Introduction

In everyday work, institutional racism can be found amid the practices of professionals and service providers, presenting themselves in exclusionary, ignorant and prejudiced attitudes based on preestablished and accepted norms and practices, forming barriers to the access of black population to the advantages and benefits that are due to it by institutions.¹ In the field of public health, evidence of inequality points to the paradox of the Unified Health System (SUS), in which 70% of the users are black people, and such evidence can be verified through epidemiological data showing high rates of maternal-neonatal mortality and violence suffered by this population, directly affecting their quality and life expectancy.²

Aiming at promoting and guaranteeing equity in health for the black population, the National Policy for Integral Health of the Black Population (PNSIPN) was instituted through Administrative Rule no. 992 of May 13, 2009, unfolding on inequalities with which this segment of the population is often linked, ensuring the promotion of racial equality and the realization of equity and access to the right to health, focusing on all aspects of it.³ Despite this, primary health care professionals in their context and understanding reinforce the non-existence of racism, blocking the actions of the system in such situations.⁴

When an institution, in its exercise, is not in a position to provide the service properly and appropriately, based on the needs and interests of a given population due to the influence of preconceptions and difficulties in relation to ethnic, racial and of skin color, it can be said that institutional racism is being exercised.⁵

Nurses are an important part of public health. Taking into account all the aspects that involve public health and the effectiveness of the SUS principles with the black population, it is considered important to understand the perception of these professionals regarding institutional racism and their actions against such situations, since, often, they are involved with the organization of services and have a greater link with users. From this, it may be possible to offer fundamentals that promote knowledge and modifications in their actions and routines or reinforce those considered adequate, with the aim of providing integral and equitable care to the black population in a fair and effective way. Faced with this reality, the research was developed based on the following question: What is the perception and actions of nurses regarding institutional racism in public health? To understand this problem, the study had as its objective to know the perceptions and actions of nurses in relation to institutional racism in public health.

Method

This is a qualitative research, with a descriptive and exploratory approach, that was carried out in the municipality of Capão da Canoa, on the northern coast of the State of Rio Grande do Sul, from July to November 2016. Nine nurses in the health care network of the municipality, selected from the number of health units in operation, made up a total of nine, one professional for each unit, considering that they are responsible for the management of the services and nursing care in the studied reality. In the units that had more than one nurse – two units with four nurses in their staff –, the participant was drawn. It was established as inclusion criteria, nurses who were working in the municipal health units, working on the stipulated day for the research. As exclusion criterion, nurses who were working in other sectors of the public health service of the municipality were adopted.

Visits were carried out in the health units during the month of August 2016, when the nurses in professional practice were invited to participate in the research, through a semi-structured interview - a questionnaire was elaborated based on the study variables: perception of nurses in relation to institutional racism in public health and their actions in such situations on a day to day basis. This instrument consisted of seven open questions formulated according to the concept of “institutional racism” and based on the National Policy on Integral Health of the Black Population adopted by the Ministry of Health. After the recordings of the interviews in mp3, these were transcribed in order to facilitate the analysis of the material, proceeded according to the method of Content Analysis.⁶

Initially, the floating reading of the collected material was carried out, in order to allow the knowledge of all the information obtained and, by the homogeneity rule in the constitution of the corpus, it was possible to reach the raw data, allowing the definition of the recording and context, in addition to coding the data in the thematic analysis. The information was presented according to anonymity, preserving the integrity of the research participants. Identification codes have been used in which the letter “E” refers to the participating professional category, the nurses, and is followed by a point and a number in ascending order, for example, in E.3.

From this first treatment of the material, the categorization of the elements raised became possible based on their grouping into categories, according to their similarities in given aspect of their constitution and/or semantics, according to the principles of quality as the mutual exclusion, the homogeneity, relevance, objectivity and fidelity and productivity. Then, the analysis of the information that enabled the achievement of inferences and interpretations through the study of inferred variables and inferences in the context revealed by the material collected for the research was carried out. The discussion about the data collected was carried out together with relevant updated scientific bibliographies on the subject in question.

In order to carry out the research, the Committee for Ethics in Research Involving Human Beings of the Lutheran University of Brazil, Canoas, obtained the following approval: 1.521.570, CAAE number: 55120516.1.0000.5349 on April 29, 2016, meeting the requirements of Resolution 466/2012 of the National Health Council.

