Abstracts
Objective:to describe the behavior of children during the instructional session of therapeutic play (ITP) in the preoperative period and to verify the behavior presented by them during the perioperative period. Methods: Exploratory descriptive study with a quantitative approach, developed in a large private hospital in Sao Paulo, in which the behaviors presented by 30 children between three and five years old, undergoing minor surgery were seen at the hospital during the session of TP and in the surgical center, from admission to awaken from anesthesia. Results: Most children participated in the ITP session (21; 70%), entered the surgical room spontaneously (22; 73.3%) without resisting mother separation (24; 80%), collaborating with the anesthetic procedure (16; 53.3%) and quietly awakening from anesthesia (26; 87%). Conclusion: The use of ITP led the child to understand the surgical procedure, making it less traumatic.
Play and playthings ; Child, hospitalized ; Perioperative nursing ; Humanization of assistance ; Pediatric nursing
Objetivo:Describir el comportamiento de los niños durante una sesión de juego terapéutico instruccional en el periodo preoperatorio y verificar el comportamiento mostrado en el periodo intraoperatorio. Método: Estudio descriptivo, exploratorio, de abordaje cuantitativo, desarrollado en un hospital privado en la ciudad de São Paulo. Se observaron los comportamientos de 30 niños entre los 3 y los 5 años sometidos a cirugías menores durante la sesión de juego instruccional realizada en la unidad de internación y en el quirófano, desde su admisión en el hospital hasta el despertar de la anestesia. Resultados: La mayoría de los niños participaron efectivamente de la sesión de juego terapéutico instruccional (21; 70%), el 73% entró espontáneamente en el quirófano, el 80% no se resistió a la separación de la madre, el 53,3% colaboró con el procedimiento anestésico y el 87% despertó tranquilamente de la anestesia. Conclusión: El uso del juego terapéutico instruccional ayudó a los niños a entender el procedimiento quirúrgico, haciéndolo menos traumático.
Juego e implementos de juego ; Niño hospitalizado ; Enfermería perioperatoria ; Humanización de la atención ; Enfermería pediátrica
Objetivo: Descrever o comportamento de crianças durante a sessão de brinquedo terapêutico instrucional (BTI) no período pré-operatório e verificar o comportamento apresentado por elas no período transoperatório. Método: Pesquisa descritiva exploratória de abordagem quantitativa, desenvolvida em um hospital particular de grande porte da cidade de São Paulo, na qual os comportamentos apresentados por 30 crianças entre três e cinco anos submetidas à cirurgia de pequeno porte foram observados na unidade de internação durante a sessão de BT e na sala de cirurgia, desde a admissão até despertarem da anestesia. Resultados: A maioria participou efetivamente da sessão de BTI (21; 70%), entrou espontaneamente na sala operatória (22; 73,3%) e sem resistir à separação da mãe (24; 80%), colaborando com o procedimento anestésico (16; 53,3%) e despertando da anestesia tranquilamente (26; 87%). Conclusão: O uso do BTI propiciou à criança compreender o procedimento cirúrgico, tornando-o menos traumático.
Jogos e brinquedos ; Criança hospitalizada ; Enfermagem perioperatória ; Humanização da assistência ; Enfermagem pediátrica
Introduction
Surgery can be a very traumatic experience for the child, who has limited cognitive resources to understand what happens with herself/himself and deal with situations that cause stress(101 1.Sanders J. Cuidado centrado na família da criança durante a doença e hospitalização. In: Hockenberry MJ, Wilson D, Winkelstein ML, editores. Wong Fundamentos de Enfermagem Pediátrica. 8ª ed. Rio de Janeiro: Elsevier; 2011. p. 675-702.). The need to be hospitalized makes this an even more delicate moment, keeping her/him away from the safe environment of her/his home. In contact with the unknown and frightening hospital environment, the child has to undergo a different routine, which includes several invasive and painful procedures(101 1.Sanders J. Cuidado centrado na família da criança durante a doença e hospitalização. In: Hockenberry MJ, Wilson D, Winkelstein ML, editores. Wong Fundamentos de Enfermagem Pediátrica. 8ª ed. Rio de Janeiro: Elsevier; 2011. p. 675-702.-202 2.Sabates AL. Reações da criança e do adolescente e de sua família. In: Almeida FA, Sabates AL, organizadoras. Enfermagem pediátrica: a criança, o adolescente e sua família no hospital. Barueri: Manole; 2008. p. 49-56.).
