STRATEGIES FOR THE DEVELOPMENT OF COMMUNICATION IN AN URGENCY AND EMERGENCY HOSPITAL ESTRATÉGIAS PARA O DESENVOLVIMENTO DA COMUNICAÇÃO EM UM HOSPITAL DE URGÊNCIA E EMERGÊNCIA ESTRATEGIAS PARA EL DESARROLLO DE LA COMUNICACIÓN EN UN HOSPITAL DE URGENCIAS Y EMERGENCIAS

Objective: to identify and develop strategies for improving communication skills in hospital nurses. Methods: exploratory study, with a qualitative approach, type of intervention research. The scenario was constituted by a public teaching hospital, a reference in urgent and emergency care, located in the interior of São Paulo. The investigation took place from November 2016 to March 2017, in which 21 nurses participated. The operative group technique was used to identify and develop communication skills, with a clinical case study as support for the intervention; subsequently, individual interviews were conducted to verify the effectiveness of the applied intervention. Data analysis took place through inductive thematic analysis. Results: seven operational learning groups were carried out, in which the participants, through the intervention, identified collective strategies to improve the communication process, such as: formalized documents; communication channels; meetings; multidisciplinary discussion groups; and the use of information and communication technologies: Whatsapp. After the intervention, the participants applied the strategies raised in the group. Conclusion: the implementation of strategies that can bring improvements to communication in the hospital context should contribute to the unification of information and a better understanding of professionals about their work process, thus promoting transformations in the professional praxis of nurses, as well as in their attitudes, making them encouraged and involved with the institution's ethical and political commitment.


INTRODUCTION
Currently, professional skills have become the target of concerns and attention from health service managers, as well as from the nurses who work in management and care. In this direction, identifying and developing them has become a challenge and focus of interest for all actors involved in the multidisciplinary team, especially in the hospital environment. 1 The nurse, in the work process, assumes and develops care and management activities in a shared way, needing specific skills to guarantee the excellence of the quality of care, 1 as is the case of communication.
In this sense, communication within any health institution must be a competence that seeks success and organizational results. Communication as a basic competence can happen in several ways, among them, the verbal spoken form and face to face, which are the most used. On the other hand, they can be considered insufficient when used exclusively, compromising the objectives of the organization. 2 In this context, it is understood that the result of favorable communication makes it possible to standardize actions, share knowledge and values, in addition to facilitating relations with the internal and external public. 3 Given this note, communication failures can occur due to the lack of teamwork, the lack of training of professionals and the nonuse of standardized instruments for communication, as well as the vertical hierarchy and interpersonal conflicts of the institution. 4 The way communication happens affects human life with respect to interpersonal relationships. Thus, understanding this process, its determinants and its consequences increases the individual' s ability to understand and overcome the difficulties and obstacles related to living in his work environment, since the action of communication is complex and goes beyond the meaning of words. 5 However, there is no interaction without communication, and both are inherent to health care. That is why, when one understands the communicative process, its forming elements and its implications, it becomes more simplified to face the communication challenges that arise at work. 6 In this perspective, it becomes relevant that the communication competence is developed, considering the nurse's work; strategies that promote improved communication can be proposed by managers of organizations, to align organizational objectives and actions of individuals and teams, as well as awakening the feeling of belonging and proactive action. 7 Thus, this study presents the following question: can group learning strategies identify and improve communication skills in nurses?
In view of the above, this study aimed to identify and develop strategies for improving communication skills in hospital nurses.

METHODS
This is an exploratory study, with a qualitative approach, such as intervention research.
The option for intervention research occurs as the researcher realizes that it offers the opportunity to act directly in the field, establishing and creating practices and/or devices that constitute differentiating events, with great potential for analysis. This is a Para identificar y desarrollar habilidades de comunicaciónse utilizó la técnica grupal operativa; la intervención se basó en un estudio de caso clínico; posteriormente, se realizaron entrevistas individuales para verificar la efectividad de dicha intervención; luego se efectuó el análisis de contenido temático de los datos. Resultados: se formaron siete grupos de aprendizaje operativo y, a través de la intervención, los participantes identificaron estrategias colectivas para mejorar el proceso de comunicación tales como: documentos formalizados, canales de comunicación, reuniones, grupos de discusión multidisciplinarios y tecnologías de información y comunicación: Whatsapp. Después de la intervención, los participantes aplicaron las estrategias planteadas en el grupo. Conclusión: la implementación de estrategias para mejorar la comunicación en el contexto hospitalario podrá llevar a la unificación de la información y mejor comprensión de los profesionales sobre su proceso de trabajo, promover transformaciones en las actitudes y en la práctica profesional de los enfermeros y fomentar su compromiso con la ética y la política de la institución.

