Communication process in the nursing teama based on the dialogue between Berlo and King

Objective: The aim of this research was to analyze the communication process in the nursing team, based on the theoretical approach proposed by Berlo and King, and to discuss their contributions to nursing care. Method: Descriptive qualitative method, developed with 25 members of the nursing team at a hospital-based medical clinic. The theoretical frameworks were Berlo’s communication theory and King’s nursing theory. Results: For nursing staff, communication is expressed in various ways, being something much broader than the discourse itself. The team is consolidated as a social system, which can be influenced by the hierarchy, power and status. Conclusion: The efficient communication among nursing staff members preserves good interpersonal relationships, supporting care practice and making the work more effective.


INTRODUCTION
The health professionals have constant contact with communication problems, which consequently interfere in the continuity, quality and consecution of the work or in the satisfaction of the professionals' needs, so that the work evolves productive and effectively.To develop teamwork, communication is fundamental and acts as a factor of disintegration or integration, depending on how it takes place 1,2 .Communication is another important and essential tool for obtain valuable information to conduct the treatment 3 .
With a view to an effective nursing treatment, it is fundamental to develop skills with a view to the good application of the communication process in nursing care 4 , acknowledging it as an important base for interaction with the client, which should depart from sensitive and empathetic attitudes among the subjects involved in care 5 .Communication is a powerful basic instrument in the care process, aiming for the construction of an effective relationship with the client.Through communication, the nursing team can better understand the needs of the clients, their relatives and the community.It is valued as a component of the humanization of nursing care 6 .
There is no interaction without communication and both are inherent in care, being skills that need to be developed for care to take place.When the communication process, its constituent elements and consequences are understood, coping with the challenges of communication that emerge at work becomes easier.
The way communication takes place affects human life in terms of interpersonal relationships; hence, understanding this process, its determinants and consequences increase individuals' ability to understand and overcome the difficulties related communication in the work environment, as the communication process is complex and goes beyond the meaning of the words 7 , involving gestures and expressions.
The problem that gave rise to this research rests on the fact that the nursing team uses more verbal resources in communication, without privileging the potentials of the process as a whole and its other elements.The authors identify this issue in the empirical sphere 8 .As an example, it is highlighted that non-verbal communication takes place, but that the verbal element is more frequent in team communication; as discussed earlier, however, communication is the base for interaction, whose construction does not only rest on the verbal elements of communication 2 .The complexity of the communication process involves many expression channels beyond speech and needs to be taken into account in the process with a view to broader possibilities for understanding among the team members.
The research is justified because the overvaluation of communication as an instrument to transmit verbal information impoverishes the relation and impedes the valuation of other also very important expression channels for the interaction process.Therefore, knowing the elements of the communication process and what interferes negative and positively for communication to be effective and achieve the objective both interlocutors expect, so as to achieve a concrete and strong relation among the professionals, will contribute to humanized care provided.
Nursing is a team profession, in which its members' activities are complementary.For the same reason, the multiple relations that permeate the communication process in health/nursing care need to be valued and understood and the challenge of being a transformative agent needs to be faced, adopting a practice based on sensitive communication.In that sense, the professionals can better understand their forms of dealing with this object -communication -not only in terms of its relation with the team, but with client care and with the multidisciplinary team.
The objective in this study was to: analyze the communication process in the nursing team and discuss its contributions to nursing care.

