GROUP THERAPY WITH NURSING STUDENTS DURING THE THEORY-PRACTICE TRANSITION

O objetivo do estudo foi verificar se a intervenção de grupo de curto prazo pode proporcionar às estudantes de enfermagem meios de lidarem com o estresse, próprio da transição do aprendizado teórico para o prático. Utilizou-se a observação participante como método, possibilitando que 12 alunas que cursaram a disciplina de Fundamentos II expressassem suas ansiedades e angústias frente ao novo e futuro papel de cuidadoras da saúde de outros. A técnica grupal aparece como um instrumento a ser considerado pelas instituições de ensino superior de enfermagem como recurso não apenas de apoio, mas também didático, em seus currículos. No momento em que são discutidas reformas do ensino, é importante lembrar que qualquer mudança planejada não será somente técnica, mas terá efeitos no ser humano.


INTRODUCTION
Undergraduate courses in health have accompanied the changes occurred in education, which underlie higher education institutions' curricular guidelines.Education and health are knowledge production and usage areas destined for human development.Moreover, knowledge accumulation and the consequent need for updating require professional training to turn into a continuous process, not only to acquire technical skills, but also to develop potentials in the labor world and in the social environment (1) .Some experts interested in nursing students' academic and professional training suggest that the school should understand the meaning of the first clinical experiences for students, as well as the relation established with the teacher, mainly when the latter does not make room for joint reflection in a situation of pain or death for example.On the opposite, the teacher frequently closes himself off, creating an image of insensitivity and coldness that impairs the students' human and professional growth (2) .
It was observed that, when students are put in contact with practical learning to develop certain procedures they learned in theoretical classes, they display insecurity and fear, and can even manifest signs of stress.Anxious reactions occur, also because they are accustomed neither to the specific procedures clinical practice requires nor to the speed needed to execute techniques.Moreover, they are not prepared to deal with the emotions aroused by potential risks the client is exposed to (3) .
Groups have been used for a long time to relieve and treat somatic and mental disorders (going back to Antiquity) and emerged before the known group dynamics theories.The group can be understood as "a set of people in an interactive action with shared objectives" (4) .Therefore, in order to constitute a group, its members need to develop an interactive action, that is, the relational aspect needs to be present.As a result, the person can become more spontaneous, objective and realistic, revealing to be less dependent on the other (5) .
Group psychotherapy practice itself was developed in the first half of the 20 th century and has grown in Brazilian reality as a treatment resource in different care contexts (4,(6)(7) .The therapeutic group favors the exploration of subjectivity by acting as a "social laboratory", in which the participants reproduce the roles they play in their daily lives (6) .When the group consists of a specific population, with similar characteristics, this facilitates "the identification, the revelation of particularities and intimacies, the offering of support to peers, the development of a common goal and the solution of similar difficulties and challenges" (7) .
Goals are of considerable importance to classify groups (8)(9) .One group activity that is based on its goal is considered within the classification of psychotherapies as "short groups" or "short-term group psychotherapy" or simply "short psychotherapy" (10) .
Researchers in this area consider short psychotherapies as those characterized by a limited time, in function of a specific focus (8,10) .Hence, what defines a group as short is neither a minimum quantity of hours nor the task in itself, nor the theoretical framework that is used, but the proposal to respect the pre-established limit in function of the focus (4)   .
Therapists who use short-term approaches should therefore develop a planning, including clear objectives, and determine a work focus and clarity about the temporal limits of the group (8,10) .Moreover, structural and group development aspects need to be taken into account when establishing an approach, so as not to be subject to errors or failure while performing the task.
Just like individuals, groups are able to grow and develop.Within this logic, three stages were described: orientation, conflict and cohesion (11)   .These stages correspond to the so-called initial phase of group development (12) .This phase is characterized by participants' feelings of anxiety about being accepted by the group, about the establishment of standards and about the adoption of different roles.Besides the initial phase, two other group development phases are considered: the operational and the end phase (12) .
In the operational phase, the group assumes itself as a team, in which participants work quite a lot and responsibility for the group is divided in a more equal way.Anxiety becomes more intense, although members control and tolerate it better.Problems appear, such as the formation of subgroups, conflict, level of self-revelation and resistance.The end phase is addressed since the start of the group, but literature rarely discusses it as a defined phase (12) .
These phases can be imagined as a course the group follows to establish and conquer its objectives.It should be emphasized that the group's development, in turn, does not happen in isolation, that is, the different phases occur jointly.
In this study, short-term (short duration) group intervention was used to provide nursing students with ways of coping with the stress characteristic of the passage from theoretical to practical learning.

