THE NEW STATE AND NURSING: PROFESSIONALIZATION AS “A STRONG ARM”

Post-1930 Nursing in Brazil follows a deep reformulation undertaken by the Sesp Nursing Program. Within the historical context under analysis, the Brazilian health history shows the broadening of public health services as a highly significant occurrence, the result of agreements between Brazil and the USA. The issue implied in the restructuring of the professional exercise of Nursing which since the 1920s had been limited to the big cities, organized with a small number of elite personnel and described by an narrative built around excellent nursing, since the 1920s (^{BARREIRA, 1997}).

Diametrically opposed the Getúlio Vargas’s populist and interventional emergence, the older model did not favor the new guidelines for the promotion of public policies in favor of the inclusion of different groups within urban labor. The prerogative finds an answer in the possibilities of the educational formation in Nursing that benefitted the government doubly, or rather, employing the common Brazilian coming from the “subaltern classes” and promoting public services in health care for the population throughout the country (^{WEFFORT, 1978}; ^{SILVA, 1991}; ^{GOMES, 1998}). It was thus necessary to break away from the established educational and professional patterns.

Special attention for health workers was required by high insertion capacity of personnel within the labor sphere and the great female population attracted by health formation. The above required a new standard of political relationship between the dominant elites and “subalterns”, historically marked by oppression and neglect, albeit a necessary tool within the war context, as an organization of the internal war front in World War II (1939-1945). It was highly important for Getúlio Vargas’s policy to engage the labor of males and females, black and poor people, since they would work in auxiliary services vastly required within the health field.

The professions and vacancies established since the foundation and dissemination of public institutions, such as hospitals, health units, home attendance and health programs, required a great number of workers prepared for a war attack and for the attendance within the public network of medical-hospital assistance or as teachers in auxiliary courses. It was a highly promising field and capable of responding to demands of the post-1930 society, especially for females who at that time became voters, too.

Consequently, the “domestication of workers” became concomitant to the perils of diseases (^{SILVA, 1991}). These issues favorably pervaded discourses that placed Getúlio Vargas as the “father of the poor” since, through Nursing, significant numbers of men and women would be admitted in the labor world and public service. It would prove Vargas’s discourse and guarantee US interests since “disease does not acknowledge borders”, as the slogan on the Boletim do Sesp announced (^{LEVINE, 2001}; ^{SOUZA CAMPOS; OGUISSO, 2013}), even between social classes.

The inclusion of women in urban labor potentially favored Getúlio Vargas’s claims. It became one of his priorities to open possibilities for women in a professional field social considered adequate for their gender. The fronts foregrounded discourse on the positivity of labor/worker whose activities preponderantly favored popular health and socially projected them, as proposed by universal suffrage, acknowledged in 1932, when new expectations with regard to a renewed voting public were provided. Results did not merely give visibility to the statesman, but also legitimated the administration´s proposal favoring the masses, strengthened the nationalists ideal of development and social protection within a symptomatically war-tainted situation. It was not chance that mass policies and Vargas’s style of government were echoed in the activities of Darcy Vargas, who inaugurated the First Lady stance in Brazil when the Legião Brasileira de Assistência (LBA) was founded. According to Ivana ^{Simili (2008}, p. 135), “the formation of an internal front made up of females prepared to work for the country’s victory was one of the bases of the mobilization triggered by Vargas”.

Nursing became highly conspicuous within the changes processed in so far as progress comprised social well-being of Brazilians and labor fronts. The Nursing statute redirected services by sanitary visitors and educators, broadened professional activities in public service, especially in institutions established and maintained by the government. New perspectives within medical milieu, public administration or governmental programs restructured representations, practices and appropriations of Nursing with regard to social visibility and the need for workers in the area.

Strengthened by the possibility of insertion of a significant number of females in occupations established by the public service, the reconfiguration of Nursing in Brazil transformed the political discourse. Enlargement of hospitals and health assistance networks maintained by the administration potentially increased the number of hospital beds and labor vacancies according to technological changes and to medical and hospital renewal. The above was consolidated by imports of instruments, medicines and other products manufactured by US industries. Consequently, the interests of good neighborhood policies were broadened due to Brazil becoming a consumer of US hospital technology (^{MOTA; MARINHO, 2011}).

Notions of hygiene and health were aligned to the patriotic and nationalist discourse in consonance to the historical moment. Health would change behavior and daily practices in a direct association with the ideas of order and progress, values that would lead the country towards civility and modernity. Getúlio Vargas was greatly benefitted by agreements established to promote political and military adjustments during the New State period. In fact, the war imaginary represented Nursing as a patriotic, nationalist, good-will activity, very similar to the type of Americanism by which modernity was imitated. Ronei ^{Cytrynowicz (2002}) underscored that the strengthening of a medical-assistance network in case of an invasion or war conflict was mandatory for the maintenance of a host of workers prepared to act in the internal front.

Consequently, one has to take into account that, in the case of Brazil, the American way of life ruptured the old standard of social reference (^{TOTA, 2000}). Control on the “subaltern classes” through labor laws and trade union structures, bonded to an authoritarian state, restructured the public service and established new labor posts and occupations which were appropriated by a technical-bureaucratic elite coopted by an inflation of the administrative apparatus (^{PESAVENTO, 1994}). Since literacy rates in Brazil during the early decades of the 20^th century were low, the prerogatives with regard to Nursing provided unique conditions for the success of the New State.

