FAMILY GROUPS IN NURSING GRADUATION TEACHING PRACTICE GRUPO DE FAMILIARES EN LA PRÁCTICA DE ENSEÑANZA DE GRADUACIÓN EN ENFERMERÍA

The Centers of Psychosocial Care (CAPS, acronym in Portuguese) are strategic devices for mental health care currently available in Brazil. Nurses are professionals required to compose the minimum staff of this device, which values the group activities involving users. This study presents a r report of the experience of nursing undergraduates from Universidade Federal do Mato Grosso(UFMT) on their conducting waiting-room group sessions with relatives of users of a CAPS from Cuiabá, Mato Grosso state. This experience is justified by the fact that nursing students have few opportunities to develop group approach abilities during their graduation course, which focuses mainly on clinical individual care. The aim of the experience was to provide theoretical-practical learning of all the work stages of group work: recognizing the need and possibility of conducting the activity, planning, coordination and group evaluation. The results confirm the need and possibility of performing group experiences in mental health care and in nursing education.


RESUMEN
Los Centros de Atención Psicosocial (CAPS) son dispositivos estratégicos para la asistencia a la salud mental en Brasil en la actualidad. Los enfermeros son profesionales exigidos en el mínimo equipo de este dispositivo que valoriza las actividades grupales en el abordaje de los usuarios. Relato de experiencia de alumnos del Curso de Graduación en Enfermería de la UFMT en la realización de grupo de sala de espera con familiares de usuarios de un CAPS de Cuiabá, MT, Brasil. Se justifica en virtud de las pocas oportunidades que tienen los estudiantes de enfermería en el desarrollo de competencias de abordaje grupal en su formación, focalizada principalmente para la atención clínica individual. El objetivo de la experiencia era proporcionar aprendizaje teórico-práctico de todas las etapas del trabajo con grupos: reconocimiento de la necesidad y posibilidad de la actividad, planificación, coordinación y evaluación del grupo. Los resultados confirman la necesidad y la viabilidad de la realización de experiencias de grupo en el cuidado de la salud mental y la educación de enfermería.

INTRODUCTION
Psychosocial Care Centers (CAPS) are strategic tools currently used in Brazil to change the mental health care model. They are extra-hospital services mainly intended to care for people in severe and persistent mental distress with a view to care for or treat these patients and enable their social integration (1) .
Care within CAPS is undertaken considering collective activities according to the proposal to socially integrate users, with the participation of families in the treatment and integrating the service in the scope area (2) .
CAPS are classified as type I, II or III according to the complexity of care provided, number of professionals within the team and its clientele, in addition to those focused on caring for children and adolescents (CAPS i) and chemical dependents (CAPS ad). There is a minimum configuration of teams and the participation of a nurse is always required in these teams in all the services (2) .
Teams working in CAPS are expected to share the time needed and responsibility of caring for patients with the patients' families, to support them during difficulties and support and care for users, establishing a partnership in the care delivered to individuals in mental distress. In addition, family members should be seen as a target of the team, heeding their doubts, needs and be incorporated in an individualized therapeutic project designed for the user (3) .
Many studies have indicated the need for nurses to perform group activities in care practice, given the need to develop more socially-committed actions (4) , more efficient care actions (5) , or to more widely reach the community (6) . The need for nurses to have the skills to coordinate groups and include families in this type of nursing care has long been acknowledged (7) .
Hence, we assume that CAPS are central and strategic tools within mental health care currently delivered. They value group activities and the family approach in their care and nurses are professionals required for the functioning of all types of CAPS. Thus, it is essential to value theoretical-practical activities related to learning how to coordinate groups in nursing teaching.
Despite acknowledgment and legal approval of curricular guidelines that indicate the need for changes, we find that undergraduate nursing programs still give priority to biological-clinical content to the detriment of social, emotional and behavioral content in their curricula, and therefore practices are still focused on the individuals' clinical approach (4) .
The experiences reported here are justified by the need to develop student competency in working with groups in the health services during nursing education programs. It is also justified by the needs of users and families identified in CAPS daily practice, which will be presented in the context of this experience.
This article describes the experience of developing a waiting-room group with family members of patients in a CAPS, analyzing its repercussions as a strategy of theoretical-practical teaching of the course Mental Health Nursing in the nursing undergraduate program at the Federal University of Mato Grosso (FUMT), and as a practice that includes family members of CAPS users.
Waiting-room groups can be developed by various professionals, however, we assert this is a practice inherent to the work of nurses in health promotion and needs to be encouraged as a problematizing theoretical and practical resource in nursing education (8) .
The work with groups performed by nurses is mainly related to health education and implies linking popular and academic knowledge and the co-responsibility of workers, learners and users/families of services, which all have in common the construction of citizenship among the involved subjects (6,(8)(9) . From this perspective, it becomes an important instrument in teaching practice aimed to develop competencies derived from critical reflection, scientific curiosity and creativity, based on a concrete and real ground of health servicesthe field of practice of students and professors (10) .

