LA OCCURENCIA DEL CUIDADO DE "LO NOSOTROS" EN LOS MOVIMIENTOS Y ONDULACIONES DE LOS PROCESOS INTERACTIVOS EN EL AMBIENTE HOSPITALARIO

1 Article from the dissertation - The occurrence of the care "of us" in the movements and fluctuations of the interactive processes, presented to the Programa de Pos-Graduacao em Enfermagem (PEN) of the Universidade Federal de Santa Catarina (UFSC), in 2012. ABSTRACT: This study's objective was to understand how nursing and health professionals experience and signify the relationships in the care "of us" process, using Grounded Theory as its method. A total of 25 nursing and health workers from a university hospital, distributed into four sample groups, participated in the study. Data were collected through semi-structured interviews in March-July 2011. The contextualization of the institution and management form the context. The movements of human relations/interactions and the professionals' health are causal conditions, while the advance of technology and decline of human care and social life are intervenient conditions. The processed human relations/interactions of care are the strategies that cause the care "of us" to take place in the procedural circularity of care and being-cared-for. The professionals construct the care "of us" in their practice, understood as relational and procedural, in the movements and fluctuations of processes of human interactions. DESCRIPTORS: Nursing. Nursing care. Interpersonal interaction. Research in health services.


INTRODUCTION
The relationships of care, in their movements, present multiple and interlinked dimensions, arising from complex living.These are subjective and plural relationships which are also unique to the human experience, and which involve, besides the forming of mutual bonds and exchange, conflicts, disturbances, and animosities inherent to the collective relationships. 1 In the intersubjective relationships established between health professionals, each one places a little of herself, shows her way of acting, and influences the other either positively or negatively. 2 Understanding these relationships requires one to recognize the peculiarities inherent to the subjectivity of those involved, the multiplicity of possible interpretations by the human mind, and the distinct phenomena which occur in the environment of interaction, and which permeate the actions of care. 3he environment, the people, the working conditions and the institutional infrastructure, among other aspects, can influence the relationships of care which take place in the multifaceted and dynamic hospital space. 4The relationships established may also be influenced by the multiple inter-relationships with other beings, through the exchanges and through the multiple aspects which involve each being, whether biological, social, cultural, psychological and/or economic. 5he care as a way of being and doing has been addressed in various studies, hence it assumes different shapes in the history of nursing as a profession.The theme of caring/being-cared-for deserves a broader understanding in the light of new references 6 and -why not -deserves new focuses, such as the care "of us", to be understood through/ in the interactions established between the beings involved in the process of caring/being-cared-for.
In the light of the above, the study was guided by the following investigation question: how do the nursing and health professionals experience and signify the relationships in the process of care "of us"?As a result, this study aimed to understand how the nursing and health professionals experience and signify the relationships in the process of care "of us".

METHODOLOGY
This is a qualitative study using Grounded Theory (GT) as its methodological reference 7 and Complexity Theory as its theoretical reference. 5e scenario investigated was a university hospital located in the southern region of Brazil.A total of 25 subjects participated, who were divided into four sample groups.The first group was made up of six nursing professionals from a surgical care unit (open unit), who indicated the forming of the second group, made up of five professionals from the multi-professional team (a psychologist, a physician, a nurse, a pharmacist and a nutritionist) from this unit.With a view to comparing data and confirming hypotheses, the third group was made up of 11 Nursing and Health professionals (nurses, nursing technicians, physicians, a psychologist, a speech and language therapist and a social worker) from an intensive care unit (closed unit).
The phenomena were compared and the hypotheses confirmed, so that it would be possible to obtain data saturation through the formation of a fourth sample group, made up of three directors of the hospital (the general board, nursing management and welfare support management).In order to maintain anonymity, the participants were identified by the letter P representing Participant, followed by an ordinal number corresponding to their order of participation (P1, P2... P25).
The data were collected in March-July, 2011, through individual, semistructured interviews digitally recorded for the recording of the accounts.The interviews were provided by the participants following explanation of the study objective and signing of the terms of free and informed consent.The study began with the following question: tell me about the meaning of the care "of us" based on your experience of care in the hospital environment.Other questions were directed according to the interviewees' responses and hypotheses raised from previous interviews.
