SciELO - Scientific Electronic Library Online

 
vol.7 número3El cuidado a los usuarios de un centro de atención psicosocial alcohol y otras drogas: una visión del sujeto colectivoActitudes de las embarazadas e de la población general respecto al uso de sustancias psicoactivas durante el embarazo índice de autoresíndice de materiabúsqueda de artículos
Home Pagelista alfabética de revistas  

SMAD. Revista eletrônica saúde mental álcool e drogas

versión On-line ISSN 1806-6976

SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. (Ed. port.) vol.7 no.3 Ribeirão Preto dic. 2011

 

ORIGINAL ARTICLE

 

The group concept according to mental health and psychiatry nurses1

 

Concepto de grupo en la percepción de enfermeros en el área de salud mental y psiquiatría

 

 

Luciene Simões SpadiniI; Maria Conceição Bernardo de Mello e SouzaII

IRN, M.Sc. in Psychiatry, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, SP, Brazil. E-mail: luspadini@hotmail.com
IIRN, Free Lecturer, Associate Professor, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, SP, Brazil. E-mail: consouza@eerp.usp.br

Correspondence

 

 


ABSTRACT

This study aimed to identify, among nurses in the Mental Health network in a city in the interior of São Paulo State, their understanding about the "group" theme. A qualitative, descriptive and exploratory study was developed. Twenty-six nurses participated. The data were collected by means of individual interviews. For data analysis, thematic analysis was used. Some of the nurses define group as a therapeutic modality; others relate it with multi-professional meetings; and still others even relate the concept with group coordination. This theme lacks a better approach, both in care and teaching, with a view to the appropriate application of this resource as a source of nursing actions.

Descriptors: Nursing; Mental Health; Psychiatric Nursing.


RESUMEN

La finalidad del estudio fue identificar entre los enfermeros de la red de Salud Mental de un municipio del interior del estado de São Paulo la comprensión que tienen sobre grupo. Estudio cualitativo del tipo descriptivo-exploratorio. Fueron 26 enfermeros los participantes de esa investigación. Los datos fueron recolectados a través de entrevista individual. Para análisis de los datos, se utilizó el análisis temático. Algunos participantes definen grupo como una modalidad terapéutica; otros lo relacionan con reuniones multiprofesionales, y además hay otros que relacionan grupo con la coordinación de los mismos. El tema carece de un mejor enfoque, tanto en la atención como en la enseñanza, con vistas a la aplicación apropiada de ese recurso como fuente de las acciones de enfermería.

Descriptores: Enfermería; Salud Mental; Enfermería Psiquiátrica.


 

 

Introduction

The term group is recent and has similar vocabulary in different languages, with several origins. According to linguists, the Italian term groppo comes from the German work kruppa, meaning round table; while the French term groupe comes from the Italian groppo or gruppo, as a technical term for fine arts, indicating several individuals painted or sculpted comprising the idea of circle, designating the gathering of people(1).

A cluster of people consists a group, a cluster of groups consists a community and a cluster of communities that Interact represents a society. An individual spends most of his/her life living and interacting in groups, therefore the knowledge and use of group strategy becomes important for studies in human relations(2).

The definition of group is vague and imprecise, since it could be a group of two or three people, as well as a family, a gang, a class or therapy group(3).

Group, however, it is not the sum of people, but an entity with its own specific mechanisms, and with laws, and all the members are united to reach a common goal(1).

There are two types of groups, the primary and secondary. The family would be an example of primary group and school, work, institutions examples of secondary groups. In groups, each being finds his place, a role in which constitutes their way of being, in this space, they perform such role according to each one's history(4).

The main difference among groups occurs in their purpose, that is, what they were created for. Te groups can be divided into two generic branches, operative and therapeutic. The operative can have several applications, including therapeutic, even if the psychoanalytic approach is used exclusively. The operative groups involve the following fields: teaching/learning, institutional (companies, church, associations, schools, army etc.) and community - mental health programs(3,5).

The psychotherapy groups are the ones with exclusive psychotherapeutic action, that is, those that enable the participants, acquisition to insight in their own unconscious aspect as well as the group's. There are several approaches to work with groups with exclusively therapeutic means, for example, psychodramatic, psychoanalysis, and from the systemic theory, cognitive-behavioral and multiple approaches.