Vargas’s program comprised aid to poor people and their insertion in social life through their inclusion in labor fronts established by the administration without discarding the effects of an attack daily reported in the newspapers where photos of nurses were constant. Through the establishment of labor fronts, the government controlled whole populations and responded to social demands since people were identified, measured and evaluated even by Anthropology, an activity greatly supported by the Rockefeller Foundation (^{FIGUEIREDO, 2014}). According to Francisco ^{Weffort (1978}), Brazilian policy of the period was the product of a long social transformation period inaugurated since the so-called 1930 Revolution and manifested by the government style and mass policy, a fact corroborated by Ângela de Castro ^{Gomes (1998}).

The political situation experienced by the New State narrowed common interests and linked professional formation with the American way of life model. The insertion of the masses in the labor world through Nursing obeyed its double function and foregrounded the good-neighbor policy. American values of health and labor would be disseminated throughout Brazil through government programs, movement of people and the massive import of pharmaceutical and medical-hospital products. Nursing radically changed the social place it occupied and, similar to the “head nurse”, appropriated decision power in government policies, including the purchase of imported hospital products from the US.

One of the crucial aspects to the anchoring of Nursing within the political discourse comprised the reestablishment of existing representations, or rather, the deconstruction of symbolic capital molded in the 1920s for the profession and its main character, the nurse, deeply rooted in the social imagination, equivalent to a selfless heroine or a nun without the religious habit. The undoing of the old standard was foregrounded on the Rockefeller Foundation´s Nursing Program, the institution that supported the legendary Parson’s Mission² during the first reconfiguration of the teaching of Nursing in Brazil within the context of the 1922 Sanitary Reform (^{SANTOS; BARREIRA, 2002}). As observed above, the Nursing Program transferred to São Paulo the irradiating nucleus of the educational-professional formation and the Nursing School annexed to the Faculty of Medicine of São Paulo, and redirected the educational processes of Nursing in Brazil which remained solidly established.

Since many people in the professional field were involved, investments allowed for mobility between the popular classes, an expression employed to characterize poor, negro, brown and mixed--race men and women that made up the “subaltern classes”. Common typologies of distinctions and exclusion/inclusion modes proper to the race/color representations in Brazil have been reported by Oracy ^{Nogueira (1998}) who considers them as a mark and origin of the social relationships between white and blacks in Brazil, a criterion of qualifying and disqualifying of the Other. Even though the original proposal of post-1930 Nursing was not a racial issue, the new dimensions permitted the social ascension of the “subaltern classes” emergent from slavery, poor and vulnerable, through their formation in Nursing. It is not by chance that the Sesp model reinserted black men and women in the profession and spread the model nationwide.

SESP’S NURSING PROGRAM: UNDOING THE OLD TEACHING PATTERN

Bilateral agreements between Brazil and US comprised improvements in health services. At the same time, sanitation and assistance programs required the formation of professional people capable of administering issues in direct assistance and in the administration of health services such as collection of biological material, tests, hospital professional and auxiliary formation throughout the country. In times of war, Samaritans, first aid people, war nurses, stretcher bearers, removers of the wounded from the battlefields, trained in fast courses, affiliated to the Red Cross, were compounded to the people above. The general demand for the extension of medical assistance made practical the inclusion of a great number of men and women hailing from the poor classes within the context of urban labor. This possibility favored the political maintenance and the strengthening of Vargas´s leadership among the popular masses (^{LEVINE, 2001}).

It was during the Vargas Era that for the first time in the History of Brazil a comprehensive policy on workers’ rights with regard to health, now dealt with as priority, has been implemented. Increasing public health services was a response to the demands of the popular classes in Brazil, with the strengthening of Vargas’s image nationwide. Consequently, in the joint venture with the Rockefeller Foundation during the heyday of good neighborhood policies, the administration implements the Nursing Program to restructure the professional exercise with regard to educational formation and nurses’ activities, or rather, a new concept and attributes are given to the profession and its professional status is redefined (^{CAMPOS, 2006}).

The Nursing Program was based on the “demonstration effect” (^{CASTRO SANTOS; FARIA, 2010}), or rather, the replication of the health formation and assistance model from an irradiating nucleus whose effects would reach the country´s different regions and strengthen the reconstruction process of health public policies engendered by the Brazil-US alliance. However, so that the Nursing Program could reach its expected aims, the formation of professionals from several states would be necessary. They would be aware of the social difficulties which the population had to cope within their localities, they would be able to disseminate new techniques learnt during their renewed training so that they would administer assistance programs complying with local situations and not foregrounded on previously established excluding criteria, politically outdated and restrictive. Nursing was progressing towards internationalization, clinical studies, administration and scientific research.

The elitism of Nursing in Brazil, as proposed during the 1920s as the reinvention of autochthonous tradition, was against the Sesp model and was contrary to the developmental policy of Getúlio Vargas who detected political interests and field of action in Nursing. The reinsertion of Negro females and the demystification of males in the profession changed the professional status and allowed its reach to the whole of the country in a short time. The previous professional model was diametrically opposed to the New State’s national policy.

The few professionals were quickly absorbed by hospitals of the great urban centers or by professional schools as teachers, counselors, tutors in short-term courses which proliferated during the war, without taking into consideration refusals due to personal interests that hindered them from making displacements or working in the hinterland. In other words, the post-1930 social reality met the aims for the formation of a new type of health workers within the Vargas policy which defined society as “a collection of groups hierarchically differentiated and organized according to their productive and economic role” (^{LEVINE, 2001}, p. 51).

