O grupo operativo como instrumento de aprendizagem do cuidado por mães de filhos com deficiência

Objetivo: Comprender los significados atribuidos al grupo operativo por madres que cuidan de hijos con deficiencia. Metodos: Estudio de abordaje cualitativo, con ocho madres participantes de grupos operativos, cuyos hijos son acompanados en un programa especializado, de Minas Gerais. Los datos fueron recolectados en 2013, en entrevistas con cuestiones abiertas y presentadas al analisis de contenido, siendo interpretados a la luz de Pichon-Riviere. Resultados: Del analisis emergieron las categorias "Espacio de acogida, intercambio y resignificaciones" y "Estrategia inductora del cuidado de si misma y del hijo". Los resultados demuestran la importancia del grupo en el cotidiano de las participantes, lo que evidencia el valor que esta actividad educativa agrega a la experiencia de cuidado de estas madres. Conclusion: El grupo operativo constituye un instrumento de aprendizaje de cuidado, lo que muestra la necesidad de que los servicios de salud inviertan en actividades grupales para cuidadores de personas con deficiencia.


INTRODUCTION
In the current society, unlike in other historical moments, there is a movement in favor of social inclusion for people with disabilities.This may be associated with the expansion of the democratic vision for the rights of all citizens, including individuals with disabilities 1 .
From the perspective of the social microstructure, the birth of a disabled child predicts a complex and unpredictable event in the family context.The impact of such news can leave deep marks on the family, especially on the mother and father, significant others directly related to the child 2,3 .
The fact of having a disability makes this child need a differentiated aid for carrying out activities of daily living, being such a commonly transferred task for their family caregivers, who go through a process of reconfiguration of their lives as a result of the child's care needs.It is known that the function of caring for people with disabilities is significantly performed by a family member, who assumes the primary caregiver role, a responsibility that implies dedication of more time to the child 4 .
In this context falls the mother, who usually takes care of the child.The impact of disability is experienced as a painful process and one of many conflicts for this mother, who initially feels unprepared in the face of new requirements of care.Having a child with disabilities represents the breakdown of expectations as to what was intended 5,6 .Having overcome the early stage, the mother commonly transposes the first disability-related obstacles, seeking to restore the emotional balance that allows that child to be raised in society 7 .
The challenges will arise over the years for the family, especially for this mother.National and international studies show that the network of support to the mother who lives through the experience of having a child with disabilities is restricted, often added to the absence of policies that prioritize approaches to these families, requiring that they cope with the daily task of caring for the child alone 6,8 .A study conducted in Australia revealed that the families of disabled children present complex needs, making it essential to develop strategies to help them in this context, such as operative groups 9 .
The operative group is considered an intervention technique that places the person as the protagonist of their learning process, making them active in the production of their health, in building their knowledge and senses that give meaning to their human experience 10 .
This group technique was theorized by Pichon-Rivière.His ideological matrix transcends gathering individuals around a common goal, with the aim of forming a group centered in an explicit task -such as learning, diagnosis or treatment -and implicitly guided by the subjective experience of the explicit task that is, how each member experiences the group.It also involves a frame, consisting of fixed elements involved in the group process -time, duration, frequency, function of the coordinator and the observer 11 .
The aim of the operative group technique is to enhance the operational capacity that a group has, centering its members in the recognition of their needs in preparation of a project and task performance 11 .As a group intervention tool, it promotes interaction between people and their environment, enhancing the learning experience that is built on this interaction.In this sense, group participants tend to learn to organize and reframe their experiences, feelings, perceptions, emotions and thoughts 11 .
This group technique has been used by health professionals, with the purpose of learning and coping with challenging situations such groups can give to people who participate in them [12][13][14] .In this perspective is the nurse who, among health professionals, by virtue of their training guided by the development of educational competence, is presented as the one who is usually involved in coordinating operative groups, performed with different audiences in different health care scenarios 13 .
One of the contexts in which the group educational modality has been held concerns those who register people with disabilities, still experiencing many challenges to be faced in the fields of health, education, professional training and insertion in the labor market.To help overcome this reality it is necessary that the professionals who care for these patients know the experience of these people and their families, finding strategies that enable them to face daily challenges 15 .
Starting from the assumption that the operative group assists participants in facing these challenges, it is necessary to investigate whether this attempt is identified in the experience of mothers who care for children with disabilities and that are supported by this group technique.
Studies commonly found in literature involving the relatives of those with disabilities have addressed the health needsespecially the psychic order -of families and caregivers 3,4 and the importance of support networks in the care of people with disabilities 5,7,9 .Regarding mothers, evidence can be found on their work on the care of disabled children 5 , but not linked to their participation in operative groups.
A shortage of research findings that reveal the impact of group interventions on the experience of family members of persons with disabilities is evident 16 , therefore, making this gap even greater with regard to the evidence that is brought by mothers who take care of children with this condition and are assisted through operative groups.
Given the above, and considering the purpose of the operative group, the following questions emerge: Does the operative group create a learning context for mothers who care

