Group Process : reflections of a nursing team

The objecti ve of this qualitati ve, exploratory-descripti ve study was to analyze the group process of a nursing team at Hospital de Clínicas de Porto Alegre (HCPA), under the light of Pichon-Rivière’s Operati ve Group Theory. Data collecti on took place in 2008, using a semi-structured questi onnaire and focal group. The group work concept is one of the four categories that resulted from the study, and is the object of approach in the present arti cle. It was found that the knowledge about the group process must be shared, disseminated and discussed since the undergraduate studies and developed across the professional career. As the team learns and is able to identi fy the main indicators of the group process, it becomes possible to improve operati vely, considering not only the outcomes but mainly the course covered unti l achieving the goal, aiming at group learning.


DESCRIPTORS
Nursing, team Group processes Focus groups Communicati on Interprofessional relati ons RESUMEN Estudio cualitati vo, exploratorio, descriptivo, que objeti vó analizar el proceso grupal de un equipo de enfermería del Hospital de Clínicas de Porto Alegre (HCPA), según la Teoría de Grupo Operati vo de Pichon-Rivière. La recolección de datos aconteció en 2008, mediante cuesti onario semiestructurado y grupo focal. Concepción de trabajo en grupo es una de las cuatro categorías resultantes del estudio, siendo objeto de abordaje en este artí culo. Se desprendió que el conocimiento sobre proceso grupal necesita ser comparti do, divulgado y discuti do desde la formación académica, en el curso de graduación en enfermería, y desarrollado a lo largo de toda la carrera profesional. A medida que se conoce y consigue identi fi car los principales indicadores presentes en el proceso grupal, el equipo puede conducirse operati vamente, considerando no sólo resultados, sino principalmente el camino recorrido hasta la conclusión de la tarea, apuntando al aprendizaje grupal. Developing skills for group coordination when grounded on a practicaltheoretical framework [...], supports the understanding of several processes that take place within the group and the resources that the coordinator needs in order to manage it.

INTRODUCÃO
Coordinati ng a group of people is oft en quite diffi cult, and always implies facing diversity, because, besides the individuals' parti cular moti vati ons, diff erent thoughts and ways of acti ng and understanding ideas occur in a working group. Among so many parti culariti es, eff orts must be converged in order to achieve common objecti ves and goals that translate as being the purpose of the group itself. In this setti ng, nurses stand out as professionals responsible for coordinati ng teams, usually consisti ng of nursing auxiliaries and technicians, in additi on to other nurses.
It should be emphasized that, although human beings parti cipate in diff erent groups in life (family, school, church, club, etc.), not always is this process clearly noti ced. However, since one's birth, one is demanded to have a dispositi on towards sociability in order to become a member of society, considering the individual does not have the necessary physical conditi on to survive in isolati on (1) . This conti nuous process of forming groups shows the gregarious nature of human beings, who are constantly in the search to preserve their identi ty in the micro and macro society. Their several relati onships somehow had and/or have an impact on their own individuality. It must be considered that, within a group, there are intersecti ons among several networks, each holding their own values, beliefs, fears, affi niti es, and defense mechanisms. Each individual's accumulated asset, fi lled with this collecti ve inheritance, represents the nuances of the communicati on process of the unique group to which he/she belongs. Other people, with other backgrounds, will provide other combinati ons (2) .
The collecti ve dimension of nursing work requires specifi c knowledge about the group dynamics that is not limited to the simple use of techniques, but involves understanding the group movement due to its complexity. Nurses receive an academic educati on during their undergraduate studies, with no specifi c preparati on for working in groups, and, therefore, face great diffi culti es in the work market by having to deal with obstacles related to leadership, communicati on and interpersonal relati onships. Coordinati ng a group is no simple task (3) .
Developing skills for group coordinati on when grounded on a practi cal-theoreti cal framework -in this case, the Operati ve Group Theory-supports the understanding of several processes that take place within the group and the resources that the coordinator needs in order to manage it. Understanding group movements implies on mastering an essenti al skill in order to improve the effi cacy of the coordinator's interventi ons, as well as to investi gate and encourage the potenti als of the group itself. Therefore, by creati ng a place for dialogue, which main principle is the parti cipati on, in diff erent forms and levels of intensity, of all the actors involved in the proposed questi onings, the general objecti ve of this study was to analyze the group process of a nursing team, hence, the results presented herein result from the fi ndings achieved from knowing the concept that a nursing team has for group work. Therefore, we aim at contributi ng with the development of a refl exive process that could provide support for interventi on and reorientati ons of team practi ce, thus improving and triggering possibiliti es for investi gati ng and understanding the group process in nursing teams.