INITIAL SETTING
The course Mental Health Nursing is offered in the sixth semester of the Undergraduate Nursing Program at the FUMT: 60 hours of theory and 60 hours of practical activities. Practical activities were developed with a group composed of six students in a CAPS II in Cuiabá, MT, Brazil. The course planning, discussed with the CAPS team and students, provides that every two undergraduate students develop an individualized therapeutic project for a user in the service.
This practical experience carried out in health services linked to the university includes care actions in which there is implicit consent of all those involved in the practice: students, families, professors and team members. All the participants were invited and had their decisions concerning participation respected. Because this was a teaching-learning experience, there was no need to formalize a free and informed consent form as provided in Resolution 196/1996 of the National Council of Health.
The CAPS where the practical course activities were held has some particular characteristics: it had a new address that was not widely disseminated and its physical structure is composed of areas only slightly divided, distributed over two floors connected by stairs including rooms for professional care, administrative offices, dining, kitchen, therapeutic work-...it is essential to value theoreticalpractical activities related to learning how to coordinate groups in nursing teaching. shops rooms, a swimming pool that is out of service, bathrooms and two passage areas centrally located with access to rooms, where users and families wait for care or activities to be developed by the service professionals. These two passage areas are used as waiting rooms where family members of users cared for in the CAPS wait while their relatives are in consultations, workshops or having snacks. Among pictures, uncomfortable and damaged chairs, with some conversation and interaction, mothers, fathers and spouses wait for the team to provide care.

Rev Esc
The first task was to introduce ourselves to the CAPS team, users and families, proposing for the first time interaction with family members and users in an attempt to know them during introductions: men and women affected by mental disorders, mothers, fathers and partners and caregivers of people in mental distress. Among introductions and conversations we shared our histories: students with the responsibility to capture through our interactions some possibility of learning, and patients and families who told their histories and experiences with mental disease and all the hardship such a condition causes in the lives of all those involved, both individuals and families.
We identified this dynamic territory -the waiting room -which is not actually a room but a passage area composed of the intersection between the public space and the professionals' space and where affections, knowledge, experiences are expressed, which can be appropriated by professionals when they plan the waiting-room activity (8) .
Two ladies, a mother of a 20-year-old boy and the wife of a patient, who were waiting in one of the rooms for their relatives, were very communicative and during a conversation in which a student was very attentive, they told a little about the difficulties they and their families face in the search for care and treatment for the child and husband: the phantom disease that takes away your relative who becomes aggressive, solitary and a stranger to the family; events that disturb and afflict living with the disease such as fights, "crises" and hospitalizations in psychiatric facilities; economic and social hardships they have to face and which are aggravated by the disease, evident in the poor public transportation used to travel to the CAPS for morning care and the difficulty in obtaining benefits from the social security service; and a narrative that mixed few certainties and many doubts. They also told how they cared for their relatives and how, with an incredible force of life, they tried to alleviate suffering brought by the disease and its complications to their dear ones and themselves.
During the conversation and wait, this scenario revealed a possibility for learning and more interaction: students tried to understand the families' experience of living with a mental disease, families who wait with their afflictions and needs in a waiting room for a mental health service not yet capable to properly care for them and the proposed group task to exchange meanings and significations attributed to becoming sick and mental health.
The group, as a locus that articulates several human dimensions -subjective, social and biological (6) , was a possibility for enabling interaction between the desire to learn beyond clinical care and to alleviate suffering experienced alone and individually.
Some organization would be necessary given the challenge presented: the study that would ground the group activities both in relation to theoretical aspects and those related to the definitions of setting and planning to integrate the content of the undergraduate course with the service team.
The fundamentals that guided the understanding of the group were related to the concept of "operative groups" as proposed by Pichon Rivière, groups that are organized around a task and presuppose the establishment of bonds (11) . Hence, the task -to develop a group with family members in a CAPS -also enabled the group of students to dialectically produce themselves as a group. Through the participation of each person, each transforming individually, seeking references, discussing strategies and interacting, simultaneously transforming and composing ourselves into a group, with bonds more visible than before (12) . We decided that activities would take place on Monday mornings between June 9 th and 30 th 2008, during the waiting time and the most sensible resource common to the participants would be used: talking and listening.