Mothers of children with disabilities
Oliveira DM, Rena PBO, Mendonça ET, Pereira ET, Jesus MCP, Merighi MAB for children with disabilities?What is the support provided by the operative group to the daily care routine of these mothers?In this perspective, the study aimed to understand the meanings attributed to the operative group for mothers who care for disabled children.

METHODS
This is a qualitative descriptive study with the perspective of analyzing the experience of mothers participating in an operative group.This is considered an intervention technique that places the person as protagonist of their learning process, making them active in the production of their health, and in the building of their knowledge and senses that give meaning to their human experience 10 .
As an analytical perspective for the experience described in this study, the theoretical assumptions of the operative group proposed by Pichon-Rivière 11 were used, which were found in the experience of mothers who take care of children with disabilities assisted by this group technique.
The study was conducted in the Adapted Physical Activity Program (PROAFA, as per its acronym in Portuguese), at the Federal University of Viçosa (UFV, as per its acronym in Portuguese).This program assists individuals with disabilities, drug addicts and institutionalized elderly people, who are assisted in the logic of rehabilitation and socialization, with actions aimed at increasing their independence and autonomy.The PROAFA works with a multidisciplinary team, involving undergraduate students and professionals in the field of Physical Education, Nursing, Dancing and Medicine from UFV.
People with disabilities are regularly assisted in the Psychomotor Stimulation Laboratory (PSL) of PROAFA.They are taken to the PSL by their caregivers who wait for them at the site while the activities are carried out by the program team.The idle presence of these caregivers encouraged the team -in which the researchers of this study work or have worked -to establish operative groups focused on this audience, in order to provide a space for listening, dialogue and care while waiting for their children.
The study included mothers who care for children with disabilities assisted in the PSL and who participated in at least three operative groups.The approach to them occurred when they were taking their children to this laboratory, when the researchers explained the purpose of the research.Those who agreed to participate signed a free and informed consent form.The interviews took place on the premises of the PSL -venue of choice of the participants -on agreed dates and times according to their availability, with an average duration of 40 minutes each.
The testimonies were collected from August to October 2013, through an interview script with the following open-ended questions: What is it like for you to participate in the operative group with caregivers of people with disabilities?As a caregiver of a child with disability, how do you believe the group helps you to face this reality?
The interviews were finished when the study questions were answered and their purpose achieved in accordance with the theoretical saturation method 17 .The convergence of the meanings attributed to the operative group occurred in the seventh interview.In order to confirm theoretical saturation, another interview was held totaling eight participants.
To preserve their anonymity, the interviewees were identified with the initial letter M, as in mother, followed by the number corresponding to the order of the interviews, namely: M1 to M8.
After authorization by the participants, the interviews were recorded and fully transcribed.Data were organized into study categories, based on the main ideas contained in the statements, and analyzed from the perspective of Lawrence Bardin's content analysis technique 18 .
Data analysis was conducted according to the following steps: pre-analysis, material exploration, and processing and interpretation of results.These steps were initiated by a repetitive and attentive reading of the transcripts of the interviews.In accordance with the objectives of the study, significant sections were defined for further elaboration of the categories, which revealed the convergence of the senses that emerged from the participants' testimonies 18 .Interpretation of the results was based on conceptual assumptions of the theory of the operative group by Pichon-Rivière and the literature on the theme.
In line with the ethical standards set by the Brazilian National Health Council resolution 466/2012, the research proposal was approved by the Human Research Ethics Committee of UFV, registered under nº 300584/2013.