THEORETICAL FRAMEWORK
Studying the communication process implies contextualizing it in the light of the channels that make it feasible and considering it as an important base for interaction among people.Therefore, this research uses two theoreticians to analyze the communication process in the nursing team.One is Berlo 9 , from psychosociology, and one Nursing theoretician's King 10 as both discuss the communication process in distinct although not contradictory theoretical fields.
Communication is everything people can use and that makes them attribute meaning 9 .Communication comes with objectives and targets that are to be achieved, so as to produce a certain reaction; thus, "when we learn to express our objectives in terms of specific answers by the people receiving our messages, we have taken the first step towards positive and efficient communication" 9:12 .But for this to happen, attention is needed to human behavior; it needs to be specific enough to relate with the actual communication behavior; communication should be coherent with the midst it occurs in, and logic should be used so as not to be incoherent and contradictory with oneself.
The communication process consists of verbal forms and other human communication forms that do not directly involve words, i.e. non-verbal communication 4 .Verbal communication refers to language and written communication to the sounds of the words issued.And non-verbal communication refers to gestures, expressions, the position towards the other and the surrounding objects, touch and posture.
In a communication process, there are interrelated elements that structure it, which are: source, coder, message, channel, decoder and receiver 9 .Sources and receivers do not act freely, but are influenced by the positions they occupy in the The interaction between Berlo and King  Broca PV, Ferreira MA sociocultural system, besides the personal factors.One needs to know where individuals fit into the social system, their role, functions, prestige, how people see them and their cultural context, such as behavior, beliefs and values.Each of the constituent elements of the communication process contains factors that exert positive and negative influence.For the sake of this article, the following elements were selected: power, authority, hierarchy and status, as these are the theoretical concepts that are most applied to the empirical data produced in the research.
Authority is when an individual in a certain position is able to control other people's behavior; hierarchy is characterized by an authoritarian classification, in which one is perceived as more valuable, important and influential in a group; status is an individual's position in a group, provided that (s)he is perceived by the others in this outstanding role; and power is what is typical or peculiar to someone and can influence the other 9,10 .
The focus of the nursing team's activity is care for human beings and its target is the health of the individuals and the groups they belong to 10 , considering that the human beings constitute open systems that are in constant interaction with the environment.
According to the conceptual structure of interactive systems, the personal system comprises the individual's position in the environment; the interpersonal alludes to the individuals' mutual interaction, and the social system refers to the training needs of organizations that constitute communities or societies, due to special interests and needs 10 .
The personal system is represented by each individual, is related to the particular subject and the way each subject experiences a certain situation.In the interpersonal systems, verbal and non-verbal communication stand out, learning when efficient communication, one-way orientation, irreversibility, dynamism and the space-time dimension are present 10 .
In this system, communication is "a process through which information is given from one person to another, directly in a face-to-face meeting, or indirectly over the phone, television or in writing" 10:74 .As a social and fundamental process, communication develops and maintains human relationships and facilitates the organization of groups and society.
A set of organized interpersonal systems delimited by social rules, behaviors and practices constitute the social systems, which rest on organization, authority, power, status and on decision making of the people in those systems 10 .
The application of this reference framework is justified because both authors acknowledge communication as a process, that is, a phenomenon in constant change over time.In that sense, communication is considered as something dynamic, constantly evolving and always changing in a continuum of time and relationships, containing structural elements that exert influence towards the effectiveness or not of the process.

METHOD
This is a qualitative, exploratory and descriptive research.The field was the Medical Clinic of a public and federal teaching hospital that recommends the alliance among teaching, scientific research and care.In this field, the researcher identified the problem with communication, based on her academic and professional experiences.
The nursing team in the sector consisted of 40 members, but only 25 participated in the research: eight nurses, 13 technicians and four auxiliaries, who complied with the following inclusion criteria: being more than 18 years old, male and female, professionally active during the research period in any shift.The exclusion criteria were: being away from work due to vacation or leave of any kind.Hence, nine were excluded because they were on leave from work.The remaining six did not accept to participate in the research.
The data were produced during the daytime period, between March and April 2010.Team members from both shifts, day and night, participated, as the night-shift professionals complement their workload during the day shift.The data production technique was the semi-structured interview, based on a script with open questions that explored the communication forms and their objectives among the nursing team members.Data were registered digitally.
The head nurse in the sector served as a mediator between the researcher and the research participants.Through this approach, the research objectives and the method were explained so as not to interfere in the dynamics of work.
Thematic content analysis techniques were applied to the data, using the categorization process per box and mile.The first is organized when a previous system of categories has been established, based on the concepts of the theoretical research frameworks that allocate the elements as they are found in the registry units 11 ; the second is organized based on the empirical elements, by proximity and similarity of theme words that give meaning to the participants' testimonies.The category organized per box was: Constituent elements of the communication process and their expressions in the nursing team's daily work, discussed in the light of the concepts extracted from the theoretical frameworks of this research 9,10 .Based on the discussion of this category, it was detected that a concept emerged from the data with a high level of significance, giving meaning to the participants' discourse: the concept of interaction, used to give meaning to the personal system in the team communication process.Then, the empirical category was organized: Convergence between the communication and interaction concepts: potential application in nursing care, which was discussed in the light of the theoretical frameworks applied and of other reference frameworks that served to properly discuss the theme communication.

The interaction between Berlo and King Broca PV, Ferreira MA
The research was undertaken in 2010.Therefore, National Health Council Resolution Nº 196/96 was applied.All participants signed the Informed Consent Form.Approval for the project was obtained from the Institutional Review Board of the hospital where the study was undertaken, under protocol 198/09.The participants were identified using alphanumerical codes, in which the letter N means nurse, NT for nursing technician and A for auxiliary nurse, and the number indicate the order in which the interviews were held.