Regarding the group modalities that may be used by nurses, there is the operative group, which has its goal focused in a task that might be learning, the difficulties, the cure, the diagnosis and others.(6).

In the field teaching/learning, the operative group has been used as technique to work with small groups of students using the Pichonian theory reference, which opens the possibility for constant re-thinking and fundamentally, of remaking the teaching practice, incorporating students and teachers as critical and creative subjects that have the ability to transform the every-day(7).

As for the self-help groups, it is a modality of the operative therapeutic group and consist in groups of spontaneous people formation that identify themselves with each other by similar characteristics. The therapeutic use of self-help groups deserves attention, for its efficacy as well as large scope of application and expansion(2). The self-help groups are organized around a common experience, that may or may not receive assistance from a healthcare professional, like a nurse, however, they are operated by their members(8).

The waiting room group modality, usually, is used to fill the idle time of people that are waiting for assistance or by the family member that is being taken care of at healthcare services. In the institutions that offer free psychological care, this service is being requested even more. Therefore, the need is evident for new solutions for this clientele.

The main objective of groups is to help their members to face life's stress, since the focus of these types of groups are in the thoughts, feelings and dysfunctional behaviors to which emotional support and critical information are offered to increase the capacity of their members, to face and solve problems, reinforcing the support system among patients(8).

The groups in the services of clinic, outpatient and in hospital context are lead and organized depending on several situations.

A study made in a day hospital reported that community groups are lead by principles of therapeutic community, known as spaces of reflection on the treatment offered. The contents are focused on the disease and its psychosocial repercussions. The same authors describe how the group is perceived by the participants, reflected as an integrating and enabling space for the new(9).

Clinics, in mental health services, offer group therapy as one of the modalities. The resource is justified because it saves time, productivity demand, the need to decrease long lines; however it is necessary to assess its adequacy towards indicating this modality to the user. Research data show that the proposals of psychotherapeutic services in mental health clinics has been little effective, resulting in high rates of dropouts, re-admittance and chronification(10-11).

Depending on how it is led and organized, the group resource can be used in several situations and for several objectives, improving considerably the quality of life of people in their relationships, family, workplace and society as a whole(12).

Considering what was mentioned above, this study had the objective of identifying, among nurses of a Mental Health and Psychiatry network in a city of the State of São Paulo, their comprehension on the group thematic.

 

Methodology

It is a qualitative study of the descriptive-exploratory type. The theme of this study, concept of group in the perception of nurses in the Mental Health and Psychiatry area, was extracted from the master degree dissertation titled "A inserção do enfermeiro no contexto de Saúde Mental: o trabalho com grupos." The data was obtained with individual interviews only after permission granted from the nurses, following the conditions of Resolution nº196/96, of the National Health Council, regarding research with humans(13) and, after permission of the Clinical Hospital's Research Ethics Committee of the School of Medical Sciences of Ribeirão Preto - University of São Paulo, and signed and informed consent form by the participants, as well as permission by the study locations. For data collection and interviews, a previously elaborated script was used with a few guiding questions, one of these questions were: what does group mean to you?

The interviews were made in a single meeting, in a private room at the institutions, with pre-established date and time. They lasted an average of 15 minutes; they were recorded and later transcribed in full by the researcher.

The interview is a procedure used in field research where the researcher tries to obtain information contained in the speech of the social actors. It is inserted as a way to collect data of correlated factors that experience the reality that is been investigated(14).

The participants were 26 nurses from the Mental Health and Psychiatry network of a city located in the countryside of the State of São Paulo and this network comprised of outpatient, partial-admittance and full admittance services.

After collecting the data and transcribing the interviews, the material was organized and read as many times deemed necessary, identifying the themes from the interviews. Then, they were analyzed according to the objectives of this investigation.

The analysis of the collected material, in the qualitative research, must be made with three distinct purposes: identifying and knowing the information, confirming or denying the research's conjuncture, and third increase the knowledge on the studied issue(14).

To classify means to organize or sort a series of different data of classes; or the entire studied universe, divided into parts, clustering data in the categories that are going to be analyzed(15).

