Model for the systematic implementation of therapeutic play in pediatric hospital units^a

Abstract

There is a consensus in the literature on the importance of using therapeutic play, recommending its systematization in pediatric care planning, however, there are gaps in knowledge about how to systematize this care and implement it in hospital units.

Objectives

to propose a model for the systematic implementation of therapeutic play for pediatric hospital units and describe the steps of this process.

Method

descriptive qualitative study, developed in pediatric hospitalization and intensive care units, supported by the PDCA (Plan, Do, Check and Action) tool. Data were collected through observation of the dynamics of care at the unit and an interview with 11 professionals from the reference group, followed by thematic analysis.

Results

the implementation of therapeutic play showed positive results, from the perspective of the members of the reference group, in the perception of increased frequency in the practice of performing therapeutic play, and due to the recognition of the family and the institution.

Conclusion and implications for practice

the steps taken in the process of implementing TP in pediatric units provide support to guide professionals from different institutions to systematically implement this playful practice.

Keywords:
Hospitalized child; Implementation Science; Nursing Care; Pediatric Nursing; Play and Playthings

Resumo

Existe consenso na literatura sobre a importância do uso do brinquedo terapêutico (BT), recomendando-se a sua sistematização no planejamento do cuidado pediátrico, contudo há lacunas no conhecimento sobre como sistematizar esse cuidado e implementa-lo em unidades hospitalares.

Objetivos

Propor um modelo de implementação sistemática do BT para unidades pediátricas hospitalares e descrever as etapas desse processo.

Método

estudo descritivo, de abordagem qualitativa, desenvolvido em unidades de internação e terapia intensiva pediátricas, apoiado pela ferramenta PDCA (Plan, Do, Check e Action). Os dados foram coletados por meio da observação da dinâmica dos atendimentos da unidade e entrevista com onze dos profissionais do grupo de referência de BT e, a seguir procedeu-se a análise temática.

Resultados

a implementação do BT evidenciou resultados positivos, seja na perspectiva dos integrantes do grupo de referência, seja na percepção de aumento da frequência na prática de realização do BT ou, ainda, pelo reconhecimento da família e da instituição.

Conclusão e implicações para a prática

As etapas percorridas no processo de implementação do BT em unidades pediátricas fornecem subsídios para direcionar profissionais de diferentes instituições a implementar de forma sistemática esta prática lúdica.

Palavras-chave:
Ciência da Implementação; Criança hospitalizada; Cuidados de enfermagem; Enfermagem pediátrica; Jogos e brinquedos

Resumen

Existe consenso en la literatura sobre la importancia del uso de juguetes terapéuticos (JT), recomendándose su sistematización en la planificación del cuidado pediátrico, sin embargo existen lagunas en el conocimiento sobre cómo sistematizar este cuidado e implementarlo en las unidades hospitalarias.

Objetivos

Proponer un modelo para la implementación sistemática de PT para unidades hospitalarias de pediatría y describir los pasos de este proceso.

Método

estudio descriptivo, con enfoque cualitativo, desarrollado en unidades de hospitalización y cuidados intensivos pediátricos, apoyado en la herramienta PDCA (Plan, Do, Check and Action). Los datos fueron recolectados a través de la observación de la dinámica de atención en la unidad y entrevista con once profesionales del grupo de referencia de JT, seguida del análisis temático.

Resultados

la implementación de la JT mostró resultados positivos, ya sea desde la perspectiva de los miembros del grupo de referencia, ya sea en la percepción de mayor frecuencia en la práctica de la realización de la JT o, incluso, por el reconocimiento de la familia y la institución.

Conclusión e implicaciones para la práctica

Los pasos dados en el proceso de implementación de la PT en las unidades pediátricas brindan subsidios para orientar a los profesionales de diferentes instituciones a implementar sistemáticamente esta práctica lúdica.

Palabras clave:
Ciencia de la implementación; Cuidado de enfermera; Enfermería Pediátrica Juego e Implementos de Juego; Niño hospitalizado

INTRODUCTION

Play has long been recognized as a way for children to deal with the challenges of illness and hospitalization¹. In the therapeutic modality, there is evidence of its impact on promoting well-being and reducing fear and anxiety, as it allows the child to express and deal with difficulties while playing various games, with the presence of an adult who respects their manifestations and anxieties^2,3.