Results and discussion

Among the participants in this study, six were female and three were male, aged between 33 and 62 years old; six worked in Family Health Strategy (ESF), two in Ready Care and one in the Center for Psychosocial Care; all with eight or more years of training, and only two have been in the network for more than five years.

After the Content Analysis, three categories were established: Knowledge and opinion about the National Policy of Integral Health of the Black Population and Institutional Racism; Experience of situations of racism, existence of discrimination and inequality in access to health services; Knowledge about the health of the black population, actions and prevention against institutional racism.

Knowledge and opinion on the National Policy of Integral Health of the Black Population and Institutional Racism

The National Policy of Integral Health of the Black Population was not known by a great part of the professional nurses during the accomplishment of the interview.

I do not know this policy; I never went deep! So I have no knowledge. (E.3)

I know, but I've never really had more contact on it. (E.5)

For some researchers, health service managers need to know about the existence of the PNSIPN, recognizing it as a tool to combat discrimination in SUS services and the product of historical struggles of this population for the scope of their rights, ensuring their effectiveness by respect for the citizenship of the black population and their needs.⁷

The PNSIPN has a transversal character and aims at combating ethnic and racial discrimination at the level of the public health services offered by SUS, increasing the access of this segment of the population to quality health services, healing their needs and guaranteeing the integral care.³ Its recognition as a tool for the prevention of racism must understand that the deconstruction of this requires the development of intersectoral strategies that mainly involve health and education to strengthen social control and transformation of discriminatory social relations in a more comprehensive and that goes beyond the health sector.⁸

However, lack of attention to the broader aspects of population health could be observed in the interviews, in which most of the participants did not comment on the policy or considered it unnecessary.

I'll be frank, I do not think it would be, in my opinion, at least for our region, [...] It's an unnecessary policy, I think we in our region do not face that racial difference, it's not so strong. I do not see a real favoring of this population through this policy. Maybe it's because even I do not know this policy. (E.5)

The PNSIPN is often considered unnecessary by primary care professionals because it is seen as an affront to the principle of equal access to SUS services, since they believe that the black population does not suffer social discrimination in the present day. This is the result of the belief that there is no discrimination between races in Brazil, together with little information about politics and its equity.⁹ In addition, nurses were unanimously unaware of the meaning of the term “institutional racism,” and those who gave meaning to the term focused only on situations of racism within the nursing team or within the institution's staff health, forgetting the influence of this problem on the users of the service. In this way, professionals demonstrate the understanding of the term “institutional racism” as the racial discrimination processes that occur strictly in the functioning and organization of the “health institution”.

I do not know it either, I do not know. Racism we know it's racism, but what does it mean? Then I do not know. (E.3)

Look, institutional racism is you have employees of black color and you do not favor her about the possibility of her having promotions, I think that's the way it is, understand? (E.5)

Researchers indicate that institutional racism constitutes racist and discriminatory practices and actions that have a silent nature of action, consequently, being difficult to recognize. However, with a focused and critical attention to reality, it is possible to perceive such situations in the day to day of the public health service.¹⁰ In addition, according to a study about the subject, primary care nurses have poorly informed perceptions of the health of the black population, emphasizing the importance of the implementation of the PNSIPN and the consideration on the part of these professionals, since, even though it is mostly significant in health public, the black population, in general, is still in low health conditions.⁵

Institutional racism includes segregation when an institution acts through exclusionary and discriminatory behavior, with practices based on preconceptions and ignorance of ethnic and racial aspects in its work processes. In this way, consequently, it fails to provide adequate assistance, subjecting such populations to situations of lack of service and disadvantages.³

In the health sphere, institutional racism can be found in several points of its constitution, from the refusal to recognize the specificities of the black population and differences in illness among races, to the lack of knowledge, debate and specialization of health professionals in relation to racial issues, as well as racist actions linked to professional activities as exclusionary and diminishing attitudes of the other, covered by looks, silence and disinterest for assistance.¹¹

Experience of situations of racism, existence of discrimination and inequality in access to health services

Regarding the experiences of situations of racism, all the nurses mentioned that they had never lived or witnessed during their professional career in the places where they had worked.

