Group teaching in nursing / teaching group nursing practices guided by the Pichon-Rivière theoretical framework

To analyze a didactic and pedagogical proposal for undergraduate group learning in a descriptive, qualitative nursing study in which 54 students participated in 28 operative group sessions. Following a proposal for group learning involving interplay among roles (participant, coordinator and observer), data were collected during group meetings and analyzed for thematic content, following the Pichon-Rivière theoretical framework. From the meetings of the operative groups, three categories emerged: “learning group techniques from group work”, “the group in confrontation, reflection and conflict management”, and “recommendations and weak points”. Learning in groups outperformed the traditional model of teaching, and is an important tool in the management of care and nursing teams.


INTRODUCTION
Nursing education is often criticized for how many practices are reproduced based on the biomedical model, through technical teaching that sometimes distances aspiring professionals from more effective care practices based on the real healthcare needs of people.Overcoming this assistentialist approach requires a new view of health care and innovative teaching practices, setting aside the role of duties and moving towards humanized, comprehensive practice 1 .One way to overcome this situation is group and cooperative work in nursing education, by introducing teaching tools that stimulate discussion, critique and reflection 2 .
This study examined the use of operative groups (OGs) to guide nursing practices for group care, taking into account scientific evidence about gains in the construction of the assertive model for nursing, in both health care of people and team management 1,3,4 .There was special focus on interventions in the health-disease process and confronting differences 5 .
Operating groups are a technique based on a teaching--learning process that occurs in interactions with others.The group is guided by collective interest in and attention to the common goal 6 .Capable of mobilizing a process of change, the practice of group nursing care also requires training of coherent individuals, i.e., it requires mediation of knowledge in more dynamic and enlightening education, enabling the construction of subjects that are responsible, reflective and able to work with the autonomy of others 5 .
A major part of the critical and reflective potential of this technology [a] is centered on the development of cognitive, personal, technical, social and political dimensions and on the effects of teaching-learning, discarding of roles and exchanges of operative techniques, in addition to conducting comprehensive, coherent professional training that is committed to reality 7 .The teacher's role is to promote the teaching-learning process, embrace new teaching techniques, and train individuals that are reflective and critical of reality 8 .
Given the above, the present study aimed to analyze a didactic-pedagogical proposal for teaching group technologies to undergraduate nursing students, based on the theoretical framework of Pichón Rivière.To this end, an intervention was carried out in the teaching-learning process in the format of curricular course, which guided the construction of knowledge about groups making groups.

