ORIGINAL RESEARCH

Work conditions in the hospital: perceptions of obstetric nurses

Noelle Juliana Melo de Paula Moreira^I; Norma Valéria Dantas de Oliveira Souza^II; Jane Márcia Progianti^III

^IObstetric Nurse. MS in Nursing. State University of Rio de Janeiro. Brazil. E-mail: moreiranoelle86@gmail.com
^IIPhD. Adjunct Professor, State University of Rio de Janeiro. Brazil. E-mail: norval_souza@yahoo.com.br
^IIIPhD. Associate Professor, State University of Rio de Janeiro. Brazil. E-mail: jmprogi@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.26999

ABSTRACT

Objective: to describe the obstetric nurses' perceptions about their working conditions. Method: qualitative research with 15 obstetric nurses working in hospitals in the city of Rio de Janeiro, Brasil. The interviews were carried out from April to May 2016 and were then transcribed, coded, categorized and discussed based on Bourdieu's reference. The research was approved by the Ethics and Research Committee / CAAE 54061315.9.0000.5282. Results: the working conditions perceived by nurses were caracterized by instability in the job contract, leading to fear of losing their job; the search for productivity that de-characterizes the humanized care and symbolic violence represented by the disqualification and sexual division of labor. Conclusion: these conditions indicate to the precariousness of work and may interfere directly in the development of humanized care practices in childbirth and birth as well as in nurses' health.

Keywords: Obstetric nursing; women working; humanization of assistance; women's health.

INTRODUCTION

Since 1990, the government actions have been focused on the reduction of expenses that, in the obstetric field, meant to prioritize the light technologies that would bring the reduction of maternal expenses and morbimortality.¹ In addition, it would answer the claims of feminist and humanization social movements that were critical regarding the medicalization of care.²

In this context, obstetrical nurses fought to occupy spaces in the gestation, delivery and postpartum care in the Unified Health System (SUS - Sistema Único de Saúde), implanting less invasive practices with women.³ At the same time, there were changes happening in labor relations in Brazil, which, as a result of the productive restructuring,⁴ demanded an autonomous worker and changes in the models of work organization.⁵ For the nursing work, this process leads to precariousness, impacting the care provided in SUS,⁶ as well as the occurrence of occupational diseases and accidents.⁷

Thus, as the obstetric nurse was inserted in the care of the pregnant woman, parturient and puerpera patients, the management of human resources in SUS was carried out by private companies known as Social Organizations (SO), legitimized in the health of Rio de Janeiro, from of the enactment of the Law 5.026/2009.⁸

In view of the above, the objective was to describe the perceptions of obstetrical nurses about their working conditions in the hospital. This study is important because, from an objective perspective, it reveals the work conditions of obstetrical nurses, which can harm the lives and health of these professionals.

THEORETICAL REFERENCE

This study considered as theoretical reference the concepts of symbolic power, field, symbolic violence and sexual division of labor.

The symbolic power is the invisible power, which can only be exercised by someone with the complicity of those who do not want to know to whom they are subject or even who exercises it. This power is exercised by those who hold the best positions in the field and who strive to maintain them.⁹ It should be highlighted that the field is defined as a space that has a set of rules, rules and specific classification schemes, and also, where power relations and strategies of struggles arise around peculiar interests.¹⁰ This dynamic of the social field implies in the exercise of symbolic violence on the part of those who have better positions, both for the imposition and for the legitimation of their interests.¹¹

The sexual division of labor is a social division resulting from gender relations that adapts to the historical moment and to society. It primarily targets men in the sphere of production and the taking of high value-added functions (political, religious, military, etc.) and women are destined to the reproductive sphere, with less added value, because they are related to household activities. This form of social division of labor is organized on the basis of two principles that are valid for all the societies known in times and spaces: that of separating men's and women's work and hierarchization (assigning more value to the male work).¹² In this sense, the gender division of labor is a form of male domination in the field of labor and it is carried out by the exercise of symbolic violence, which, because it is a consequence of the exercise of symbolic power, is invisible to agents.

METHODOLOGY

This is a qualitative descriptive research, with 15 nurses graduating from Obstetrical Nursing Residency Courses. The inclusion criteria were: to be graduated from 2011 on and to be active in the obstetric field for at least six months, which added to the two years of training in the Residency Course, resulting in the recommended time to adapt to the dynamics of the organization and work processes in order to deepen their perceptions and make them clearer.¹³

In order to attract the participants, some contacts were made from the graduates of the Specialization Courses in Obstetric Nursing, at the secretary of the lato sensu Postgraduate Program at the State University of Rio de Janeiro (UERJ). From the first contacts, some nurses referred other possible participants. The total number of nurses contacted was 30, and 18 professionals responded. However, only 15 nurses met the inclusion criteria. They also agreed to participate by signing the Free and Informed Consent Term (FICT).

The research was carried out in accordance with the ethical precepts established in Resolution 466, of December 12, 2012, of the National Health Council (CNS - Conselho Nacional de Saúde), of the Ministry of Health. The study project was approved by the Ethics and Research Committee of the State University of Rio de Janeiro under the opinion number: 1.459.532.

The interviews were conducted individually, in the city of Rio de Janeiro, from April to May 2016 and in a place chosen by the participants. In order to preserve their anonymity, the participants were identified by the letter E followed by a number (E1, E2, ...), according to the order of occurrence of the interviews.

Adopting the steps proposed by Minayo,¹⁴ the ordering of the data followed the classification and organization of the material, then, a cut of the units of registration and codification of the units of signification was performed. After the grouping of the meaning units, the categories addressed in the study emerged.

RESULTS AND DISCUSSION

The perceptions found were represented in this study by three categories that demonstrate the working conditions of the participants: instability in employment with labor contract, search for productivity and symbolic violence.