Char acterization of participants
The characterization of the participants is presented below, as well as the strategies identified as necessary to improve communication skills.
Of the 45 invited nurses, 21 participated in the study, in which three held leadership positions and 18 provide direct care to patients. There was a predominance of female participants (16), demonstrating that the female population in Nursing represents the majority of professionals. 12 Age ranged between 25 and 63 years and the average time of professional experience was 13.39 years, being possible to observe that the longer time of hospital Nursing care gives the nurse corroborates with professional maturity, causing resourcefulness and an expanded critical view in the face of the situations conferred by professional practice. 13

Formalized documents
The nurses participating in the study, within the groups, highlighted strategies that could assist in the development of communication skills with the hospital's administrative staff; indicated that the organization should offer means, as well as formalized documents, so that workers could harmoniously carry out their inquiries and/or information to the top hierarchy about administrative issues. fundamental point considering the situation of subservience/utility that, historically, involves institutional relations. 8 The field of development of this investigation was a public teaching hospital, a reference in urgent and emergency care and located in the interior of São Paulo. The investigation period took place from November 2016 to March 2017. Forty-five nurses working in five inpatient units of the referred institution were invited to participate in the research, including: Pediatrics, Psychiatry, Internal Medicine, Surgical Clinic and Neurology, with invitations carried out by printed letter and electronically. However, of these 45, only 21 nurses participated in the interventions.
The present investigation selected the following inclusion criterion: the participation of nurses in managerial and care positions, exercising their activities for more than six months at the institution, assuming that this period of time would make it possible to identify the skills necessary for their performance. Nurses who were on vacation or other work leave due to health reasons were excluded.
The study started with the application of a sociodemographic questionnaire presenting a script with data on training and professional performance, such as: sex, age and length of professional experience.
For data collection, the operative group (OG) technique was chosen, which is considered an instrument of group intervention with a unit of interaction between participants who are in constant dialectic with the work environment in which they live, that is , the hospital institution, scenario of this research, that build the world and build in it. 9 Such technique is due to the opportunity to involve the participants, enabling the development of their skills and mobilizing four interchangeable elements: trust, cooperation, subjective mobilization and recognition. 10 According to the nurses' sizing of the chosen hospital institution, seven meetings were held using digital recorders to register the participants' speeches. The sessions were organized with the following activities: preparation, presentation of the participants, brief introduction of the theme, explanation of the objectives of the work including ethical aspects, development with the OG technique and, finally, the closing, making a synthesis of the subject at hand. During the group intervention, a clinical case study prepared by the authors was used to instigate the survey and the development of strategies that can assist in the communication process within the organization.
The period of the meetings ranged from 45 minutes to an hour and 30 minutes and they happened in a place made available by the institution, located close to the nurses' work units, to facilitate their displacement for the intervention, being organized according to the periods of work, that is, on duty in the morning, afternoon and night, as well as the availability of each nurse to participate in group strategies. The participants belonging to each operative group were identified by the letter "E" and were numbered in sequential Arabic There had to be notification for everything, there had to be a notification, there was a problem we will notify (e16).
Thus, based on these speeches, it is emphasized that written communication is an imperative need for nurses and formalized documents are more reliable strategies.

Communication channels
Another strategy proposed during the operational groups was the need for the existence of communication channels within the company, free of direct intervention by the head nurse, that is, workers from the lowest hierarchical levels can, through interviews or meetings, expose your doubts and questions to the superintendent, which can be seen in the speeches of the participants:

Meetings
The strategy of holding periodic meetings was identified by the participants, being of paramount importance for solving the problems of daily work. This fact can be observed in the speeches of some nurses when reporting that, in the past, the holding of meetings was very valid, once the workers, while exposing their difficulties, some would be already set, when possible.

Multidisciplinary discussion groups
The creation of multidisciplinary discussion groups was an outstanding strategy among nurses, composed of professionals from the most diverse areas, among them, the administrative sector, doctors, Nutrition personnel, Physiotherapy personnel, nurse directors, superiors and supervisors. It is worth mentioning that this strategy is already being developed and they are receiving feedback with positive results. The elaboration of a report is a formal means of communication between professionals. The nurse is responsible for coordinating and planning the care provided by the team, and must be attentive to all the activities performed by the peers, as well as notify the administrative sector and/or the hierarchy when these activities are below the desired level.
In this regard, it was observed that the development of the operative groups, together with the strategies proposed by the participating nurses, brought benefits to the communication with the hospital administration, as well as providing reflections on this premise in the daily work process of nurses.