A recent scoping review identified that in the last twenty years play interventions have been used in child health care, as a preparation and support for procedures, a non-pharmacological measure in pain management through distraction an educational support to enhance skills and attitudes regarding the disease and treatment, and as a way to promote adaptation in different contexts, through recreation and activities aimed at coping with hospitalization with reduced anxiety, stress and improved mood¹.

As one of the play interventions, therapeutic play (TP) stands out. This is a type of structured play that allows the child to relieve the anxiety generated by experiences that are atypical for their age and that are usually threatening, requiring more than recreation to resolve the associated anxiety. It should be used whenever the child has difficulty understanding or dealing with the experience⁴. Depending on its indication, three modalities can be highlighted: dramatic TP, which offers the child the possibility to play freely and express their feelings and regain self-control; instructional TP, when the care provider aims to instruct the child about something unknown, such as performing a procedure and clarifying mistakes; and the TP that enables physiological functions, when through a game it is sought to optimize some physiological function that needs to be trained to improve physical health^2,5.

Although this intervention represents a real possibility of comprehensive and humanized care for children, nurses still do not use it routinely in their practice⁶. In general, these care providers recognize playful actions as something unintentional and not systematized in the nursing process, despite recognizing the benefits arising from the interaction between nurses, play, children and the care environment⁷.

One study showed that 46.6% of nurses who knew about TP used it only sporadically, due to: overload of activities; lack of time, material and an appropriate environment; lack of knowledge and devaluation of play by colleagues and the institution. The lack of toys and the noise from playing that bothers the care providers are further impediments to its use^8,9. Another study reinforced the barriers that can hamper the play-care connection, such as lack of physical resources and lack of institutional play culture⁷.

Therefore, the need to establish implementation strategies that optimize the systematization of TP in pediatric hospital units is evident. The implementation of a new practice or new knowledge in the health context encompasses three main components: planning and practicing the change, carrying out the change, and evaluating the impact of its use on the health system and its results, both for the organization and for the patient¹⁰.

There are several frameworks and templates available to assist implementation processes. A recent narrative review study identified 41 frameworks and models, however, despite some being used more than others, none of them were found to be effective^11-12. Few instruments show as much effectiveness in the search for continuous improvement as the PDCA tool, as it leads to systematic interventions that accelerate the achievement of better results, in order to solidify the implementation process, as well as the growth of the organization^13-14.

Accordingly, the implementation of TP in pediatric units, based on the protocols proposed by the Joanna Briggs Institute (JBI)¹⁰ and the PDCA tool¹⁴, can be a way to intensify and solidify the practice of TP in child care, outlining the difficulties and motivations involved as a way to improve the process.

Objectives

To propose a model for the systematic implementation of TP for pediatric hospital units and to describe the steps of this process.

METHOD

This was a descriptive qualitative study, using the PDCA tool (Plan, Do, Check and Act)^13,14 to create a model for the systematic implementation of TP in pediatric hospital units, as the product of a professional Master’s degree.

The implementation model was carried out in four phases according to the PDCA tool. The PDCA cycle (Plan, Do, Check, Act) or Deming cycle was chosen because it is a method applied for the effective and reliable control of activities, especially those related to improvements, enabling standardization for quality control. It is composed of four defined and distinct stages. The “Plan” stage consists of establishing an action plan with the definition of objectives, strategies, actions and goals, as well as the methods used to achieve them. The second “Do” stage covers the performance of the tasks that were defined in the previous stage and the collection of data to be analyzed in the next stage of verification of the process. In this stage, it is essential to train the team so that the implementation takes place involving individual and institutional learning. The next step, “Check”, consists of comparing the data obtained in the Do phase and assessing whether the goals were achieved. Finally, the “Act” stage, which involves acting in the process according to the results obtained and, if the goal has been reached, adopting it as a standard or, on the contrary, acting in order to carry out the necessary corrections^13-15.

