverse experiences of nurses in their work process. Thus, the objective of the research is to understand the nursing work from the experience of nurses in the front line against Covid-19 in Alagoas, Brazil. It differs because it is linked to the perspective of worker’s health, a field that deals with the work-health relationship from an approximation to the Marxian critique of political economy⁹9. Souza DO. Saúde do(s) trabalhador(es): análise ontológica da “questão” e do “campo”. Maceió: Edufal; 2019..

It should be noted that the key difference of the worker’s health perspective in relation to labor medicine and occupational health consists in bringing the experience of the working class to the center of the investigation/intervention. While labor medicine and occupational health deal with health through the prism of the authority of health technicians at the service of productivity, the field of worker’s health defends that the primacy in the investigation/intervention lies in the experience of the workers, subjects (protagonists) of the process¹⁰10. Mendes R, Dias EC. Da medicina do trabalho à saúde do trabalhador. Rev Saude Publica. 1991; 25(5):341-9. doi: 10.1590/S0034-89101991000500003.
https://doi.org/10.1590/S0034-8910199100... ,¹¹11. Vasconcellos LCF. Entre a saúde ocupacional e a saúde do trabalhador: as coisas nos seus lugares. In: Vasconcellos LCF, Oliveira MHB, organizadores. Saúde, trabalho, direito: uma trajetória crítica e a crítica de uma trajetória. Rio de Janeiro: Educam; 2011. p. 401-22..

This understanding is based on the Marxian assumption that the category of work is central to social relations, including health. Considering that, in the capitalist production mode, work is developed through an unequal relationship of exploitation, multifaceted inequalities unfold, from the economic sphere to other social spheres, such as health itself⁹9. Souza DO. Saúde do(s) trabalhador(es): análise ontológica da “questão” e do “campo”. Maceió: Edufal; 2019..

Worker’s health, as a field, takes the position of analyzing and intervening in the work-health relationship from the perspective of the workers, seeking not only to understand and transform the biological dimension of health, but also its social determination. For this, Marx’s social theory appears as a decisive contribution to understand the deepest social roots of the issue of workers’ health⁹9. Souza DO. Saúde do(s) trabalhador(es): análise ontológica da “questão” e do “campo”. Maceió: Edufal; 2019..

It is worth remembering that Marx¹²12. Marx K. O Capital: crítica da economia política: Livro primeiro. Tomo I. São Paulo: Nova Cultural; 1988. understands the work category as a process that allows human beings to transform reality, while transforming themselves (process of human self-construction), but that, in capitalism, it is subsumed to the valorization process (with production and accumulation of capital), in reciprocal determination with the antagonism established between those who work and those who exploit the work. From this generic premise it is possible to deduce other processes, such as the class struggle itself (with its political corollary in the state sphere), the impoverishment of the working class, chronic unemployment and, considering the focus of this study, the various forms of degradation promoted by work based on exploitation.

Based on this premise, this article is intended to contribute to the understanding the issue of health of nursing workers, especially in the unique context of the Covid-19 pandemic, considering the particular case of the state of Alagoas/Brazil.

Methodology

This is a qualitative research, based upon the perspective of the worker’s health field. It is noteworthy that the research has an exploratory nature, as it allows approaching the object of study in order to grasp theoretical and methodological assumptions consistent with the investigated particularity.

For the research, we intentionally selected six workers in nursing (with university education) who worked in health institutions in the two largest cities of the state of Alagoas, Brazil - Arapiraca and Maceió - during the pandemic, for at least 1 month, between April 2020 and April 2021. The nurses were contacted by e-mail and/or WhatsApp to participate in stages of the larger research, when there were previous conversations about their experiences in the pandemic and, from that, they were directed to the individual interviews. All participants were volunteers, duly informed about the research, and signed the Free and Informed Consent Form.

Data collection happened between March and June 2022, through semi-structured interviews, according to the methodological approach of thematic oral history, owing to the fact that this technique allows the systematization of elements of the reality experienced by subjects in their daily lives, and therefore pertinent to the objective of this research¹³13. Meihy JCS, Holanda F. História oral: como fazer, como pensar. 2a ed. São Paulo: Contexto; 2014.. It differs from other interview modalities in that it reconstructs a lived history focused on a certain theme that is part of the subject’s experience, which requires the prior development of a script directed to the theme in focus, creating an articulation between the questions, without stifling or fragmenting the subjects’ statements.