The anxiety from separation, loss of control and fear of bodily injury and pain are some of the negative effects of illness and hospitalization that affect child development, especially in the first years of life, when the child is most vulnerable to these events. Giving her/him the opportunity to play is one of the strategies that may mitigate the negative effects of this experience(101 1.Sanders J. Cuidado centrado na família da criança durante a doença e hospitalização. In: Hockenberry MJ, Wilson D, Winkelstein ML, editores. Wong Fundamentos de Enfermagem Pediátrica. 8ª ed. Rio de Janeiro: Elsevier; 2011. p. 675-702.,303 3.Almeida FA. Psicologia do desenvolvimento: a criança. In: Farah OGD, Sá AC, organizadoras. Psicologia aplicada à enfermagem. Barueri: Manole; 2008. p. 30-59).
Playing is the most important activity of a child’s life. In addition to promoting child development in all its dimensions, it is the most genuine way they use to communicate and express feelings, anxieties and frustrations, which otherwise would not be possible, due to their emotional immaturity(404 4.Ribeiro CA, Almeida FA, Borba RIH. A criança e o brinquedo no hospital. In: Almeida FA, Sabates AL, organizadoras. Enfermagem pediátrica: a criança, o adolescente e sua família no hospital. Barueri: Manole; 2008. p. 65-77-505 5.Ribeiro CA, Borba RIH, Rezende MA. O brinquedo na assistência à saúde da criança. In: Fujimori E, Ohara CVS, organizadoras. Enfermagem e a saúde da criança na atenção básica. Barueri: Manole; 2008. p. 287-327).
Recognized as a basic need for childhood, playing is advocated by the Declaration of
the Rights of the Child – United Nations(606 6.United Nations. Resolution n.1386, of 20 November 1959.
Declaration of the rights of the child. Official Records of the General Assembly
[Internet]. New York; 1959 [cited 2014 Feb 5]. Available from:
http://www.unicef.org/malaysia/1959-Declaration-of-the-Rights-of-the-Child.pdf
http://www.unicef.org/malaysia/1959-Decl...
) 1959, which includes playing along with other basic needs
such as food, shelter, medical care, education and parental love, and by the Statute
of Children and Adolescents(707 7.Brasil, Ministério da Saúde. Estatuto da criança e do adolescente
[Internet]. Brasília; 2008 [citado 2014 fev. 5]. Disponível em:
http://bvsms.saude.gov.br/bvs/publicacoes/estatuto_crianca_adolescente_3ed.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
),
which considers playing children’s right.
At the hospital, playing may be performed in different ways. Recreational play
includes activities in which children engage spontaneously just for pleasure, being
the playroom a conducive environment to develop it(404 4.Ribeiro CA, Almeida FA, Borba RIH. A criança e o brinquedo no
hospital. In: Almeida FA, Sabates AL, organizadoras. Enfermagem pediátrica: a
criança, o adolescente e sua família no hospital. Barueri: Manole; 2008. p.
65-77-505 5.Ribeiro CA, Borba RIH, Rezende MA. O brinquedo na assistência à
saúde da criança. In: Fujimori E, Ohara CVS, organizadoras. Enfermagem e a saúde
da criança na atenção básica. Barueri: Manole; 2008. p. 287-327). The role
of this physical space in promoting play in the hospital provides to the adult a
rich access to the seriously ill children experience(808 8.Melo LL, Valle ERM. The toy library as a possibility to unveil the
life of children with cancer under outpatient treatment. Rev Esc Enferm USP
[Internet]. 2010 [cited 2014 Feb 5];44(2):517-25. Available from:
http://www.scielo.br/pdf/reeusp/v44n2/en_39.pdf
http://www.scielo.br/pdf/reeusp/v44n2/en...