OBJECTIVE
To verify if short-term group intervention can provide nursing students with ways of coping with the stress characteristic of the transition from theoretical to practical learning.

METHOD
This study was based on the premises of qualitative research methods, using participant observation (13) .

Subjects and study site
The research was carried out with a group of It was also agreed upon that no new students would be admitted as from the third meeting, characterizing the group as closed.This has the advantage of consistent leadership, standards and expectations, without ignoring group affiliation (12) .It was explained verbally and in writing that, after three consecutive absences, the participant would be disconnected from the group.
Group meetings were held on a weekly basis during the first school semester of 2002 (March to June), taking 60 minutes each.In total, 16 meetings took place.
Permission was asked to use a camera.
Participants' statements were audio-taped, as this was the instrument that best recorded their voices (14) .The dialogues from the videotapes were transcribed and explored during supervision sessions, which were held weekly after each group meeting and coordinated by a psychiatrist graduated in group psychotherapy.This transcribed material was submitted to content analysis (13) for identification and group exploration, based on the group development phases (11)(12) .
At The transcribed material from the individual interviews was submitted to content analysis in order to capture thematic phrases (13) that characterized the students' perception of the group experience.

RESULTS AND DISCUSSION
Group participants were female and single.
Their ages ranged from 18 to 27 years, with an average age of 21 years.Fictional names are used here.
Group therapy with nursing students...  (15) .Despite the loss of three (25%) participants due to abandonment or disconnection, the group work could take place.
Figure 1 presents the study results for the characterization of each phase.

Initial phase
The initial phase is characterized by the participants' feelings of anxiety about being accepted by the group, about the establishment of standards and the adoption of roles (12) .In this study, meetings 1, 2, 3, 4, 5 and 6 corresponded to this phase.

(Meeting 5 -Conflict Stage)
This situation facilitated their reports about how they felt the impact of their own idealizations (desired) of teachers, the subject, training sites and about how they got frustrated when they were confronted with the real (something different from the desired).
Marina: They have the power, they are the teachers.

(Meeting 6 -Cohesion Stage)
Rules are inherent to any institution, but are not always welcome.They can be questioned, provided that this is done respectfully and using appropriate arguments.In the group experience presented here, one situation created conflict and clearly broke the group structure.A change in one activity date (meeting 6), decided by some participants, culminated in an absentee rate of more than 30 %.This situation was discussed during meeting 7, readdressing initial appointments.The participants considered this moment as a landmark, at which they positively learned how to live better with established principles.This learning was not restricted to those specific meetings, but, according to the students, it was extended to any other situation in which they would be confronted with standards in any other institution.

(Meeting 4 -Orientation Stage)
Marina: So, at that time, when we went to ask to postpone the group, it was high time, I had already asked the Immunology teacher and she really scorned us.Then I remembered that I had to warn you, that the girls and I could not come to the group, because we were going to distribute pamphlets and sell entry tickets to our party at the university restaurant.
Juliana: I was at the university restaurant, I ate quickly, then I was told that there wouldn't be any group today.I didn't miss it at that moment, but later it seemed that something was missing.
Coordinator: Can you perceive what happens when we change the time, the day, without any prevision?The group already has its own day.(At that moment they were talking about the party).