The analysis and discussion of the data were based on the steps proposed by Minayo(14):

1-sorting of the data - gather all the material, that is, organize the data (beginning of the classification);

2-classification of the data - exhaustive reading of the transcribed contents of the interviews; capturing of the central ideas and establishing the empirical categories of the study;

3-final analysis - articulate the theoretical and empirical material of the research, guided by the objectives of the investigation.

To elaborate the themes, exhaustive reading of the collected data was made; and analysis of th themes that emerged from the interviews, related to literature revision and the objectives of the investigation. In this study, an outline was traced, focusing on the theme "group concept".

 

Results and Discussion

From a total of 44 nurses admitted in the network, 26 (59%) agreed to participate in the research. All the interviewees are currently participating or have at some point participated of group activities in their network. Of the subjects involved, 15 (57.7%) are in the schedule of professionals in units of full admittance, nine (31%) in outpatient services and two (7.7%) in partial-admittance services.

From the 26 nurses, 24 are female (92.4%) and two are male (7.6%). Their age varied from 24 to 52 years old. Analyzing the education institutions their degree came from, 15 (57.7%) concluded nursing undergraduate course in public school and 11 (42.3%) in private schools. As for the year of graduation, it varied from 1979 to 2003.

Regarding the function of the nurses in the groups, six (23%) claimed to be group coordinators; six (23%) co-therapists; two (7.7%) observers and 12 (46.3%) claimed to be participants in the groups of psychiatric and mental health services.

It was analyzed how the nurses have comprehended and conceptualized "group".

It was observed, in the obtained results, several conceptions of group pointed out by nurses of mental health and psychiatry services. The participants of the study, mostly, define group according to what is seen in several theoretical references about group. Some define group as a therapeutic modality; others relate them as multi-professional meetings to improve the provided assistance and other, relate the concept of group with their coordination.

One of the interviewees, in conceptualizing group, referred to a cluster of people gathered with the same objective, as seen the testimony. "....group is a cluster of people that have the same objective" (E3).

The concept of group mentioned above differs a little from the conceptual approach referred by some scholars, in which groups are formed when the members have an objective in common and not only the same objective(3).

There is a distinction between group and clustering per say. It is referred that in a clustering of people the same space and interest is shared, however, there is no bond between them. After a certain situation occurs, the group configuration can modify and the people consist in an interactive workgroup. The authors mention that the passage from a cluster to a proper group consist in the transformation from having common interests to having interests in common(5).

What separates a cluster of people from a group would be the human system that builds around group interaction, performing equivalency between group expressions and human systems(16).

Other interviewees, however, presented their testimonies of group conception as people gathered with objectives in common, differing themselves from the one cited above. "Are people with an objective in common... that gather with objectives in common (E8). "Meeting of people with the same objective...seeking a common work..." (E4).

The conception of objective in common, or shared objective, has in itself the idea of that entire cluster of is people capable of recognizing itself in its particularity, and at the same time, making an interactive effort towards reaching this objective(16).

The nurse expresses the relation that must exist in order for a group to be characterized as a group. In this testimony, despite the subject using the term "cluster", expresses and confirms that, in order for a group to exist, there must be a relation between the people, and therefore, moving towards the concept of human system by Osório(16). "Group to me, is when people cluster with the same objective and have a relation between them"(E15).

As for the concept pointed out by another nurse, about group, his quote is close to the conception of group cited by a scholar in this theme, when the authors state that the definition of group is vague and imprecise, it could be the clustering of two or three people, as well as a family, gang or class(3). In this same statement the matter of an objective in common was approached. "It is every activity in which more than one person, more than two persons gather to discuss and reflect about specific problems... search something in common" (E6).

In another interview, a nurse while conceptualizing group, made reference to the location where the patients meet and the determined rules of a group, as seen as follows. "... group to me, is the location where the patients meet... where there are some established rules..." (E10).

The set of rules forms the group setting, which would be an important technical recommendation to establish and preserve the group. The setting, would then be the sum of all the procedures that organize and enable group functioning, result of a conjecture of rules like, for example, the location of the meetings, the schedule, the frequency, vacation plans, the fees and the average number of participants. The main elements to be considered in configuring a group setting are: if the group is open or closed, homogeneous or heterogeneous, if the duration in limited or unlimited, number of participants, group type and purpose, duration of each meeting, weekly or monthly meetings(2).