The interview script was prepared by the research team and contains questions to characterize the interviewee and open questions on the following theme: the experience of working in the frontline, assisting patients infected with Covid-19. The interviews were conducted online, using the Google Meet platform (the first two) and Zoom platform (the other four), recorded, and lasted between 25 minutes and 1 hour and 18 minutes. The interviews were conducted by the two scientific initiation researchers, undergraduate nursing students, after training, guidance, and supervision of a researcher, a nursing professor with previous experience in the area of worker’s health and qualitative research.

The thematic oral history technique resulted in the production of a historical document, a record of the present time, according to the following three stages

1. transcription: passage from oral to written in its entirety, still in its raw state. In this stage, the questions asked by the researchers, repeated expressions, mistakes, and words without semantic weight or used only in oral language¹³13. Meihy JCS, Holanda F. História oral: como fazer, como pensar. 2a ed. São Paulo: Contexto; 2014. are kept.

2. textualization: the questions asked by the researchers are removed or adapted to the interviewees’ statements. This adaptation has the intention of facilitating the reading of the text, through adjustments to grammatical rules and/or the suppression of repetitive elements or elements used only in oral language. The objective is to enable a better understanding of the narrative, when it is read¹³13. Meihy JCS, Holanda F. História oral: como fazer, como pensar. 2a ed. São Paulo: Contexto; 2014..

3. transcreation: there is the incorporation of external elements to the text, with the intention of recreating the context of the interview in the written document. Complete verbatim is not always maintained, but the meaning and the context are preserved. It is a text with interventions and, therefore, it is considered a product of the researcher’s analysis, although validated by the subjects¹³13. Meihy JCS, Holanda F. História oral: como fazer, como pensar. 2a ed. São Paulo: Contexto; 2014..

The analysis followed the procedures defined for thematic content analysis, also following three stages 1) pre-analysis, with floating reading of the transcreations for the survey of indicators of the thematic categories; 2) exploration of the material, stage in which manual coding and organization of the thematic categories present in the interviews was performed, extracting excerpts from the transcreations (registration units and context units) and organizing them in a table; and 3) treatment of the results, with interpretation and inferences of the most relevant categories in the set of interviews¹⁴14. Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011., based on the perspective of workers’ health, linked to the Marxian critique of political economy.

The procedure was carried out in parallel and separately by the two scientific initiation researchers, later comparing the two analyses and reaching a consensus. The analyses were reviewed by the supervising researcher and the final version was validated by two other PhD researchers, a nurse and a social scientist, both professors of the undergraduate nursing course.

It is noteworthy that the anonymity of the six nurses participating in the research was preserved. The authorship of excerpts from oral histories, when cited, was identified by codes ranging from N1 to N6, corresponding to the six nurses. The research was cleared by the Research Ethics Committee (CEP), with Certificate of Ethics Appreciation Presentation (CAAE) number 39997720.5.0000.5013.

Results

The story of each of the interviewees reveals a unique experience, rich in mediations that concern particular issues, marked by past experiences, contingencies of the current work and personal life. At the same time, we can see the strong presence of objective elements of the nursing work process, shared by the workers. The universalizing character of the Covid-19 pandemic brings marks that go beyond the particular field, especially when it comes to the experience of being on the front line.

Analyzing this shared dynamic, we present the most representative excerpts of the categories of analysis that stand out in the history lived by the interviewees. It is worth mentioning that all participants were women, nurses (university graduation), aged between 27 and 31 years, and with a training time between 2 and 9 years.

Considering the most present points in the common experience, four categories stand out: devaluation; lack of structure and resources for the work; precarious work bond and; relationship between work overload, wear and tear and illness.

About the devaluation of the work in nursing, it is necessary to say that the term is not related to the process of creation of value in the work, as in the treatment given to this category in political economy, but it is a widespread term around (the lack of) recognition of the importance or prestige of certain work, which can translate into inadequate conditions for its performance. At first, see what N1 says:

In a similar sense, N2 states:

We can see the presence of a kind of historical mark, in the sense that the nurses demonstrate that they had already heard about the devaluation. However, now they seem to have felt it more forcefully, effectively, even ratifying the need to be aware of its existence, in order to transform it.

