Ethics, COVID-19 and nursing vulnerability: analysis of photographs released by the media

Ética, COVID-19 y vulnerabilidad de enfermería: análisis de fotografías difundidas por los medios

ABSTRACT

Objectives:

to analyze nursing vulnerability through photos released by the media amidst the COVID-19 pandemic.

Methods:

a documentary study, with a qualitative approach. The object of analysis were photographic images selected between January 2020 and March 2021, published by the main news portals in countries such as Brazil, the United States, France, Spain, England and Germany. Thematic categorical analysis was the method of analysis used.

Results:

we found 74 photographs that portrayed nursing professionals in different work situations. It was possible to identify stigma and social devaluation about this class’s representation and professional attribution. Moreover, we found an underrepresentation of black professionals in Brazilian portals and the man as the prominent figure in the spaces of claims.

Final Considerations:

the photographs represented an important tool for the social analysis of nursing vulnerability, favoring the unveiling of situations that may go unnoticed by nursing and society.

Descriptors:
Vulnerability Analysis; COVID-19; Ethics, Nursing; Photograph; Nursing

RESUMEN

Objetivos:

analizar la vulnerabilidad de la enfermería a través de fotos difundidas por los medios de comunicación en el contexto de la pandemia de la COVID-19.

Métodos:

estudio documental, con abordaje cualitativo. El objeto de análisis fueron imágenes fotográficas seleccionadas entre enero de 2020 y marzo de 2021, publicadas por los principales portales de noticias de países como Brasil, Estados Unidos, Francia, España, Inglaterra y Alemania. El análisis categórico temático fue el método de análisis utilizado.

Resultados:

se encontraron 74 fotografías que retrataban a profesionales de enfermería en diferentes situaciones de trabajo. Fue posible identificar el estigma y la desvalorización social sobre la representación y atribución profesional de esta clase. Además, se constató una subrepresentación de los profesionales negros en los portales brasileños y del hombre como figura destacada en los espacios de reclamos.

Consideraciones Finales:

las fotografías representaron una importante herramienta para el análisis social de la vulnerabilidad de la enfermería, favoreciendo el develamiento de situaciones que pueden pasar desapercibidas por la enfermería y la sociedad.

Descriptores:
Análisis de Vulnerabilidad; COVID-19; Ética en Enfermería; Fotografía; Enfermería

RESUMO

Objetivos:

analisar a vulnerabilidade da enfermagem por meio de fotos divulgadas pela mídia no contexto da pandemia de COVID-19.

Métodos:

estudo documental, com abordagem qualitativa. O objeto de análise foram imagens fotográficas selecionadas entre janeiro de 2020 e março de 2021, veiculadas pelos principais portais de notícia de países, como Brasil, Estados Unidos, França, Espanha, Inglaterra e Alemanha. A análise categorial temática foi o método de análise utilizado.

Resultados:

foram encontradas 74 fotografias que retratavam profissionais de enfermagem em diferentes situações de trabalho. Pôde-se identificar o estigma e a desvalorização social acerca da representação e atribuição profissional desta classe. Além disso, foi constatada uma sub-representação de profissionais negras nos portais brasileiros e o homem como a figura de destaque nos espaços de reivindicações.

Considerações Finais:

as fotografias representaram importante ferramenta para análise social da vulnerabilidade da enfermagem, favorecendo o desvelar de situações que podem passar despercebidas pela profissão e sociedade.

Descritores:
Análise de Vulnerabilidade; COVID-19; Ética em Enfermagem; Fotografias; Enfermagem

INTRODUCTION

Amid the growth of the health market, its expansion and the presence of technological innovations, the world was faced with a new infection caused by SARS-CoV-2, which caused COVID-19. The presence of the virus was first reported in December 2019, in the city of Wuhan, China and quickly spread, reaching an alarming situation on a global level. The World Health Organization (WHO) declared that it was a pandemic in March 2020(¹).

Health systems collapsed, making the inequality of access to Intensive Care Unit beds, respirators and health care visible(²). Parallel to this, nursing and the care provided by the team received international visibility, considering that 60% of health teams are composed of nursing professionals(³). Their actions aimed at direct care offered to infected individuals, to community health promotion and, later, to the wide vaccination process in the different countries(⁴). The importance of their work brought to light the devaluation and stigma suffered by nursing and which, amidst the pandemic, was confronted with the social vision about their professional performance widely exposed by the media(¹).