The process of collection and analysis was guided by theoretical sampling, as stipulated in GT.The codes were grouped and the categories and subcategories defined in terms of their properties and dimensions, following the process of open, axial and selective coding.In the open coding, words and phrases were analyzed, line by line, so as to form the preliminary codes.In the axial coding, the codes were grouped so as to constitute the categories and subcategories which, when related between themselves, provided explanations regarding the phenomenon studied as well as its properties and dimensions.In the selective coding, there was the integration and the refining of the categories, for the identification, based on the categories and systematic relationships of the same, of the central category or phenomenon of the study.The analytical process was constructed in the paradigmatic perspective, based on five components (context, cause, intervenient condition, strategies and consequences). 7ght categories and 26 subcategories emerged from the analytical process, which, interrelated, support the central phenomenon.The Theoretical Model was validated in accordance with the return to the raw data and by two researchers who were experts in the method.

RESULTS
The phenomenon of "The Occurrence of the Care "of Us" in other Movements and Fluctuations of the Interactive Processes" is made up of eight categories and their subcategories, organized in five components, in accordance with the paradigmatic model, 6 whose graphic presentation is available in Figure 1.The context in which the phenomenon takes place is presented by the categories "Knowing the institution" and "Signifying the management".The institution studied is a public hospital where teaching, care, research and extension courses take place, funded by the Government, linked to a high visibility university.As they belong to a teaching hospital, the professionals are in a constant state of learning and intellectual growth, which favors the care "of us".
The professional training, qualification and improvement are made possible and continuously encouraged.As a consequence, the professionals, in improving their knowledges and practices, contribute to the unit in which they are found and to the institutional whole for the care "of us".Currently, the institution has medical residency, multi-professional integrated residency in health, and the professional Master's degree in Nursing, an important contribution in the process of work for the care "of us".This favors the interprofessional interactions for teamwork.Due to the link with the university, the professionals have been favored through the training in health at the lato and stricto sensu levels, whose results from this training contribute to the quality of the services in their area/unit where they work, promoting the care when they benefit the context and the multiple subjects involved.
[...] because it is a teaching hospital, there is always training geared towards the care "of us", in the intellectual sense, always keeping us informed and up-to-date [...] the care "of us" is knowing that we are in a constant process of learning (P12).
The inpatient units (work environments) are understood as micro-spaces which, when inserted in an institutional macro-space, relate with multiple support services for their functioning, where multiple professionals pass and interact, a multiplicity "of us", who care and are cared for.In these places, the professional intercommunication occurs between the different areas.The same is considered a care "of us" when healthy and efficient, that is, when the communication processed through writing, speech or body language clearly communicates with the collective involved, especially for the benefit of the patient.Nevertheless, it is identified that the information of collective interest needs to be well communicated, as it has not reached all of those involved.The communication between the professionals of the multi-professional team, between the different areas/departments and between the nurses themselves also indicates failures, as does the communication between the professionals of the referral institution with those of the counter referral institution.
[...] there is not enough organization for the information to occur better… Sometimes, they send a communication in writing… They put it on a board… (P3).
In the process of the management of the institutional micro-and macro-space, the circularity of the processes of caring/being-cared-for occurs with the members who lead and with those who are led, and the perspective that if a director has an attitude of care for the directly subordinate management, consequently the management will care for the worker who is subordinate to it, who will return the care to her leaders or colleagues directly or indirectly, in a circular action or reaction of care.
The management actions of the institutional micro-and macro-space are articulated and closely associated, integrated and related, with the conducts held in a micro-space influencing other micro-spaces and altering the dynamic and the movements in the institutional macro space, and vice versa; leading to random and circular movements of action and reaction of care between the leaders and the led.Nevertheless, the institutional management actions for the care "of us" can be intensified, given that they are perceived in isolated and fragmented movements, which do not always reach all of the subjects.
The managers are elected by their own peers, whose function is permeated with administrative and bureaucratic responsibilities.The general management is principally concerned with the institution's sustainability, also with a view to the care "of us".The managers of the area seek as a priority to maintain the full functioning of the units for which they are responsible, so as to ensure both an appropriate physical environment and sufficient human resources for the work.On the other hand, the management of the unit pay attention to the work team itself, its relationships and interactions, so as to mediate conflicts arising from the relational movements and processes.