RESULTS
The study participants were aged between 35 and 59 years, six were housewives, one was a nursing technician and one was a school service technician.With respect to education, three reported having incomplete primary education and one complete; three had finished high school and one had not.The study group had an average income of two minimum wages.Regarding the number of children, three had two children, four women had three children and one was the mother of four children.All women had a child with disabilities.
The statements of the study participants led to the construction of two categories, which allowed the identification of the meanings attributed to the operative group by the mothers who take care of disabled children, "Embracement space, exchanges and new meanings" and "Inducing strategy for caring for yourself and your child".

Mothers of children with disabilities
Oliveira DM, Rena PBO, Mendonça ET, Pereira ET, Jesus MCP, Merighi MAB

Embracement space, exchanges and new meanings
The participants' statements made it possible to understand that the operative group is configured as a place where mothers feel embraced in the reality they experience.In this space, they perceive being seen by the team beyond social labels -as mothers of a child with a disability -which makes them feel like equals, not as different mothers.Embracement is also perceived by participants as something present among other people who make up the group, creating a sense of security and comfort, which they associate with the representation of a family: I like the group because it embraces us a lot.We feel at ease and it is very good (M4).

In the group we have the feeling of family warmth, everyone comes together [...] (M5).
People here in the group treat you as we are not treated elsewhere.They treat people equally, not differently [...] sometimes we're down, but when we see that the PSL team treats us as equals, we are lifted [.

..] (M6).
Anchored in the interaction with other family members who make up the group and the horizontality of the relationship with the team that leads it, the embracement expressed by mothers allows participants to feel open to sharing experiences.This is guided in the dialogue they can establish with the team that coordinates the group and the people who live the experience of being caregivers for children with disabilities, creating a mutual understanding of the universe:

[...] They always ask for our opinion. [...] They don't take things ready and just show them to us. [...] It really is a group. The team and us working together (M1).
[...] Everyone will be talking, then one will be talking about their life, we will be talking about ours and everyone will be identified.We will give some advice to others [...], because everyone understands (M2).

We have to talk to people who belong with us, who understand us. I have to talk to people who live with us, living the same reality, who know our problems and who can help (M7).
The experiences shared in the operative group produce new meanings to individual experiences, enabling mutual learning that extends into the daily lives of mothers who care for disabled children:

You learn that you can live better with the problem we have [...] sometimes I am very stressed and I remember the group, where I learn many things that help me in the day to day (M6).
In the learning universe that supports mothers in their everyday, another important representation of the operative group in their lives emerges, in which it is understood as a space that helps in the care for themselves and their child.

Inducing strategy for caring for yourself and your child
The operative group is seen by mothers as a care storehouse.One perspective brought in their speeches concerns the dimension of care itself.In this sense, the group allows to see themselves as beings that need to be looked after by encouraging self-care:

The group helped me to see many things in my life, that once I left aside [...] for example, think of me, have some time just for myself [...] (M5).
What is good in the group is that it addresses the selfesteem of people, they are not only concerned about health but also about physical appearance, which we forget a little [...] it shakes people in order not to forget [...] that it is important we take care of ourselves (M8).
On the other hand, the operative group is also evidenced by the participants as an important support in the direction of care for the disabled children.In this perspective, it is understood by the mothers as a mediating space for care, in which the overprotection and victimization generated by the deficiency gives rise to looking out for the child's potential in order to lead to a greater degree of autonomy and independence: I used to treat him differently.I felt sorrier for him.Now I don't feel sorry any more.I think this is good for him.[

...] I can't treat him as fully equal to my other son, but I do not do whatever he wants me to as I did before (M2).
My daughter had some crazes, but for me they were just crazes.Through the group, it was said that they may cause harm in her life.So today when she does these

Mothers of children with disabilities
Oliveira DM, Rena PBO, Mendonça ET, Pereira ET, Jesus MCP, Merighi MAB things and hides them, it's because I call her attention and before I did not (M1).
In the group I learned a lot, gained more strength [...] learned to understand better and cope better with it [...] cope better with the situation [...] things that I helped him in day-to-day tasks, today I do not help (M6).