Nursing is a profession mostly practiced by women and, in the case of Brazil, by black women, as pointed out by a research carried out by the Federal Nursing Council (COFEN). The data indicated that women account for 86.2% of professionals, and brown and black correspond to 53%(⁵-⁶). This scenario reflects with itself a history of stigma and prejudices existing in society. Stigma is a concept that has a direct relationship with themes such as race and sex, and in the field of health, it can be an instrument that can disseminate different forms of discrimination. Furthermore, it enables social inequality strengthening, opportunity restriction and social marginalization perpetuation of individuals or groups(⁷).

Nursing stereotype brings the homogeneous belief of an underrepresented minority, affecting their social identity, as occurs with blacks and women(⁸). Thus, it denotes, through the media broadcasting of an exacerbated femininity, an association with domestic, angelic and merciful characteristics(⁹). Despite the recognition and visibility that the category has received from world leaders in the context of COVID-19, it is necessary to direct attention to the new zeitgeist (German term, meaning the spirit of the age, purpose), which connects nurses to the hero figure(⁹).

This analogy can favor the perpetuation of representations linked to nursing, due to recognition as a professional category that has theoretical and scientific foundations and has rights to better working conditions(⁹). Thus, with regard to the cultural and social context, the stigma and stereotype may corroborate with distance, invisibility and social prejudice, affecting professionals’ self-esteem(⁸).

Throughout the pandemic, it could be seen that tireless dedication took its toll. In a survey conducted during the first year of the pandemic by the International Council of Nurses, North America appeared to account for more than 60% of nursing deaths(¹⁰). In Europe, the infected individuals’ epidemiological context, hospital overcrowding and the need for intensive care culminated in the emergence of ethical conflicts, which would affect the world in terms of scarcity of health resources and absence of guidelines to guide health professionals in the decision-making process(¹¹).

In addition to this context, factors such as precarious working conditions and insecurity about how to deal with a new and deadly disease have brought physical, cognitive and psychological strain that these professionals cannot ignore, essential for combating the pandemic(¹). Social isolation was enhanced by the fear of infecting the family, with the imposition of an even stricter distance(¹²).

Nursing vulnerability as a professional category was brought to light. Without a homogeneous definition, vulnerability is seen as relevant to assist in the conception of ethical and moral obligations in the face of an individual’s (in)ability to safeguard their own interests(¹³). In this context, the pandemic only exacerbated nursing vulnerabilities, which had already suffered from cuts in investments and budgets, a decrease in the number of hiring professionals and wage devaluation(¹⁴).

In Germany, there are records of a migration movement of nursing to countries such as the United Kingdom, which is justified by the mention of poor working conditions, low recognition, remuneration and autonomy(¹⁵). With regard to autonomy, the United Kingdom was one of the first nations in the world to designate nurses to prescribe medications in the context of their area of expertise(¹⁶). In the United States, the state of California is the only one that, since 1999, has legislation regarding the number of users who must be under the responsibility of nurses. This position was due to the high rates of COVID-19 infection and bed occupation(¹⁷).

Therefore, SARS-CoV-2 emerged in the midst of a political-social context of nursing, which already preceded an institutionalized vulnerability. This category has health promotion as a characteristic of nursing and which was essential for managing the pandemic(¹⁸). This process had the media as one of the main tools to promote health communication and reach the population with guidelines and reinforcements of measures against COVID-19(¹⁸).

Thus, considering that the media are the main form of communication used by society, the research question of this study was: was there a change in the way nursing is seen by society?

OBJECTIVES

To analyze nursing vulnerability through photos released by the media amidst the COVID-19 pandemic.

METHODS

Ethical aspects

As this is a study that seeks to analyze photographs in the public domain, there was no need to submit it for review by a Research Ethics Committee. However, the selected photograph’s copyright and sources analyzed were inserted, being cited throughout the text.

Study design

This is a documentary study with a qualitative approach. The document analysis is characterized by the identification, checking and analysis of iconographic documents that are related to the object under investigation. It benefits the analysis of cultural and social aspects, through primary sources, which have not undergone any analytical treatment as in bibliographic research(¹⁹).

Data source

In order to survey the photographs that portrayed nursing, news portals were elected from 6 different countries, selected from the diversity of organization of health systems, namely Brazil, the United States, France, Spain, England and Germany, as well as the Portuguese, English, French, Spanish and German languages. Using the keywords Enfermagem, Covid, Nursing, Nurse, Krankenschwester, Photograpy and Infirmière, 115 photographs were selected from the main news portals, such as The New York Times, The Guardian, G1, O Globo, Berliner Morgenpost, Reuters, El País and Le Monde, from January 2020 to March 2021.

