Group Process: reflections of a nursing team

Abstracts

Estudo qualitativo, exploratório-descritivo com o objetivo de analisar o processo grupal de uma equipe de enfermagem do Hospital de Clínicas de Porto Alegre (HCPA), à luz da Teoria de Grupo Operativo de Pichon-Rivière. A coleta de dados ocorreu em 2008, por meio de questionário semiestruturado e grupo focal. Concepção de trabalho em grupo é uma das quatro categorias resultantes do estudo, sendo objeto de abordagem neste artigo. Depreendeu-se que o conhecimento sobre processo grupal necessita ser compartilhado, divulgado e discutido desde a formação acadêmica, no curso de graduação em enfermagem, e desenvolvido ao longo de toda a carreira profissional. À medida que se conhece e consegue identificar os principais indicadores presentes no processo grupal, a equipe pode conduzir-se operativamente, considerando não apenas resultados, mas principalmente o caminho percorrido até o alcance da tarefa, visando à aprendizagem grupal.

Equipe de enfermagem; Processos grupais; Grupos focais; Comunicação; Relações interprofissionais

ORIGINAL ARTICLE

Group Process: reflections of a nursing team

Adriana Serdotte Freitas Cardoso^I; Clarice Maria Dall'Agnol^II

^IMaster Nursing. Clincal Nurse at Hospital de Clínicas de Porto Alegre. Member of the Center for Studies on Nursing Management - Núcleo de Estudos sobre Gestão em Enfermagem (NEGE). Porto Alegre, RS, Brazil. [e-mail]

^IIPh.D. in Nursing. Professor at the School of Nursing, Universidade Federal do Rio Grande do Sul. Coordinator of the Center for Studies on Nursing Management - Núcleo de Estudos sobre Gestão em Enfermagem (NEGE). Porto Alegre, RS, Brazil. [e-mail]

ABSTRACT

The objective of this qualitative, exploratory-descriptive 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 Operative Group Theory. Data collection took place in 2008, using a semi-structured questionnaire 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 article. 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 identify the main indicators of the group process, it becomes possible to improve operatively, considering not only the outcomes but mainly the course covered until achieving the goal, aiming at group learning.

DESCRIPTORS: Nursing, team; Group processes; Focus groups; Communication; Interprofessional relations.

RESUMEN

Estudio cualitativo, exploratorio, descriptivo, que objetivó analizar el proceso grupal de un equipo de enfermería del Hospital de Clínicas de Porto Alegre (HCPA), según la Teoría de Grupo Operativo de Pichon-Rivière. La recolección de datos aconteció en 2008, mediante cuestionario semiestructurado y grupo focal. Concepción de trabajo en grupo es una de las cuatro categorías resultantes del estudio, siendo objeto de abordaje en este artículo. Se desprendió que el conocimiento sobre proceso grupal necesita ser compartido, divulgado y discutido 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 identificar los principales indicadores presentes en el proceso grupal, el equipo puede conducirse operativamente, considerando no sólo resultados, sino principalmente el camino recorrido hasta la conclusión de la tarea, apuntando al aprendizaje grupal.

DESCRIPTORES: Grupo de enfermería; Procesos de grupo; Grupos focales; Comunicación; Relaciones interprofesionales.

INTRODUCÃO

Coordinating a group of people is often quite difficult, and always implies facing diversity, because, besides the individuals' particular motivations, different thoughts and ways of acting and understanding ideas occur in a working group. Among so many particularities, efforts must be converged in order to achieve common objectives and goals that translate as being the purpose of the group itself. In this setting, nurses stand out as professionals responsible for coordinating teams, usually consisting of nursing auxiliaries and technicians, in addition to other nurses.

It should be emphasized that, although human beings participate in different groups in life (family, school, church, club, etc.), not always is this process clearly noticed. However, since one's birth, one is demanded to have a disposition towards sociability in order to become a member of society, considering the individual does not have the necessary physical condition to survive in isolation⁽¹⁾. This continuous process of forming groups shows the gregarious nature of human beings, who are constantly in the search to preserve their identity in the micro and macro society. Their several relationships somehow had and/or have an impact on their own individuality. It must be considered that, within a group, there are intersections among several networks, each holding their own values, beliefs, fears, affinities, and defense mechanisms. Each individual's accumulated asset, filled with this collective inheritance, represents the nuances of the communication process of the unique group to which he/she belongs. Other people, with other backgrounds, will provide other combinations⁽²⁾.

The collective dimension of nursing work requires specific 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 education during their undergraduate studies, with no specific preparation for working in groups, and, therefore, face great difficulties in the work market by having to deal with obstacles related to leadership, communication and interpersonal relationships. Coordinating a group is no simple task ⁽³⁾.