LITERATURE REVIEW
With the aim to understand the relati onships that exist in the nursing team, it is necessary to be grounded on theoreti cal frameworks that off er the necessary support. The operati ve group framework provides the basis to choose the appropriate techniques and to make group interventi ons. It is expected that those interventi ons occur in line with a transforming perspecti ve where people who parti cipate of a group process are seen as subjects capable of build things together, with a clear view of their strengths and weaknesses.
In the present study, teamwork is understood as an interrelati on process, analyzing the relati onships between workers as group processes. By understanding the group processes present in a team's relati onships, it is possible to build it using diff erent criti ques and refl ecti ons from those previously made. In line with this proposal, Pichon-Rivière's operati ve group framework has the purpose to help the teams throughout the extensive process of understanding and building their praxis, allowing for the implementati on of transforming acti ons that recreate their own work.
Understanding the dynamics involved in the constructi on-deconstructi on-reconstructi on of a health team is a great challenge. When building groupality, there is a pervading idea of recomposing knowledge and team as one, though it is understood that such totality does not exist, and neither do uniform ideas or views of the world. In the group imaginary, the illusion of a perfect team remains more in the plan of idealizati on than actually in reality, and it is therefore necessary to break the myth of perfecti on and learn how to deal with imperfecti ons (4)(5) . This unleashes a creati ve process based on one's current resources, which characterizes a conti nuous spiral-like process (6) .
The operati ve group technique is characterized for being centered on the task and its explicit and implicit dimensions. Explicitly, the task can refer to learning, diag- nosing a professional organizati on, creati ng a marketi ng ad, etc. Another task underlies this fi rst one, pointi ng at the rupture of stereotyped agendas that hinder learning and communicati on, which are an obstacle in view of the whole situati on of progress or change. Therefore, the implicit task consists of elaborati ng two basic anxieties understood as the fear of losing the stability won in the previous situati on and the fear of an att ack in the new situati on. These two anxieti es, which are coexisti ng and cooperati ng, confi gure the basic situati on of resistance to change. In the operati ve group, this situati on should be overcome by going through the three dialecti c moments: thesis, anti thesis, and synthesis. This is a clarifying process that goes from explicit to implicit. The allusion to an operati ve mode relates to functi oning in the sense of creati ng the right conditi ons for group members to promote a creati ve change and an acti ve adapti on to the reality, which means to understand the group as an instrument used for learning (6) .
According to this perspecti ve, group learning means to be concerned not only with the product of learning but also with the process that allows subjects to make changes in their lives. Therefore, the operati ve group work has the purpose of helping the person learn to think, or, bett er yet, relearn how to think, changing dilemmati c into dialecti c thinking. Dilemmati c thinking triggers infl exibility in the possibility of learning, being creati ve and changing the reality. This form of thinking established a distorted reading of the reality as it fragments the object of learning, dissociati ng it from other objects and from its context, which also produces a fragmentati on of the bonding and of the self. On the other hand, dialecti c thinking seeks to integrate the object, understanding it in a constant movement, associati ng it to other objects and to the context, in a concrete historical situati on (6) .
Relearning how to think based on dialecti c thoughts is related to the search of a more refl exive view of everyday life. Everyday facts and phenomena usually appear as non-questi onable or non-problemati zed, as if they composed the reality by excellence. Therefore, everyday living becomes covered, distorted: this covering and distorti on occur by means of a unique mechanism, characteristi c of the dominant ideology, which naturalizes what is social, universalizes what is parti cular, and makes ti meless that which is historical. Through this mysti fying process, everyday life consists of a natural, universal, eternal and unchangeable order (7) . Hence, the operati ve group technique, whatever its objecti ves (learning, insti tuti onal diagnosis, planning, etc.), has the purpose to teach its members to think about a co-parti cipati on of the object of knowledge, understanding that thought and knowledge are not individual facts, but social producti ons (6) .
The operati ve group is founded on the idea that the process to achieve the task results in learning, i.e., making an analyti cal reading of the reality. Learning means a process that permits the subject involved in the task to change so as to increase the individual and group capacity to understand the reality and create the means to change it. Therefore, the operati ve group is not centered on people or on the group, rather, it is centered on the process of including the subject in the group (6) .