In the oral histories, mention is made to the narrative echoed during the pandemic, about the essentiality of nursing work, its heroic nature, worthy of applause. However, this mention is present in a critical way, in the sense of demystifying this (pseudo)valorization, as in the example of N5:

This excerpt also remarks the issue of the search for transforming the situation of devaluation, markedly expressed by mentioning the fight for better salaries, with legal guarantees. Therefore, we see a horizon of recognition or appreciation that is linked to better working conditions more than media repercussions or narratives echoed socially.

The dialectic present in the contradictory feelings around the undervalued work is also highlighted, because although this issue brings discomfort, it does not eliminate the happiness in being a nurse:

It is a dilemma between feeling attached to the role of nursing in health care, but, at the same time, being frustrated with its devaluation, especially when materialized in the lack of conditions to be able to work, with possibilities of achieving success in care. Specifically, about the lack of structure and resources for the work, some excerpts from the oral histories reveal how the confrontation of the pandemic was weakened:

In fact, it is frustrating not to have the adequate structure to develop the potentiality of nursing care in the context of Covid-19. In the two excerpts above, the issue of the physical environment was highlighted, but the lack of basic supplies is also emphasized in other statements, including for the protection of the nurses themselves:

As can be seen, the severity of the pandemic conflicts with the lack of resources necessary for its mitigation, when we also highlight the insufficient number of workers for the number of infected people who arrived in health units, including in severe cases that required intensive care. Exacerbating the situation, workers without the proper training acted in severe cases, which demonstrates the previous sharp edges in the health system and in professional training.

Related to this issue is the need to hire additional resources fast, which may be related to the incorporation of young nurses with little or no professional experience (or without specific training for certain specialties demanded by Covid-19 cases) in larger numbers than usual. This dynamic, to a certain extent, is expected in the face of a public health emergency that evolves abruptly and forcefully, but has exposed several weaknesses. In this field of weaknesses, the issue of unstable bonds and high turnover in the services corroborates the inadequacy of working conditions and insufficient number of workers, which seems to have increased with the pandemic dynamics. The statements about the type of contract reveal that the precarious contract was an alternative used by the health services in Alagoas: “About the type of contract, I am hired and without labor rights, as if it were an extra” (N4).

The nurses, in the excerpts highlighted above, express their experience of precarious work, without stability, labor rights and financial security, which converges to the precariousness of work as a whole, beyond the bond.

Considering all these issues, it is not difficult to assume that the consequences for the nurses’ health become more relevant, such as the infection by SARS-CoV-2. It is verified that the illness of the workers is linked to work overload - constituting the fourth thematic category of this analysis - and the absence of adequate conditions:

As reported by nurse N2, illness was common, as well as acting in reciprocal determination with the terrible working conditions. That is, workers get sick to a large extent due to unprotected work, and when they are absent from work, they overload even more those who remain active. It is also worth adding that this issue is linked to precarious jobs, since the inexistence of labor rights implies the absence of guarantees regarding health and financial assistance during the absence from work:

The illness is the culmination of this experience. However, it does not necessarily establish the disease, with a definite diagnosis. Several times, the repercussions reveal themselves as weariness, tiredness, exhaustion, in a process that only later on can mark the appearance of a disease. Some of the statements demonstrate the levels of stress:

Further on, the nurse adds:

Corroborating:

The devalued, unprotected, unfit, sickened, and worn-out workers stood firm on the front line, sharing the tragic experience for everyone, as was the Covid-19 pandemic, but from an even more degrading and contradictory bias.

Discussion

Work precarization stood out as a process that synthesizes the thematic categories present in the analyzed oral histories. In this respect, it is necessary to consider that the precariousness of work had hit nursing, in a strong way, even before the pandemic.