Another interview presents the subjects mentioning the term gathering of people. "... I think it is a gathering of people..." (E18).

It is worth mentioning that there must be interaction between the members of the group to be characterized as such. A group is not merely the sum of individuals that are gathered around an objective in common(3).

Other nurses, in conceptualizing group, referred to the importance of the coordination and the multidisciplinary team in solving issues related to assistance, and the group as a therapeutic modality.

In the following statement, the participant makes reference to the coordination in his conceptualization. "... if there is no coordination it is a not group" (E7).

A group, however, can function without a properly assigned coordinator, for example, in self-help groups, in which people with the same characteristics meet to help each other, and in this case, there is no need for a pre-established coordinator.

Self-help groups have the characteristic of been groups of spontaneous formation of people that identify themselves by similar characteristics(5).

Still, regarding self-help groups, these groups are organized by a common experience among their members; and they might or might not receive assistance from a healthcare provider that could be a nurse. However, they are operated by their own members(8).

The authors cited above state that, with the exception of self-help groups, the other types of groups need coordinators, with preparation and competency to perform this task.

The role of group coordinator is to organize with someone the thinking, feeling and acting of an articulated setting; and is not compromised emotionally by the group situation, but it is not neutral, lives and feels with the group, offers psychological help, shelters needs(17).

The coordinator attributes are an integral part of the technical basis. Besides the knowledge from studying, skills (training and supervision) and attitudes (psychoanalytical treatment) are indispensible for a good group functioning(2).

Regarding the conception on a multidisciplinary team to solve issues connected the assistance the subjects made for their conceptualization of group, are the following statements. "A group is everyone working together, tracing ideas to improve the sector..." (E19). "I think is a meeting with several people, of several professions..." (E12).

Team meetings are essential for a good development of the assistance provided to the users. It is a space of aggregated value within the service of psychiatry and mental health, as far as a work team has a group task focused on the adequate treatment, which would be the objective in common of the team.

Decision making, after long discussions, reflecting on rights and wrongs, the search for alternatives provide elements for the critical refection on a multi-professional and inter-professional work(18).

The team functioning properly, while the group focused on an objective in common, consists in a group modality in the life experience of these nurses in their definition of what would be group, reporting the experience from their workplace.

One participant, in conceptualizing groups, refers to it as a treatment modality. "It is a treatment modality... in which people meet with therapists having specific techniques to treat issues of disease, life and day to day of the patients..." (E4).

The Psychiatric Reform that happened in Brazil during the 70's, takes on group strategy as a treatment modality, in which psychosocial rehabilitation went on to be the basis of a therapeutic project in the treatment of people with psychic disorder.

Group resource is an important strategy in nursing actions, since it favors improvement in the quality of assistance to the patients and their families. In literature study, it was identified that the group modalities most used by nurses in the area of mental health are: the operative groups, the support/help groups and the waiting room groups(19).

 

Final considerations

The results of this study enabled the observation that some of the participants have conceptions that are suitable with literature on groups regarding the concept of group, while others, conceptualizing groups inadequately. For example, when they are refereeing to the specific conceptualization of group, they understand that it must have objective in common, contrasting to some other nurses that referred a group as having common objectives. Still, there was also in the interviews, the definition of group as a gathering/clustering of people.

It was still observed, in relation to conceptualizing group, that the nurses turned to the meeting of a multi-professional team, as been an important venue for improving assistance, and that, when all the members are focused on an objective in common, the team will be established as group, therefore, improvement in the quality of assistance will be possible.

The point of view of the authors of this study is that nurses that work in Psychiatry and Mental Health must be better prepared to work in groups, once this activity is used a lot in the area, as well as investments should be made in teaching institutions aimed at professional training and healthcare institutions organizing assistance groups.

The results point out that the nurses need to be better prepared to work with groups, especially in relation to their coordination, these findings do not differ from the ones found in literature.

In our opinion, this research can contribute so that professionals in health and teaching institutions may reflect upon issues of educating nurses on the coordination of mental health groups, in order to improve the quality of assistance.