(Meeting 6 -Cohesion Stage)
The structuring of the setting is the search to organize themselves as people living in a group, who can produce something or allow something to "be" within a certain time frame.The fact that a group gets structured, organized, establishes its objectives, inevitably gives rise to authority (16) .Therefore, as soon as a group's spontaneous structuring process is started, a collective function appears, which is a power to regulate and control conducts.
Carol: We miss it when there's no group.
Marina: I think it's complicated here in the group (... (Meeting 5 -Conflict Stage) Operational phase In the second phase, according to literature (12) , the group is compared to a team, in which participants work a lot and responsibility is divided more equally.Anxiety becomes more intense, but members control and tolerate it better.Problems appear, such as the formation of subgroups, conflicts, level of self-revelation and resistance.
In this research, the students perceived that in group meetings as well as in the course, there were singularities, differences among teachers, students and the coordinator.This gave rise to the need to adapt to the new moment they experienced, including changes and transformations in their attitudes towards the course and the group.This movement includes the known and the unknown, progression and regression, success and failure.The need to adapt to "new things" the students commented on seems to be the manifestation that they perceived the changes they were going through in the interactions they establish with the university and with practical learning.
Change or transformation supposes that people want to face the new and intend to develop innovative skills to get involved with reality (17)   .
Simone: There's no dialogue out there.You The student or any other person "can only dedicate him-/herself to an activity if (s)he has a positive orientation towards it" (18) .Therefore, knowledge acquisition, participation in group activities, among others, require positive affective support.
Formal curricular activity does not necessarily have to be coercive in order to achieve its main objective, which is learning.The latter, in turn, can occur through the pleasure and joy it produces.The coordinator identified the conflict that emerged and let the group discuss the possible reasons involved, in an attempt to manage the conflict, believing that this could lead to each member's growth and to the group's growth as a single body.As the students were actively participating in group work, the coordinator now acts as a consultant, helping the group to keep its focus on its objective and trying to decrease the impact of anything that could turn back or delay the group's execution of the task.

End phase
The third phase, i.e. the end phase is addressed since the start of the group, but literature rarely discusses it as a defined period (12)   .During the last three meetings, the students assessed the changes that occurred in their behaviors as people "inside" and "outside" the group.They drew a parallel between the therapeutic group and the training group, concluding that they are complementary.The students revealed that they started the course and the group with prejudices and that they finished with a feeling of starting to walk alone.The students become more able to reflect on what they go through in a context of significant experiences.When perceiving their internal transformation, they become more secure and aware of their actions as trainees and future professionals (19) .
Nina: (...) The group was fundamental for us, like, to mitigate our suffering during training, during the first contact.

That history, what luggage we take to the training in order to
suffer less, what we leave in the closet.I think that was very important.The group feeling we learned to take in the team, which we started to deal with this term.So, there were many important things in this group and we shouldn't see this group as dependence, but as something that helped us to take off.

(Meeting 16)
This statement reveals the freedom they acquired to explore themselves in the "here and now".
When students go through the teaching experience, sharing their experiences with their colleagues, the teachers and the health team, receiving their respect and understanding, they will certainly have the possibility to repeat this behavior in care for other people and for themselves.