When the social-sanitary conditions in Brazil’s different regions were restructured, with special emphasis on the northern and northeastern region, the Nursing Program made possible the implementation of labor fronts within the sphere of public service, with significant feminine participation. The provision of urgency to health workers’ qualifications triggered the formation of work units which were opened in several states and thus conferred social visibility to the statesman. Social laws on help and assistance which reordered public life during the New State, were responses to demands expressed in the vindications of political, trade union and mutual organizations, highly enhancing Vargas’s populist ideals (^{LEVINE, 2001}). Consequently, Nursing played a leading role in the public health policy initiated during the New State, and women, especially black women, were significantly benefitted (^{SOUZA CAMPOS; OGUISSO, 2013}).

Although Sesp was established as a temporary war agency, it survived for 48 years, giving priority to public health, especially the professional formation and qualification of physicians, sanitary engineers, agronomists and nurses. Health public policies reached populations in the Brazilian hinterland to tackle endemics, build networks of sanitary units and other equipments of medical assistance in regions very far off the urban centers. It was not by chance that these places had US aerial bases, especially in the states of Bahia and Amazonas. Consequently, agreements provided for the establishment of nursing schools, hospitals and health centers, financial assistance to already existing schools, promotion of programs, public policies and postgraduate studies in Brazil, US and Canada, coupled to the learning of the English language and maintaining Rockefeller Foundation’s consultants in the main centers of professional training in Brazil.

Besides implementing water and sewage systems, Sesp made agreements with states and municipalities to introduce, standardize and expand public health benefits, conferring on the movement a sort of pioneering stance in the public policies of republican Brazil. It also included the introduction of work fronts to health professionals, especially nurses, and hosts of helpers in the public administration. Its activities comprised the standardization of procedures, and the hiring and expansion of a bureaucracy for the organization of health services with the training of skilled labor in health education, as foreseen in the Pan-American health agenda (^{CAMPOS, 2006}; ^{TOTA, 2000}).

The Nursing Program included applicants for the nursing career with scholarships, whose grant term provided assistance to professional training, personal and academic maintenance during the school years, round trips to those who did not reside in the localities of the schools supported by the Sesp, and other benefits. These included displacement of scholarship holders from the various regions of Brazil. On the other hand, nursing services were required for two years at the places of origin of the former students. Thus, organized teams would be formed for health services, monitoring of government programs and administration of clinics, hospitals, urban and rural health centers and schools. Consequently, there was a replication of the knowledge acquired in Sesp- -maintained training centers, identified as a strategy of the administrative principle of American nursing education and care. In other words, the “demonstration effect” would be concretized (^{CASTRO SANTOS; FARIA, 2010}).

The maintenance of Sesp scholarships warranted investments through the insertion of new teams in the labor market and reorganization of health care services, especially among populations living in the Brazilian hinterland. Scholarships provided men and women, mostly women, from various regions with professional training given in the large urban centers, especially São Paulo, as long as they returned to their places of origin and replicated the knowledge acquired so that auxiliary labor could be disseminated. The demonstration effect guided the new professional training, whose incentives founded and maintained educational spaces focused on the proposed purpose, that is, to professionalize care and to insert the popular masses in the labor market. The School of Nursing of São Paulo became the irradiating nucleus of nursing for Brazil (^{CARVALHO, 1980}).

Consequently, the restructuring of Nursing towed the line of the New State policy. The 1937 Constitution, which gave the President of the Brazilian Republic the powers to appoint governors in the states and govern through decree-laws, centralized decisions and their implementation, featuring different political and governmental interests, in the hands of the president. The administrative reform instituted, under the Ministry of Education and Health, the National Department of Health (HDH) and other executive bodies to replace the former National Department of Public Health (NDPH), created by Carlos Chagas in the 1920s (^{OGUISSO; SCHMIDT, 2017}). Therefore, the novel nursing definitively broke away from the old model of training and professional guidance, centered on hospital space and on systematic study of diseases, whose nurses would be adjuvants of hospital medical practice that favored a curative action and not focused on public sanitation (^{RIZZOTTO, 1999}).

THE NURSING SCHOOL OF SÃO PAULO: THE ESTABLISHMENT OF THE SESP EDUCACIONAL AND PROFESSIONAL MODEL

The post-1930 Nursing nucleus, foregrounding the process of professional restructuring, lay close to the Faculty of Medicine of São Paulo between 1942 and 1963. In 1963, Maria Rosa Sousa Pinheiro, supported by Glete de Alcântara, provided resources for its de-attachment and thus enhanced the School of Nursing as an independent unit of the University of São Paulo (USP) (^{SANTIAGO, 2011}). Its history dates back to the effective participation of the Sesp mediating interests of the Institute of Inter-American Affairs (IIAA) of the Rockefeller Foundation, which funded Public Health in Latin-American countries (^{SILES GONZÁLEZ et al., 2011}).

One of Sesp’s attributes comprised the maintenance of existing schools and funding for the construction of new premises for professional training. The School of Nursing of São Paulo became hegemonic and decisively altered Brazilian nursing. In fact, lack of professionals and the emblematic strings that ritualized nursing in previous decades had ideologically marked the profession. However, the a priori training of a renewed teaching staff was required, that is, a staff which was not tied to the old training and professional guidance standard, but focused on the new performance of nursing as a political, social and scientific activity.