The study began in 2019 and was carried out in the pediatric units of a large hospital in the city of São Paulo, which has 20 rooms/beds, and the pediatric intensive care unit, with 18 rooms/beds. These units serve patients of low, medium and high complexity, from newborns to 18 years of age, including surgical, clinical and chronic patients, therefore indicating the use of all TP modalities to meet the needs of the clientele. The team that worked in the units consisted of 106 care providers, among them: 27 nurses, 66 nursing technicians, two psychologists, six nutritionists, one psychopedagogue, three play specialists and one speech therapist.

Data collection took place at two moments. The first was during the “Plan” stage, through participant observation for a period of 2 months, during the researcher’s work shift, at times of shift changes and through analysis in the medical records of reports of playful actions developed by the team with the children. The aim was to verify how the playful actions occurred, what supported and undermined their use and the possible barriers. All observations were recorded in a field diary, which was also the object of analysis and the basis for further questions during the subsequent interviews.

The second moment of data collection took place during the “Check” stage, with the aim of evaluating the process. Here, the care providers who were part of the reference group were invited to participate, as they were considered to be professionals interested in the theme, involved with the implementation process and committed to the success of the process, which allowed them to speak freely about the difficulties, as well as the need for improvements, despite the researcher being one of the team members. The interviews were carried out individually, at the institution, at a place and time convenient for the participants, usually after the work shift finished. They were conducted through the guiding questions: What has been your experience of the process of TP implementation in the pediatric units? How do you perceive your performance as a member of the BrinquEinstein working group? The interviews were audio-recorded and later transcribed in full, to be analyzed according to the precepts of Thematic Analysis¹⁶.

In compliance with Resolution 466/12, the project was approved by the Research Ethics Committee of the proposing institution, under number 4.376.155 (CAAE: 38581120.6.0000.0071), and all ethical precepts were respected.

RESULTS

The results will be presented according to the steps taken for the systematic implementation of the use of TP in the units: Plan, Do, Check and Act.

Plan

In this stage, the identification of the unit’s problem and the barriers that were presented considering the use of TP were established, as well as the planning of improvements and the definition of goals to be achieved with the first PDCA cycle, which will be described below.

Identification of the problem and barriers to implementing the use of TP

The first stage of the process was aimed at diagnosing the problem, that is, investigating the use of TP in the pediatric units in question and identifying the reasons for its non-inclusion in the team’s care actions for children, adolescents and families as part of the nursing team’s work process.

From the observation and conversations with the care providers on the subject during the work shift, some “barriers” were evidenced that hindered the routine inclusion of TP in the care. The lack of time and material resources, as well as little knowledge regarding the importance and benefits arising from the use of TP were some factors identified in the units studied.

From this initial information, continuing the planning phase, the availability of materials and recreational resources necessary for the implementation of TP was verified, with the possibility of buying playthings. Places for their storage that were easily accessible to the team and close to the nursing station were also defined.

Another important point was to establish a procedure for correct cleaning of the playthings, according to the standards defined by the Hospital Infection Control Service of the institution. Cleaning would be the responsibility of the nurses, according to a roster previously defined and decided by the nursing team, with the aim of integrating and not imposing the rules.

In this stage, it was important to identify the characteristics of the sector in which the implementation process would be carried out, as well as the particularities of the hospitalized children and their needs. This diagnosis guided the design of interventions in a more assertive way during the process.

Planning improvements

From the situational diagnosis regarding the application of TP in pediatrics, the next step was to plan the best strategy to overcome, in particular, the barriers of lack of knowledge on the subject by professionals, and the perception of lack of time vs. work overload. Accordingly, the training of the nursing team was outlined. When planning this step, the need was identified to elect a nurse to assume the role of leader as a TP reference in the unit, who would be responsible for training the entire team.

However, during the observation period, it was also possible to notice that there were clinically stable children, adapted to the hospital environment, with the need to play and be distracted, while others were hospitalized only for physical therapy, who often showed resistance and did not cooperate with the service. Therefore, the need for greater interdisciplinary communication was observed. The interdisciplinary team was invited to participate in the implementation process, including training on the subject, considering that care for the patients and their positive experience with hospitalization are the main focus shared by all care providers of the units in question.