Play actions and activities are identified, referent to the management of human resources, which aim to integrate, associate and bring together people; and to care for the individuals and the work group.Such actions are commonly promoted by nurses, such as the undertaking of "secret Santa" activities, group dynamics and fraternization.There is also the Dawn Project (Projeto Amanhecer), a Nursing initiative, which makes use of integrative and complementary practices -the use of traditional and complementary alternative medicines -for the care of the institution's workers.
Improvement in the communication… The people come to work feeling lighter… It makes the atmosphere genuinely more tranquil for working (P14).
In this context, the interactions which are established in the institutional arena are agitated by the order/disorder/organization inherent in a complex environment such as that of the hospital, where multiple people, in their uniquenesses and pluralities, autonomies and dependencies interrelate, retro-act, are cared for and produce care.In the movements and fluctuations of the relationships between workers and managers, one can make out contradictions which oscillate between satisfaction and dissatisfaction, conflicts and harmonious relationships, discourses and practices which sometimes indicate results which are more negative than positive, which require improvement in order to meet the expectations of the care "of us".
The categories "Perceiving the movements and fluctuations of the human relationships and interactions" and "Signifying the health of the nursing professional" trigger the phenomena.The human relationships and interactions, in their movements and fluctuations, are permeated by attitudes and actions of care, but also by conflicts intermediated by the subjectivity of each individual, which are organized/ disorganized and confer balance/imbalance upon the human and professional relationships established.
Based on attitudes, actions and conditions created in the relational environment, the human being contributes to the success of the relationships/ interactions/associations of care, or, contradictorily, creates a space of weak and unstable relationships.Availability, solidarity, trust, participation, attention, collaboration, respect, teamwork, positive leadership, companionship, optimism, motivation, maturity, punctuality, listening and hoping are attitudes, actions and conditions which strengthen the human relationships and interactions.They also favor the work process and, consequently, the care "of us" in the workspace.
Care "of us" is taking care of the relationships, above all… They are based in objective, practical issues, but are intermediaries for the subjectivity of each one… They involve multiple persons… and suggest conflictual relationships (P17).
The care "of us" is manifested linked to the professionals' ethical acting, being based upon actions, attitudes and behaviors, premises of the profession (professional ethics) and of the morality which constitute the society and culture in which they live.On the other hand, in the field of the Biological Sciences and the Health Sciences, bioethics contemplates the care "of us" through indicating possibilities for safe, humane and care-based decisions regarding the life and living of the other.
Physical and mental health confers conditions for caring for the other, others and "of us".However, the undertaking of physical effort in the care for patients, and coexisting with diseases and ill people, peculiar to the hospital environment, are responsible for the manifestation of physical and psychic illnesses in the nursing professionals, which require preventing.The multiple actions of the professionals are also related to health disorders, which are conditioned by working a double or triple shift, explained by financial necessity; as well as the parallel commitments to undergraduate or postgraduate studies.
These situations signal that health -not just physical or mental, but of all the dimensions of the professional's life -depends on one's own actions for the care of oneself, which also integrates and depends on actions of care deriving from other beings of interaction, which permit the conditions necessary for a broader care of the nursing professional's health, as it involves each one and all the subjects, each institutional micro-and macro-space, imbued with responsibilities and feelings of belonging through the healthcare of the I and of the other, through the individual health and of the institutional collective, whether this is based on studies or on experiences.
The intervenient conditions, which negatively influence the phenomenon, are presented in the categories "Facing the advance of technology and the decline of human care" and "Signifying living in a modern/postmodern/globalized society".The presence of technological innovation in health materials, instruments and equipment has had an effect on safety, the maintenance of life and on the survival of patients, and has also facilitated the work process of the health professionals.This fact occurs through qualification in the technical work, as it allows safe procedures and care which converge for a care "of us".In the counterflow of this movement, at the same time as the technologies advance, the human care of the professionals for the patients declines.Hence, weaknesses and neglected points are identified in the healthcare, which can cease to process the care, as the accounts below indicate.

I can see the speeding up of the processes through the technologies (P14).
The technology helps a lot… The pacemaker, for example, has really helped regarding peoples' health and survival (P3).
[...] people come here to work, but they don't want to care (P1).