The nurse's education to work with groups in the area of Psychiatry and Mental Health needs to go back to the drawing board, since according to some of the participants in this study, for them the specialize, they need to find courses and that takes time; and this time is not always possible or available due to the service requirements and demands of the institution's policies.

The group thematic deserves better attention regarding assistance as well as teaching, so that there is proper application of this resource as a nursing source of action.

 

References

1. Anzieu DY, Martim JY. La dinâmica de los grupos pequenos. Buenos Aires: Kapeluz; 1971.

2. Zimerman DE. Fundamentos teóricos. In: Zimerman DE, Osorio LC, organizadores. Como trabalhamos com grupos. Porto Alegre: Artes Médicas; 1997. p. 23-31.

3. Zimerman DE. Fundamentos básicos das grupoterapias. Porto Alegre: Artes Médicas Sul; 2000.

4. Freire M. O que é um grupo? In: Grossi EP, Brodim J, organizadores. A paixão de aprender. Rio de Janeiro: Vozes; 1996. p. 59-68.

5. Zimerman DE, Osorio LC, organizadores. Como trabalhamos com grupos. Porto Alegre: Artes Médicas; 1997.

6. Escola Politécnica de Saúde Joaquim Venâncio, organizador. Textos de apoio em saúde mental. Rio de Janeiro: Editora FIOCRUZ; 2003.

7. Corrêa AK, Souza MCBM, Saeki T. Transição para o exercício profissional em enfermagem: uma experiência em grupo operativo. Esc Anna Nery Rev Enferm. 2005;9(3):421-8.

8. Lasalle LC, Lasalle AJ. Grupos terapêuticos. In: Sturt GW, Laraia MT. Enfermagem psiquiátrica: princípio e prática. Porto Alegre: Artmed; 2001. p. 695-709.

9. Campos MA, Contel JOB. Reuniões comunitárias em um hospital-dia psiquiátrico universitário: implantação e análise preliminar da experiência. Rev ABP-APAL. 1996;18(4):111-6.

10. Bezerra JRB. Considerações sobre terapêuticas ambulatoriais em saúde mental. In: Tundis AS, Costa NR, organizadores. Cidadania e loucura: políticas de saúde mental no Brasil. Petrópolis: Vozes; 1987. p. 143-69.

11. Ribeiro V, Munari DB. Saúde mental em clientes cirúrgicos: o desenvolvimento de ações de enfermagem através do grupo de suporte/apoio. Rev Bras Enferm. 1998;51(1):147-64.

12. Godoy MTH. Análise da produção científica sobre a utilização de atividades grupais no trabalho do enfermeiro no Brasil: 1980 a 2003 [dissertação]. [Goiânia]: Universidade Federal de Goiás - Faculdade de Enfermagem; 2004. 125 p.

13. Palácios M. Ética na pesquisa em seres humanos. In: Palácios M, Martins A, Pegorano OA. Ética, ciência e saúde - desafios da bioética. Petrópolis: Vozes; 2001. p. 164-75.

14. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Hucitec - Abrasco; 1996.

15. Marconi MA, Lakatos EM. Técnica de pesquisa. São Paulo: Atlas; 2002.

16. Osorio LC, organizador. Grupoterapia hoje. Artes Médicas: Porto Alegre; 1989.

17. Gayotto ML, organizador. Liderança II: aprender a coordenar grupos. Petrópolis. Rio de Janeiro: Vozes; 2003.

18. Campos MA. O trabalho em equipe multiprofissional: uma reflexão crítica. J Bras Psiquiatria. 1992;41(6):255-7.

19. Spadini LS, Souza MCM. Grupos realizados por enfermeiros na área de saúde mental. Esc Anna Nery Rev Enferm. 2006;10(1):132-8.

 

 

Correspondence:
Luciene Simões Spadini
Rua Itapira, 187
Jardim Paulista
CEP: 14090-120, Ribeirão Preto, SP, Brasil
E-mail: luspadini@hotmail.com

Received: June 29th 2010
Accepted: Dec. 8th 2010

 

 

1 Paper extracted from Master's Thesis "A inserção do enfermeiro no contexto de saúde mental: o trabalho com grupos" presented to Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, SP, Brazil.