An important aspect is that during the observation of the research scenario, the researcher continued to perform her care activities as a nurse in the pediatric unit, including TP, although this was carried out almost alone and on her own initiative. This movement helped to demystify some barriers for the other care providers, such as the lack of time to apply TP, since the positive results arising from this practice led the team, who previously did not believe in the possibility of carrying it out during the work shift, to reframe it as something viable.

The care providers began to report their own perceptions that children undergoing TP sessions became more collaborative in the procedures, optimizing the time spent in the care process. This finding was mobilizing for the increased interest of the team in relation to the proposal and, consequently, for the increase in requests for TP interventions. This increase in demand revealed the need for more qualified care providers to apply the technique and, consequently, the need for training of a greater number of employees.

Concomitantly, the families of children who received the playful intervention with TP, from these nurses, experienced its benefits, praising the initiative to the coordinator of the sector, who was receptive and interested. From then on, the coordination started to increasingly encourage actions that optimized the practice of TP in the sector, such as support for the development of innovative recreational proposals, which was fundamental for the team to understand the importance of using TP, initiating, from this, greater involvement of all for the implementation in the service.

Define the goals

The main goal established was the implementation of the use of TP in a systematic way by the interdisciplinary team in the care of the child.

Do

In this stage, the planned actions were performed, including: identification of the lead nurse; establishment of partnerships; training of the team; formation of the reference group; description of the institutional protocol for the use of TP; and evaluation of the process from the perspective of the members of the reference team in relation to the experience of participating in the implementation process. These are described below:

Identification of the lead nurse

In general, the performance of a new nursing procedure is monitored by the nurse responsible for supervising the team or by the nurse from the institution’s training sector, a fact that also applies to interventions that involved playful activities, such as TP. Considering this monitoring and the need to carry out training of the interdisciplinary team, it was necessary to appoint a lead nurse. Their functions included: accompanying and supporting the first TP sessions performed by nurses and nursing technicians; providing assistance in case of doubts, even from a distance; training new team members; sharing clinical cases and outcomes; encouraging discussion and team participation; maintaining team motivation; disseminating the opinions and feedback of the family and the interdisciplinary team; paying attention and giving support to cases considered difficult; and assisting in other possible approaches.

In order to fulfill their duties, it was necessary for the chosen nurse to demonstrate engagement with the TP theme, master the importance of its application as part of the work process, identify the possible barriers and assume responsibility for the action plans to overcome them. It was also desirable to have a good interpersonal relationship with the team and a constructive leadership profile, involving the team in the decision process.

Establishing partnerships

Initially, the partnership took place with the team of play specialists and the psychopedagogue responsible for the playroom. The purpose of the partnership was to borrow playthings for use during TP sessions, as well as helping to formulate new toys, games and recreational activities. In addition, the professionals of this team collaborated in maintaining the children’s free play, increasing the bond between the nursing teams and play specialists.

With the process in motion, the play specialists began to discuss the cases with the nursing team, helping in the interventions when they observed something that represented fear or anxiety during the children’s play and, therefore, something that could benefit from TP sessions. With this, the playroom team was invited to join the implementation process and the invitation was extended to the psychologist responsible for the sector, to help in the discussion and comprehension of the cases attended.

Another important partnership was with the Nursing Coordination which, in addition to providing support in providing materials for the education of pediatric patients through instructional TP, also acted in encouraging the participation of the team in congresses and symposia and the purchase of toys, through requests to the responsible sector of the institution.

Training of the interdisciplinary team

The training on the topic of TP was developed in person, at the nursing station, during work shifts. Two models were organized. The first was intended for the nursing team and took place through a dynamic conversation circle, with the support of an audiovisual resource, having an average duration of 20 minutes. The content was briefly addressed and included the discussion of the following topics: the importance of pediatric patient-centered care and adequate communication; legislation on the use of TP in nursing; concept, indication and modes of TP; methodology for the systematic application of TP in the nursing process; cleaning procedure and plaything storage places. Throughout the process, case reports and results from the playful experience were included.

For the professionals of other teams, training also took place through conversation circles, with the aim of presenting the implementation proposal and sensitizing professionals on the topic, their indications and the role of each professional in the process, especially, in the evaluation and indication of children with playful intervention needs.