Meetings
After the intervention, the nurses explained that the hospital's administrative staff is proposing meetings with multidisciplinary teams, bringing benefits to all sectors of the hospital.

[... ] there is this communication that will now reflect throughout the hospital [... ] So this is improving the processes in the face of these meetings that they are having. Everything is done here when we discuss in a meeting, we do an information dissemination, this is a communication that we do with the team. So, we make this communication with the dissemination of information regarding what is informed to the coordination (e8).
[... ] one thing that I think this management has now brought, which I think maybe comes up against what you are bringing, which is the issue of discussing processes for the institution (e11).
The speeches revealed that the organization is beginning to propose strategies to expand communication with the team, people still haven't felt this impact, but we who are in charge of leadership, we already noticed that there was a difference (e11).

Information and Communication Technologies (ICT): WhatsApp
It should be noted that ICT was one of the strategies that had the most distinction during the operational groups, bringing a fundamental context to the working praxis of nurses in the hospital environment. In view of the relevance of ICTs in the current world, the data brought unique strategies about the use of technology, so that the WhatsApp application came to contribute to the issue of communication through face-to-face disagreements, that is, when used correctly and appropriately, in the case of a hospital organization. There is a group, but there is no headship, right, there is the group of technicians (e15). feel less embarrassed when exposing their needs, their desires or even some criticism in relation to their service, so that they would be attended to without serious punishment.

We have a group of superiors and nurses on
In this sense, it is considered essential that managers and coordinators identify the information needs and the degree of knowledge of their teams, aiming at adapting the language to be used in the multiple communication channels. 17 Still, in the case of other strategies identified in the research setting institution, the multidisciplinary meetings and discussion groups seem to act positively for the nurses' work process. The meeting strategy allows reflection on the importance of relational skills in the nurse's performance, especially observation, listening and communication. Therefore, it is essential to promote spaces where professionals can express their feelings and expose the conflicts that are happening in their work process. 18 In the strategies identified, with the technological advent and the increasing use of information and communication technologies (ICT) applied to the educational and professional scenery, the adoption of devices in the nurses' work process became relevant. The purpose of ICTs is to enable new communication resources, one of which is the communication through the WhatsApp applicative, which allows the exchange of text messages, images, sounds and videos, being widely used in the social scenario. However, as a communicative strategy in health services, there are few studies performed. 19 Thus, what is verified in the use of WhatsApp as a communication strategy is the idea of continuous dialogue. In this sense, it becomes possible to achieve convenient goals about the rapid and accessible communicative approach in a virtual environment, with the creation of specific groups and responses in real time at low cost. 19 Thus, it is worth emphasizing that, in the age of technology, a message can circulate with frightening speed and cause both positive and negative effects. Therefore, messages need to be defined and well prepared, in language accessible to the most diverse audiences. 15 Thus, it is essential to emphasize that the appropriation of technological resources allows nurses to spend time in their activities, optimizing the work process. Hence, the Nursing team must be attentive to the development of competences, that is, knowledge, skills and attitudes, to the use of computational technologies. 20 However, the applied intervention contributed to the joint construction of some strategies proposed by nurses, among them, the meaning of holding meetings to align the professionals' practice. For communication to be successful, therefore, managers/ administrators, as well as employees, must be convinced of the need for multidisciplinary discussion groups, with the manager being the link for building joint thinking among the various social actors in the relationship policy. interpersonal. generating worker satisfaction, which can be associated with discussions coming from the operating groups, with a consequent improvement in this competence.