GROUP WORK
We had initially planned the activity choosing a coordinator, who would introduce and conduct the group activity and one observer/reporter who would record the responses and reports of the participants. We decided to take turns among students so that everyone would have the opportunity to coordinate the group work.
Planning was based on a bibliographic search and discussion in two meetings with the students and the course's professor, where we decided not to define a specific topic for the first task because it would be a moment to present the students' intentions and mediate the expectations of family members. We only defined the presentation technique and a technique to end the group's first meeting.
In the first activity we invited the family members who were in the waiting room. In addition to the two students, six female family members and the CAPS psychologist also participated in the activity. The activity was held in the workshop room. It was initiated with a presentation technique where everyone was in a circle and, with a string wrapped around their fingers, they said their names, addresses and personal characteristics and then threw the spool to another person. At the end, a web was formed in the center and the coordinator, using the image composed by the task, reminded that everyone there had something in common, being family members and caregivers of a person in mental distress Afterwards we talked about how everyone's weekends were. The first reports were marked by the narratives of two participants complaining of the conflicts experienced with their children, both users of CAPS.
We also discussed other issues: food, leisure, behavior, facts that marked their lives concerning the disease and the use of medication. One service-user, the daughter of a woman participating in the group, called her mother and interrupted the meeting three times during the meeting. The mother told the group that her daughter was very dependent and attached to her. This event showed us how much the group altered the CAPS routine and the users' perception of space when the waiting room was moved, creating a new scenario and denouncing the deterritorialization of the waiting room as a public space through professional/academic intervention (8) .
To end the meeting we used the technique Receive the candy I give you. The participants received a piece of candy and they had to give this candy to the person to whom they had thrown the spool during the initial technique, wishing success for the next week. We asked them whether they wanted the activity to continue and closed the meeting after everyone consented to the proposal to continue the activity on the next Monday.
In the second activity with the participation of seven family members, we initiated the meeting with an activity regarding group dynamics, the objective of which was to get familiar with each participant: we asked them to write on a paper in the shape of a badge their name, address, one quality or defect and then observe, without talking, what was written on each other's badges. At the beginning everyone was intimidated to look at their fellows' badges but after a few minutes, everyone had already become acquainted with each other and then we teamed up each person with another person who had similar characteristics.
The coordinator suggested family relationships as the topic for that day's discussion and everyone agreed. Some participants told how their family members used their diseases to escape from daily responsibilities, that is, how they felt doubly weary: due to the care itself, stressful from dealing with a patient oftentimes inaccessible and incomprehensible and also, as they defined it, to be always available as a provider, responsible to solve all the patient's problems, without being considered as a person who also has problems and difficulties. The discussion got more interesting when we discussed living in the family, leisure and social relationships. We ended the activity with the reading and distribution of a message whose title is It all depends by Charlie Chaplin.
There were three participants in the third meeting. The coordinator initiated it asking whether the message distributed at the end of the last meeting had any meaning for them and whether the meetings were helping them somehow. Two participants reported they read the message whenever they felt sad in order to become patient and to have hope. All of them explained how they had passed the week and the difficulties they had to deal with concerning family conflicts and tensions, already very common in their daily lives.
The meeting was ended with a dynamic activity in which all the members participated using a piece of paper on which we asked them to write down their difficulties, sadness, anger, anguish and bad feelings/experiences, and then to crumple the paper while thinking. Then, we asked them to carefully open the paper and observe how marked it got; those marks would not go away and we understand that we are like that paper because all events in our lives leave marks in our history and we learn how to deal with difficulties. With time we collect many marks but they can become milder. Finally, the coordinator read a poem to close the meeting and we hugged each other affectionately and parted.