News portals have a high impact and circulation, belonging to 6 of the 20 largest economies in the world (G20). A group that, since 2017, has been proposing debates about its role in global public health, focusing on sharing experiences and strategies with health issues, such as non-communicable diseases (NCDs), emission of polluting gases and refugees(²⁰). The vulnerability analysis imposed by COVID-19 and those that precede it, with regard to nursing professionals, are relevant.

Data collection and organization

For data collection, photos linked to the news with title or caption that referred to nursing were included. Repeated photos were excluded. In this process, 41 photographs were excluded, due to caption ambiguity, which adopted the term “health professional”, and if the sample was included, they could affect the findings and results resulting from the analysis of all images.

Thus, the research had a sample of 74 photographs, which were distributed as follows: 19 photographs in The New York Times, 13 photographs in The Guardian, 12 photographs in G1, 10 photographs in O Globo, 09 photographs in the Berliner Morgenpost, 08 photographs in Reuters, 02 photographs in El País and 01 photograph in Le Monde.

During the collection period, the images were stored in Dropbox, named by numbers and distributed in four folders, the 1^st being responsible for all 74 photographs, the 2^nd, for the care group, the 3^rd, for the imagination group, and the 4^th, for the demonstration group. At the same time, the photographs were controlled via an Excel spreadsheet according to photo number, keyword, news portal, article title, publication month, publication year, access link and photograph caption.

The periods correspond to search portal selection, photograph data collection and analysis, such as naming the groups, were carried out in pairs. Regarding the analysis of the images, a parallel was drawn between the photographs and their respective captions, in order to guarantee the use of photos that portray nursing professionals, ensured the photograph geographic location and professionals’ sex, a variable that, depending on the level of donning, the caption was used as a reliable resource for the answer.

Data analysis

The 74 photographs analyzed were divided into three different groups: Group 01: care; Group 2: imagination; and Group 3: demonstration. Each group’s name was designed in order to favor the analysis of selected images, with words “care” being chosen, due to the historical link of nursing practice only in the care context(²¹); “imagination”, as it encompasses the stereotypes of characteristics conferred on a femininity socially attributed to nurses(²²); and “demonstration”, because, despite the absence of records, nursing was a figure present in major humanitarian movements throughout history(²³).

The thematic categorical methodology was used to analyze the photographs, an instrument that allows obtaining and deepening information about social behaviors on social aspects(²⁴), focusing on the subject and the context, allowing analyzing the descriptive or denotative content (manifest) and the interpretive or connotative content (latent)(²⁵).

In parallel, interpretations of the photographs were carried out, according to the selection of themes, a step that made it possible to inquire about the message that was being conveyed by the photographs(²⁵). Thus, the themes were thought according to the characteristics attributed to the figure of nursing, with topics such as sex, color, equipment/instrument/accessories, characters, environment and characteristics associated with nurses’ work, routine/technical activity and representation.

RESULTS

Through the photographs’ denotative character with regard to sex, 06 images had only male representation: 04 were in the care group, 02 in the demonstration group, with no representation in the imagination group. Regarding the care group, the activities performed by males portrayed by the 4 photographs were patient transfer, donning, comfort and N95 mask sterilization, published on the news portals of the United States, Spain and England.

The combination between female and male representation concomitantly was found in 07 photos: 01 in the care group, 02 in the imagination and 04 in the demonstration group, with actions that involve changing positions (care), a humanized portrait of professionals, or with photographs that expose professionals with and without vestments and the moment of pause in the work environment (imagination).

When observing the origin of these 05 images allocated in the demonstration group, 04 corresponded to Brazilian news portals, with death rates, claims for basic protective equipment and appreciation as one of the reasons for protest. However, the photographs’ connotative context allowed us to perceive the symbolism directed to the male figure, who has a prominent role, having leadership characteristics in the movements.

There was only a massive representation of nursing, in the imagination group, referring to the care delivery environment and associated with the use of protective equipment, revealing a lack of representation of nursing professionals beyond the work environment. This gap is proven considering the significant number of images that portray nursing fatigue, sadness and discomfort, but which, unfortunately, did not reach the reality outside health centers.

In the color category assessment, only 13 photographs exclusively portrayed brown and black professionals, 7 in the care group, 5 in the imagination and 1 in the demonstration group. Among these photographs, all portrayed female professionals, with 5 photos broadcast on news portals in Brazil.