Formation and constitution of the Reference Group – BrinquEinstein

In the Do stage, after training 36 employees (nurses and nursing technicians) and eight care providers from the multidisciplinary team (psychologists, play specialists, physiotherapists, psychopedagogists), the plan was initiated for forming the reference group for the use of TP in the unit, involving those who showed an interested in joining the group during the training.

Among the 44 participants in the TP training, 28 were interested in constituting the TP reference group. The name for this group BrinquEinstein was democratically chosen by its members. Regarding the role of the different members of this group, it should be emphasized that all the care providers in the group had the role of promoting free play and, when this was not possible, requesting the support of the play specialists, in addition to identifying children who were suffering in some way due to the hospitalization. It was the group’s responsibility to jointly develop the best playful care strategy for these children.

The nursing care providers were responsible for planning, applying and evaluating the results of the TP use. The play specialists, on the other hand, were involved in promoting free play and the psychologists, in addition to participating in the discussion of cases and also helping to choose the best play strategy, were called whenever there was a need for specific care according to the institutional procedure and protocol. The physiotherapists also worked on the promotion of therapeutic play in partnership with the nursing care providers and together they decided the best play strategy for approaching the children.

Concerning the members of the medical team, even though they were not represented in the BrinquEinstein group, many of them were familiar with the group’s practice and requested support before carrying out surgical procedures and interventions in the sector. They also communicated in advance the need for hospitalization so that a playful intervention could be previously scheduled.

The WhatsApp application, a multiplatform instant messaging and voice calling application for smartphones¹⁶, was the strategy chosen by the group to optimize communication among its members. These characteristics ensured agility in the exchange of information among the team, such as: exchange of experiences on the application of TP; discussion of cases to improve the patient experience; dissemination and sharing of articles, research and scientific events in the area; and dissemination of a proposal for the creation of games. Some rules were established by the group in relation to the use of this application: communication exclusively on matters pertaining to TP and games, and respecting the confidentiality of the shared material, especially videos, photos and the developments of clinical cases.

The group’s activities were also organized through the WhatsApp application, including: scheduling face-to-face or virtual meetings, discussions of clinical cases, sharing of ideas, and workshops to construct training games with physiological or instructional functions.

With the TP reference group consolidated, sharing the same goals and values, the need to construct a visual identity for BrinquEinstein was identified, initially a logo was created as a way of representing it (Figure 1). Its meaning contemplates the union between the children and the different care providers of the multidisciplinary team, supporting the playful actions in the care.

Figure 1
TP reference group logo: BrinquEinstein.

With the process of implementing the use of TP, there was greater involvement of group members in improvement activities and research on the topic, including participation in national and international congresses and symposia related to the theme, with the achievement of awards and honorable mentions for the work developed.

Description of the institutional protocol for the use of TP

Based on the training of the care providers in the use of TP and the practice of TP in the institution, the need to develop an institutional protocol was identified in order to establish guidelines for performing the TP technique. The protocol was prepared by the BrinquEinstein members, being reviewed and approved by the institution’s care practices committee. It is currently available on the institutional website, with access for all employees.

Check

In the third step, 13 BrinquEinstein care providers were interviewed about their experience in participating in the implementation process. For them, all stages of the TP implementation were considered of great importance, highlighting the formation of the leader, the training of the care providers in the use of TP, and the creation of the reference group.

According to the participants, the formation of the reference group and the creation of an application providing more effective and faster communication, positively impacting the continuity of the care, with regard to the need to perform the TP and games.

The professionals also considered the significant role of the institution’s recognition in relation to the impact of the insertion of TP into the daily routine of the pediatric units.

Accordingly, this recognition acted as a driving force for the solidification of the TP implementation process, both through praise communicated by the families to the customer service, and through the awards obtained inside and outside the institution and for the satisfaction of the care providers themselves when taking part in the implementation and experiencing the results of the TP practice with pediatric patients. All these factors contributed to the expansion of the reference group and to the development of improvement actions in relation to the application of the TP.

In the Check stage, it was essential to recognize and evaluate the aspects that were imposed as barriers in the implementation process, so that improvement actions could be initiated, which could lead to the development of a new PDCA cycle. Among the barriers highlighted by the BrinquEinstein members, the following stand out: the lack of recognition by some professionals regarding the use of TP as a team care action; the uncertainties about the most appropriate moment for its application, as it is not always possible to perform the TP during the child’s process of admission into the pediatric ICU or at night; and the attitude of some parents, resisting the use of TP due to lack of knowledge about its benefits for the child.