The School of Nursing has a long history and evokes agreements for the construction of the School of Medicine of São Paulo, mediated by the Rockefeller Foundation (^{CARVALHO, 1980}; ^{MARINHO, 2001}). It was implemented after a 1942 mission, conducted by nurse Mary Elisabeth Tenant, was sent to define the criteria with Adhemar Pereira de Barros, governor of the State of São Paulo, in the famous “meeting of Campos do Jordão”. This led to the appointment of the first Brazilian nurse, Edith de Magalhães Fraenkel, to graduate in the US, to make technical visits in nursing schools in the US and in Canada as an organizational strategy of the São Paulo School of Nursing. The latter started its activities in 1942 attached to the Faculty of Medicine of São Paulo and with the Hospital das Clínicas for the practical field and internships, as proposed by the Curriculum Guide.

Although there were other nursing training places, the School of Nursing provided a new professional training standard. Its foundation included the transition from the official model of modern nursing training, legally determined by Decree 20,109 of 1931, which attributed to the Anna Nery School of Nursing, an offshoot of the School of Nurses of the National Department of Public Health (NDPH), the standard that had to be imitated by other nursing schools. The new teaching model and professional training distanced itself from the religious, racial and sexual sectarianism that symbolically predominated in the former formation. As a strategy, it comprised new leaders, men and women, black and white, which would disseminate the renewed bases of nursing throughout the country, even though the official discourse was specifically for women. This aspect may be considered a feminist contribution for the construction of solidarity spaces. In fact, Edith Fraenke personally knew Bertha Lutz³ and lived in the U.S. in the singular context of women’s struggle in racial, social, and academic conflicts.

The foundation of the São Paulo School of Nursing, however, did not reject the American model of teaching that historically pervaded professional training. From the start, the novel School of Nursing was linked to a hospital institution (Hospital das Clínicas) and higher education (Faculty of Medicine). Since training focused on medical clinic work and the administration of nursing services, the School of Nursing was organized on a curriculum structured by previously disregarded disciplines, for example, those focused on mental health. The practical activities for the course´s minimum curricular structure included the study of clinical medicine, tropical diseases, urban and rural collective health and psychiatric nursing, as part of the teaching, research and extension activities of the new nursing center in post-1930 Brazil (^{SOUZA CAMPOS; OGUISSO, 2013}).

The space dedicated to clinical medicine was enhanced in the School´s training with regard to teaching resources and contents of disciplines. Lectures, especially the specific ones, were given by professors of the Faculty of Medicine and internships were held in state hospitals, such as the Hospital das Clínicas and Santa Casa de Misericórdia in the cities of Santos and São Paulo, and at Hospital do Juquery. The above actually underscored practical knowledge on what was more technical and modern in the period. The practical activities and theoretical bases that underpinned the teaching by the School of Nursing were a replica of the North American teaching pattern, albeit featuring new dimensions.

Modernity reflected investments in hospital technology that structured the complex Faculty of Medicine, Hospital das Clínicas and Instituto de Higiene de São Paulo, coupled to new techniques, materials and educational resources brought from the USA by Edith de Magalhães Fraenkel who was appointed to organize and head the School of Nursing of São Paulo with the consulting stance of Ella Hansenjaeger. All these factors multiplied possibilities of access to the most modern standards of care, teaching, research and extension in the field of care/care-giving, whose scope projected the School onto Latin America. On July 17, 1943, the headlines of the newspaper A Gazeta were “In São Paulo, the largest Nursing School in South America”.

CURRICULUM GUIDE: THE RENEWED NURSING TEACHING IN BRAZIL

The curriculum of the School of Nursing of São Paulo was structured on the handbook Fundamentals of a Good Nursing School, first published in 1936 by the National League of Nursing Education, in New York, with its second edition translated and published in Brazil, in 1951, by Sesp. The handbook’s second edition was revised by a special committee chaired by Stella Goostray and published in the USA in 1942. The handbook was translated into Portuguese, in 1951, by Haydée Guanais Dourado, former director of the School of Nursing of the University of Bahia, and by Celina Viegas, former director of the Hermantina Beraldo School of Nursing in Juiz de Fora, Minas Gerais.

The handbook, organized in chapters, had, as its model reference, the Curriculum Guide for Nursing Schools published under the title A Curriculum Guide for Schools of Nursing, first published in 1917, revised and published in 1927, with the third and last revision published in 1937. The final text was prepared and published by the Curriculum Commission of the National League of Nursing Education. The same reference was used for the regulation of nursing education in Brazil, Act 775 of 1949, which dealt on the course curriculum, its 36-month duration, full high school course. It also acknowledged the category of nursing assistant, with an 18-month training course.

The National League of Nursing Education defined the Nursing School “as a social institution to promote the interests of its students and to meet the needs of the society it serves” (FUNDAMENTOS, 1951, p. 2). Accordingly, the curriculum “should include all the learning experiences necessary for the training of competent professional nurses - practical activities in clinics, outpatient clinics, classroom and library” (FUNDAMENTOS, 1951, p. 42). Even if it underscored the biomedical aspect linked to the nursing know-how, the concern with specific training focused on scientific research, intellectual and reflective learning has characterized the School of Nursing of São Paulo throughout its history up to the present.