DISCUSSION
It is known that the use of active methodologies that change learning to daily work, through problematizing discussions, facilitates technical-scientific updating, the creation of teamwork and communication, which are essential to improve the performance of nurses and to fill gaps in educational and investigative practice. 14 Thus, in the hospital, various skills are required of professionals and communication stands out in this study, considered an essential competence in the nurse's work process, from the planning and organization of their tasks to the interpersonal relationship with the Nursing and multiprofessional team.
The concept of communication has expanded in the globalized world, requiring not only basic elements, such as sender, receiver and message, but also aspects such as understanding the content, assimilation and processing of information to incite conscious action and, possibly, transforming, in the life of each and everyone. 15 The field of communication at the intersection with the hospital's internal development exposes a way of reflecting on cultures and their manifestations, including communicational ones, of articulating them in contact with the spatial dynamics of the territory. Communication moves through regional development, detailing trajectories, processes and articulations between culture and communication, built in the daily life of a society that is globalized, highlighting the various possibilities in the way of experiencing time and space. 16 In this sense, the starting point for a communication plan in the hospital organization is the diagnosis and analysis of the situation and scenarios, since the different communication strategies for each of the means to be used would need to be worked on. Therefore, it is necessary to reinforce that they must be contextualized and adapted, depending on the place where they are created and the cultural characteristics of the organization. 15 In this study, strategies or tools that could be used by professionals to enhance communication were highlighted, such as documents already formalized by the institution. In addition, the existence of communication channels between the various professional categories should direct the flow of information on an ongoing basis.
It should be emphasized that effective communication channels are of great value among workers in the same professional category or even in different categories, since the integrated and cooperative channels provide bonds in which the highest hierarchical levels do not interfere in communication with the lower hierarchical levels. Thus, through these channels, workers would The field of communication at the intersection with the hospital's internal development exposes a way of reflecting on cultures and their manifestations, including communicational ones, of articulating them in contact with the spatial dynamics of the territory. Communication moves through regional development, detailing trajectories, processes and articulations between culture and communication, built in the daily life of a society that is globalized, highlighting the various possibilities in the way of experiencing time and space. 16 In this sense, weekly meetings between teams, the transmission of information with feedback and the involvement of healthcare professionals in the analysis of work processes are fundamental tools for achieving effective communication and more team engagement and autonomy. 21 In addition, the guidelines individual meetings and multiprofessional meetings to analyze and study the events that have taken place are fundamental for joint accountability for the rehabilitation of the patient. 22 Therefore, the preparation of a report is a formal means of communication between professionals. The nurse is responsible for coordinating and planning the care provided by his team, and he must be attentive to all the tasks performed by the peers, as well as notify the administrative sector and/or the hierarchy when these activities are below the desired level.
It is observed that the development of operative groups with nurses, together with the strategies proposed by the institution, brought benefits to communication with the hospital's administrative sector, as well as reflections on this premise in the daily work process of professionals.
The study had limitations since it was carried out in a single municipal hospital institution, although this is a reference in emergency care. Thus, other institutions of different legal nature were not considered.
Another limiting factor was the nurses' lack of availability and interest in adhering to operative groups. This can be justified, as it is a reference hospital for urgent and emergency care and where there is an overload of activities for nurses from the selected units, which makes it difficult for them to travel and leave the work sector to participate in the investigation.
In this context, it is emphasized that the greatest difficulty faced by researchers was when professionals approached to participate in the groups, since the concern was to feel absent in their work.
With regard to contributions to Nursing, it is expected that training centers at the undergraduate and graduate levels should be concerned with developing and/or implementing active learning methodologies in their curricula for future professionals, aiming to build with their knowledge, because in the authors' perception, innovation with group techniques scientifically strengthens working praxis.

CONCLUSION
In the reality of the hospital examined, nurses identified and developed and/or improved strategies of communication competence. In this line, the implementation of an intervention proved to be relevant, in order to fill the gaps in knowledge, skills and attitudes of nurses that may interfere in their interaction with the health team.
However, health administrators/managers, from time to time, must carry out evaluations of their professionals through diagnoses of the real situation of communication in the organization's space, since their lack or inefficiency can result in the non-fulfillment of the tasks to be performed developed, compromising the health team's work process.
Faced with a range of obstacles in their working praxis, nurses clarified that they must adapt critically and reflexively, especially in relation to the communication competence necessary for their good professional performance. However, for this reflective action to happen, it is necessary for the employing institution to become aware and support its workers in the constant search for permanent education, so that they are instrumental in improving their conduct.
Given this reason and by dozens of others, much remains to be considered for nurses to really reach consensus on the transformation of working praxis in their competencies. To this end, it is important to emphasize that training centers in partnership with hospital institutions must propose teachinglearning strategies in order to contribute to the development of nurses in relation to their skills, such as dynamics and group workshops; study groups; operative learning groups; elaboration of protocols and forms, to arouse the interest and motivation of his human talent.
Consequently, the development of strategies to improve communication has contributed to the unification of information and better understanding of professionals about the work process, thus promoting changes in their professional practice, as well as in the attitudes of workers, making them encouraged and involved with the institution's ethical and political commitment.