).
Therapeutic play, in turn, encompasses specialized activities and directed by professionals to promote physical and emotional well-being to the child in order to experience a situation of unusual life for their age, such as hospitalization and surgery(404 4.Ribeiro CA, Almeida FA, Borba RIH. A criança e o brinquedo no hospital. In: Almeida FA, Sabates AL, organizadoras. Enfermagem pediátrica: a criança, o adolescente e sua família no hospital. Barueri: Manole; 2008. p. 65-77-505 5.Ribeiro CA, Borba RIH, Rezende MA. O brinquedo na assistência à saúde da criança. In: Fujimori E, Ohara CVS, organizadoras. Enfermagem e a saúde da criança na atenção básica. Barueri: Manole; 2008. p. 287-327).
Among therapeutic play, we highlight the therapeutic toy (TT). This is a non-directive play, which gives the child freedom to express themselves non-verbally and without concern that the adults around them will identify when they are talking about themselves(404 4.Ribeiro CA, Almeida FA, Borba RIH. A criança e o brinquedo no hospital. In: Almeida FA, Sabates AL, organizadoras. Enfermagem pediátrica: a criança, o adolescente e sua família no hospital. Barueri: Manole; 2008. p. 65-77-505 5.Ribeiro CA, Borba RIH, Rezende MA. O brinquedo na assistência à saúde da criança. In: Fujimori E, Ohara CVS, organizadoras. Enfermagem e a saúde da criança na atenção básica. Barueri: Manole; 2008. p. 287-327). Suitable for any child who experiences a crisis situation, the TT can be developed by different professionals and anywhere, and the sessions last about 15 to 45 minutes(404 4.Ribeiro CA, Almeida FA, Borba RIH. A criança e o brinquedo no hospital. In: Almeida FA, Sabates AL, organizadoras. Enfermagem pediátrica: a criança, o adolescente e sua família no hospital. Barueri: Manole; 2008. p. 65-77-505 5.Ribeiro CA, Borba RIH, Rezende MA. O brinquedo na assistência à saúde da criança. In: Fujimori E, Ohara CVS, organizadoras. Enfermagem e a saúde da criança na atenção básica. Barueri: Manole; 2008. p. 287-327).
In recent years, research on TT have become more frequent(909 9.Almeida FA. O brinquedo na pesquisa em enfermagem pediátrica
[editorial]. Rev Soc Bras Enferm Pediatr. 2012;12(1):5-6), especially those that address the child’s
experience on critical and invasive procedures, in various contexts, not just in the
hospital, but also at other levels of health care(1010.Jansen MF, Santos RM, Favero L. Benefícios da utilização do
brinquedo durante o cuidado de enfermagem prestado à criança hospitalizada. Rev
Gaúcha Enferm [Internet]. 2010 [citado 2014 fev. 5];31(2):247-53. Disponível em:
http://www.scielo.br/pdf/rgenf/v31n2/07.pdf
http://www.scielo.br/pdf/rgenf/v31n2/07....
11.Leite TMC, Shimo AKK. Uso do brinquedo no hospital: o que os
enfermeiros brasileiros estão estudando? Rev Esc Enferm USP.
2008;42(2):389-95-1212.Cruz DSM, Virgínio NA, Maia FSB, Martins DL, Oliveira AMS.
Therapeutic toy: integrative review. J Nurs UFPE on line [Internet]. 2013 [cited
2014 Jan 16];7(5):1443-8. Available from:
http://www.revista.ufpe.br/revistaenfermagem/index.php/revista/article/viewFile/2833/pdf_2557
http://www.revista.ufpe.br/revistaenferm...
).