The presuppositions foregrounding the curriculum of a good nursing school were based especially on planning, featuring nine factors: Standards, Teaching Level, Contents, Organization, Timetable, Program Organization, Teaching Method, Student Assessment and Didactic Resources. Planning was the responsibility of the School Board accountable for the curriculum´s development and administration, and for the elaboration of clinical education plans in the several services. These meeting minutes have not been yet historically or deeply analyzed.

In the case of “standards”, curricular guidelines enhanced that the curriculum should be flexible, or rather, adjusted to changes in society, even though they should meet predetermined requirements and common practice models for all. In other words, a nurse pattern should be envisaged. It must be underscored that the term “nurse” is adopted throughout the guidelines of the Curriculum Guide as a feminine tradition based on Nightingale Model. Only young women were selected, enhancing the social representations of nursing as an appropriate function for women, even if males also chose the profession.

The above aspects reveal discussions on professional identity due to the fact that rites, taboos and traditions were rooted in the social imaginary and conflicted with the redefinition of nursing and its local specificities. Simultaneously, we have to consider the mobilization of females in public life and in the imposition of limits on spaces occupied by them. The definition of the term standard nurse, adopted by the International Council of Nurses (ICN) in 1935, quoted in the handbook, has been given by Isabel Stewart a year earlier, in 1934:

A standard nurse is a person of good general education and cultural basis who has successfully finished a systematic professional course, lasting approximately three years, as a full-time student in an acknowledged nursing school and who has met the requirements for registration of the diploma in the country and state where the school is located, with rights for membership in the association of graduate nurses of her country.⁴ (FUNDAMENTOS, 1951, p. 43, own translation)

A good nursing school´s curriculum should be liberal, flexible and not strictly limited to technical education. The document states that higher education nursing students need a previous general culture base, which would provide them with a greater maturity and a vast and safe basis for their profession. A liberal curriculum, distinguished from that of the technician, would give a greater importance to reflection, understanding, social attitudes and the integral development of students as human persons. Although technical contents are crucial, more balance was needed between technical and scientific, cultural and social training “of the nurse”, a characteristic required up to the present.

The handbook’s curricular contents recommended that nursing education should “lead the students to cope with issues of the people they will have to serve in the future and to adjust themselves to the continually changing demands of the professional practice”⁵ (FUNDAMENTOS, 1951, p. 45, own translation). Therefore, it has been crucial to nursing and related professions to develop principles and facts, specialized techniques and skills, social and moral attitudes, and ideals that govern the standards of personal and professional behavior. Theory and practice should be closely related from the beginning for a satisfactory curriculum. The text points out that the organization of the subject matters would make integration and learning effective from the functional point of view and not strictly logical. It then furnished the main groups of subject matters:

Group 1 - Biological and Physical Sciences: Anatomy, Physiology, Microbiology and Chemistry; Group 2 - Social Sciences: Sociology, Psychology, History of Nursing, Professional and Social adjustments; Group 3 - Medical Sciences: Introduction to Medical Science including Pathology, Pharmacology, Principles of Medicine, Surgery, Pediatrics, Obstetrics and Psychiatry; Group 4 - Nursing and related disciplines: Principles and Practice of Nursing, Hygiene, Sanitation, Domestic Economy, Nutrition, Diet therapy, Medical and Surgical nursing, Obstetric Nursing, Pediatric Nursing, Childcare, Psychiatric Nursing, Public Health Nursing, Advanced nursing and Optional subjects.⁶ (FUNDAMENTOS, 1951, p. 46, own translation)

The student attended the pre-clinical (six months), junior (six months), intermediate (one year) and senior (one year) courses, in which the disciplines mentioned in Act 13140 of 1942 were distributed throughout 36 months. Workload did not differ from that recommended for Standard School. It differed only in their distribution throughout the course with a concomitantly supplied theoretical and practical program.

The pre-clinical period comprised basic subjects in the field of Biological Sciences, such as Anatomy, Physiology, Biochemistry and Microbiology, coupled to the teaching of Educational Psychology, Sociology and Social Aspects of Nursing. The course was largely theoretical during this stage, albeit with experimental practical internship. During the second and intermediate period, Nursing students were taught such subjects as Medical Clinic practice, Surgical Clinic practice, Nutrition and Pharmacology. They also sat for curricular internships in the Medical and Surgical clinics of the Hospital das Clínicas.

The intermediate period comprised specialized lectures and internships, such as “Dermatology, Obstetrics, Neurology, Diet Therapy, Orthopedics”, and others. The senior period involved nursing practice in Pediatrics, Hygiene, Public health, Psychiatry, with internships at the Hospital do Juquery (^{CARVALHO, 1980}). Highly important is a reference to the teaching of the History of Nursing during the initial period of the course, with characteristics identified in the available historical records:

[It comprises the] study of the development of the humanitarian ideal from its beginnings to modern times, especially in its relationship with Nursing. It is a course full of inspiration, prepared to give students the understanding of nursing as a social movement, stimulating their interest in the continuation and development and study of the subject matter.⁷ (ESCOLA DE ENFERMAGEM, 194-, p. 3, own translation)

As a subject matter, the History of Nursing aimed at developing the humanitarian ideal and the understanding of nursing as a social practice, albeit within a linear and progressive stance. However, the organization of subject matters recommended that the curriculum would allocate its workload to practical and theoretical classes, besides student’s rest and recreation. Students’ mental health and their personal and professional development was a relevant concern. When the workload for theoretical and practical classes was planned, plus study time, the “Program Organization” revealed the approximate percentages in the teaching of the great areas, such as Biological and Physical Sciences (20%), Social sciences (15%), Medical sciences (25%), Nursing and related disciplines (40%), which steered professional training. The above greatly differed from that of other schools in the period. Although the sociocultural profiles of women entering nursing schools in Brazil were the same, the proposed teaching model, the recruitment pattern including black men and women, and exclusion of denominational formation were distinctive items within the scientifically-based changes.