PARTICIPANTS' PERCEPTION OF GROUP MEETINGS
Members' impressions of the group When assessing the meetings, participants revealed that they felt motivated, as their needs became more common and they mutually articulated in order to put their objectives in practice.Seven of the nine participants highlighted the fact that they perceived during the meetings that their fears, anguish and solitude, deriving from the transition from theory to practice, were feelings the others experienced (identification) and, therefore, not unique.
Flávia: Another good thing that helped to relieve anxiety, in this process we've been through, in this care term, was because we were all in the same boat, we went through the same things and this helped to relieve me a lot.(...) I have to go ahead.In college, I felt great fear and insecurity, I think everyone felt it and knowing this relieved me a lot.I loved group therapy, I loved it because I didn't feel alone.
During their education, students will need a supervisor or trained professional to give support and advice, who can also assess this student's resources and limitations.It is recommended that this experience be shared with a group of colleagues, giving rise to feelings of empathy, in which they will be able to criticize and support one another, while learning more about themselves (20) .
Nina: I thought it was positive, when the colleague blew off steam and "touched" the entire group because everyone was going through the same situation.(...).We were experiencing something similar, so then you identify with the person.Then she was letting off steam it's as if you had also understood your own problem.
They perceived the group as a space to identify with one another and in which they found support to deal with the course demands.The participants' self-revelation facilitated their mutual attraction and between them and the group.This progressive contact is known as the therapeutic factor of cohesion (11)   .It is known that the group's cohesion increases when members acknowledge it as a rich source of interpersonal information and support.They learned to live with others, to listen, establish exchanges and value themselves.They also manifested the desire to continue the group, although they knew about its end, as determined in the Therapeutic Contract.They complimented the coordination, its attitude and mediating role.Some participants even suggested the offering of a similar activity as an optional subject.particularly marked the group as a negative fact.
Participants felt demoralized when a colleague gave up, despite their repeated efforts to make her continue.
Both abandonment and disconnection threaten group stability, because they consume the therapist's and the participants' time and energy to the extent that they try to prevent the person from leaving the group; they can impede the development of cohesion, threatening the stability of the affiliation.Moreover, they can implicitly and sometimes explicitly devalue the group (11,15) .The therapist should help participants to interpret the event in a more realistic and constructive way.In the cases of abandonment and disconnection that occurred in this group, the coordinator, acting as a facilitator, stimulated the students to reflect on the fact.Thus, they ended up concluding that perhaps her interests and the group's were not being attended to, and that the people who left could probably obtain benefits some other time.
Diana: I met her afterwards and she told me that she gave up the term, but not the course.She'll come back next term, less tense, she said she had to take care of herself.Now I see that there was a result, she's taking care of herself, she's going to get married and said that she didn't forget about us.It surprised me a lot.During the group, we didn't see any result.
It was only on the occasion of the assessment that one participant managed to perceive how healthy the colleague's disconnection from the group had been, because it allowed her to follow new courses in her search for well being, new horizons, allowing her a healthy return to academic life.The group probably contributed in some way to that participant's decision to give up, which was interesting for who stayed as well as for who left.
A reasonable level of confrontation, anger and conflict solving can offer interpersonal learning among group members (9) .
Carol: When you said to a colleague to wait a bit because another person was going to talk, you "cut" here off (...) this created an unpleasant atmosphere at that time, but another colleague put up the subject during the next session and it was solved.(...) everyone got educated and there were no further interruptions... it was cleared up.
Vitória: I didn't like it, one day, when I was crying a lot (...) and I found the door closed (...) I couldn't get in, then I understood that there was a schedule.We had to respect it.
Marina: I think that not having previously agreed on the change in the time and date of that meeting ended up being a positive point for the group because, from that day onwards, we started to talk as a group.
Cohesion is an essential prerequisite for successful conflict management.In this study, this was possible because the participants developed a feeling of respect and mutual confidence, besides valuing the group, This made them capable of tolerating some uncomfortable situations.It was very important to maintain honest communication, no matter the extent to which the members got irritated about this.