The TT can be widely used by nurses as a best practice and regulated by the Federal
Board of Nursing(1313.Conselho Federal de Enfermagem. Resolução nº 295, de 24 de
outubro de 2004. Dispõe sobre a utilização de técnica do brinquedo/brinquedo
terapêutico pelo enfermeiro na assistência à criança hospitalizada [Internet].
Rio de Janeiro; 2004 [citado 2014 fev. 5]. Disponível em:
http://novo.portalcofen.gov.br/resoluo-cofen-2952004_4331.html
http://novo.portalcofen.gov.br/resoluo-c...
). It is an
important tool to better understand and diagnose child’s needs, providing subsidies
for professional nursing care plan(1111.Leite TMC, Shimo AKK. Uso do brinquedo no hospital: o que os
enfermeiros brasileiros estão estudando? Rev Esc Enferm USP.
2008;42(2):389-95).
Studies on the perception of nurses regarding the use of TT showed that they are
aware of the benefits of their practice(1414.Maia EBS, Ribeiro CA, Borba RIH. Brinquedo terapeutico:
benefícios vivenciados por enfermeiras na prática assistencial à criança e
família. Rev Gaúcha Enferm [Internet]. 2008 [citado 2014 fev. 5];29(1):39-46.
Disponível em:
http://seer.ufrgs.br/RevistaGauchadeEnfermagem/article/viewFile/5262/2996
http://seer.ufrgs.br/RevistaGauchadeEnfe...
). These studies, however, point out to the need to prepare
professional to do it and incorporate it into their daily lives(1515.Francischinelli AGB, Almeida FA, Fernandes DMSO. Routine use of
therapeutic play in the care of hospitalized children: nurses' perceptions. Acta
Paul Enferm [Internet]. 2012 [cited 2014 Feb 5];(1):18-23. Available from:
http://www.scielo.br/pdf/ape/v25n1/en_v25n1a04.pdf
http://www.scielo.br/pdf/ape/v25n1/en_v2...
), emphasizing that teaching about
the toy and integrating it with care are still challenges to be overcome(1616.Maia EBS, Ribeiro CA, Borba RIH. Understanding nurses’ awareness
as to the se of therapeutic play in child care. Rev Esc Enferm USP [Internet].
2011 [cited 2014 Feb 5]; 45(4):839-46. Available from:
http://www.scielo.br/pdf/reeusp/v45n4/en_v45n4a07.pdf
http://www.scielo.br/pdf/reeusp/v45n4/en...
).
There are different types of TT, depending on the purpose for which it is employed, and instructional and therapeutic play (ITP) is one of them. This play allows the child to learn about a particular event, such as surgery or other hospital procedures, which the understanding would be impossible with only verbal explanation. It also enables children to understand how to act and how they will feel in real time, facilitating the expression of feelings and clarifying misconceptions(404 4.Ribeiro CA, Almeida FA, Borba RIH. A criança e o brinquedo no hospital. In: Almeida FA, Sabates AL, organizadoras. Enfermagem pediátrica: a criança, o adolescente e sua família no hospital. Barueri: Manole; 2008. p. 65-77-505 5.Ribeiro CA, Borba RIH, Rezende MA. O brinquedo na assistência à saúde da criança. In: Fujimori E, Ohara CVS, organizadoras. Enfermagem e a saúde da criança na atenção básica. Barueri: Manole; 2008. p. 287-327).
Its routine use in units that care for children is justified by the fact that information should be clear about the need for hospitalization and surgery, which helps to alleviate anxiety, making them feel safe and able to trust the adult who cares for them. Parents and professionals find it difficult to convey this information, often omitting the truth in an attempt to save the child and not causing them suffering. When this happens, the child’s trust in adults who care for them can be terribly shaken, leading them to believe that they are no longer loved.
Given these findings and considering the experience of the authors in childcare who undergo surgery, this study aimed to explore the use of ITP in preparation for surgery and its influence on child behavior in these events.