[...] they repeatedly fit the patient in for surgery when another patient is cancelled.This affects the person quite a lot, based on how she is prepared for that mo-ment… they suspend this slot, sometimes, for up to four days consecutively.They leave the patient for an entire day without eating... (P5).
[...] calling people by number, or by case: 'Four hundred and five'... 'The vesicle which is there', 'the gastric cancer is in number such and such' (P11).
It is identified that the care "of us" is strongly related to living in a modern society and, at the same time, postmodern or contemporary and globalized -or, rather, attuned to the more global ambit.The social, cultural, spiritual, economic and technological aspects, among others, are, at the same time, causes and causers of changes and transformations, whose acts, attitudes and behaviors of the professionals change and cause to change the relationships constituted in the micro-and macro spaces of interactions, whether in the hospital environment in which they work, in their homes, or in the spaces in which they coexist with other people, understood as conditions which intervene for the care "of us" to take place or not.Thus, due to occurring in the relationship/interaction/integration between one and the multiple dimensions of the professionals' lives, between one and all of the heterogenous elements which constitute their lives, the care "of us" as a complex phenomenon associates with and is integrated into the way of life of the professionals who have in themselves the characteristics of a modern/ postmodern/contemporary/globalized society.
I think that this modernization has caused some people to seek situations which are more stressful (P2).
[...] there are always two sides: there is the good side of this acceleration, of this globalization, and also there will always be the losses (P14).
The category "Processing the care "of us" in the human relationships and interactions" represents the actions/strategies for the achieving of the phenomenon.The care "of us" is understood as relational and procedural, as it involves multiple relationships and interactive processes between individuals, in a specified context, whose relationships are maximized by: affinity, coexistence and physical and temporal proximity established between the subjects.These, consequently, lead to a relationship of intimacy, of exchange, of dialogue and of mutual help, as well as assisting in constituting affective links.As the interactive process occurs through human interaction, the same is in constant growth, movement and change based on the entrances, exits and exchanges between the different subjects.These relationships are made up of the expectations of some in relation to the others, of weaknesses and failures inherent to the beings themselves.
In the relational process, the care "of us" happens based on simple actions and attitudes of care between the professionals, in the inter-group coexis-tence, such as the presence, listening, attention, smile, praise, empathy, embracement, respect, valorization, availability, concern and interest which one manifests in relation to the other.Manifestations of tenderness, zeal, warmth and solidarity are peculiar and understood as personal characteristics which are summed up in the care processed for the people who pass through and relate in the workspace and care space.
[...] when you can respect, value and care… in the little things (P7).
The care "of us" is related to the collective care.It means thinking in the plural, and the care of multiple persons or groups of persons; it also means caring beyond the I, others, various others, being an active participant in the constituted relationships; of thinking about the others, about the well-being and the care of all those involved and members of a same social group, but with distinct and specific characteristics.The care "of us" in the collective dimension relates a multiplicity of subjects of interactions who interact in the hospital environment and also outside it, whose interpersonal relationships with the various "us" are woven in the subjectivity and uniqueness of the beings, based on how each subject perceives the the other's particular needs, and the needs of the various others who make up the attendance of what is essential for the care "of us".
It is a collective construction, and everybody, with specific characteristics, is important in this process (P17).
"Of us", is us, the group, everybody who is in contact (P21).
[...] this collective us… goes beyond the professional, the patient and the patient's family…, it also involves the professional's relationships outside the work environment (P18). [

...] we cannot think only of ourselves, only of our well-being, because we care for another human being, we coexist with another human being, so we have to think of the collective well-being (P5).
The hospital care aims for the care of the patient, who brings with him his family members and close persons.The relationship and the interaction of care for the patients and their family members constitute an important meaning for the professionals and are permeated with care, tenderness, concern, embracement, sensitivity, respect, reciprocity, empathy and touch.The interaction of care between the professionals, patients and family members has characteristics of goodness, generosity, solidarity and spirituality.Therefore, it represents the nobility of the human attitudes and actions in the relationships of care "of us".