Some studies from the period immediately before the pandemic analyzed this phenomenon, in Brazil and in other countries. In the research by Silva et al.¹⁵15. Silva RM, Vieira LJES, Garcia Filho C, Bezerra IC, Cavalcante AN, Borba Netto FC, et al. Precarização do mercado de trabalho de auxiliares e técnicos de enfermagem no Ceará, Brasil. Cienc Saude Colet. 2020; 25(1):135-45. doi: 10.1590/1413-81232020251.28902019.
https://doi.org/10.1590/1413-81232020251... , it was demonstrated that nursing assistants and technicians working in the state of Ceará, Brazil, face precarization in terms of the temporal, economic, social and organizational aspects of their work. The authors highlight new forms of precariousness in the public sector, reducing the number of public servants. In the case of Ceará, Brazil, the percentage of employment through cooperatives was close to the percentage of employment through public employees, with 30.7% and 35.7%, respectively.

Araújo-dos-Santos et al.¹⁶16. Santos TA, Santos HS, Silva MN, Coelho ACC, Pires CGS, Melo CMM. Precarização do trabalho de enfermeiras, técnicas e auxiliares de enfermagem nos hospitais públicos. Rev Esc Enferm USP. 2018; 52:e03411. doi: 10.1590/s1980-220x2017050503411.
https://doi.org/10.1590/s1980-220x201705... reported the case of nursing workers in health services in Bahia, Brazil. In this research, it was revealed that the lack of working conditions characterizes the reality of 46.8% of the nurses. Among the technicians and assistants, the dimension of work precariousness that stood out the most was the “intensity of the work by the organization of its process”, registered for 51.2% of the participants of the study.

Another study in Bahia, conducted by researchers of the same group and based on census research with 2,305 nursing workers, ratified gender inequality as a remarkable aspect of work insecurity in this professional field. The study highlights that, although men are the minority in absolute numbers, they are, proportionally, the most present in the highest salary range. The research also showed that the professional field is poorly paid in Bahia, in general terms, since 61.56% of the workers earn up to two minimum wages¹⁷17. Melo CMM, Carvalho CA, Silva LA, Leal JAL, Santos TA, Santos HS. Força de trabalho da enfermeira em serviços estaduais com gestão direta: revelando a precarização. Esc Anna Nery. 2016; 20(3):e20160067. doi: 10.5935/1414-8145.20160067.
https://doi.org/10.5935/1414-8145.201600... .

In a study conducted in Mexico, Aristizabal et al.¹⁸18. Aristizabal P, Nigenda G, Serván-Mori E. The precarization of the mexican nursing labor market: a repeated cross-sectional analysis for the period 2005-2018. Hum Resour Health. 2019; 17(1):87. doi: 10.1186/s12960-019-0417-x.
https://doi.org/10.1186/s12960-019-0417-... revealed that the precariousness of nursing work was amplified between 2005 and 2018, considering that there was an increase in female workers without formal contracts, with income below two minimum wages, without social security or benefits. In the period studied, the percentage of female workers under some condition of precarization increased from 46% (2005/2006) to 54% (2018).

Considering this recent history, the pandemic is a reciprocal determination in face of the precariousness of work. While the pandemic amplifies precarization, the latter (especially in health work), contributed to the worsening of the pandemic or, at least, to the difficulty of confronting it. Therefore, the pandemic potentiated the precariousness process previously underway, since the emergency measures implemented to face Covid-19 required the temporary and precarious hiring of several professionals to work in field hospitals or other hospitals in the network, but that needed to (re)structure themselves with the public health emergency underway. The history of dismantling public health became even more evident, expressed in the absence of minimum equipment to treat the infected, such as intensive care beds, mechanical respirators, and protection equipment for workers¹⁹19. Souza DO. As dimensões da precarização do trabalho em face da pandemia de Covid-19. Trab Educ Saude. 2021; 19:e00311143. doi: 10.1590/1981-7746-sol00311.
https://doi.org/10.1590/1981-7746-sol003... .

With the visibility of the pandemic, in the midst of this whirlwind of problems, some nursing work issues began to be highlighted in the social and political agenda, such as the proposal of a salary floor and the regulation of the minimum work week, as in the Brazilian case. Despite the greater mobilization, the challenges are of great proportion and raised from complex structural conditions, as revealed by the data from some research conducted in the context of the pandemic, corroborated in this study.