Figure 1
Combination of images shows nursing assistants before and after wearing the masks, 05/12/2020

Figure 2
Nurses pay tribute in Brasilia to co-workers who died due to COVID-19

Figure 3
Nasrec rural hospital’s nurse, Johannesburg (South Africa), protected by her personal protective equipment to care for COVID-19 patients

Figure 4
A technician hangs N95 masks to be sterilized with UVC light in Abu Dhabi, United Arab Emirates

Figure 5
Even in the Rural Zone, priority groups received the vaccine

Referring to photographs that concurrently mixed brown, black and white professionals, 6 specimens were found, 1 in the care group, 2 in the imagination and 3 in the demonstration. The care representation identified an professional’ action in helping to change an individual’s position; the imagination photo had the representation of donned and doffed professionals; and 3 from the demonstration group revealed aspects such as concentration and motivation of protest acts.

The presence of personal protective equipment (PPE) had 58 photographs portraying professionals with at least one PPE, with considerable presence in the imagination and demonstration groups. The white coat was highlighted in 11 photographs (9 in the demonstration group and 2 in the imagination), 30 photographs with the use of private clothes (10 in the care group, 11 in the imagination and 6 in the demonstration), 9 photographs with overalls (6 in the care group and 3 in the imagination) and 28 photographs with professionals using cloak (24 in the care group, 2 in the imagination and 3 in the demonstration).

The mask, a material adopted as mandatory for SARS-CoV-2 prevention, was analyzed separately, considering that it was an equipment that extrapolated the linkage of health care environments and spread in all social sectors. It had the presence of different materials, being 27 photographs with surgical masks (14 in the care group, 3 in the imagination and 9 in the demonstration), 3 photographs, all in the care group, with fabric mask, 10 photographs with N95 (8 in the care group and 2 in the imagination) and 8 photographs only with the Filtering Facepiece (FFP2): 5 in the care group, 2 in the imagination and 1 in the demonstration. In the absence of representation of nursing professionals with masks, 17 images were found, 3 in the care group, 12 in the imagination and 1 in the demonstration.

Regarding the activities represented in the care group, the main actions identified were donning, vaccination, bed preparation, testing for COVID-19 and medication preparation and application. In the imagination group, the main actions portrayed were tiredness, hero figure representation, emotional and physical exhaustion. In the demonstration group, 5 of the 18 photographs showed health care environments, with 3 photographs honoring professionals with applause or flowers and 2 portraying professionals’ protest in relation to deaths caused by COVID-19.

DISCUSSION

Considering the historical context of nursing, the findings referring to the highlight of males raise the following question: why did the man have a claiming character of positioning and greater visibility in a profession with a significant presence of females?(⁴). What leads to this type of masculine attitude in a predominantly feminine profession?

With regard to the institutionalization process, nursing adopted stereotypes of “assistant” in the medical category, as well as a placement of domestic duties, with a view to social recognition as an area of activity conducive to females(²⁶), having a strong link with charity, care, love and the roots of humanitarian work attributed to the profession(²²,²⁶). In the 19^th century, for instance, nursing had the figure of Arenal as a model of Spanish femininity in tender care provision in humanitarian situations(²⁶).

This construction of professional profile, which began at the end of the 19^th century and was consolidated throughout the 20^th century, emerged in a historical context of conflicts and made the insertion of women, such as Florence Nightingale, Mary Seacole and Anna Nery, opportune(²⁶-²⁷). These figures and their work provided visibility to female representation, imprinting a new way of caring and the significant role for nursing as a profession. However, feminist bioethics makes an expanded reflection on the indifference/scarcity of records about these women who delimited their space, especially in periods of difficulty resulting from humanitarian crises(²²).

In this process of understanding female silencing, documents, such as letters, diaries, photo albums and autobiographies, despite having a subjective character, became tools used to investigate and analyze the real female role in history(²⁸). However, this prominence of men in Brazilian news portals, either because they are in greater numbers or in the foreground in the photographs allocated to the demonstration group, alerts to a female invisibility that has surpassed the theoretical field and is also propagated in the reproduction media.

Considering the aspects that involved nursing organization and conception as a professional category, the hierarchy and division of nurses’ and lady nurses’ work proved to be essential tools for the subjugation of brown and black women working in the area(²⁶). They were disowned in the process institutionalization of nursing, as a result of an attempt to link the profile of nursing to a higher socioeconomic level and to the white population(²⁶). These denominators were listed for the elitism of nursing, and informal requirements were considered for selecting vacancies in the first nursing schools, with the degree being used for applying the category technical division(⁵).

This context and way of thinking are still reflected in current society, which can be verified in the analysis of imagination and demonstration groups, which did not have significant portraits of brown and black professionals in photographs published on news portals in Brazil, even though the first nurse vaccinated and portrayed was a black woman. This situation reinforces the absence of representation, which silences most of the professional category. When analyzing Oliveira’s statement, in which nursing is composed of 53% of brown and black people in Brazil, it is evident that this invisibility transcends nursing to be seen as a reflection of the absence of social representativeness(²²).