The teaching methodology, described in the Teaching Method, Student Evaluation and Didactic Resources, suggests that the items should be adjusted to the aims and contents of each course, according to the curriculum’s purpose and principles, stimulating the students’ imagination, arousing their interest and forming the habit of independent study. Teaching tools varied according to the purposes of the discipline and was done through the employment of demonstrations and laboratory methods for the teaching of the sciences and for the art of nursing, case studies and clinical teachings, complementing lectures when related to clinical disciplines; group discussions, conferences, symposia and seminars. The latter were proposed for the study of social sciences. It may be underscored that they were very modern subject matters for the period, whose relevance in the field of training and production of knowledge in Nursing made the institution in post-1930 Brazil a leader in the field.

Guidelines on student evaluation aimed at methods that would demonstrate students’ progress, as much as possible. Therefore, for evaluation purposes, teachers would need to constantly assess and verify students’ methods and habits, their capacity to apply principles and make generalizations, and the attitudes they developed to cope with nursing situations. Evaluation methods included written, practical and oral tests, case studies, observation charts on the students’ work completed by the supervisors, evaluation scales, lists of techniques, case relationship, individual conferences and interviews. The above were actually highly innovative proposals, which constructed an awareness focused on the administration of nursing services.

Teaching Resources should include materials, equipments, books, resources from other libraries and clinical facilities necessary for effective teaching and available to students and teachers. Evidently, the best curriculum would not become feasible when adequate teaching resources, reference books and scientific journals, large number of patients for observation and treatment and the proper organization of all these resources from the educational point of view are lacking. According to the handbook, highly prepared personnel to administer programs, teach and supervise were conditions for a good nursing school. This aspect was the basis of the Nursing School of São Paulo a center of excellence in teaching, research and extension in Latin America and the concretization of the Nursing Program’s aims.

Since the Curriculum Guide went through three editions (1917, 1927 and 1937), it was due to such guidelines that the School of Nursing of São Paulo organized its curricular structure. The founding decree warranted its autonomy within the jurisdiction of the Faculty of Medicine, regulated the 3-year duration higher education course and postgraduate courses, established the list of disciplines and their serialization, and made mandatory the internships at the Hospital das Clínicas and in the sanitary district of the Institute of Hygiene as published by Ernesto de Souza Campos, Director of the recently established Faculty of Medicine of the University of São Paulo (^{SANTIAGO, 2011}).

Minimum requirements for admission to the Nursing course consisted of either a diploma of Normal School, or equivalent, or even a certificate of completion of the course, age between 18 and 35 years old and certificate of moral suitability. Applicants (initially, exclusively for females) were required to have a health check, be single, widowed or proven separation from husband. Several nursing schools were established in Brazil within the process proposed by the Nursing Program from which emerged the School of Nursing of the University of São Paulo. Benefiting from professional training, Brazilian political history actually heralded the change of a model centered on the heritage of a history based on archaic traditionalisms, linked to the French, religious model, which no longer responded to the material and social progress in Brazil. Deliberately or not, post--1930 Nursing courses favored the New State Novo by including men and women in urban labor within a context of the redefinition of Brazilian society.

With regard to the teaching-learning process, one may ponder that the teaching of historical contents in current professional education, at the margin of the formative process, does not contribute towards the demystification of the bias that represents nursing as a non-prestigious profession at its historical origin or subordinated to medicine.

THE FIRST FEMALE STUDENTS OF THE SCHOOL OF NURSING: THE 1946 GRADUATE STUDENTS

The institutional history of the sixteen graduate students of the first class, in 1946, evidences an academic background based on teaching, research and extension proposed in the Curriculum Guide. The available historical records reveal that the Admission Forms [Ficha de Admissão] are the main sources for analysis and indicate that males were absent in the School’s first two classes of the School, even if they were theoretically accepted. Similarly, nursing education should prepare “true professional nursing” based on scientific training and technical knowledge, applicable to different social groups, taught by researchers in the field of “the art and science of care”, as recorded on the school’s motto.

The first graduate students were Amália Correa de Carvalho, Clélia Mainardi, Carmen Alves de Seixas, Dinah Alves Coelho, Elizabeth Barcellos, Eulina Bastos, Filomena Chiariello, Maria Conceição Leite Aranha, Maria José de Almeida Leite, Maria Salomé Coura, Maria Silvana Teixeira, Marilia de Dirceu da Cunha, Nahyda de Almeida Velloso, Ophélia Ribeiro, Zaira Bittencourt and Zuleika Mendonça Kannebley, who were admitted with twenty-two other students who quitted the course. Reasons for quittance comprised sudden change of the social environment, rigid discipline, which required “living in the hospital”, and uninterrupted professional practice and coping with realities not always easy to assimilate.