Developing skills for group coordination when grounded on a practical-theoretical framework - in this case, the Operative 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 essential skill in order to improve the efficacy of the coordinator's interventions, as well as to investigate and encourage the potentials of the group itself.

Therefore, by creating a place for dialogue, which main principle is the participation, in different forms and levels of intensity, of all the actors involved in the proposed questionings, the general objective of this study was to analyze the group process of a nursing team, hence, the results presented herein result from the findings achieved from knowing the concept that a nursing team has for group work. Therefore, we aim at contributing with the development of a reflexive process that could provide support for intervention and reorientations of team practice, thus improving and triggering possibilities for investigating and understanding the group process in nursing teams.

LITERATURE REVIEW

With the aim to understand the relationships that exist in the nursing team, it is necessary to be grounded on theoretical frameworks that offer the necessary support. The operative group framework provides the basis to choose the appropriate techniques and to make group interventions. It is expected that those interventions occur in line with a transforming perspective where people who participate 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 interrelation process, analyzing the relationships between workers as group processes. By understanding the group processes present in a team's relationships, it is possible to build it using different critiques and reflections from those previously made. In line with this proposal, Pichon-Rivière's operative group framework has the purpose to help the teams throughout the extensive process of understanding and building their praxis, allowing for the implementation of transforming actions that recreate their own work.

Understanding the dynamics involved in the construction-deconstruction-reconstruction 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 idealization than actually in reality, and it is therefore necessary to break the myth of perfection and learn how to deal with imperfections^(4-5). This unleashes a creative process based on one's current resources, which characterizes a continuous spiral-like process ⁽⁶⁾.

The operative group technique is characterized for being centered on the task and its explicit and implicit dimensions. Explicitly, the task can refer to learning, diagnosing a professional organization, creating a marketing ad, etc. Another task underlies this first one, pointing at the rupture of stereotyped agendas that hinder learning and communication, which are an obstacle in view of the whole situation of progress or change. Therefore, the implicit task consists of elaborating two basic anxieties understood as the fear of losing the stability won in the previous situation and the fear of an attack in the new situation. These two anxieties, which are coexisting and cooperating, configure the basic situation of resistance to change. In the operative group, this situation should be overcome by going through the three dialectic moments: thesis, antithesis, and synthesis. This is a clarifying process that goes from explicit to implicit. The allusion to an operative mode relates to functioning in the sense of creating the right conditions for group members to promote a creative change and an active adaption to the reality, which means to understand the group as an instrument used for learning ⁽⁶⁾.

According to this perspective, 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 operative group work has the purpose of helping the person learn to think, or, better yet, relearn how to think, changing dilemmatic into dialectic thinking. Dilemmatic thinking triggers inflexibility in the possibility of learning, being creative and changing the reality. This form of thinking established a distorted reading of the reality as it fragments the object of learning, dissociating it from other objects and from its context, which also produces a fragmentation of the bonding and of the self. On the other hand, dialectic thinking seeks to integrate the object, understanding it in a constant movement, associating it to other objects and to the context, in a concrete historical situation⁽⁶⁾.

Relearning how to think based on dialectic thoughts is related to the search of a more reflexive view of everyday life. Everyday facts and phenomena usually appear as non-questionable or non-problematized, as if they composed the reality by excellence. Therefore, everyday living becomes covered, distorted: this covering and distortion occur by means of a unique mechanism, characteristic of the dominant ideology, which naturalizes what is social, universalizes what is particular, and makes timeless that which is historical. Through this mystifying process, everyday life consists of a natural, universal, eternal and unchangeable order⁽⁷⁾. Hence, the operative group technique, whatever its objectives (learning, institutional diagnosis, planning, etc.), has the purpose to teach its members to think about a co-participation of the object of knowledge, understanding that thought and knowledge are not individual facts, but social productions⁽⁶⁾.

The operative group is founded on the idea that the process to achieve the task results in learning, i.e., making an analytical 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 operative 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 revitalization of Pichon-Rivière's framework should be performed in issues related to working in the health field, thus permitting to constantly rethink and, essentially, recreate the practice, as an analytical and creative subject who can, together, change everyday reality. Considering that the thought of analytical and creative 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 additional possibility to seek changes in the practice of nursing management, with a view to bringing relationships to a horizontal level.