About this, Llop-Gironés et al.²2. Llop-Gironés A, Vračar A, Llop-Gironés G, Benach J, Angeli-Silva L, Jaimez L, et al. Employment and working conditions of nurses: where and how health inequalities have increased during the Covid-19 pandemic? Hum Resour Health. 2021; 19(1):112. doi: 10.1186/s12960-021-00651-7.
https://doi.org/10.1186/s12960-021-00651... systematized a set of research studies and documents from several countries, revealing situations that occurred worldwide. Among these, the main were: the use of nursing students as a precarious work force in confronting the pandemic, acting beyond the limits of their training and outside the application of labor laws; the difficulty in guaranteeing testing and immunization; social inequalities referring to migration, class, race, gender, and age, implying precarious forms of hiring, in jobs with inferior health and safety conditions for some groups of worker(s) when compared to other groups in the same professional area; the weakening of the class representative entities and the union of the category; the hierarchization of the work in health, notably with privileges for the medical category; exclusion of the nursing workers from the community and even from their homes, for fear of contamination, in some cases resulting in physical and verbal aggressions.

Corroborating this, research with 719 nursing workers by Rezio et al.⁸8. Rezio LA, Oliveira E, Queiroz AM, Sousa AR, Zerbetto SR, Marcheti PM, et al. Neoliberalism and precarious work in nursing in the Covid-19 pandemic: repercussions on mental health. Rev Esc Enferm USP. 2022; 56:e20210257. doi: 10.1590/1980-220X-REEUSP-2021-0257.
https://doi.org/10.1590/1980-220X-REEUSP... identified the presence of exhausting work, overload, long working hours, insufficient conditions for rest, lack of Personal Protection Equipment (PPE), low salaries, devaluation, loss of social labor rights, reduction of stable jobs, outsourcing of contracts, and repercussions on the mental health of the workers. The authors correlate the particular context of nursing with the broader process of weakening social policies, determined by the neoliberal phase of capitalism.

Additionally, it is worth noting that the analyzed experiences point to objective repercussions of the work on nurses’ health, especially by the contagion and development of Covid-19 itself, but also in a broader process of wear and tear due to work overload, as identified in the fourth thematic category of this research. Because of this, we titled this category overload, illness, and exhaustion, because it was understood that, much more than the disease itself, the overload of work (extended work day, intensification, responsibilities, etc.) was at the base of the health-disease process, not always materialized in an immediate diagnosis, but expressed in tiredness and exhaustion, as they appear in the excerpts extracted from the oral histories.

We must consider the peculiarity of the disease in a pandemic context, in this case Covid-19, acting as a prominent mediation for wear and tear, such as the cascading effect caused by the dismissal of the infected nurses, overloading and, therefore, accentuating the wear and tear of those who needed to keep on working. Obviously, this feeds back the spiral of precariousness, since it increases the risk of infection of nurses by SARS CoV-2, perpetuating the dynamic.

It is worth mentioning that some studies reveal the impact of the disease for those who were on the frontline, especially in the first year of the pandemic, with many severe cases and deaths⁴4. David HMSL, Rafael RMR, Alves MGM, Breda KL, Faria MGA, Neto M, et al. Infection and mortality of nursing personnel in Brazil from COVID-19: a cross-sectional study. Int J Nurs Stud. 2021; 124:104089. doi: 10.1016/j.ijnurstu.2021.104089.
https://doi.org/10.1016/j.ijnurstu.2021.... . Professional associations have tried to monitor the cases, as in the case of the International Council of Nurses (ICN), which, at the end of 2020, showed that there had been 2,262 deaths of nurses worldwide¹1. Llop-Gironés A, Santillan-Garcia A, Cash-Gibson L, Benach J, Zabalegui A. Covid-19 and the global need for knowledge on nurses’ health. Int Nurs Rev. 2022; 69(2):196-200. doi: 10.1111/inr.12722.
https://doi.org/10.1111/inr.12722... . However, Llop-Gironés et al.¹1. Llop-Gironés A, Santillan-Garcia A, Cash-Gibson L, Benach J, Zabalegui A. Covid-19 and the global need for knowledge on nurses’ health. Int Nurs Rev. 2022; 69(2):196-200. doi: 10.1111/inr.12722.
https://doi.org/10.1111/inr.12722... warn that this number is underestimated because there are weaknesses in the information systems regarding nursing follow-up. For the authors, the fact that the pandemic affected the entire globe, but only 59 countries reported nursing worker deaths to the ICN, is a reflection of the negligence in the health surveillance of these workers.