With the exception of students who resided or had relatives in the city of São Paulo, during the years of professional training, students from other cities and states lived in the Hospital das Clínicas or in a rented house in the neighborhood. When the premises were turned over in 1947, the students began to live in the School of Nursing. In fact, nursing schools were also a boarding school, with a single room with a balcony, properly furnished with bed, closet, desk, chair and a small washbasin for personal hygiene. The bathrooms with showers and toilets were available on the three floors of the premises, the 11^th Modernist construction in the city of São Paulo (^{MOTT; SANGLARD, 2011}).

The first sixteen graduates, hailing from wealthy families living in the city of São Paulo and in the interior of the state of São Paulo, were Primary and Normal School teachers who entered the nursing course due to a concession by the State Department of Education and Public Health under Article 41, Act 12,273 of October 28, 1941. Without jeopardizing their salary and other acquired advantages, they were admitted for a new vocational training. The aim was to select a professional team from which a board of professors for the School of Nursing would emerge.

In fact, the State Secretary for Educational Affairs sought a team of excellence, already initiated in the teaching exercise, or rather, young women prepared to face the dynamic challenges of the teaching profession at a higher level and distant from the old standards. Requirements echoed current legal provisions that would require, after a relatively short period, a minimum degree of training for admittance to the nursing course, namely Act 775 of 1949. If we compare the recruitment patterns of the Nursing Program with historical nursing studies, we may perceive that the social and cultural characteristics of nurses who graduated in Brazilian schools between the 1920s and 1960s did not diverge significantly (^{FERREIRA; BROTTO, 2018}). Only professional training changes or the place occupied by nursing within university and health institutions.

Selection requirements characterized the expected strictness and the training provided. Since the School of Nursing constituted the scientific bases of the new national professional and intellectual nursing, it would capacitate the teaching-administrative performance in schools and hospital services throughout Brazil. With regard to the social and cultural origins of the first graduates, the records identify their origin as mainly from small urban bourgeoisie families who maintained business and offices in the interior of the state of São Paulo. In other words, young women very close to the intellectual milieu characterized by the Sesp model. The level of their formal education and social insertion in their places of origin made them members of a small elite, that is, daughters of doctors, lawyers, teachers, pharmacists, public servants, farmers and owners of commercial stores, daughters and granddaughters of immigrants, translating the ideal advocated for the modern nurse, or rather, an educational background, mastery of a foreign language and close contact with world literature.

Ages ranged between 22 and 32 years old, mostly adult females over 25 years. Besides the Normal School graduates, two students of the first Nursing class, Dinah Alves Coelho and Maria Conceição Leite Aranha, were Sanitary Educators who had received a degree from the School of Hygiene of São Paulo. The reasons which triggered their option for the School of Nursing reveal the pioneers’ cosmopolitan profile. The records point to a significant decision, as we may see in the affidavit by Maria Salomé Coura when asked about the choice of profession:

a) to move from the hinterland to the capital city; b) to increasingly improve the cultural level; (c) the possible ascension to a better-paid job; d) desire of the family to gradually migrate to a larger center; e) perhaps a vocation for the nursing career, influenced by the medical environment in which the declarant always lived.⁸ (FICHA DE ADMISSÃO, 1942, own translation)

Ophélia Ribeiro’s affidavit reinforces the interpretation that they were women initiated in the labor and professional milieu. When she was asked on the reasons that would have led to her choice, the candidate replied: “I have two brothers, both medical students; I want to dedicate myself to nursing to help them”. The above is also evident in Zaira Bittencourt’s statement: “In my opinion, nursing is a noble career; besides, I like to acquire new knowledge whenever an opportunity presents itself” (FICHA DE ADMISSÃO, 1942). Although the profile of the graduates establishes a sort of elite with regard to cultural capital, this fact changes within the second class when Sesp scholarship holders are admitted (^{SOUZA CAMPOS; OGUISSO, 2013}).

Opportunity pervades most of the records analyzed. The frequency of the syllogism assesses the interfaces between nursing and female projection in the labor society. The first students rarely mention even covert clues of charity and selflessness as values underlying the choice of profession. On the contrary, their purpose is social ascension, professional positioning, expansion of knowledge and professional specialization, acknowledgement of Brazilian women´s stance in the urban labor milieu. Amália Correa de Carvalho is an exemplary figure since she states that she has chosen the profession moved by the “desire to have a useful life” and concludes the answer by indicating “interest in study” (FICHA DE ADMISSÃO, 1942).

When the records are contextualized, they evidence the positioning of females in the wake of the new demands of modern life. Zuleika Kannebley also stated in her Admission Form that she competed for one of the vacancies offered by the School for “willingness to dedicate myself to further studies” (FICHA DE ADMISSÃO, 1942), whereas Eulina Bastos, objectively characterized her choice of profession as “a vocation” (FICHA DE ADMISSÃO, 1942). The records reveal women attentive to the possibilities offered by the profession. Women, at the same time voters and professionals, distance themselves from the centuries-old impositions of male domination, such as marriage and motherhood, and strive for a life that underscores emancipation and the imperative values of the new model proposed for Nursing in Brazil.