Action

The aim of this stage was to standardize and solidify the use of TP, based on the analysis of the current situation and the implementation of corrective actions and new proposals, evidenced through the qualitative evaluation with the care providers of the reference group.

To ensure the continuity of the implementation process, new actions were proposed with the objective of overcoming the barriers that persisted or that emerged during the process, such as: the creation of multipliers, represented by nurses who were already part of BrinquEinstein; and the initiation of qualitative research, which seeks to understand the perception of parents regarding the use of TP by the professionals in the care provided to their children during hospitalization, with the purpose of developing an informative folder for the family. It is hoped that the results obtained will provide support for carrying out a new PDCA cycle.

Considering the motivating aspects for the performance of the TP from the perspective of the participants, the following aspects became evident: the solidification of the reference group as support for the professional; the children’s positive response to the use of TP; the family’s reports in relation to their satisfaction with the care provided to the children; involvement in the group’s scientific production, with greater participation of its members in studies developed in the sector; and the awards given to some members of BrinquEinstein.

Figure 2 presents the infographic of the PDCA cycle for the implementation of therapeutic play in pediatric hospital units.

Figure 2
Infographic of the model of TP implementation in pediatric units.

DISCUSSION

The proposal for the implementation of TP, based on the PDCA tool, showed positive results when put into practice in the pediatric units and ICUs. This was evidenced through the perspective of the members of the reference group and through the perception of the increased frequency in the practice of TP and games, as well as through the recognition of the family and the institution itself.

These results corroborate the World Health Organization’s (WHO) definition of best practices in child care, highlighting the need for the systematic inclusion of games and therapeutic play in the care plan of health care providers¹⁷. These practices place patients at the center of the care, respecting their best interest and their right to quality health, so that they are protected and emotionally supported through better evidence-based care models. Current systematic reviews support the use of playful interventions in child care due to their broad benefits, emphasizing the need to carry out studies with greater methodological rigor^18-20.

However, professionals must be trained to do this, with the availability of additional training on the use of play, which can increase the feasibility of its use in pediatric care settings^20,21. The training proposal developed in this study is in line with what has been highlighted in the literature: that investment in training expands the essential competencies of pediatric care providers and positively influences the quality of care for children and their families¹⁷. This was, in fact, verified in the present study, with the satisfaction of the families and the enthusiasm of the reference group in relation to the training.

The WHO positioning in relation to best practices in pediatric care is in line with the concept that is at the heart of the Joanna Briggs Institute Model of Evidence-Based Healthcare (MEBH), in which clinical decision-making considers the feasibility, adequacy, significance and effectiveness of health practices informed by the best available evidence¹⁰.

The implementation proposal developed in this study was based on this model, which considers the local context in promoting the facilitation of change, including the evaluation of the process and the results, to measure the benefits of the nursing practice for the pediatric patient and their family¹⁰.

As previously discussed, the steps proposed by the PDCA tool and the actions developed in this study are connected with the standards of good practices presented by the WHO, such as: adoption of evidence-based practices, in the care of children and in the treatment of diseases; use of actionable information systems (reference group available for intervention with TP at any time) and reference systems in operation (BrinquEinstein group); effective communication and meaningful participation of collaborators in the process; respect, protection and fulfillment of children’s rights; emotional and psychological support; competent, motivated and empathetic human resources; and essential physical resources for the children and adolescents^10,17. These aspects were part of the TP implementation process in the hospital environment, influencing the quality of care centered on pediatric patients and their families.

In the present study, the formation of the BrinquEinstein reference group for performing the TP was recognized as a strength by the participants. Its potency as an interdisciplinary communication strategy was widely valued by the study participants who, based on the discussions and exchange of experiences, realized that they benefited from the significant learning provided by the interactions among its members.