I have never seen it said thus: No, I will not answer! Oh! Answer that one because he's black, no! Of our part of the whites with the blacks. Now the blacks become inferior, I do not know why, I say even in college there, black bag! Why scholarship for the black people? [...] Let's go to the fight, let's study so you get there. These scholarships for black people are not necessary because that, yes, is racism. (E.1)

Ah! I never witnessed it,[...] I've never been in a situation like this. On second thought, now, never! (E.2)

On the other hand, a study showed that 48.6% of the blacks and 40.5% of the browns declared to perceive some type of racist situation in the public health services. The difficulty in perceiving situations of racism and understanding the health reality of the black population in Brazil can be explained by the fact that the country has a surreal social construction of peace among the ethnic groups, based on the theory of ‘mestiçagem’, also known as “racial democracy“. Such a theory asserts that all people have equal possibilities of access to social goods and services, and thus individually achieve success in an egalitarian way.⁹

Racism in Brazil has taken paths throughout history that have allowed it to remain internalized in society, since the respect imposed on the achievements of the black population for dignity and the construction of a false ideology of racial democracy have determined the concealment of racial discrimination in a logic of inefficient social repression. In this way, institutional racism is based on practice and not on the manifestation itself, that is, racist actions occur in a little evident and perceptible way, through routine acts, internalized in customs and cultures, lowering the blacks in the various faces of the their social life.¹²The conception of racial democracy can be observed in nurses' statements when they demonstrate that they believe that there is no discrimination and inequality in access to health by the black population.

I do not see! [...], there is no discrimination. (E.1)

No, I think not now, I think I've had enough in any institution, but I think now not more, I think now even the service is equal. (E.6)

In Brazil, relations between classes and races have discrepancies in their manifestations and social functioning, which reflect directly on health, and can be defined as the product of various political, economic, environmental, social and cultural factors which, in a tangential way, maintain racism in a dynamic way in the population collective, fomenting inequalities.¹³ In this way, the black population remains, currently, in a situation of social vulnerability. This is due to the lack of recognition of the existence of racial discrimination still today, influenced by institutional racism, contributing to the formation and maintenance of a structured society on inequality.¹⁴

The provision of vocational training spaces and the promotion of continuing education has the potential for developing the empowerment necessary to deconstruct discrimination. Such discrimination takes place both in social relations and in scientific production since, not infrequently, institutional racism is present in organizations in a process of maintaining inequality and social exclusion, capable of directly health care offered to the black population.¹⁵

Knowledge on the health of the black population, actions and prevention against institutional racism

Most of the nurses interviewed stressed the need for a greater scope of knowledge about the health of the black population in order to offer quality health services and actions for this segment. When asked the question “Within your scope of knowledge, do you think you know enough about the health of the black population to offer quality actions in your care? Justify!”, answers were obtained that reflect the professional unpreparedness for the daily practice of quality in the community before the black population. One of the professionals even acknowledged that this is a topic that should be more debated and evidenced in the profession.

I needed some specialization, some better support. (E.1)

No, I do not think so, you must learn a lot more. (E.2)

No, I think this is still something that needs to be well discussed because they have many things that are different, so I think it's something that needs to be more clearly highlighted. (E.6)

Nursing education has historically established itself on the foundations of biomedical care since it began as a health science, turning in many cases only to the technical aspects of the profession and forgetting about social factors of health in the approach to teaching, as well as the culture and the economic question, that directly influence the health conditions of the black population. In a study that addresses the problem, it was possible to observe that nurses did not have knowledge about the relationship between race and health and their influence on the health/disease process of this population, which hinders a more comprehensive view of professionals on social determinants of health in this segment of the population, often bumping into ineffective actions or even driving away users, due to the fact that their needs are not met.¹⁶

The nurse, as a person and a social actor, influences society and is influenced by it and, in this way, can prevent or reproduce racism in its actions. From this conception, it is understood that for the deconstruction of institutional racism, the professional should rely on solid knowledge on the subject so that he can work the true needs of the black population.¹⁷Understanding the dynamics of discrimination and inequality is the basis for understanding the health-disease process of a group. For this, a more in-depth analysis of their life and health situation, which can achieve the constitution of a corpus knowledge that covers the true health reality of a segment. Such a practice is essential and not yet present in training processes.¹⁸