METHOD

This qualitative, exploratory-descriptive study was founded on the research-action method⁽⁹⁾ and performed at the adult patients hospitalization unit at Hospital de Clínicas de Porto Alegre (HCPA). HCPA is one of the hospitals of the Ministry of Education 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 national public health system (SUS), and live in Porto Alegre, the metropolitan region, and the interior of Rio Grande do Sul⁽¹⁰⁾.

The hospitalization unit where the data were collected has 45 beds, distributed among 15 wards (three beds each), and is characterized by the hospitalization of adult patients. The nursing team is comprised by 45 professionals: 36 nursing auxiliaries and nine nurses, working the morning, afternoon, night, intermediate (5pm to11:15pm) shifts, and sixth shift (daily 12h shifts on weekends and holidays).

Data collection was collected in two phases. The first took place in June 2008 and consisted of applying a questionnaire with semi-structured open-answer questions with the objective to survey the participants' overall perceptions about the nursing team's group work. Participants filled out the questionnaire individually during their work shift and placed their answered questionnaire in a collector box at the unit. The inclusion criteria used were: being a member of the nursing team, volunteer to participate and be interested in discussion on the theme. The exclusion criteria were: being away from work for different 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 five meetings, each with a mean duration of one hour and participation seven subjects. The inclusion criteria were: the subject's interest on the theme and his or her availability to participate in the meetings.

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 participants from this professional category. However, logistic issues demanded a change in the group composition. Among them was the difficulty to cover nursing auxiliaries who would need to be absent to their work shift in order to participate in the focal group, as well as the data collection 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 coordination team consisted of the debate moderator (master's student) and the participant-observer. The latter, besides being part of the same research center (NEGE), has previous work experience with the focus groups technique.

The information obtained with the questionnaires was analyzed as follows: for the results regarding the closed-questions, descriptive statistics was used; the information 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 classified according to content similarity, and grouped in pre-categories, using thematic analysis as framework⁽¹¹⁾. The results obtained with the semi-structured questionnaire provided the necessary support to create the manual with the themes to guide the Focal Group sessions. Also, the source of information generated in the Focal Group was also submitted to thematic analysis.

As to the ethical aspects, this study complied with all recommendations of the National Health Council Resolution 196/96⁽¹²⁾. The study was only initiated after being approved by the Scientific Commission and Research Ethics Committee at Hospital de Clínicas de Porto Alegre, (protocol 08-116). In the first data collection stage, each participant received an Explanation Sheet with the Questionnaire. The Questionnaires were collected using a collector box, without any identification of the respondents. Prior to the Focal Group meeting, participants provided written consent.

RESULTS AND DISCUSSION

The results to the closed-questions permitted a brief categorization of the 33 participants while nursing professionals working at the unit, the field of study. It was found that most were female (68%) of age between 41 and 50 years (34%). As to their time 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 five years. It was also found that most participants (60%) have worked at HCPA for more than five years, and that 54% of them are members of the nursing team at the studied unit also for over five years. The results obtained with the open semi-structured questions provided clues about the perception that team members had about the group process of which they are part, and were grouped in four thematic lines: conception of group work, facilitating/hindrance aspects of the group process, critical nodes in the group process and strategies to create group work. These thematic lines, extracted from the analysis of the questionnaires, comprised the triggers for the discussions in the Focal Group.

The results of the focal group were combined into four thematic categories: conception of group work; communication as the central aspect that facilitates/hinders the group process; the distancing between professional categories as the main critical node in the group process; and strategies to create group work. This article analyzed and discusses on the data referring to the conception of group work category. The illustrative statements of the debates in the focal group are identified as P1 (Participant 1), P2 (Participant 2) and so forth.

Conception of group work

Based on the guiding question what do you understand by group work?, the debate was initiated and the participants of the focal group, after 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 relationship⁽⁶⁾. Considering Pichon-Rivière's framework, the meaning of a common objective relates with the concept of task, which consists in the group, itself, addressing and elaborating its current concerns.

With the objective to improve the discussion, other nurses stated that the concept of group work pervades and idea of cooperation and is associated with the combination of actions:

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, cooperation is understood as one of the six indicators used to evaluate the group process. Cooperation is established in view of a group elaboration 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 often results in competition, which has the objective to impede the other's actions, and, instead of being complementary to each other, one tries to take over the other's position. In this regard, it was stated in the discussion that group work means being able to deal with situations involving competition. This fact was observed and pointed out by one of the nurses:

[...] it's like if someone, I don't know, sometimes I notice that a competition environment is set in [...] asking for help, talking to the administration[...] they are like, oh, he's the boss' favorite, sometimes it happens (P1).

