Group therapy with nursing students during the theory-practice transition

Abstracts

La finalidad del estudio fue verificar si la intervención de grupo a corto plazo puede proporcionar a las estudiantes de enfermería recursos para enfrentar el stress, propio del paso, del aprendizaje teórico al práctico. Se utilizó la observación participante como método, lo que permitió que 12 alumnas matriculadas en el curso de Fundamentos II, pudieran expresar sus ansiedades y angustias ante el nuevo y futuro rol de cuidadoras de la salud. La técnica grupal aparece como un instrumento a ser considerado por las instituciones de enseñanza superior en enfermería no solo como un recurso de apoyo, sino también didáctico dentro de los programas curriculares. Considerando las actuales discusiones sobre las reformas en la enseñanza, cualquier planificación de cambio no solo se dará nivel técnico, sino también traerá efectos en el ser humano.

psicoterapia de grupo; educación en enfermería; enseñanza; estudiantes de enfermería

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.

psicoterapia de grupo; educação em enfermagem; ensino; estudantes de enfermagem

ORIGINAL ARTICLE

Group therapy with nursing students during the theory-practice transition¹

Zeyne Alves Pires Scherer^I; Edson Arthur Scherer^II; Ana Maria Pimenta Carvalho^I

^IPhD, Professor at the University of São Paulo at Ribeirão Preto College of Nursing Psychiatric and Human Sciences Department, WHO Collaborating Centre for Nursing Research Development, e-mail: [e-mail], [e-mail]

^IIPsychiatrist, Doctoral Student, Assistant at Hospital das Clínicas University of São Paulo at Ribeirão Preto Medical School

ABSTRACT

This study aimed to verify whether the intervention of short term groups could provide nursing students means to cope with stress, typical of the transition process from the theoretical to the practical learning. Participant observation was used, allowing 12 students in the discipline Fundamentals II, to express their anxieties and anguish towards the new and future role of taking care of other people's health. Results suggest that higher nursing education institutions should consider the group technique not only as a support resource, but also as a didactical resource in their curricula. At a time when educational reforms are discussed, is important to bear in mind that any planned changes will have an effect not only in technical terms but will also affect the human being.

Descriptors: psychotherapy, group; education, nursing; teaching; students, nursing

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 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.

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 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 tape-recorded and later transcribed.

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.

Table 1 presents the students' participation in terms of frequency and abandonment or disconnection during the 16 meetings.

The group started with 12 participants. At the start of the semester, one of the students temporarily blocked her registration and ceased participating in the fourth meeting. In two groups (4 and 6), more than 30% of participants was absent. For the sixth meeting, this was justified by a change in the meeting date, requested by three students. Two participants were disconnected from the group activity because they were absent for three times (groups 9 and 12, respectively), in accordance with the absence limit established for disconnection in the therapeutic contract. Hence, the study ended with 9 participants (75%).

In general, group frequency was good, demonstrating interest and group cohesion from the beginning. What abandonment is concerned, our findings are in line with literature, according to which an abandonment rate of about 10% to 30% is expected in group therapy processes⁽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.

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".

Bianca: The course is very hard, very fast (...) you'd like to give up. (...) All teachers ask something of you. The teacher makes demands during training. They ask: haven't you learned that yet?

Diana: The nursing course is like that... you go on, you study very hard for one subject, while you leave others aside. (...) you take the course a bit forward as it comes.

Talita: You know what I'm afraid of. Sometimes I think we're gonna graduate without knowing anything.

Diana: But we will. Just like everybody.

Bianca: Did you know that the nurse has to be able to do everything? You have to be able to do everything. You have to know what the nursing aid does, what the doctor does, what the pharmacist does...

Vitória: Yeah, if the aid makes a mistake she "pays the bill", and if she's doesn't, she equally "pays the bill". (Laughs).

Bianca: Man, it's always her (nurse) running after the doctor (...)

Diana: That's why we have to know what the nurse's function actually is. (Laughs).

(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. They've warned us that teacher X flunks you on training. You have to suck up to the teachers if you want to get approved.

Coordinator: (...) we have to think, work on how to face this moment, with the teacher, with the patient, at that specific moment. Think about what is provoking fears, frightens us. What we are doing here is talking, crying, so that we won't cry when we are with the patient, with the teacher. There are different ways of talking. Calling the teacher and saying that you haven't understood. Have you already thought that this teacher can also experience fears, anxieties, fear of making a mistake while teaching you?

Juliana: But they're the teachers, they think they don't make mistakes, they protect themselves. (...)

(Meeting 2 Orientation Stage)

Diana: I asked a question and the teacher didn't pay attention to me, she said she didn't know.

Carol: Yeah, it's like that, it's no use, last year I asked to revise a question, I tried to dialogue, but nothing, it's a waste of time... Today I saw somebody at the hospital performing a wrong technique, I was shocked.

Juliana: I was disappointed, I heard people say so much that hospital X was this, was that, a reference point. Hospital Y is much more organized.

Marina: I feel happy. Oh dear, you are seeing wrong things. That means that you know, that you can identify what's right and wrong.

Coordinator: I perceive that you are disenchanted.

Elza: (...) I don't know, it's all very strange... I was observing... I think I bothered more...

(Meeting 3 Conflict Stage)

At the same time, during group meetings, they had their first contact with group functioning rules. This way, they showed feelings of anxiety about the institutions (university, health services and group activity), their standards, principles and functioning structure.

The coordinator ended the group on time and cut off some statements.