In the case of Brazil, the Federal Council of Nursing (Cofen) has structured an observatory to follow the number of cases and deaths, registering more than 64 thousand cases and 872 deaths of female workers until July 2022²⁰20. Brasil. Conselho Federal de Enfermagem. Observatório da enfermagem [Internet]. Brasília: Cofen; 2022 [citado 13 Jul 2022]. Disponível em: http://observatoriodaenfermagem.cofen.gov.br/
http://observatoriodaenfermagem.cofen.go... . David et al.⁴4. David HMSL, Rafael RMR, Alves MGM, Breda KL, Faria MGA, Neto M, et al. Infection and mortality of nursing personnel in Brazil from COVID-19: a cross-sectional study. Int J Nurs Stud. 2021; 124:104089. doi: 10.1016/j.ijnurstu.2021.104089.
https://doi.org/10.1016/j.ijnurstu.2021.... state that the Brazilian experience is the most consistent worldwide in terms of monitoring Covid-19 cases and deaths in nursing.

The illness-and-weariness spiral produces other forms of illness or concrete damage to health, in addition to Covid-19, highlighting the repercussions on mental health, such as cases of depression, anxiety, feelings of fear and anguish, occupational stress, sleep disorders, suicidal ideation, and Burnout syndrome, reported in some studies⁵5. Okechukwu EC, Tibaldi L, La Torre G. The impact of Covid-19 pandemic on mental health of nurses. Clin Ter. 2020; 171(5):e399-e400. doi: 10.7417/CT.2020.2247.
https://doi.org/10.7417/CT.2020.2247...

6. Rahman A, Plummer V. Covid-19 related suicide among hospital nurses; case study evidence from worldwide media reports. Psychiatry Res. 2020; 291:113272. doi: 10.1016/j.psychres.2020.113272.
https://doi.org/10.1016/j.psychres.2020....

7. Fernandez M, Lotta G, Passos H, Cavalcanti P, Corrêa MG. Condições de trabalho e percepções de profissionais de enfermagem que atuam no enfrentamento à covid-19 no Brasil. Saude Soc. 2021; 30(4):e201011. doi: 10.1590/S0104-12902021201011.
https://doi.org/10.1590/S0104-1290202120... -⁸8. Rezio LA, Oliveira E, Queiroz AM, Sousa AR, Zerbetto SR, Marcheti PM, et al. Neoliberalism and precarious work in nursing in the Covid-19 pandemic: repercussions on mental health. Rev Esc Enferm USP. 2022; 56:e20210257. doi: 10.1590/1980-220X-REEUSP-2021-0257.
https://doi.org/10.1590/1980-220X-REEUSP... .

From the point of view of the worker’s health field, it is observed that the health-disease process of nurses is socially constituted, intertwined with work precariousness. In this way, this process, beyond the biological manifestations, reveals itself as wear and tear, conceived according to Laurell and Noriega²¹21. Laurell AC, Noriega M. Processo de produção e saúde: trabalho e desgaste operário. São Paulo: Hucitec; 1989., that is, the reduction of the physical and psychological capacities of the workers due to the loads (interacting with each other) exerted by the work process on their bodies, their minds, and their collective organization.

As can be seen in the studies above, the aspects learned in the present research go beyond the context of the state of Alagoas, reaching nursing in other countries, even before the pandemic. The presence of temporary contracts or even non-existent formal contracts, inadequate working conditions, inequalities between different groups of workers, illness, among other issues that have characterized the precariousness of work are frequent. According to Franco, Druck, and Seligmann-Silva²²22. Franco T, Druck G; Silva ES. As novas relações de trabalho, o desgaste mental do trabalhador e os transtornos mentais no trabalho precarizado. Rev Bras Saude Ocup. 2010; 35(122):229-48. doi: 10.1590/S0303-76572010000200006.
https://doi.org/10.1590/S0303-7657201000... , these characteristics can be grouped into five dimensions, emblematic of the transformations in the world of work since the last third of the 20th century. These dimensions are: work bonds and contractual relations; work organization and conditions; precariousness of workers’ health; low social recognition and deconstruction of identities (individual and collective); and difficulties for representation and collective organization.