A revitalizati on of Pichon-Rivière's framework should be performed in issues related to working in the health fi eld, thus permitti ng to constantly rethink and, essenti ally, recreate the practi ce, as an analyti cal and creati ve subject who can, together, change everyday reality. Considering that the thought of analyti cal and creati ve subjects is one of the main issues addressed in Nursing today, in view of the new proposed curricular guidelines (8) , this approach can be an additi onal possibility to seek changes in the practi ce of nursing management, with a view to bringing relati onships to a horizontal level.

METHOD
This qualitati ve, exploratory-descripti ve study was founded on the research-acti on method (9) and performed at the adult pati ents hospitalizati on unit at Hospital de Clínicas de Porto Alegre (HCPA). HCPA is one of the hospitals of the Ministry of Educati on network of university hospitals and has an academic partnership with Universidade Federal do Rio Grande do Sul (UFRGS). The HCPA has 750 beds, and provides health care in 62 specialist areas. Most users are from the nati onal public health system (SUS), and live in Porto Alegre, the metropolitan region, and the interior of Rio Grande do Sul (10) .
The hospitalizati on unit where the data were collected has 45 beds, distributed among 15 wards (three beds each), and is characterized by the hospitalizati on of adult pati ents. The nursing team is comprised by 45 professionals: 36 nursing auxiliaries and nine nurses, working the morning, aft ernoon, night, intermediate (5pm to11:15pm) shift s, and sixth shift (daily 12h shift s on weekends and holidays).
Data collecti on was collected in two phases. The fi rst took place in June 2008 and consisted of applying a questi onnaire with semi-structured open-answer questi ons with the objecti ve to survey the parti cipants' overall percepti ons about the nursing team's group work. Parti cipants fi lled out the questi onnaire individually during their work shift and placed their answered questi onnaire in a collector box at the unit. The inclusion criteria used were: being a member of the nursing team, volunteer to parti cipate and be interested in discussion on the theme. The exclusion criteria were: being away from work for diff erent reasons such as holidays and other leaves. Hence, of the total 45 nursing workers, the study counted with 33 respondents, as 12 workers were excluded for being on holiday and/or other leaves. The second stage occurred from August to October 2008, by means of a Focal Group, with a total fi ve meeti ngs, each with a mean durati on of one hour and parti cipati on seven subjects. The inclusion criteria were: the subject's interest on the theme and his or her availability to parti cipate in the meeti ngs.
Due to an experience that the workers had at the unit, the group of nursing auxiliaries mobilized some concerns at the enrollment, which resulted in only two parti cipants from this professional category. However, logisti c issues demanded a change in the group compositi on. Among them was the diffi culty to cover nursing auxiliaries who would need to be absent to their work shift in order to parti cipate in the focal group, as well as the data collecti on period, which was a period with many holiday and other leaves, and the need of a previously established research schedule. Therefore, the research group was comprised exclusively by nurses from the unit.
The sessions were tape recorded and transcribed in full by the researcher. The coordinati on team consisted of the debate moderator (master's student) and the parti cipant-observer. The latt er, besides being part of the same research center (NEGE), has previous work experience with the focus groups technique.
The informati on obtained with the questi onnaires was analyzed as follows: for the results regarding the closed-questi ons, descripti ve stati sti cs was used; the informati on was arranged in tables so as to check the frequency of each answer, expressed in absolute and percentage values. The results to the semi-structured interviews, on the other hand, were classifi ed according to content similarity, and grouped in pre-categories, using themati c analysis as framework (11) . The results obtained with the semi-structured questi onnaire provided the necessary support to create the manual with the themes to guide the Focal Group sessions. Also, the source of informati on generated in the Focal Group was also submitted to themati c analysis.
As to the ethical aspects, this study complied with all recommendati ons of the Nati onal Health Council Resoluti on 196/96 (12) . The study was only initi ated aft er being approved by the Scienti fi c Commission and Research Ethics Committ ee at Hospital de Clínicas de Porto Alegre, (protocol 08-116). In the fi rst data collecti on stage, each parti cipant received an Explanati on Sheet with the Questi onnaire. The Questi onnaires were collected using a collector box, without any identi fi cati on of the respondents. Prior to the Focal Group meeti ng, parti cipants provided writt en consent.

RESULTS AND DISCUSSION
The results to the closed-questi ons permitt ed a brief categorizati on of the 33 parti cipants while nursing professionals working at the unit, the fi eld of study. It was found that most were female (68%) of age between 41 and 50 years (34%). As to their ti me working, it was observed that most (43%) have worked as nurses for over 15 years, and none of the subjects reported having worked with nursing for less than fi ve years. It was also found that most parti cipants (60%) have worked at HCPA for more than fi ve years, and that 54% of them are members of the nursing team at the studied unit also for over fi ve years. The results obtained with the open semi-structured questi ons provided clues about the percepti on that team members had about the group process of which they are part, and were grouped in four themati c lines: concepti on of group work, facilitati ng/hindrance aspects of the group process, criti cal nodes in the group process and strategies to create group work. These themati c lines, extracted from the analysis of the questi onnaires, comprised the triggers for the discussions in the Focal Group.