Constituent elements of the communication process and their expressions in the daily work of the nursing team
Human beings are generally unable to achieve their goals, their objectives without the cooperation of other human beings, as they are interdependent to accomplish their objectives 9 .This relation originates the formation of multipersonal systems, in which two or more people are mutually dependent and need to find means to relate their behaviors with those of the other people to achieve their objectives.
These systems can also be defined based on their organization according to social roles, behaviors and practices developed to maintain values and mechanisms that regulate these actions, as a meeting of groups with special interests and needs 10 .
These research results evidenced the importance of communication in the interactive process to keep the multipersonal system united, as a way to achieve the team objective, which is nursing care.When one has a weak and poor interpersonal relationship, errors may occur in the communication process, giving rise to noise and barriers that lead to friction and difficulties among the nursing professionals, negatively affecting the care offered 12 .
When the information is broken or modified, this can cause the worsening of communication and impair the work.In addition, it is important to respect the members of the system, including the head, and transmit all information so that everything works out during the shift.By respecting the hierarchy, adding up to each member's performance, one is able to deliver high-quality care.

That famous "wireless phone" b [...] And it shows to the team what this can cause, when the information is broken, when it is modified along the road! You can get better, but you can also drop and get worse, definitely! (NT 8)
You know that there is always someone you owe explanations [head], that you should be there, always transmitting everything that is happening correctly, everything with the team.I think it's like that, for everything to work out!Joint communication always works! ( NT 12)   By adding up each person performing his function, we will achieve everything and our goal: which is to deliver high-quality care.Communicating effectively, without communication it's impossible!It's difficult!(N3) These contents reveal the existence of a social system, consisting of individuals with role behaviors, who join to achieve a goal or objective, but with imposed rules and values 9,10 .The social system can consist of two people, provided that they are in an interdependent relationship 9 or by groups 10 , in which care can be provided based on the union of parts in a whole, which can lead to a better integration among the individuals.This relation of interdependence can be characterized by the integrality and integration of the team in favor of the production of health care 13 .
Each nursing team member has a function in the social system, each has an occupation.This relation brings the Role into the system, a concept that, according to both authors who theoretically sustain this research, is related to a specific set of behaviors the individual in a certain position performs.This individual has expected behaviors according to his/her position; obligations and rights, and always a target 9,10 .The Role behaviors are independent from the person playing the role, being imposed by the system, but the individual can influence this behavior, depending on his/her personal characteristics.

I won't deny that the maximum hierarchy leaves you somewhat fearful, you need to take more caution to say what you have to say, take more caution in the message you're going to transmit, it seems that you are "stepping on eggshells" c , you need to take care with what you say. (N3)
With each individual playing a certain Role and performing a certain function in the social system, the relations of authority, hierarchy, power and status are present.Hence, these relations influence actions in the system and communication among people.

You should respect your colleague, not only nursing colleagues, and your own boss. (NT 12)
The language should not be hermetic, but understandable, so that information is transmitted without any doubts for the team.The use of sophisticated words and expressions are not attributes of hierarchy but, on the opposite, instead of valuing the Role of the team members, they impair their interaction and joint work.

The interaction between Berlo and King
Broca PV, Ferreira MA

You always want to be superior, you see? Despite the hierarchy, you always want to show you're on top and use words that are sometimes incomprehensible, people won't understand. (N6)
To achieve the objectives, people get specialized in their functions and, thus, some of these behaviors are perceived as more important than others in the achievement of the objectives, which brings the hierarchy into the system 9 .Hierarchy can be defined as the set of rights attributed to a certain position-role, which permits controlling the behavior of other members in the system.