Analyzing the same photographs, but using a connotative character to broaden the perception, there was a great link between nursing and care delivery environments, especially in the care category, with 26 photographs. When analyzing photographs allocated to the demonstration group, it was observed that, although they were mostly recorded in environments outside the hospital, there was a symbolic use of PPE during the acts. This was the way found by nursing to enhance and draw attention to their claims, seek for rights, recognition and demonstrations of struggle, whether on the streets or in front of spaces of public agencies(²⁹-³⁰).

Having its first records in the bubonic plague period, the mask was PPE with social prominence in the coronavirus pandemic. Amidst its worldwide obligation, it was portrayed as a symbol of current society already in March 2020 by The New York Times(³⁰). It has acquired cultural, ethical and political connotations and biases by being used by the population as a demonstration of support for science and a form of collective protection. As a contrary prerogative, it was used with the analogy of the obligatoriness of the object as a form of coercion. Use compliance has acquired an ideological and political character throughout the world(³¹).

In this research, the absence of a mask in photographs was found in the imagination group, with 12 photographs, in the care group, with 3 and in the demonstration group, with only 1. These photographic representations in the field of health demonstrated the scarcity of resources for individual protection, crystallizing professionals’ vulnerability and scarcity of resource for their protection, which occurred globally at the beginning of the pandemic(²,¹⁴).

In the imagination group, the absence of a mask is a denominator that can be justified as an attempt to portray health professionals in their multiple faces and experiences. The impact on professionals’ mental health, aggravated by the fear of infection, isolation and the absence of theoretical references that guided care in the pandemic context, was significant(¹,¹²). This fact, added to the need for constant use of personal protective equipment in care, especially for those positive for SARS-CoV-2(¹) and high patient demand, can be considered a decisive element for health workers’ physical and emotional exhaustion(¹,¹²).

In nursing attributions, especially in the imagination group, the absence of representations focused on the greater complexity of nursing attributions was evident. The activities represented were vaccination, bedside care and testing of the population. Therefore, there is a lack of knowledge about the breadth of nurses’ work, which includes technical, managerial, supervisory and administrative actions, teaching and research. The media use of evidence-based practice should be sought as an instrument to promote social and political visibility of nursing dimensions(³²). This factor can contribute to stereotypes, favoring nursing devaluation by mischaracterizing, stigmatizing and under-representing professionals in their professional practice(⁸).

Thus, it is understood that the vulnerabilities involving nursing are connected to its historical conception, especially in Brazil. Where, despite the consolidation as a professional category, there is still a vision of them as an assistant to medical professionals, being reflected in the hierarchy, low social and salary recognition present in society(²⁶).

Study limitations

As a gap of this study, there is the fact that the analyzed photographs are broadcast to countries of the group of 20 (G20), being an analysis of the main news portals in the 6 continents (Africa, Asia, Europe, Oceania, America and Antarctica). Moreover, it was not possible to carry out an expanded discussion on the different vulnerabilities underlying nursing practices. This is due to the fact that the photographs did not specify the category of professionals portrayed in the images.

Contributions to nursing, health, and public policies

It is necessary to create and implement strategies, such as the use of photographs, to promote the understanding of society to nursing as a professional category, which seeks to adopt scientific knowledge and practices for the exercise of nursing. It is necessary to initiate and/or consolidate initiatives to promote social recognition, favoring the demand for a decent and adequate work environment, despite the extreme vulnerability in the scenario of health practices aggravated by SARS-CoV-2.

FINAL CONSIDERATIONS

Using photographs as an instrument of this research revealed an archaic association between sex and nursing attributions that refer to the period of nursing institutionalization. In the 22 photographs published by Brazilian news portals, underrepresentation of black women and men was observed as prominent figures in spaces of political and social claims. In the global context, vulnerabilities related to working conditions were evidenced, which had consequences on professionals’ psychological and physical dimensions, infection rate and deaths throughout the pandemic.

Thus, although the group of countries analyzed make up the largest world economies, it was possible to observe nursing vulnerability prior to the pandemic, in which cultural and sex stereotypes interfere with the social conception regarding nursing attributions and recognition, with COVID-19 as a stage for claiming and opportunity for worldwide visibility.

• FUNDING
  This study was funded by the Federal District research support foundation (FAP-DF).

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Edited by

EDITOR IN CHIEF: Antonio José de Almeida Filho

ASSOCIATE EDITOR: Maria Itayra Padilha

Publication Dates

• Publication in this collection
  17 Oct 2022
• Date of issue
  2022

History

• Received
  02 Feb 2022
• Accepted
  12 June 2022