DISCUSSION
By bringing to light the meaning of the operative group for mothers who care for disabled children this study made it possible to identify this important therapeutic tool and learn the experience of mothers who participated in groups in the study setting.
It was possible to understand the emergence of an explicit task -the implied learning in the care of a child with disability and herself -and an implied task, with respect to how each parent is internally organized to carry out this care dimension, enabling, through this process, successive resignifications of their care experience.
These tasks, together with the embracement from the group members and the link established between the participants, are principles that support the ideology of the operative group.The bond is expressed in the interaction among the group members and between them and the group coordinator, setting up twodimensional and three-dimensional mechanisms, respectively 11 .
The results of this research show that these principles of the operative group made their presence felt in the experience of the participating mothers.The group context was expressed as a mediating space for embracement practices, bonding and listening, by giving priority in their approach to sharing among members who live similar experiences and the team that coordinates the group.
Thus, the operative group helps everyone to organize themselves internally and to mobilize themselves through group interaction, which enables learning and dialogue about the experienced and shared challenges, favoring the process of coping with the situations experienced by its members 12 .
The task forms the path taken by the group to achieve its objectives and relates to how each participant interacts, based on their own needs.The sharing of these, around the group's common goals, forms a common thread for flexibility, decentralization and the possibility of openness to what is new 19 .
The group participants interact through feelings of belonging and relevance, which unites them around a task and a common goal.The relevance, regarding the perception of the members as to centering tasks 11 could be identified in the daily life of mothers who, even absent from the group context had remained focused on care that creates new meanings, supported by cooperation built in the operative group.
The relevance was also present in the statements of participants by expressing the feeling of identification with the experiences of other mothers in the group, who played an important role of mutual support to reframe the experience of caring for a child with disabilities.
Learning in a group means that, in the educational activity, concern is not given only to the product of learning, but to the process that enabled the reinterpretation of experiences 11 .This process is guided in the dialogue between scientific knowledge and experiences of the participants, valuing each as a way of teaching and learning, resulting in a collective construction 20 .
In this context, it is evident that bonding, relevance and belonging were translated in the discourse of mothers from the dialogic and horizontal relationship between the group's coordinating team and other members, leading to the emergence of a collective sense for the group experience.
The respondents made use of a collective language to refer to learning in the group and contact with other mothers, understanding that these experiences are common among them, since they refer to a shared experience -the care of a child with disabilities.Studies that deal with practical operative groups claim that the appreciation of unique experiences has the potential of reframing collective experiences, while socialized in the group context 13,14 .
Despite the conflicts and disagreements that may originate from the operative group -because of differences among people that make it up -the exchange of experiences among the participants forms a positive aspect.This is due to the fact that the group enables people to deal with their singularities, building a dynamic collective learning mediated by the group experience 21 .
It was evident in this study that these new meanings are given expressively in the mothers' caregiving dimension, both to them and to their children.Based on the group experiences, the action of taking care of a child was rebuilt in the daily lives of participants who concurrently recovered their self-esteem, giving power to self-care, which was previously in second place due to the care of the child.
Another study on operative groups reported that they help to improve the complexity inscribed on lived experiences, based on a perspective of exploration of emotions, feelings, knowledge and practices at the individual and group level.Moreover, on the premise of a critical reading of the reality, groups enable a process of changes and readjustments by the participants in situations that triggered negative behaviors in them, thus contributing to the improvement of care and self-care 13,14 .
In this regard, it is worth noting the strategic role of health professionals, including nurses, in order to enable the caregiver dimension present in the operative group.They should act to enhance the group space as a place of openness and dialogue among its members, so that the care experience emanates from the group itself and reverberates in their daily lives, managing changes projects and reinterpretations of living 14 .By bringing this discussion to the universe of mothers interviewed in this