This professional category needs to broaden its foundations in relation to the black population, due to its greater representativeness and vulnerability in relation to certain diseases, such as diabetes, hypertension, sickle cell anemia, fibroids, glucose 6-phosphate dehydrogenase deficiency and mental disorders. These factors, when linked to their susceptibility to the low socioeconomic conditions established by society and culture, contribute to their distancing from services.¹⁷

However, it is important to emphasize the existence of an important scientific gap on the subject, marked by the reduced deepening in the training of health professionals, capable of directly jeopardizing the assistance to the demands of this public.¹⁹This fact can be explained by the low technical support for the research, contributing to the nurses distancing themselves from the black population contingent, ignoring their peculiarities. The actions of this professional are paramount, since through his holistic vision and care, he can understand situations and act efficiently with blacks, improving the quality of life of those living in a country considered the second in the world with the greater number of Afro-descendants, surrounded by inequalities and discriminations.⁵

In the interviews, it was possible to identify that an event of racism in the health service is considered, among nurses, a warning sign for the initiation of interventions in education and awareness of the team on the health of the black population and institutional racism, with the objective the situation to allow the development of work.

It is, if it were an embarrassing situation, [...]. Would you try to soften? Talk. [...] Do you often get hurt, for example, if you were a patient? It hurts and [...], try to articulate ways to soften the situation, so that care can be given to the service offered to that person. (E.4)

In a study carried out in FHU units, the discussions about the policies directed to the black population were defined as strategies to facilitate the implementation of the same and for the greater qualification of the care provided to this segment. It also understands an effective strategy to deal with institutional racism, since anyone can practice the same, being an important source for the affirmation of the PNSIPN.²⁰

According to the literature, unprepared health professionals and managers to act with the black population can constitute a barrier to access, reaffirming health disparities, marked by socioeconomic factors, social class and race.²¹In this context, it is considered important to approach the health of this segment still in the training of professionals, since such an implementation would allow a significant improvement in the living and health conditions of this part of the population through action at all levels of attention, respecting the specific needs, in addition to enabling education for the population, conducting research on the subject and enabling participatory management of services.⁷ Work on ethnic, racial and discriminatory issues in the training of health professionals has the power to deconstruct inequalities and respect for differences, as well as the formation of an equitable identity essential for health work, free from any discriminatory act.²² In this premise, participating professionals perceive guidance, training and ongoing and continuing education for professionals, as a way to prevent racism in public health.

I think, of course, it is training professionals, offering courses, offering politics, showing politics, [...] so that we are well equipped to meet people with equality. I think it would be there, empower the professionals, lest that sort of situation happen. I think that’s the way. (E.4)

The lack of discussion and exchange of knowledge in the team be a source for the reproduction of discriminatory and excluding acts from Brazilian social racism, making possible the reproduction of institutional racism in the health service. The use of information and debate on the health of the black population and the racial relations in which it is embedded is a basis for the prevention of institutional racism, since it allows professionals to develop a more precise attention to practices that may be discriminatory during their performance.¹¹

Currently, the black population segment continues to be in a state of vulnerability, propitious for damages arising from social racism, and are constantly forgotten in relation to the actions of public policies that are right to it, including those related to health.²³ Thus, it is necessary to deconstruct racism in the SUS through management by the managers in the promotion of training and continuing education of professionals, with a view to ensuring prevention and attention to the particular problems and needs of this population segment.²⁴

Work with the community was also highlighted among the interviewees as an effective way to prevent racism in all its forms, especially in health.

I think it's education. The education of the population. And, above all, education for the blacks themselves and for the people who go through it [...], permanent education, something like that. (E.3)

It's from there, in my head like that, I think it would be more effective so in the infantile stage, children, to hit the school that way! I think now, these people who are coming back there, as the ESF has been growing a lot, I think this is already being done. (E.7)

The debate on the topic of ethnicity and the presentation of the PNSIPN to the community was seen as necessary in a study carried out in Porto Alegre/RS, as it allows the population to understand the reasons why it is necessary to collect the color/race question in documents of the health service and the importance of respecting the ethnic and cultural differences of each segment of the population.²⁰Promoting racial equality is not only restricted to providing rights to the black population, but also allowing them to be achieved and ensuring conditions for its realization, reducing barriers to it and guaranteeing citizenship, based on the fight against racial discrimination socially.²⁵