A highly interesting fact in the formation process of the School of Nursing’s first class lies in the granting of scholarships to the 1946 graduates. Eight of the sixteen students were awarded funds for professional improvement abroad for postgraduate internships at U.S. institutions, such as the universities of Boston, Minnesota, Toronto and Columbia, granted by organizations linked to the Rockefeller and Kellogg Foundations. The graduates who studied in the USA were Dinah Alves Coelho, in 1947; Amália Corrêa de Carvalho, Maria José de Almeida Leite and Ophélia Ribeiro, in 1948, and Nahyda de Almeida Velloso, Zuleika Mendonça Kannebley, Elizabeth Barcelos, Eulina Bastos and Zaira Bittencourt, in 1949. The fact that scholarship holders were hired by the School of Nursing as teachers immediately after their course should be underscored.

Amália Corrêa de Carvalho, one of the School of Nursing´s most brilliant students, earned a Bachelor’s Degree in Nursing Education at Boston University School of Nursing. Dinah Alves Coelho specialized in neurological nursing at the Philadelphia Hospital for Nervous and Mental Diseases and Maria José de Almeida Leite and Nahyda de Almeida Velloso specialized in Pediatric Nursing, Ophélia Ribeiro specialized in Orthopedic Nursing and Zuleika Kannebley in Surgical Nursing at Boston University School of Nursing. Among the graduates who completed a Master’s degree in the USA, the following may be underscored: Elizabeth Barcellos obtained a Master’s degree in Psychiatric Nursing; Eulina Bastos, a Master’s degree in Surgical Nursing, and Zaira Bittencourt, a Master’s degree in Medical Nursing. The three obtained their degrees at the University of Pittsburgh School of Nursing.

The American consultant Ella Hansenjaeger, a constant during the consolidation period of the new School of Nursing, significantly favored the structuring of professional training in Brazil. Miss Ella, as she was called, was a researcher, author, professor and consultant of the Rockefeller Foundation. She did not merely added value to the teaching offered by the School of Nursing, but also supported Edith de Magalhães Fraenkel’s decisions, not without lengthy discussions and board meetings. As a representative of the Rockefeller Foundation in the Sesp Nursing Program of Sesp, her presence strengthened the paradigmatic change of professional training, as several studies on the subject have demonstrated:

Ella Hasenjaeger, IAIA/Sesp consultant at the School of Nursing was of the opinion that the success of a nursing school should be attributed not only to its principal, but to its ability to gather around it an efficient body of collaborators, namely, the head nurses. The head nurses should occupy a strategic position in the hospital environment, since they constituted the basis of the administrative, executive and educational pyramid of the nursing service. The head nurse should have a special preparation, with adequate teaching and great experience in hospital environment; she must have moral and intellectual qualities that capacitate her to deal with people with understanding and tact. She should also have the “gift of direction” to efficiently guide her aids and give lectures, keeping alive interest on social issues.⁹ (^{FRANÇA; BARREIRA, 2004}, p. 509, own translation)

The students of the 1946 class were the first head nurses trained in the new teaching and research model of nursing in Brazil. The School of Nursing was the core of the Nursing Program and was organized for this purpose, even though other nursing schools received consultants or investments from IAIA/Sesp. Miss Ella, the most important consultant in Brazil, enhanced the desired training with the support of Maria Rosa Sousa Pinheiro, Glete de Alcântara, Clarisse Ferrarine, Ruth Borges Teixeira and Edith de Magalhães Fraenkel, professors of the School of Nursing of São Paulo. The latter two were the last graduates of the old standard. In fact, innovations brought together a group of intellectuals who restructured the nursing education in post-1930 Brazil. They were later joined by Anayde Corrêa de Carvalho, Wanda Horta and others.

Such visibility mirrored the educational level projected by the School and its interest in the dissemination of new perspectives of professional training among other nursing schools in the country. Owing to its characteristics, the School of Nursing of São Paulo established a system of affiliation which consisted of acceptance of students from other schools to attend subjects as special students. Among the novelties, the discipline Psychiatric Nursing with internship at the Hospital do Juquery, the psychiatric hospital in São Paulo, was provided. The affiliation system, another historical and social indication of changes in professionalization, received students from Nursing schools in Bahia, Rio de Janeiro, Goiás, Minas Gerais and even from Uruguay and Paraguay, such as Maria Ivete Ribeiro de Oliveira, a paradigm of Nursing in Brazil (SANTOS et al., 2012).

Rereading and reflections on professional formation favor the perception that the former teaching standard proposed for nursing prevented political change experienced in post-1930 Brazil. As a political-pedagogical practice, such perspective maintained a linear narrative that hinders criticism through the propagation of myths and the forging of practices and fixed representations, since it is historically important to analyze the dynamics processed in time. In the case of the female nurses mentioned above, their initial experiences and histories expand the historical interpretation of nursing and recreat the past. New incursions on the history of Nursing, memories, histories and biographies of anonymous nurses, who consolidated the Nursing Program and the Sesp model, are made possible. Thus, the analysis of the profile of 22 students reassemble the bases of a historical process that significantly impacted the change of the recruitment pattern, which not only favored the admittance of poor and black women in Brazilian nursing, but empowered significant achievements (^{SOUZA CAMPOS; CARRIJO, 2019}).

The School of Nursing of São Paulo, a crucial component of the Nursing Program, restructured the educational-professional training of the art and science of care/care-giving during the New State. Students of the first class headed the public policy implemented by the Getúlio Vargas’s administration which, among other aspects, permitted the reconfiguration of the profession’s social imaginary as from a policy that reached all regions of the country, through the dissemination of nursing care to all the regions of Brazil.