The category "identifying the care "of us" in the procedural circularity of care and beingcared-for" reveals the consequences which shape the phenomenon.In caring, the professionals feel themselves to be cared for and pay back the care they have received.It is possible to understand that care for the other first implies the undertaking of the care for oneself by the professional.However, caring for the other, through the exchanges deriving from the interaction with this other, brings us back to the care of oneself undertaken by the professional as a being of care.It is identified that at the time in which they care for themselves and the other, the professionals feel the care deriving from the multiple interactions constituted in the space/environment of work and of care, with various others, whether these be patients, family members, their own peers, or other professionals who integrate and circulate in the same space/environment.Hence, the professionals care and feel themselves to be cared for in the procedural circularity of the care, shaping the care "of us".

Care 'of us', I think it integrates us… It is being alert to ourselves, to be perceiving, besides the care of others, this care of ourselves, 'of us'. (P17).
The family occupies a salient position in the process of care of the health and nursing professionals, whose values learned in the body of the family are brought to the relationships constituted with other people (colleagues and friends).The family is the structure which strengthens the professionals for the necessary confrontations which arise in the process of living, whether in personal or professional life.In the circularity of the processes of care and being-cared-for, the family is cared for and a caregiver.
[...] this concern with the us… I think it is a thing which comes from your family (P10).
In the process of caring, the professionals from the multi-professional team perceive the nursing professional as a professional who cares "for us", as in addition to providing the holistic care, she spends more time with, and has greater involvement with the patients; this professional interlinks the patients with the multiple health professionals (physicians, psychologists, social workers, speech and language therapist) who are found in the care space.In the process of caring, the nurse is the articulator, the facilitator and the organizer of the care and the health in the patient, professional and institution triad.As well as being responsible for the care for herself and for her work team, being the vision of all and of the complexity which permeates the environment and the people, fundamental for the care "of us" to be processed.
[...] it is the technician and the nurse who are most present in the ward the whole time (P8).

DISCUSSION
The interactions constitute the essential point of the care, being the object-product of the human actions which, established through communication, make the development of the relationships and interactions possible. 3,9Verbal and nonverbal communication are a fundamental basis for the interpersonal relationships. 10It is impossible that the nurse cares, the doctor cures, the physiotherapist rehabilitates, the psychologist understands and counsels or that one should undertake any other action in the care for the human being without using communication skills. 11Nonverbal communication is necessary and important for the intersubjective interactions.It can complete, contradict or substitute verbal communication 10 in the relationships of care with patients, family members and professionals.] In the work environment, in the movements and fluctuations of the human relationships and interactions, the occurrence of conflicts is common, 1,3,[14][15] deriving from the movements and fluctuations which are intrinsic to the complexity, which in the order/disorder self organize so as to confer a new state of equilibrium. 5The order/disorder of the conflicts is mediated by the ethics of the relationships and the care occurs in the interaction between the individuals when it indicates ethical attitudes based in the opening of dialogue as between equals. 3he dialogical interaction allows one to establish and reach common objectives; it leads to the exchanging of experiences and knowledges, moments of reflection, the sharing of ideas and decisions and, hence, culminates in the mutual enrichment and transformation of those involved.
The work in the public hospitals is complex and demanding and can easily produce the interpersonal conflicts which provoke wearing of the trust and respect in the relationship between staff and professionals with management positions.For this reason, in a practical perspective, the management can strengthen the ethical dimension of the relationship with their subordinates, 16 so as to ensure the harmony of the relationships which do not depend upon the hierarchy.
The participation in the choice of the managers mobilizes the professionals for the definition of their leaderships.However, it is hoped that the manager should be a leader and be able to integrate technical and administrative knowledges in a concrete practice which allies the rational and humane.The exercising of leadership, although complex, is inherent to the organization of the work and has repercussions in the articulation of the teams, 17 in the processes which require actions of care with those who are led and behaviors which are appropriate to resolving relational problems and technical problems every time these appear.
It is a challenge for management in health to meet the need for care of a collectivity and to seek the commitment of the health professionals in the perspective of establishing interaction and articulating actions with views to the holistic care in the hospital environment.In this regard, one can identify the possibility for investments in actions to meet the care needs, both of the ill people and their family members, and of the workers. 13he perspective of actions of care which meet the needs of a collectivity is part of a broader social context in which the hospital aims to help the patient to recover, and the primary care centers to aim for the continuity of the care with a view to health promotion. 13The healthy interaction between the health professionals in the different levels of complexity is one path for the care in the collective dimension -"of us".