METHOD
This was a descriptive study with qualitative analysis, justified by the need for monitoring and evaluation of curriculum courses on group technologies in the nursing education process.The course analyzed was applied to the seventh period for two undergraduate nursing classes at the Federal University of Goiás (UFG) in southeast Goiás.
The course studied is part of the curriculum of the undergraduate nursing course pedagogic project (CPP), which is based on innovative proposals created in the 2008 expansion project for federal universities.In seeking to respond to the general requirements of the national curriculum guidelines for undergraduate nursing, specifically those that deal with health care, decision-making, communication, leadership and management, the course "groups in health" was created.The proposed course needed overturn the traditional model of education.Thus, didactic efforts were made to ensure that all of the classes would be practical, that students would learn about groups making groups using the OG as the theoretical framework, and that course rules of conduct were specified and guided by an objective contract signed on the first day of class.
In this context, the students merged the roles of apprentice-coordinator and observer, with relay between them; each group session was divided into two circles, one internal (11 participants, two apprentice-coordinators and one teacher-coordinator) and the other external (composed of 13 observer-students).The sessions began with a trigger theme related to theoretical content, and apprentice-coordinators conducted the explanation.This was followed by reading of a report on the previous meeting, consisting of analysis of group movement by the teacher-coordinator based on the observers' notes; the observers opened group discussion.The explicit task was to encourage dialogue between the theoretical framework and students' experiences, considering personal and professional dimensions.
28 operative group sessions were held, each lasting two hours, and all occurred in the first semester of the years 2012 and 2013.The students who met the following inclusion criteria were considered for the study: having completed the courses Mental Health I and II (where they worked on theoretical and practical skills to maximize participation in group techniques, such as therapeutic communication and interpersonal relationship skills), and being enrolled as full-time students and in the course Groups in Health.At the beginning of the course, students were informed that it would be monitored and analyzed for research, and all signed a Free and Informed Consent Form, of which each kept a copy, in compliance with the ethical precepts involving research with human beings.
The data were recorded on digital media.At the end of the course, a focus group was undertaken for evaluation Group teaching in nursing/teaching group nursing practices: Pichon-Rivière Lucchese R, Calixto BS, Vera I, Paula NI, Veronesi CL, Fernandes CNS of the teaching-learning process, with the following guiding question: "How was taking the course Groups in Health for you?What knowledge did you build as a group about coexisting in different social and professional groups?" The recording and notes were performed by two observer-researchers (independent from the observer--students), and participants were from the 2012 and 2013 classes, constituting essential empirical material.Data analysis took place between October 2012 and June 2013 by means of thematic mode 9 content analysis, which consists of "cores of meaning" expressed in subjects' statements.Thus, appearance and frequency have meaning for the analytical purpose chosen.
This analysis involved three phases.The first was pre--exploration of the material by means of thorough reading, which aimed to establish contact with the documents and know the text, seeking impressions and directions.Various readings were performed of all the material, seeking to grasp the main ideas and general meanings.
In the second phase, the record or meaning units (RU) were selected.In accordance with the aims of the research, snippets of the participants' statements were constructed.The RUs were given a reference code with the letter G and sequential cardinal number 1 (in reference to the class of 2012) and 2 (for the class of 2013).
The third phase was categorization, which entailed classification of constituent elements of a set by differentiation and, subsequently, by regrouping by the convergence or divergence of the RUs, constituting categories.
The present study is part of an array study that sought to monitor and evaluate the implementation process of the CPP from 2009 to 2014, as well as to point out its didactic-pedagogical innovations (Protocol 026/2009 of the Research Ethics Committee of UFG).

RESULTS
The group evaluation process was conducted with 54 participants, 49 of whom were female, with an average age of 23 years.All participants participated effectively in the entire group process, as established by the course Groups in Health, which was guided by the coordinating professor.Three categories emerged from the data analysis process: "learning group techniques from the realization of the group," "the group in confrontation, reflection and conflict management," and "recommendations and weak points" (Table 1).
The analysis showed the construction of the concept of groups, group identification as a tool for confrontation and overcoming stereotypes, conflicts and difficulties, in addition to recommending this type of intervention in different contexts.

DISCUSSION
The students appropriated the concept of OG and described the group according to their criteria.The OG is a technique driven by a learning process that occurs in interactions; by expressing themselves and listening to others, students get an opportunity to develop their own questions.The therapeutic factor of the OG is driven by learning 6 .
The group becomes operative when there are people who share the same environment, have common goals and are working collectively to achieve them, set goals and strategies, and focus on performing tasks.In this context, the participants assume and award roles, permitting diverse views and critical performance in real situations, and the collective construction of (de)alienating attitudes, i.e., in the same environment, decisions are made considering diversities and through the provision of group work.These are necessary conditions for the approach in OG, providing a favorable environment for transformation of teaching and learning 7 .
Within the concept of OG, coordinators are identified as group members who facilitate the application of group techniques.They lead the group and are concerned with maintaining a friendly and interactive atmosphere for all participants.They are also attentive to the needs of the group, the progress of roles, and facilitating ideas and reflections, enabling discussion and centralization of topics for more complex research 10 .
Together with observers, coordinators must make a clear and objective analysis of the issues listed by the group's constituents 10 .Observers have an important role in evaluation of interventions in the group, starting with registration and identification of the set of interactions in the group.Their function becomes underactive in the group setting; however, their significant impressions of what participants express are grasped as hidden feelings in statements, characters and non-verbal communication.This rich material, produced by the actions of observers, greatly assists in analysis of OG performance 11 .
Therefore, observers and coordinators must understand their roles in the group in a practical-theoretical approach 11 , in order to apply it as a teaching and learning tool that enables reflection of concepts and personal conflicts.This allows individuals to establish a process of change for resolutions, finding their own way through the reflections that arise during participation in the group.This apparatus of responses to learning is clear when assimilating the building of a bridge of knowledge established in an integrative and positive environment, such as the strategy of overlaying roles of group members 12 .
Group teaching in nursing/teaching group nursing practices: Pichon-Rivière Lucchese R, Calixto BS, Vera I, Paula NI, Veronesi CL, Fernandes CNS Table 1.Categories that emerged from the process of analysis of the research and their groupings of record units (RUs).Goiás, 2012 and 2013