The reference team helped to try to resolve or minimize the lack of definition of responsibilities, of therapeutic bonding and of integration into the healthcare, providing dignified and respectful treatment, with quality, acceptance and bonding²², as reported in this study. Reference groups are established in the hospital practice for different purposes, however, the existence of an interdisciplinary hospital group that involves games and TP is unknown in Brazil, making this an innovative experience. Its value consists of promoting the multiplication of this care practice among health institutions as a promoter of atraumatic, humanized and pediatric patient-centered care.

The plan instituted to overcome barriers, such as training the interdisciplinary team and involving its members through the formation of a reference group, was considered essential by the participants for the successful implementation of TP.

Although the lack of time and the overload of activities were still a concern for the care providers who participated in the study, a change in their attitude towards the need for recreational activities for the child in the hospital could be seen. Therefore, this recognition is close to the findings of another study, which emphasized that the act of playing and using TP by the nurse can optimize and qualify the care time and also signify a positive investment in the future relationship with the child²³.

There was a movement towards incorporating the planning of the TP practice into the team’s work routine and, in particular, there was a concern with the systematization in the continuity of playful care. Accordingly, the value of information about the performance of the TP with the children during the shift of the nursing team is emphasized, which was also shared in the BrinquEinstein reference group. This action is important, as it responds to the COFEN regulations on the responsibility of the nursing team to incorporate TP into the nursing process²⁴.

Research results indicate that nurses have the desire to learn about TP, in particular, how to evaluate its results and actually incorporate it into the nursing process^23,25. The importance of systematizing playful care is highlighted, as its performance structured in a care model contributes to reducing the negative effects of hospitalization, such as fear and anxiety²⁶, by favoring the establishment of bonds between the team and the child, stimulating a more active participation of the pediatric patient in the process of coping with the situation^27-28.

The PDCA tool, due to its cyclical characteristic, implies the need to reassess the implemented situation, as a way of guaranteeing its maintenance, recognizing barriers that have not been overcome or new barriers that present themselves and that therefore demand new planning of actions to overcome them²⁹.

With the training and awareness of employees regarding the application of TP, the team’s lack of knowledge was gradually tackled, with the realization of short courses covering the theoretical contents necessary for its understanding, and the observation of the positive results of this practice in their daily work, as highlighted in the literature^21,30-32.

CONCLUSION

The proposal for the implementation of TP, based on the PDCA tool, showed positive results when put into practice in the pediatric units and pediatric ICUs. This could be seen through the perspective of the members of the reference group and through the perception of the increased frequency in the practice of TP and games, as well as through the recognition of the family and the institution itself, with awards and honorable mentions obtained by the professionals involved.

Its results provide a great contribution, in the area of pediatric care, due to its innovative and interdisciplinary content, evidencing the plurality of play in child healthcare. Progress was made in systematizing the stages of the TP implementation process in pediatric care settings, in particular, progressing to the context of intensive care, where this practice is still hesitant and limited. Accordingly, we seek to offer an initial path responding to the knowledge gaps regarding models of implementation of the TP systematics. However, in this study, only the perspective of the BrinquEinstein members was investigated, not including the other members of the interdisciplinary team, with this constituting a limitation.

The TP implementation process is still in progress, since the steps of the PDCA tool occur in a cyclical way, generating new cycles for the improvement and updating of the process. The results of the study made it possible to propose a model for the implementation of TP in pediatric hospital units, in the form of an infographic, in order to provide support for professionals from different institutions to institute this playful practice in their daily work, a need that has been highlighted in numerous studies in Brazil. The importance of further studies should be emphasized, aiming to adapt this model to the reality of other institutions, not only for its use in hospital units, but for other pediatric care services with other characteristics.

• a
  Article derived from the dissertation Model of systematic implementation of the practice of therapeutic play in pediatric hospital units, authored by Carolline Billett Miranda, supervised by Prof. Dr. Fabiane de Amorim Almeida and Co-advisor: Prof. Dr. Edmara Bazoni Soares Maia, for the Professional Master's Program of the Faculdade Israelita de Ciências da Saúde Albert Einstein, defended in 2022.

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Edited by

ASSOCIATED EDITOR

SCIENTIFIC EDITOR

Publication Dates

• Publication in this collection
  17 Oct 2022
• Date of issue
  2022

History

• Received
  22 Apr 2022
• Accepted
  01 Aug 2022