The Multi-professional Integrated Residency in Health instituted in the scenario studied is able to overcome fragmented care through directing actions in health through teamwork.In this regard, the perspective of interprofessionality allows the professionals the understanding that holistic care is constructed based on complementarity and interdependence of the health actions, 13 intermediated by the multiple interdisciplinary interactions, which favors the care "of us".
The play activities promoted by nursing are understood as instruments of interaction, whose purposes are: to favor the meeting between people, the establishing of links and the minimization of isolation and of emotional stress, as well as avoiding the affective distancing 3 to which contemporary society predisposes people.
The working day and the accelerated work rhythm, as well as the salary, are factors in the workers' life which are related to these professionals' state of physical and mental health.The working day and the work rhythm are intensified when the worker has other employment links.9][20] However, the strain arising from social relationships at work can have a greater impact on the workers' life than that arising from the nature of the work. 19In this way, the intervention regarding the conditions which provoke strain in the worker can raise the quality of the care, of the worker's health, and of the interpersonal relationships in the work.
Currently, one is facing the advance of technologies and the decline of human care, in which the challenge for the nursing and health professionals in the health institutions is associated with the technological demands incorporated into the professions' routine, and with the use of relationships as a form of care technology.The objective is to value equally the needs of the beings being cared for and the subject who works. 3 In a context of changes which affect the collective, important and significant transformations in the institutions of the family and of marriage, in sexuality, in gender roles, and personal identity, in work and in religion have affected peoples' behavior and influenced traditions, customs and the way in which subjects' relationships and roles are configured in society, 21 influencing in some way the care "of us".
In the dimension of human care, the care "of us" leads to concern with the collective and relates to the understanding of the multiple and inexhaustible phenomena of the constant movement of interaction among the beings, and of these with the environments in which they are inserted, modifying, altering and causing to alter the networks of existing relationships of care.These relationships correspond to the complexity which permeates human coexistence.They are subjective, plural and unique to the human experience and involve the forming of links and mutual exchanges which positively attend to the individual and/or collective expectations. 1t is understood that beings depend on each other for their personal and professional care, in a constructive and creative relational process.In approaching complexity, in any context in which care is processed, the caregiver must, above all, prior to providing care to another, care for herself in her systemicity/totality.The search is for the integration of the multiple dimensions of care in order to achieve relative harmony between the care for oneself and the care for the other, 22 such that, while one cares, one cares for oneself and feels oneself to be cared for by others in a circular movement of care which shapes the care "of us".
Healthcare requires concern, knowledge and, mainly, dedication to one's fellow man and to oneself; this being the case, professionals and studies 1,22 confirm that, among health professionals, it is the nursing professionals who most possess the conditions to provide, encourage and facilitate an environment of care for clients, family members, and the multi-professional team.The objectives are to interconnect and strengthen the bonds of relationships between these different subjects.In these relationships, the care "of us" is manifested by the professionals in their commitment to care for the other human being, and for the patients and family due to the satisfaction of the human care needs met by the health professionals, a satisfaction which is strongly related to the quality of the nursing care. 23

CONCLUSIONS
In the movements and fluctuations in the human relationships and interactions in the hospital environment, the nursing professionals and health professionals construct, in their care practice, a set of meanings which are shaped in a structure of reference of the mutually collective care process, the care "of us".This takes place in the circularity of the processes of caring, being cared for, and feeling oneself to be cared for.It is understood as relational, procedural and animated by constant movements and fluctuations arising from the interactive processes in and outside the hospital environment.It has a strong relationship with living in a modern/ postmodern/globalized society.
As a limitation of the study, we can indicate the treatment of a complex theme which involves a multiplicity of concepts and meanings explored in only one context, which can and must be explored in depth in other social and health-related environments.However, it is considered to be important as it awakens the attention of those who care and are cared for regarding the care "of us", a theme which is current, emerging and relevant in the contemporary world.

Figure 1 -
Figure 1-Diagram of the phenomenon of the study 8he project's undertaking was approved by the Committee for Ethics in Research with Human Beings of the Universidade Federal de Santa Catarina, under n.860/2010.The ethical aspects were respected in all the stages of the study, as stipulated by Resolution N. 196/96, of the Brazilian National Health Council.8