Learning group techniques through making the group
The group in confrontation, reflection and conflict management

Recommendations and weak points of the group technique employed
I've been able to use a mode of therapeutic work...that can be adopted in our professional activity... (G1) I have a problem ... but this can also help someone who has experienced the same or vice versa, as things I don't want to say, but someone else says it, so then that helps her resolve it and also helps me (G1) Taught to be tolerant with each other, that we are allowed to know each other, have to accept others are different, they do not think the same way... it's learning from the differences of others (G2)

Everyone (G1)
The criteria used... go beyond traditional lectures... not here!I guess that this enables a view that is a little more critical about situations and objectives (G1) Reports that could not say, could not listen, others could not accept other opinions, so it was more to resolve inside to then start resolving for others.(G1) Psychology course (G2) I had difficulty at first until I realized that I didn't have to write everything that they said, just the important things...in the end I preferred to be an observer...I learned more... (G2) Above all, we learned to respect ourselves, I believe that we do not lose this ...the respect that we now have for each other will always allow us to listen to others and absorb their life experience a little (G2) A group that has an obvious conflict, because it is a chance to talk, share problems with the group (G1) It was very difficult for a coordinator to have many skills if he was not an observer, right?! It's hard, not everything is easy (G1) It was a period that we started apologizing for the things we had done, began to know each other, I think we had more freedom to talk openly and then cried, hugged, moved, we passed through the moment of outburst... (G1) Every professional path, whether in the hospital or company (G2) I think students are only able to notice/realize if they adopt some theoretical basis... to know the different roles within a group...I was only able to identify... the roles of spokesperson and saboteur, from the moment I knew [the theory] (G2) During the four years what happened in all our conflicts, was that there was a moment when the conflicts exploded, and we just faced each other, and after 3 or 4 months forgot what had happened, and no one else spoke about it, and today I saw that in the group we were able to bring up these conflicts and resolve them, and we managed to come together more through this course (G2) Professionals in the nursing field because there is a very large need, the team needs unity (G1) Learning to listen was very important, to observe more (G2) The barriers that were there before, those obstacles that we put up against each other without even trying... today we resolved the conflicts in the room... now we sit and talk and listen to what others have to say (G1) For the nursing staff, but now... a certain family group (G2) Group teaching in nursing/teaching group nursing practices: Pichon-Rivière Lucchese R, Calixto BS, Vera I, Paula NI, Veronesi CL, Fernandes CNS Continued Table 1.

Learning group techniques through making the group
The group in confrontation, reflection and conflict management