FINAL CONSIDERATIONS
According to the study findings, the group technique can be used as a support and adaptability factor for undergraduate nursing students when they move from theoretical to practical learning.The participants attributed the group with a gradual change in their behavior and performance in practical activities, in their relation with faculty members, colleagues and particularly in patient contact.They perceived that, as opposed to their colleagues, they started to reflect before acting or reacting towards new situations they were faced with.Therefore, group psychotherapy seems to be an instrument which nursing higher education institutions need to take into account as a resource not only for psychological, but also for didactical support in their curricula.Not only in situations like the one studied here, i.e. the transition between theory and practice.Not only as a strategy, but also as an objective.At a time when teaching reforms are discussed, it should be reminded that any planned change will not only be technical, but will also exert effects on the human being.
12 students from the Nursing course at the Ribeirão Preto College of Nursing (EERP-USP), who were taking the subject Nursing Fundamentals II, in which students have their first contact with professional practice.Procedures After obtaining a favorable opinion from the Research Ethics Committee at EERP-USP, the research objectives were presented to the universe of 76 students during a class in Nursing Fundamentals II in the first week of the curriculum.Sixteen of them voluntarily decided to participate in this group proposal and the first group meeting was scheduled.Twelve students attended the meeting, when the Therapeutic Contract was presented, the functioning of group meetings was explained and the Post-Informed Consent Term was signed.
the end of the 16 groups, an individual interview was held with the participants, when they answered two open questions about what experiences they considered positive and negative in the group context.With their consent, interviews were taperecorded and later transcribed.
Diana: I don't have time for anything.When I notice, I've already assumed several of other people's commitments (...) I think I'm silly.Talita: I don't think that.I think you're very important in the group (...) Diana: When I'm anxious I talk, talk, talk.Coordinator: There are also people who work the opposite way, in view of new situations, problems, they are more silent, retracted.Elza: I do that a lot, I close off, I'm like that, passive, I have difficulties to talk.(Meeting 1 -Orientation Stage) In experiencing their initiation in group meetings as well as in training activities (unknown environments and people), the students established their first observations about "being a nursing student".
Coordinator:.(...) We are part of an institution, this group is inserted in an institution, there are rules for its functioning.Does anyone want to remind us which?Vitória: Arrive on time, not arrive late.Marina: If you're absent three times you're out.Coordinator: As students you also have to obey some rules.Juliana: I wanted to leave after the group.But I can't because I have to mark my presence in Immunology class.Coordinator: When you are nurses you'll have to comply with times, assume responsibility for the aids, people who will work with you.
Coordinator: You are going through a moment of rights and wrongs.Through an experience in school, which will grant you security out there in the profession, in hospital, to do things right or wrong (...) school is a place for learning, where there are rights and wrongs.Even people who are totally secure about a certain issue can make mistakes, because of practical things or because they had a busy day.I think that what you should be thinking now is that this is a moment of learning.You are trying out a technique.If you're going to do it well or badly, there's the supervisor to advise you, to give you security.Does the laboratory cause stress?Maybe yes.We feel under pressure, not only here in school or in the profession.There are several things in your lives that have already caused pressure... (Meeting 9) When the group flows, this evidences the elaboration, revealing enthusiasm among participants.They establish exchanges, during which those presenting similar experiences with the addressed theme feed others, that is, based on this experience exchange, discussions make it possible to perceive that things can change or be different.There is greater integration among group members.Vitória: We are looking at things differently.(Meeting 10) Carol: We are more aware (...) The stress situation does not exert such an impact on us now because we are coming here.We would not know how to act.So we are here working on how to act.We know how to deal with several situations.I have already been through situations in which I was afraid, because I'm a fragile person, because I cry a lot and, today, it's not so heavy as I thought it would be.(Meeting 10) Vitória: We are learning to work in group, to respect the group, but putting our knowledge in practice, what we have already learned.(Meeting 13) Nina: I see it like this, starting from this group, with the training group, one complemented the other a lot.During training, it's not just because the teacher was stricter or calmer.(...) The first impact was the hospital, contact with the hospitalized patient (...) fear, insecurity, uncertainty "what am I going to do?"And this group is a complement, because you arrive here and expose yourself, there are your colleagues who are passing through the same things, you cry and see the other person crying and see that you are suffering the same problems, you see that you are no different from anyone else, you end up finding comfort (...) because it's a group, one is helping the other, perhaps because we are very different from one another, we find each other, discuss, listen to one another.It's in this phase of the first contact with the patient, from theory to practice, that it is very hard, we help each other here in the group.(Meeting 15)
).The group subject is not always what you want to blow off steam about... Group therapy with nursing students... Scherer ZAP, Scherer EA, Carvalho AMP.Rev Latino-am Enfermagem 2007 março-abril; 15(2):214-23 www.eerp.usp.br/rlaeMarina: We have a project: beginning, middle and end.Today, Simone's subject fit, a person who needed it a lot and we didn't let her talk.But if the subject hadn't been this one she wouldn't have blown off steam.I we were to talk about time, like in the past meeting, the subject wouldn't be appropriate.I don't know about your view (...) I think it won't be appropriate.It's not Bianca: I think you have the right to put forward a subject as well.
Simone: (...) I got into the group and thought: how nice, I'm going to come (...).But why talk?Juliana: Why talk?Because you're part of the group.Simone: I know how to be part of the group by listening (...) I learned to adapt.(...) Maybe here, at this university, in certain groups people do not want to listen to me, but I'm listened to in other places, so I'm useful (...) There's no way of me being useful here.Carol: You said that your utility was to listen here within the group.(...) One day, you kept your hand raised for half an hour, we could perceive that you were kind of bothered about wanting to talk, until you managed to.So the utility of the group Marina: I think we have to join.Some students were assessed during another class and we weren't supposed to be absent from that class.(...) so, thinking about our profession, ourselves as nurses... Are we going to "fix one thing and cause problems in the other?"You are working, am I going to leave this to do that?It's not like that!