Here I work in a place that is full of hierarchy, so I have to reach that person, it has to be the head nurse, because she will transmit it to the others, that's how communication finds it course (NT10)
Authority is present in one carrier and needs to be perceived as legitimate by another; it is essential to achieve the target; it is associated with a function performed by an individual and knowledge and experience are important factors to influence the others' acceptance of a certain action 10 .When effective, the communication process can facilitate the legitimacy of authority, as there is a possibility to understand the motives, the feelings, the anguish, the meanings and particularities of each individual, and also to question the shared message 2 .
Individuals in a position of authority need to be specialized and have the knowledge, experience and skills needed to occupy that function and thus exert influence on the other individuals in the system to be able to achieve the target, objective efficient and rapidly 9,10 .This communication needs to possess all elements of a process, be intended to understand the other and be understood, aiming for sharing and integration with a view to an effective relation.The channels established between them can become increasingly problematic, which can affect the nursing care, patient safety and directly influence the treatment, as the clients' participation in the therapeutic process depends on the communication processes, considering that they make possible a relationship of trust, reducing the clients' fear and anxiety 2,4 .
Authority and hierarchy are important in a group, as a leader is needed to guide the work and decisions, so as to avoid disorders.But if these hierarchies and authorities become that strict and impenetrable, the other professionals can hide crucial information about the clients or will only reveal what they believe they would like to hear 14 .These attitudes can negatively affect the nursing care, due to the fact that important information on the healthdisease process were not shared among the team professionals, and thus influence the client's treatment, cure and rehabilitation.
Power is an attribute of one or more people in the social system in terms of the position they occupy 9,10 .Through power, one can influence the others to reach the target of the system, whether due to the authority or personal skills not related to the authority.
When things work out, the trend is not to copy, it's to do the same, it's to try and make that happen always, and I see that a lot among colleagues, some things I do are repeated.That's nice, I think that's nice.(AN3) Status is related to the value the people who participate in the system attribute to a certain position, no matter who occupies it 9,10 .The participants in the system need to feel that a certain position is important and can contribute to achieve the objective.Status can be related to prestige or be accompanied by privileges, duties and obligations 9,10 .
These relations, present in the nursing team, are important to organize the care offered and, therefore, cannot be underestimated or devalued, as the opportunities to have better work environments and nursing care that attends to the individual's true needs can be wasted 12 .In addition, it is important to understand the importance and the elements that permeate the nursing team's interpersonal relationship with a view to enhancing the management communication skills and thus create competences to better cope with individuals 15 .

I talked to a certain employee and he didn't understand it well, then I asked a team colleague, who is also closely linked to that employee, I told him I was having a problem with that employee. I said I didn't know if the employee had understood me, if I had been clear, I asked for his help because, sometimes, he could have other methods the employee would understand, as the person did not understand the method I had used! I saw the result was good! It was good! A strategy I used that worked out! (E5)
As observed, the concepts that structure the personalinterpersonal-social 10 systems influence the effectiveness and fidelity of the nursing team communication process , as they modulate the status of its elements 9 .The difficulties to achieve this effectiveness and fidelity in the communication process can be overcome when the individuals admit them, that is, when they become aware of the need to reassess the channels used to perceive and share the messages and, thus, better disseminate their thoughts and feelings 16 .
Therefore, it is important to acknowledge and consider the other person's work, articulating actions, thoughts, interventions and ideas, which can be achieved through interaction among The interaction between Berlo and King Broca PV, Ferreira MA the individuals, which is provided through the communication process, breaking down the barriers that impede or hamper the relations established among the professionals from different authorities, hierarchies, power and status.
Nursing care adds up several characteristics, including the interaction and the dialogic relation constructed with the other 17 .Therefore, one needs to develop the professionals' potentialso that, in the interpersonal relationship with the clients, they can pay attention to their biological, social and emotional needs through active listening and communication.In that sense, the efficiency of communication among the nursing team members keeps up the good interpersonal relationships with the colleagues and the client, helping them with care and making the work of all more effective.Thus, it is important to tighten effective communication bonds, without impositions, noise or barriers among the professionals, in order to avoid conflicts and contradictions in the information shared about the health-disease process, avoiding any negative action in nursing care that may cause some type of risk in care and, hence, interaction makes the difference.

Convergence between communication and interaction concepts: potential application in nursing care
The communication process involves verbal and non-verbal exchanges and sharing, including feelings and emotions the people can transmit in an interpersonal relationship 18 .Thus, the complexity of the communication process could be evidenced in the research data, when the subjects reported that communication is expressed in different ways, being something much more comprehensive than the discourse itself.

It's a whole language, not only speech, but gesture, everything! It's something very broad, communication!Those are all the forms I have to express myself to the other person. That's communicating! (NT9)
The elements that structure and constitute the communication process can influence it negative or positively and influence the effectiveness of the process 9 .In addition, communication is a complex, dynamic process, evolves, has neither a beginning nor an end and is restricted to two or more people 9 .In this aspect, Berlo 9 and King 10 agree on the importance of communication for the interpersonal system, being dynamic, irreversible or moving forward in time, as something personal expressed through the verbal and non-verbal media.
Interaction is an important element that sustains the interpersonal system, being a process of perception and communication between people and the environment, among people or among groups of people, through verbal and non-verbal means to achieve a target, characterized by interdependence 10 .Interaction is the objective of human beings' communication process, in which source and receiver create a relation of interdependence, that is, one influences the other 9 .
The research participants are aware of the importance and role of communication in the interaction process, to the extent that communication is defined based on the concept of interaction, which cannot be devised beyond the interactive process.