Recommendations and weak points of the group technique employed
Non-verbal language, pay more attention to gestures (G1) ... I think already, when we resolve internal conflicts, we learn to resolve conflicts at work ... we live it here in the group classroom (G2) Doctors, multidisciplinary teams (G1) The role of the saboteur, which was X, when you poke her, I knew she would change the subject, and Y, she assumes a very clear spokeswoman role, today she assumed this role, but I am only able to identify the roles she or others assumed, from the moment learned it in the course (G1) I think any person should do it, because it improves conviviality (G2) The theoretical learning, it was not dull, it was learned during the groups, but it brought this clarification, I think if I now had to teach a class on groups, I could do it (G2) Caregivers of elderly... to exchange experiences (G1) You know I think the most important thing is that when I have to practice [nursing care]... at some time I'll feel lost...I think not only me but also everyone here can lead a group (G1) Some groups to improve coexistence and the LGBT community (G1) The teaching was not the standard we're used to, with the teacher always standing in front talking to the students, and I found it interesting that in the group, the teacher is within the group, so that opens another path for the students, right!(G2) Teachers, nursing department, because it is already separated by little room, by teacher, doctor (G2) The most interesting thing was that we did not need to take a test to learn the course (G1) ... I thought of some people, my sister, my cousin, because they have difficulty listening.. (G1) And everyone learned the material, we know the material (G2) Especially in nursing undergraduate training, learning to live in groups from the beginning (G1) And returning to the logbook, I kept remembering, there were things I cried about, I remember that day... and other days there were things that messed with us, too (G1) Patients with chronic diseases... for difficulty in adhering to treatment (G2) For this understanding, "roles" are understood as defined by Jacob Levy Moreno: the conduct and position of individuals in their network of interactions, considering their individuality and the group context.When roles are assigned, it is understood that they are the roles needed by the group.For example, in the group space, whoever assumes the role of spokesperson is the most sensitive member of the group, able to capture the underlying problems.It is in these movements of assigning and assuming roles that the group fits together and articulates itself 11 .
Thus, the interplay of roles in the group favors the treatment of different contexts and knowledge, promoting plasticity of relationships, the sense of co-participation and autonomy in their own teaching and learning process, and the conduct of relations.In this space, the teacher is the mediator of reflections and discussion, disseminator of knowledge, and organizer of the interplay of the roles of group members 7 .
Sometimes the teacher is the group coordinator, and within the sphere of learning, an essential phenomenon is the assessment that, considering the Pichonian guidelines, closeness to the design of formative assessment was identified in the analysis of data.This is a method that assists in the process of teaching and learning through dialogue between teacher and student, construction of knowledge, helping to identify positive or negative effects, and empowering of reflexive actions by students to put forward hypotheses 13 .
Therefore, formative assessment exceeds normative models, by designating means that oppose this somatic effect, based on strategies to improve teaching and learning methods.In a way, the teacher encourages learners to engage in self-assessment and pursuit of knowledge that goes beyond what is explicit in traditional teaching assessments, establishing diverse learning verification methods for training purposes, such as portfolios, journals and reports 13 .
Among the activities proposed for evaluation of techniques and paths taken by the groups, logbooks provide a report of concepts and values not noticeable during group activities, and are a source of data produced by members during the group process.Logbooks allow members to express their desires, needs, anxieties, feelings and concerns.This process of gain over relations supports subjective and professional enrichment 10 .
In this sense, the operative group seeks to "learn to think" along the lines of problem solving originated and presented in the group space, in the "here and now, with me," and, in this environment of exchange of theoretical and practical experiences, enables inter-relationship of learning 11 .Especially in this context, communication in its various forms and the phenomenon perceived among the research participants was what determined the expression of ideas and training to listen, what they termed "hearing." The students understood that "listening" was not related to auditory physiological ability, but was used in the sense of listening being knowing how to hear.Listening becomes something more complex and profound.From the group point of view, listening is a trigger for analysis because it refers to a hidden, abstract context 6 .
As a key element of analysis, coordinators become fact-finders and listen, providing an approach to explicit conflicts and interjections in the group, which guide discussions and controversy.The development of listening skills within the group creates an effective tool for the resolution of issues relevant to members, who assume their roles, actively positioning themselves in the context 2,6 .
Soon, communication among group members allows the expression of multiple concepts, feelings and identifications, characterized as distributors and triggers of growth and development through the group technique.Personal identification makes the process dynamic and applied, correlating it with projective identification, which is a reference point of training for empathy in the group.These methods are rooted in personal development, integration of participants and identification of desires that are reported in the assessment of the method adopted 14 .
Confrontation in discussions and conflicts in the group is to the group process, both at organizational levels, in a group of proactive or institutional individuals 15 .The students, by undergoing several changes during their adaptation to the routine of the institution, experienced various relationships, such as professional aspirations, that expose them to situations of distress and anxiety.This process causes an emotional overload.Based on this alarming context, undergraduate students need a space for meeting and reflection.On a daily basis, the group provides experience with conflict resolution and development of coping skills 16 .
The dialectic of the movement in the group allowed the expansion of student resources, because of the construction of relationships between the vertical history (of each participant) and horizontal history (of all, interacting) of the group 11 .This creates possible ways to approach differences, contradictions and conflict in all situations.Students perceived group growth and social involvement.The entire process was identified and added to the personal experiences of students.
The operational group technique aims to promote the growth and development of participants, propose common goals for gains, and contribute to actions in the different Group teaching in nursing/teaching group nursing practices: Pichon-Rivière Lucchese R, Calixto BS, Vera I, Paula NI, Veronesi CL, Fernandes CNS life experiences of each individual.Soon roles and learning are enriched, and there is ample knowledge.As employees in learning mode in the area of health, and as caregivers, nurses need to have a comprehensive vision of possible experiences, acting as primary members in the formation and dissemination of ideas and contributions relevant to the group.In this context, nurses lack a reflective approach to forms of care and implementation of techniques aimed at better adherence to and results of care 17 .
Of course, group work is legitimized by the needs of several scientific fields in which group learning techniques are a fundamental and effective instrument to be employed in the social milieu 18 .This intensifies adherence and conflict resolution processes, as well as personal identification strategies, in line with collective action and solidarity.This involves performance of activities demanded by proactive individuals, in the production of a comprehensive and transformative learning space, by contact with others 18 .
Based on the above, the recommendation by students that OG be applied in life, among family members, and in professional training and experience suggests a need to change the quality of current relationships, seeking to broaden the view of others and overcome individualism.
In summary, operating groups become a reference for focus and treatment in multidisciplinary work in a number of areas: as support offered to nursing students during their training 12 ; in the application of research techniques that are essentially ample treatment of study topics 3 , in multiprofessional Family Health Strategy care teams 4 ; and in group therapy experiences [b] for patients with diabetes and hypertension 5 .Operating groups are an existing practice in the field of health, especially nursing, that exhibits employment means in the social realm of OG techniques 7 .
Therefore, it is necessary to formulate and offer techniques that go beyond simple information games and the meanings that professional nurses have in their theoretical baggage.Teaching-learning methods are needed that can be diversified, becoming a means of integration of concepts in a more meaningful and participatory manner, and using more participatory and integrative methods such as group techniques 5 .
In addition to the acquiring the ability to learn and change relationships with other students and fellow protagonists in a given reality, students also undertook self-evaluation and pointed out weaknesses and guidelines for solutions.This teaching model, based on the theory of operational groups, presents innovations in a reality that enables learners to co-participate in the process.
It has been shown that Brazilian educators are fearful of innovations in teaching and learning, indicating a need to reform learning in professional training courses.Thus, there must be concern with content and means of helping students combine their psychic, social and physiological resources, as result of creativity, with a view to the improvement of pragmatism in individuals 8 .The presentations of mobilizations reported by the participants in the course indicated that the OG promoted the combination of cognitive, biological and social skills of the participants, representing significant learning.