Considering the political-economy critique of the Marxist tradition, the roots of work precarization are located in the modus operandi of the capitalist system, since it is sustained by relations of exploitation and oppression in the world of work, metamorphosing to the extent that its idiosyncrasies are translated into increasingly intense crises, which reveals its social unsustainability. Impoverishment and unemployment gain eminence as historical-universal expressions (although they vary in time and space) of this unequal mode of production, and work precarization is a mediation forged in the midst of these expressions. This is because, on one hand, capital needs to expand the production of surplus value by lowering salaries or eliminating indirect expenses with labor rights, social protection, etc.; and, on the other hand, workers, thrown into poverty and unemployment, are left with no alternative but to submit themselves to precarious jobs²³23. Alves G. Dimensões da reestruturação produtiva: ensaios de sociologia do trabalho. 2a ed. Londrina/Bauru: Praxis/Canal 6; 2007..

Notably, the substitution, on a worldwide scale, of traditional forms of contracting (in some countries, with a more consistent tradition of social protection) for precarious jobs or jobs emulated by the fallacy of individual entrepreneurship has occurred since the 1970s, when the cyclical crises of capitalism, throughout history, culminated in a crisis of a structural nature, reaching the peripheral countries in the 1980s and 1990s²⁴24. Mészáros I. A crise estrutural do capital. São Paulo: Boitempo; 2009.. This character of the capitalist crisis is expressed in the impossibility of recovering the proportionality of the rate of profits of previous periods, except through the fantasy of the financial market, with serious consequences for the financing of social policies by the nation-states, as has happened in the field of public health.

Facing this process, capital, trying to remedy the irremediable, tends to mitigate its unsustainability in the production sphere, increasing the exploitation of workers, weakening protection, lowering salaries, etc.; but also in the political sphere, with neoliberal strategies of dismantling public services and social rights. These responses of capital to its structural crisis converge to the amplification of work precarization, which, although preexistent, becomes a central element in the pattern of flexible accumulation established since the 1970s²⁵25. Harvey D. Condição pós-moderna: uma pesquisa sobre as origens da mudança cultural. São Paulo: Edições Loyola; 1992..

This process reaches all social complexes, beyond the economy and state organization, being worldwide and, in different ways, affecting several categories of the working class. As has been demonstrated, in the case of nursing, this process is clearly a contradiction, since those who fight for the health of the population end up losing their own health, which strongly marked the experience of being a nurse during the pandemic. The precarious nature of nursing work overflowed socially in the context of the pandemic, revealing the inability of this mode of production and (social) reproduction to face the crises it produces, like the pandemic itself¹⁹19. Souza DO. As dimensões da precarização do trabalho em face da pandemia de Covid-19. Trab Educ Saude. 2021; 19:e00311143. doi: 10.1590/1981-7746-sol00311.
https://doi.org/10.1590/1981-7746-sol003... .

Final considerations

The oral histories of the nurses analyzed here were marked by the process of work precarization. The statements about the difficulty of caring for patients in Covid-19 without the necessary equipment, without the structure for severe cases, and with the responsibility of dealing with the biggest public health challenge in decades, transmuted into work degradation, with nurses getting sick and worn out.

It was verified that the precariousness goes beyond the precarious bond, being in reciprocal determination for the devaluation, absence of working conditions and illness itself. Historically, precariousness shows itself to be a hypertrophied process in the last historical period and, ontologically, determined by the capitalist production mode.

This universal character, which reaches the working class as a whole, is embodied in a particular way in nursing, which was enhanced in the pandemic. In Alagoas, the experiences corroborate previous studies, ratifying the contradictory character of the current social-metabolism, by degrading the health of those who take care of everyone’s health.

Acknowledgments

To the other components of the larger research team that originated this article: Bruna Sonally Santos de Omena, Camila Pereira Abagaro, Dayana Pimentel da Silva, Roselia Arminda Rosales Flores, Sóstenes Ericson Vicente da Silva, Jenifer Bianca de Melo Silva, Rhayssa Irlley Pinheiro Pereira and Thayse Oliveira e Silva. The Universidad Autónoma de la Ciudad de México (UACM), institution co-executor of the research. To the Centers of Reference in Worker’s Health - Cerest’s (regional) of the Alagoas municipalities of Arapiraca, Maceió, and Santana do Ipanema. To all the nursing workers.

References

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