1. Anzieu DY, Martim JY. La dinâmica de los grupos pequenos. Buenos Aires: Kapeluz; 1971.         [ Links ]

2. Zimerman DE. Fundamentos teóricos. In: Zimerman DE, Osorio LC, organizadores. Como trabalhamos com grupos. Porto Alegre: Artes Médicas; 1997. p. 23-31.         [ Links ]

3. Zimerman DE. Fundamentos básicos das grupoterapias. Porto Alegre: Artes Médicas Sul; 2000.         [ Links ]

4. Freire M. O que é um grupo? In: Grossi EP, Brodim J, organizadores. A paixão de aprender. Rio de Janeiro: Vozes; 1996. p. 59-68.         [ Links ]

5. Zimerman DE, Osorio LC, organizadores. Como trabalhamos com grupos. Porto Alegre: Artes Médicas; 1997.         [ Links ]

6. Escola Politécnica de Saúde Joaquim Venâncio, organizador. Textos de apoio em saúde mental. Rio de Janeiro: Editora FIOCRUZ; 2003.         [ Links ]

7. Corrêa AK, Souza MCBM, Saeki T. Transição para o exercício profissional em enfermagem: uma experiência em grupo operativo. Esc Anna Nery Rev Enferm. 2005;9(3):421-8.         [ Links ]

8. Lasalle LC, Lasalle AJ. Grupos terapêuticos. In: Sturt GW, Laraia MT. Enfermagem psiquiátrica: princípio e prática. Porto Alegre: Artmed; 2001. p. 695-709.         [ Links ]

9. Campos MA, Contel JOB. Reuniões comunitárias em um hospital-dia psiquiátrico universitário: implantação e análise preliminar da experiência. Rev ABP-APAL. 1996;18(4):111-6.         [ Links ]

10. Bezerra JRB. Considerações sobre terapêuticas ambulatoriais em saúde mental. In: Tundis AS, Costa NR, organizadores. Cidadania e loucura: políticas de saúde mental no Brasil. Petrópolis: Vozes; 1987. p. 143-69.         [ Links ]

11. Ribeiro V, Munari DB. Saúde mental em clientes cirúrgicos: o desenvolvimento de ações de enfermagem através do grupo de suporte/apoio. Rev Bras Enferm. 1998;51(1):147-64.         [ Links ]

12. Godoy MTH. Análise da produção científica sobre a utilização de atividades grupais no trabalho do enfermeiro no Brasil: 1980 a 2003 [dissertação]. [Goiânia]: Universidade Federal de Goiás - Faculdade de Enfermagem; 2004. 125 p.         [ Links ]

13. Palácios M. Ética na pesquisa em seres humanos. In: Palácios M, Martins A, Pegorano OA. Ética, ciência e saúde - desafios da bioética. Petrópolis: Vozes; 2001. p. 164-75.         [ Links ]

14. Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. São Paulo: Hucitec - Abrasco; 1996.         [ Links ]

15. Marconi MA, Lakatos EM. Técnica de pesquisa. São Paulo: Atlas; 2002.         [ Links ]

16. Osorio LC, organizador. Grupoterapia hoje. Artes Médicas: Porto Alegre; 1989.         [ Links ]

17. Gayotto ML, organizador. Liderança II: aprender a coordenar grupos. Petrópolis. Rio de Janeiro: Vozes; 2003.         [ Links ]

18. Campos MA. O trabalho em equipe multiprofissional: uma reflexão crítica. J Bras Psiquiatria. 1992;41(6):255-7.         [ Links ]

19. Spadini LS, Souza MCM. Grupos realizados por enfermeiros na área de saúde mental. Esc Anna Nery Rev Enferm. 2006;10(1):132-8.         [ Links ]

 

 

Correspondence:
Luciene Simões Spadini
Rua Itapira, 187
Jardim Paulista
CEP: 14090-120, Ribeirão Preto, SP, Brasil
E-mail: luspadini@hotmail.com

Received: June 29th 2010
Accepted: Dec. 8th 2010

 

 

1 Paper extracted from Master's Thesis "A inserção do enfermeiro no contexto de saúde mental: o trabalho com grupos" presented to Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, SP, Brazil.