CONCLUSION
The experience of participating in an OG course enabled students to both know and learn the technology.Of course, other dimensions were identified: cognitive (obtain the ability to build arguments, deal with problem situations, and develop proposals, suggestions and projects); staff (reflecting on oneself and family relationships); technical (grasp concepts and reading of the context and learning about group movements); social (change in position with others, building relationships of solidarity and collective action); and political (assuming more effective social roles, building intervention processes in life and being given the responsibility of life for those who will be caregivers in the near future).
The OG technique enabled the awakening of students to future relationships, which tend to be maintained firm for each other.The collective work encouraged the perception of the importance of communication among group members, sensitivity to differences, listening and welcoming difficulties.It was noted that the group was based on a strong connection to the work and was applicable in various areas, especially in relation to the benefits that it could provide for particular populations, teams, organizations or individuals.
The results confirmed the importance of the practice of OG in health for nursing training, in order to act as a tool for intervention and care, both for public health and the students themselves.
Learning in operational groups should be required in order to create a new method of nursing education.Operational groups train students to make judgments, fostering critiques of and reflection on practice, illustrating their importance to employment in health care practice.Training must be comprehensive and diversified, and not look at any one system.The OG enabled the approach to and enjoyment of a real context, based on shared experiences.
However, some limitations of this research must be noted.It was in a context of specific transformations to build a PPC in a reality challenged by the need to innovate, which may add an extra level of yearning to the teaching-learning process.Studies should be undertaken in other contexts, in order to improve the teaching practices of group strategies in the training of nurses.
Group teaching in nursing/teaching group nursing practices: Pichon-Rivière Lucchese R, Calixto BS, Vera I, Paula NI, Veronesi CL, Fernandes CNS It was possible to learn how to mediate discussions, to understand what the other wants to say, to talk, not to talk on someone else's turn.It wouldn't have been so successful if it weren't like this (G1)