When this is understood in the implementation of public policies, professionals are required to work with the community, approaching their characteristics, considering the subjects in all their faces, respecting their socio-cultural insertion.⁴ In this way, in the face of racism, nurses' work constitutes an important part of the education of the patient, family and community, with informative means and campaigns that act in the development of the public and social interest by the deconstruction of racism, being a permanent educator and providing assistance free from prejudices and judgments, guided by humanization, aiming at the attention directed at each case, especially those involving violence.¹⁷

Final considerations

This study contributed to the survey of a complex theme, loaded with historical, cultural and interpersonal formations that resulted and still result in social determinants responsible for significant health problems for the black population. The research reached its objective of knowing the perceptions and actions of nurses in relation to institutional racism in public health; the majority of the interviewees did not know the term “institutional racism” and the PNSIPN, a fact that demonstrated the poor control of these professionals in relation to the specificities and needs of this segment of the population, which is highly significant in the public health sector.

Still on this premise, the interviewees assumed that institutional racism is the one that occurs within the health teams. This perception can be explained by the fact that the term “institutional” is related to institutions. However, this misconception is based on the low frequency of debates among professionals on issues involving race, color and ethnicity, as well as the limited access to training, training and lifelong education on health of the black population for the category, which still presents itself sustained by the biomedical view. This lack of training and preparation is perceived by nurses, and their need for the provision of a quality service in public health is affirmed.

The difficulty in perceiving situations of discrimination in access to health and of racism in the daily life of the service can also be explained beyond inefficient training, since professionals are part of the social system and, within the latter, are exposed to historical representational issues in relation to black, imbued with the idea of racial democracy, which covers the determinants and determinants of the health of the black population and its relationship with the social environment, directly affecting the conditions and quality of life of these people.

In the study, the lack of actions carried out by nurses regarding the health of the black population and institutional racism and their lack of knowledge about the subject was evidenced in the study. However, they perceive guidance, training, continuing and continuing education for professionals, as well as education work on the subject with the population, based on respect for ethnic and racial characteristics, as the main means of preventing institutional racism and deconstruction of this, a factor that is positive for facing the problem.

On the other hand, this study had as limitation the lack of investigation of the perception of the black on institutional racism in public health, a factor that would allow a better understanding of this determinant for the access to health in the studied reality. In addition, it was possible to perceive that this is an issue that is not discussed in the public health sector, presenting a small number of scientific evidence. Thus, it is necessary to carry out new studies with new approaches and methods, aiming at integrating the theme in the scientific environment and establishing the public interest and professionals for it. Thus, it is considered important to carry out a new study, investigating the perception of blacks in relation to institutional racism in public health, so that it is possible to reflect on the data collected and its publication in order to stimulate the formation of programs and policies directed to the health needs of this population.

Given this, nursing, as a care profession, a member of the health team, responsible for the management and supply of quality care, should be based on foundations and resources that enable the work on the needs of the population assisted. In addition, it must have a holistic and integrative vision that allows recognizing the specifics of each user of the service, respecting their rights as a person and citizen, regardless of race, color or ethnicity.

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Correspondent Author

Luiz Gustavo Fernandes da Rosa

Email: enfermeiro.luizgustavofr@outlook.com

Address: Av. Darcy Feijó, 709, Capão da Canoa, Rio Grande do Sul, Brasil.

ZIP CODE: 95555-000

Authors Contributions

1 – Luiz Gustavo Fernandes da Rosa

Creation, planning, collection, analysis and interpretation of data, writing and critical revision of content.

2 – Renata Gomes Christóvão

Help in planning, analysis and interpretation of data.

3 – Mirela Furlin

Help in interpretation of data, writing and critical revision.

4 – Jeanice Baecker Lasta

Critical revision of content and involvement in approval of manuscript’s final version.

How to cite this article

Rosa LGF, Christóvão RG, Furlin M, Lasta JB. Nurses perceptions and actions about institutional racism in public health. Rev. Enferm. UFSM. 2019 [Accessed on: June 15th, 2019];volex:1-19pf. DOI:https://doi.org/10.5902/2179769231131