The results of the focal group were combined into four themati c categories: concepti on of group work; communicati on as the central aspect that facilitates/hinders the group process; the distancing between professional categories as the main criti cal node in the group process; and strategies to create group work. This arti cle analyzed and discusses on the data referring to the concepti on of group work category. The illustrati ve statements of the debates in the focal group are identi fi ed as P1 (Parti cipant 1), P2 (Parti cipant 2) and so forth.

Concepti on of group work
Based on the guiding questi on what do you understand by group work?, the debate was initi ated and the parti cipants of the focal group, aft er thinking for a few minutes, suggested that group work is having a common goal: [...] for me it's having a common goal, working with several people, but always with a common goal (P1).
[...] we work for the purpose of the patient (P7).
The group concept gives the idea that a group of people who share a goal, who work and organize through their relati onship (6) . Considering Pichon-Rivière's framework, the meaning of a common objecti ve relates with the concept of task, which consists in the group, itself, addressing and elaborati ng its current concerns.
With the objecti ve to improve the discussion, other nurses stated that the concept of group work pervades and idea of cooperati on and is associated with the combinati on of acti ons: I think that group work is a matter of cooperation (P3). I think it is more than cooperation [...] you can cooperate when you can think or follow the same direction as your colleague (P1).
In Pichon-Rivière's framework, cooperati on is understood as one of the six indicators used to evaluate the group process. Cooperati on is established in view of a group elaborati on of the obstacles, which contributes to achieve the group task (6) . In this process, it is necessary to combine the individual and group needs. This oft en re- sults in competi ti on, which has the objecti ve to impede the other's acti ons, and, instead of being complementary to each other, one tries to take over the other's positi on. In this regard, it was stated in the discussion that group work means being able to deal with situati ons involving competi ti on. This fact was observed and pointed out by one of the nurses: The competi ti on environment that is referred in the statement, made evident by subtle everyday disputes between team members at work, might be a consequence of reiterati ve practi ces such as the inheritance and tribute to neo-liberal models. Thinking about the competi ti ve environment of nursing, competi ti on may be directly related to the work overload, the lack of bett er salaries and the large demand of services for an insuffi cient number of professionals (13) . This can be explained because, by being a part of the current capitalist producti on model, people strive to produce more in less ti me, focusing on the technical aspect and on the constant search for producti vity.
In the group, people are permanently interacti ng (14)(15)(16) , in a way that individual and group goals change over ti me, and, therefore, the groups must constantly talk about them. On this issue, one nurse stated: [...] work has a different meaning for each person, some are here because they enjoy it, others because they think it's a good job, others because it's a source of income (P1).
According to the subjects, the group work concepti on is also related to the way that work is perceived by those involved.
It is understood that the meaning of work is present throughout the process -from beginning to end (17) . When the purpose of the work is lost, the consequence is alienati on. In this situati on, the professional starts working without being able to understand the importance of his/ her acti viti es and their role in the process as a whole.
Therefore, it is understood that the subject changes from groupality to seriality, compromising the indicators of connecti on and belonging. In the dialecti c interrelati ons that occur within a group, groupality is perceived as a horizontal movement, in which the individual becomes part of a history that has been constructed as a group. Seriality, on the other hand, is understood as a verti cal movement that covers the individual's personal history, with his/her inner representati ons, transferences and projecti ons (18) .
Belonging is characterized by the feeling of being part of a group, of identi fying yourself with it, of including yourself and others in your inner world. It is through belonging that the identi ty of the group and the individual is established (6) .
Shortly aft er, moti vated by the ongoing debate, another nurse complemented, pointi ng at another important item of group work: [...] and when you don't know the person, you don't realize that she's going through problems (P3).
In fact, the knowledge and closeness between group members is a diff erenti al when analyzing the group process, and in the view of the groups, emphasis is on the sense of inclusion, appreciati on, and identi fi cati on among members (19) . As a metaphor, the consti tuti on of a group is compared to a gallery of mirrors, where each member can refl ect and be refl ect on and by others, so as to emerge the discriminati on, affi rmati on and consolidati on of their own identi ti es. A relati onship is, therefore, established, in which each individual feels welcomed and the conditi on of the other refl ects on his or her own conditi on. The basis that supports and strengthens the relati onships is, thus, constructed, and the experiences become learning (20)(21) .