It's interacting with a person, with different people. (NT3)
Communicating? That's you interacting with the environment, respecting the limit of each!(NT4) It's interacting with the team, with the people, having a good relationship!(NT11) In the light of the empirical data and the referred authors, interaction is achieved through communication 10 , being the target of communication among human beings, that is, both authors attribute the same meaning to interaction 9,10 .Through interaction, the human beings influence the way of acting and thinking about the other, that is, a level of interdependence is assumed in the relationship.Through the interpersonal relationships, with the use of the communication process in its complexity, bonds of interaction are created.And this interaction needs to be extended to the clients to welcome them, so as to be able to identify and solve the problems they bring 19 .
The communication process can be a motivational factor for the nursing professionals to work as a team as, when there is effective interaction, one can avoid the emergence of feelings of disdain, insecurity, fear, sadness, oppression and dissatisfaction 12 .Therefore, it is fundamental to tighten, stimulate and strengthen the professional and emotional relationship, so as not to weaken the integration in the team and negatively affect nursing care.Two examples stand out in the registry unit that were considered significant in this discussion: in one, a nurse (4) informs that the stimulus the communication process between her and the team permits was crucial to the success of the intervention and the ability to solve a problem at the hospital; in the other, a nursing technician (12) values the exchange of knowledge and information about the team members' actions.
I have been the head of this service, then there was an outbreak of bacteria, that many bacteria.And I with the staff, giving directions: "Look, we'll do this, we'll do that!"And I tried to lead the team, I worked with the team!Then To achieve interaction among the nursing team professionals, and even in the health team in general, it is important to share and exchange knowledge and experiences with a view to the gradual growth of the interpersonal relationship.Gaining awareness that the relationship difficulties and the conflicts are inseparable from the interpersonal relationships is necessary to overcome the conflicts and for the people to understand that they need to be favorable to the integration and union of the group 20 .

Sometimes you try to express a message to someone, but sometimes you are unable to express that message, to take a stand or, on the opposite, you try to transmit a message and the colleague does not hear you, does not know how to receive that message. (N3)
When the nursing team presents a cohesive, effective, validated and consolidated communication process, the relations established among the professionals can be considered as a motivational factor that drives them to want to be there and deliver comprehensive care.

When we have to transmit information, we sit down and talk. (N8)
Thus, the professional can demonstrate interest in extending that relation to the sphere of client care since, through the communication process, one can know the others, their values, their worldview, identify possible relationship difficulties and even find strategies to mediate the conflicts 4 ; therefore, the professionals may display further interest in knowing the client better and, thus, in attending to their true needs.

I talk a lot [to the client], I think we can always improve and use the opportunity to offer health education. We are disseminators of health. So, we have to use the opportunity and transmit that! And, also sometimes, I let the client blow off steam, talk and I also show that I'm there. (AN1)
Effective communication among the professionals can avoid possible noise and barriers that may cause some incident or even an adverse event and thus, negatively affect patient safety.When communication does not fully occur, it can interfere negatively in nursing care, leading to the loss of important information about the individual's health-disease process, impairing that person's treatment and recovery.
Tightening the communication bonds among the professionals is important to facilitate the relations established with the clients and their families, which remits to teams that work satisfactorily, determine strategies to improve communication and teamwork 13 , which in turn leads to more harmonious and effective nursing care.Establishing better interaction with the client contributes to understand and discover their feelings, doubts, fears and joys.

CONCLUSION
The application of the theoreticians Berlo and King in the nursing team communication process permitted the understanding that this process is complex, dynamic and continuous.The results showed that communication is an important tool for the nursing team to deliver care to the clients, but needs to be efficient among the nursing team members with a view to having an interactive and effective interpersonal relationship and support the care.It was evidenced that communication is an important care tool, serving as an element in the set of actions that contribute to patient safety, especially when the messages are transmitted completely, without barriers and noise among the nursing team members.
Interaction is an important element of the communication process, as the former takes place through the latter.The application of King's concept of open systems permitted understanding the intervenient factors in the relationships among people.This grants access to the best way to conduct the interpersonal relationships and, consequently, tighten the bonds of effectiveness with the client.
Establishing a theoretical dialogue between the concepts of the open systems structure, combined with Berlo's concepts about the communication process and the factors that influence it negative and positively, was appropriate to characterize the nursing team communication process, showing that both verbal and non-verbal expression should be taken into account in the communication process.In addition, in the study, a nursing theory is valued, supporting the art and science of nursing.
This study is limited by the fact that it was applied in a single sector of a single hospital, without reaching all members of the field team.The study should be replicated in other fields with a larger number of participants.