Instability in employment with labor contract

When the employment relationship of the nurses surveyed was verified, it is observed that it is precarious by the exercise of the function in the public sphere without the admission by a public tender.¹⁵ This reverberates in the perception of lack of job stability when hired:

Stability can be characterized as the frequent and uninterrupted exercise of work.¹⁶ The loss of social benefits, low wages and discontinuity in working times, allied to insecurity, constitute precarious work.¹⁷ It is observed, then, that the nurses surveyed who had the labor contract were constantly afraid of losing their job:

The removal of the stability prevents the political mobilization of the worker by attaining their capacity for economic independence.¹⁸ Insecurity and fear, due to the instability of employment with a contract, can have an impact on quality of life and professional performance, as the adjustment to the employer's rules may occur, disregarding the provisions incorporated for demedicalization in pregnancy, childbirth and birth.

The search for productivity

In its ordinance No. 1101/GM 2002, the Ministry of Health establishes the care parameters of SUS and defines productivity parameters, which are proposed to evaluate the production capacity of health care resources, equipment and services in order to promote waste reduction, improve performance and meet the standards required by customers and competition. ¹⁹ Even so, the nurses reported that they are being pressured to increase the number of assisted births:

The annoyance regarding the demand for productivity in the care is given to the extent that in the perspective of increased production, the direct care is limited to the moment of delivery, disregarding the comprehensiveness of the obstetric nursing care.

Health institutions look for ways to increase the effectiveness in services by setting goals as an incentive to the worker's productivity. However, since nursing's objectives is to provide health care, it cannot be reduced to a sum of procedures within a short time, since caring requires interpersonal relation and consideration of cultural traits and individual values that cannot be reduced to measurable data.²⁰

Thus, to achieve an increase the productivity at work, new forms of management prioritize the affective relationships between the worker and the others involved in the process. The closest leadership becomes a peculiar instrument to increase the productivity in the obstetrical field:

With these feelings of protection, the involvement of workers in the culture and in the achievement of the company's objectives is promoted. This fact shows that this form of management is interfering with the subjectivity of these nurses, who are happy to be heard by the boss, even acknowledging that they are exploited and that they have an overload of work:

A new form of work control, which is contemporary to the flexibilization and based on the relationships between bosses and employees is promoted, and it promotes the sense of autonomy and freedom of action for nurses, reducing conflicts due to productivity gains and stress due to the work overload.²¹

However, some nurses of this study realized that this proximity to the bosses has the connotation of intimidation:

The intimidation, caused by power relations between agents in hierarchical fields, is the result of domination by those who occupy the best positions in the same field and may be inscribed in the body²² in the form of shyness.²³

Symbolic violence: the disqualification and gender division of labor

The symbolic violence pointed out by the nurses surveyed is represented in this study by the disqualification and the gender division of labor. In this sense, the participants made clear in their testimonies the existence of the hierarchy of the obstetric field:

In a society where hierarchies are present, power is affirmed and exercised in the most subtle form, as unperceived violence. Thus, there is no space that is not hierarchical and that does not reveal hierarchies and social distances in a disguised way and, above all, covered by the naturalization effect of historically constructed differences.²⁴

In this logic, labor, in the capitalist mold, conceals that between masculine (human) and feminine (natural) activities there is a relation of domination and, in deeper analysis, a relation of exploitation.²⁵

In this study, it was observed that, in the hierarchy of the obstetric field, the occurrence of symbolic violence occurs in two ways: through the disqualification of female knowledge and the gender division of labor. In the next statement, there is the disqualification of the nurse's role:

The discussion about the gender division of labor states that women are still susceptible to great discrimination and devaluation by working in productive spaces. Cultural and social issues provided the necessary impetus for this to be extended to the labor market, which made it possible to maintain this order.²⁶

The categories of work appreciation, developed by women, are brought into the hospital environment also impregnated with the benefits of the system. The nurses' work, which is already seen as of little value, because it is related to motherhood, tends to lose value, even if based on scientific evidence.

The nurses reported the presence of symbolic violence in the division of labor, in the field where they operate, evidenced mainly in the characteristic and complexity of what the agents do in the field:

The male order inscribes itself in the things and the bodies by determinations implied in the routines of the division of labor or of the collective or private rituals. In this way, inferior places are assigned to women, and what has been assigned to them are painful, low and petty tasks, starting with biological differences that are the basis of social differences.²⁷

The most distressing activities would be directed to the nurses in order to facilitate the work of the physician, but it materializes the hierarchy of the field that crosses the gender division of labor.

By directing the care of the most complaining women, nurses can feel recognized and can play the game,²³ according to the rules of the dominant field, making their work more enjoyable. This facilitation is based on the domination of the female nurse over the woman user, whenever the behaviors are strictly prescriptive of actions, as the use of instruments or adoption of positions during labor and delivery.

CONCLUSION

The study showed that the working conditions of the nurses surveyed in hospitals in the city of Rio de Janeiro are precarious. This precariousness is related to the subjective work conditions, such as the fear of losing the job, the pressure to increase productivity, without taking into account the characteristics of the professional care of these specialists.

This study also revealed a new way of managing work, which is centered on the friendly and protective relationship between bosses and nurses, with the goal of increasing productivity by hiding conflicts.

Finally, it was verified that the nurses perceive a hierarchy that favors the exercise of the symbolic violence by those who are in better positions in the field. This violence is exercised through the disqualification of knowledge and the attribution of activities of lesser prestige in the field to obstetric nurses.

Therefore, it is recommended to carry out other research aimed at knowing the scope of the productivity logic in the management of the nurses' work, and how such logic can affect the care and, also, the health of these nurses.

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