Coordinator: In the group it's like that, when the subject gets heated we have to finish because of the schedule we have to comply with. We can come back to this subject during our next meeting.

(Meeting 2 Orientation Stage)

Carol: After the Pathology test we'll have an Immunology test. Except that I don't know what it will deal with. I didn't go to class anymore, I don't have the subject. Now I have to pick up the pieces.

Coordinator: I can see that you study for Pathology and take the test. Then you concentrate on Immunology to do the test, and so on. That means that you're always picking up the pieces.

Juliana: That is what it's like, there's no way of doing everything.

Vitória: When we're at the hospital, for Fundamentals II, we see how important Pharmacology and Immunology are. What is hard is to understand that, in practice, we'll use everything we've learned in theory.

(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.

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.

(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 (...). The group subject is not always what you want to blow off steam about...

Bianca: I think you have the right to put forward a subject as well.

Marina: 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 common therapy, it's a directed therapy.

Simone: It's not that I wanted to talk. No way. It was the coordinator who stimulated me. Then I felt mobilized (...). I mirrored myself, that's why I talked.

Coordinator: Can you see how the group works?

Talita: It's an exchange. In this group, you have the opportunity to talk with students who are not from your training 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're not heard, here you are listening. (Meeting 7)

Vitória: You know what the problem is? We are in a phase in our lives, the phase of university and the profession, we are adapting to new things. (Meeting 8)

Nina: They keep on talking about the difficulties and I observe my difficulties (...) It's this thing of each person talking a bit that is important for who is here listening, that's therapeutic. It's hard for you to deal with 80 women, it's hard for you to expose yourself in this space, with so many different people (...) (Meeting 8)

Carol: Going to college is more or less like moving to another city. Starting everything all over (...). You acquire a different attitude, learn to be different from now on. (Meeting 8)

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.

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 is not just listening!

(Meeting 8)

Through these statements, students were revealing themselves, in order to show that they were experiencing a particular moment. Each person was looking at herself as a person, perceiving the other, questioning her own reality and the relations she establishes with her (natural, social, cultural) environment. This was possible based on the experience exchange established in the context of the social practice they were inserted in, including the group therapy experience they passed through.

The perception was evidenced that their fears, anguish and solitude, deriving from the transition from theory to practice, were feelings the others experienced and, therefore, not unique. They would have the opportunity to share them in the group context and feel relieved.

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!

Bianca: I got it all wrong. I was doing everything right. Then she (teacher) said: you have one hour. I can't do anything in a hurry.

Vitória: But she said that you were making mistakes (...) put you under pressure. But you're not like that!

Bianca: I won't be able to do it again.

Vitória: Yes you will.

Bianca: She said: "You're not skilled but you're going to the hospital". How am I going to the hospital if I don't know? And what if I forget?

(Meeting 9)

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.

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)

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.

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 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.

Vitória: We arrived, practically the majority, tired, stressed about something that happened during training, and to the extent that we got to know one another we could say everything, blow off steam. Nobody was there to criticize you, everybody helped everybody. It was a place where you could talk about what happened, express your "nerves", your experiences, both the good and the bad ones and there was always someone to talk. It was a very good thing, the experience exchange, besides the aspect of friendship we had in the group and which continues outside the group as well. In the group, everyone accepted everyone as they are and not as they could present themselves. The way of being, one trying to help the other in difficulties (...) I also felt more security in the practical procedures I'm going to do now. In the group, we became a lot more mature. We perceived that everything we go through, it's a phase and that we have to face it with our heads high, with maturity.

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.

Diana: When you are working in a team you have to learn how to listen, talk, stop a bit to think. I learned that in the group.

Flávia: The group had the goal, reached it and it was time to end, (...) it helped me to grow and to accept, but it ended.

Vitória: In the group we had rules, discipline, because we didn't move on without that. That was something we learned: everything has rules, discipline, if not, it becomes a mess. I think it is sad that the group has to end (...), but the subject finished, LIGIE finished (laboratory where the meetings were held). We assumed a commitment, we closed friendships, we liked to be in LIGIE, this moment was ours only.

Marina: I think that this project, even when you finish your doctoral program, I think that, as there is integration in the first year, I think that this group should be part of the optional subjects, because it's very good. And we already continue college differently, it seems that we grow up in few sessions.

Bianca: I loved and I would like it if there was more, it's something that helped me a lot. I would like to have it in the second term. I need to improve my insecurity... It's also important that what happened stayed here in the group. I think that you knew how to work with the group very well, you knew how to direct it very well. I think that we would keep on hitting the same key if you hadn't directed the group. I really want to continue in other groups.

Aspects perceived as negative

In this group, abandonment and disconnection occurred. The disconnection of one participant 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)}.

Vitória: It was negative that the colleague gave up. (...) We knew that she had problems, but she did not comply with group hours, she was absent, we were concerned, but she was not concerned about us. I saw her departure as neglect, irresponsibility.

Juliana: What I didn't like in the group (...) one person who was not flexible, she only knew how to fight (...), but she didn't accept anyone's opinion (...) she left (...) I even wanted her to continue to see if she opened her mind, but it didn't work.

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.

Recebido em: 7.12.2005

Aprovado em: 14.2.2006

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1

Study extracted from Doctoral Dissertation

Publication Dates

• Publication in this collection
  29 May 2007
• Date of issue
  Apr 2007

History

• Accepted
  14 Feb 2006
• Received
  07 Dec 2005