When a person is able to understand him or herself and knows that it is possible to be aff ected by the other's behavior, they become aware that their own behavior can aff ect others (16) . This phenomenon of approximati on and/ or distancing between some group members is known as tele, which consists of the capacity or will that each of us have to work with other people (6) . A negati ve tele is the measurement of the diffi culti es that each person has in working with others, of the rejecti on; positi ve tele consists of the possibility that the individual has of working with others, of accepti ng others (6) . The positi ve and negati ve teles will provide the aff ecti ve factors and aff ecti ve ambience, facilitati ng the task or becoming a hindrance. Therefore, the fi eld of work towards the task will become more favorable as the positi ve tele becomes more prominent (6) .
The form that the relati onships are established among colleagues in the team can aff ect the work outcome. The incapacity to work these diff erences eventually results in confl icts. However, confl icts are a part of life and of the managerial process. When diff erent people learn how to deal with their own diff erences, the confl ict becomes constructi ve. Therefore, confl icts are not considered something negati ve; rather, they are a chance for group development and improvement through a dialecti c process.

CONCLUSION
The team's everyday work is an important issue, as it is permeated with confl icti ng relati onships that oft en make group work, and, consequently, reaching common goals a mixture of percepti ons, in which diversity sets the tone.
The concepti on of group work is related to achieving common goals, pervading the ideas of cooperati on and the capacity to combine acti ons. To the members of the focal group, the inability to combine individual and group goals can oft en lead competi ti on among group members. In the discussions, the parti cipants implied they face some diffi culty to establish a common line of parti cipati on in terms of being able to work together on a task, avoiding acti on overlaps and fragmentati on.
The challenge of combining individual and group goals, according to the percepti on of the focal group parti cipants is linked to the meaning that work has for people. Working without a clear defi niti on of purpose leads to alienati on and, as a consequence, groupality changes into seriality, thus compromising the group indicators of connecti on and belonging. Since belonging is also an indicator of commitment, as relati onships grow stronger, the level of group operati on increases, i.e., its ability to achieve the proposed task.
Group work requires mutual respect, tolerance and pati ence, and one is dependent of the other to occur. However, these virtues are diffi cult to be adopted by people as they imply tolerati ng and dealing with diff erences. For the focal group parti cipants, the existence of group confl icts is directly related to the diffi culty to elaborate and respect those diff erences. However, confl icts are a part of life, of the managerial process, and are the center of every group. The problem of a confl ict is not its presence, but leaving it unsolved, i.e. o camoufl age. The moment people learn how to deal with their diff erences, as opposed to being destructi ve, a confl ict can become constructi ve and mediate more eff ecti ve relati onships.
Although the nursing profession usually implies working with groups of professionals, the undergraduate student is oft en unprepared to face the work market from that perspecti ve. Pichon-Rivière's framework emphasized on the constant need to learn to learn, however, what we observed in the everyday working day is that professionals seek learning through practi ce, among wrongs and rights, without being grounded on an appropriate theoreti cal foundati on. That originates the main impasses in professional life -regarding human relati onships and their complexiti es.
Knowledge and theoreti cal preparati on on the theme could improve the process of establishing strategies to develop group work. This would permit future health workers, since their undergraduate studies, to initi ate a refl exive process of understanding the main phenomena involving group environments, with the goal to become prepared for work with and in groups.
One study limitation consists on the impossibility to form the focal group by nurses and nursing auxiliaries together -as initially proposed. The joint participation of nurses and nursing auxiliaries in the focal group could provide a broader panorama about the group process.
We expect that the present study results will collaborate in the discussion and reflection about the group process in nursing teams, making emerge the questions about teamwork, communication and bonding. We understand that the knowledge about the group process must be shared, disseminated and discussed since undergraduate studies and maintained throughout one's entire professional career. Considering that after completing their graduation, professionals leave towards the work market, which, on the other hand, wants skilled professionals, there is a need for extensive investments in developing competencies in group coordination.
As one becomes able to recognize and identi fy the main indicators present in the group process, a fi rst step can be made towards solving the primary concerns and making personal changes in the relati onship that is established with the other(s). Therefore, through a process of self-knowledge, using resources such as experienti al groups and therapy support, when necessary, the team can be operati vely conducted, considering not only the outcomes, but mainly the pathway covered unti l achieving the task, aiming at group learning.