In the last meeting with four participants, the coordinator asked how the participants were feeling. One lady reported her weekend was turbulent and she was exhausted, another expressed her sadness and feelings of guilt for getting out of control to the point of becoming aggressive with her child, which consequently generated sadness and additional suffering because she acknowledged how inappropriate her behavior was. Everyone reported his/her search for help and support, most of the time with a family member or religion, in order to cope with difficulties.
To close the group activities and curricular practice, the coordinator implemented the same web of string technique used in the first meeting, only that this time a flower was tied at the end of the string. The objective was to wish something good to their fellows offering them a flower. After a web was formed, the coordinator ended the meeting reminding them of its possible meanings: support, help, and solidarity, so necessary to life.
Right after that the observer read a message entitled Valuing the differences. After the reading, she sang and played the song: Tocando em Frente [Moving Forward] by Almir Sater. Everyone was touched by it.
In the farewell and conclusion of the activity, all had the same feeling: even with different meanings, the group was an opportunity to express feelings, share experiences, to show solidarity and learn. For students, it was an enriching and innovating learning experience, an opportunity to become familiar with the experience of having a relative with a mental disease; given the group composition, solidarity was generated between students and family members and among the groups. The family members perceived themselves as people who helped each other by listening and talking about their lives.
In all meetings, and especially in the last one, the family members reported the comfort they felt from the simple fact that someone was listening to them, not as usual, such as when they report the problems and routine concerning their relatives' treatments, but because the professionals valued the problems they faced that result from living with a mental patient. They were embraced while they waited during care delivered to the CAPS users. This activity was held in a small space but was significant for their personal valorization and self-esteem recovery, which are so crucial for them to continue to be caregivers to individuals with mental disorders.
The need to include family members in the CAPS work dynamics, a practice already widespread in psychosocial care (3) , was also indicated for this service considering its need to increase the mobilizing nature of the service for all its members -professionals, family members, students and professors -as subjects that promote health and life (13) .
The group experience reported here represented an important achievement and innovation for the development of competencies in professors and students, since CAPS, which is the field of the course practice, imposed significant restrictions on the proposal as it was initially planned. However, understanding the limits not as an impediment for learning but as a reality to be faced with the arsenal of professional experience, academic knowledge, intellectual autonomy, communication and self-criticism articulated with creativity and the initiative of students, professors and students, the students constructed a strategy to overcome conflicts and adopt innovative experiences significantly important for acquiring competencies in mental health nursing education (8,10) .

CONCLUSION
The reported experience was important for undergraduate nursing students to acknowledge that nurses, members of the CAPS team, need to quality themselves to plan and implement groups as strategies in psychosocial health care and include family members in the therapeutic projects of patients.
Coordinating groups was a theoretical-practical exercise that required study, acknowledgment and development of new skills and from this perspective, it was an innovative experience for nursing students, who traditionally have few experiences in the development of competencies to address groups during their educational program, primarily focused on individual clinical care.
The experience enabled theoretical-practical learning of all the stages in a therapeutic work with groups: acknowledging the need/possibility of activity, planning, coordinating group and evaluating results.
Even though it was an occasional activity limited in time, students and professor reflected upon this experience, which contributed to the constitution and organization of a group of students given the task to be performed -the waiting-room group with the participation of family members -and to establish bonds during its implementation. Thus, the group was simultaneously experienced and studied in its various aspects and incorporated into the work, education and nursing care processes.