The competition environment that is referred in the statement, made evident by subtle everyday disputes between team members at work, might be a consequence of reiterative practices such as the inheritance and tribute to neo-liberal models. Thinking about the competitive environment of nursing, competition may be directly related to the work overload, the lack of better salaries and the large demand of services for an insufficient number of professionals⁽¹³⁾. This can be explained because, by being a part of the current capitalist production model, people strive to produce more in less time, focusing on the technical aspect and on the constant search for productivity.

In the group, people are permanently interacting^(14-16), in a way that individual and group goals change over time, 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 conception 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 alienation. In this situation, the professional starts working without being able to understand the importance of his/her activities 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 connection and belonging. In the dialectic interrelations 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 vertical movement that covers the individual's personal history, with his/her inner representations, transferences and projections⁽¹⁸⁾.

Belonging is characterized by the feeling of being part of a group, of identifying yourself with it, of including yourself and others in your inner world. It is through belonging that the identity of the group and the individual is established⁽⁶⁾.

Shortly after, motivated by the ongoing debate, another nurse complemented, pointing 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 differential when analyzing the group process, and in the view of the groups, emphasis is on the sense of inclusion, appreciation, and identification among members⁽¹⁹⁾. As a metaphor, the constitution of a group is compared to a gallery of mirrors, where each member can reflect and be reflect on and by others, so as to emerge the discrimination, affirmation and consolidation of their own identities. A relationship is, therefore, established, in which each individual feels welcomed and the condition of the other reflects on his or her own condition. The basis that supports and strengthens the relationships 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 affected by the other's behavior, they become aware that their own behavior can affect others⁽¹⁶⁾. This phenomenon of approximation 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 negative tele is the measurement of the difficulties that each person has in working with others, of the rejection; positive tele consists of the possibility that the individual has of working with others, of accepting others⁽⁶⁾. The positive and negative teles will provide the affective factors and affective ambience, facilitating the task or becoming a hindrance. Therefore, the field of work towards the task will become more favorable as the positive tele becomes more prominent⁽⁶⁾.

The form that the relationships are established among colleagues in the team can affect the work outcome. The incapacity to work these differences eventually results in conflicts. However, conflicts are a part of life and of the managerial process. When different people learn how to deal with their own differences, the conflict becomes constructive. Therefore, conflicts are not considered something negative; rather, they are a chance for group development and improvement through a dialectic process.

CONCLUSION

The team's everyday work is an important issue, as it is permeated with conflicting relationships that often make group work, and, consequently, reaching common goals a mixture of perceptions, in which diversity sets the tone.

The conception of group work is related to achieving common goals, pervading the ideas of cooperation and the capacity to combine actions. To the members of the focal group, the inability to combine individual and group goals can often lead competition among group members. In the discussions, the participants implied they face some difficulty to establish a common line of participation in terms of being able to work together on a task, avoiding action overlaps and fragmentation.

The challenge of combining individual and group goals, according to the perception of the focal group participants is linked to the meaning that work has for people. Working without a clear definition of purpose leads to alienation and, as a consequence, groupality changes into seriality, thus compromising the group indicators of connection and belonging. Since belonging is also an indicator of commitment, as relationships grow stronger, the level of group operation increases, i.e., its ability to achieve the proposed task.

Group work requires mutual respect, tolerance and patience, and one is dependent of the other to occur. However, these virtues are difficult to be adopted by people as they imply tolerating and dealing with differences. For the focal group participants, the existence of group conflicts is directly related to the difficulty to elaborate and respect those differences. However, conflicts are a part of life, of the managerial process, and are the center of every group. The problem of a conflict is not its presence, but leaving it unsolved, i.e. o camouflage. The moment people learn how to deal with their differences, as opposed to being destructive, a conflict can become constructive and mediate more effective relationships.

Although the nursing profession usually implies working with groups of professionals, the undergraduate student is often unprepared to face the work market from that perspective. 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 practice, among wrongs and rights, without being grounded on an appropriate theoretical foundation. That originates the main impasses in professional life - regarding human relationships and their complexities.

Knowledge and theoretical preparation 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 initiate a reflexive 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 identify the main indicators present in the group process, a first step can be made towards solving the primary concerns and making personal changes in the relationship that is established with the other(s). Therefore, through a process of self-knowledge, using resources such as experiential groups and therapy support, when necessary, the team can be operatively conducted, considering not only the outcomes, but mainly the pathway covered until achieving the task, aiming at group learning.

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Proceso grupal: reflexiones de un equipo de enfermería

Correspondence addressed to:

Publication Dates

• Publication in this collection
  12 Jan 2012
• Date of issue
  Dec 2011

History

• Accepted
  18 Feb 2011
• Received
  19 Nov 2009