The aim of this study was to describe the behavior of preschool children undergoing minor surgery during an instructional session of therapeutic play (ITP) in the preoperative period, and after the session of ITP, in the perioperative period.
Method
This is a descriptive and exploratory research, conducted in the pediatric inpatient units (IU), Day Clinic and Surgical Center (SC) of an extra sized private hospital, located in the city of Sao Paulo.
The sample consisted of 30 children between three and five years old, undergoing elective minor surgery during the 2nd semester of 2010. They were intentionally selected by choosing the first 30 children who presented good general condition, who agreed to participate in the research and whose guardians authorized their participation by signing the Consent Form.
Data were collected by the first researcher of the study, who even though worked as a nurse in the SC unit, she did not participate in the perioperative procedures performed with the child. Data collection was performed through observation of the behavior manifested by children in two moments: ITP session held before surgery at surgery unit, and in the perioperative period from admission to the SC awakening from anesthesia.
For data records, we used an instrument developed by the researchers that was based on her experiences in surgical child care, consisting of: data on the child, her/his past history, clinical prognosis, surgery and anesthesia proposal, obtained from medical records before ITP session, so that, the researcher could plan it in advance; behavior and reactions presented by the child on admission to the SC during anesthetic induction and in the unity of post-anesthesia recovery in the form of a checklist.
To record the child’s behavior in the ITP session, we used another instrument, proposed by Almeida(1717.Almeida FA. Em busca da confiança necessária para viver criativamente pelo brincar: a criança diante da cirurgia cardíaca [tese]. São Paulo: Instituto de Psicologia, Universidade de São Paulo; 2003), containing two columns: the first for the full transcription of the session soon after its completion, and the second to record the behaviors identified from the careful reading of the transcription of the session.
Data collection began only after the approval of the research project by the Research Ethics Committee of the Albert Einstein Hospital (CAAE 0091.0.028.000-10) and authorization of managers of units where the data were collected.
After explaining to guardians and the child about research and if they agreed to participate, they were invited to play by choosing the location of her/his choice to perform the play. Parents or caregivers were always invited to join her/him. In ITP sessions, which lasted between 20 and 30 minutes, the researcher told the story of a child who was having a surgery, considering the details of the surgery and type of anesthesia that she/he would be subjected to. As the researcher told the story, she would dramatize the procedures with toys and in the end she would ask the child to repeat the play.
The toys were selected as recommended in the literature(404 4.Ribeiro CA, Almeida FA, Borba RIH. A criança e o brinquedo no hospital. In: Almeida FA, Sabates AL, organizadoras. Enfermagem pediátrica: a criança, o adolescente e sua família no hospital. Barueri: Manole; 2008. p. 65-77-505 5.Ribeiro CA, Borba RIH, Rezende MA. O brinquedo na assistência à saúde da criança. In: Fujimori E, Ohara CVS, organizadoras. Enfermagem e a saúde da criança na atenção básica. Barueri: Manole; 2008. p. 287-327) including: dolls representing the surgical team, the child and their parents; materials and medical instruments such as caps, masks, aprons, syringes and serum catheter, among others; toys related to everyday household as pans, games, ball, paper and crayons.
Data were analyzed quantitatively by means of descriptive statistics and the results were presented in absolute and relative numbers.
Results
Most children were male (20; 66.7%) with predominant age of three years (13; 43.3%). The tonsillectomy surgery was performed more frequently (09; 30%), followed by circumcision (07; 23.3%) and orthopedic surgeries (05; 16.7%). General anesthesia was used in the majority (22; 73.3%), whereas only eight (26.6%) received some type of lock (penile, sacral or epidural) associated with general anesthesia.
Behavior of the children during the session of ITP
Most children took part in the play effectively (21; 70%), interrupting the story and asking questions (12; 40%), becoming interested in playing again with toys at the end of the story and calling their mother/father to participate (05; 17%). In that moment, assimilated information were reproduced in session (14; 47%), dealing with hospital toys easily (11; 37%). Some children (09; 30%) would ask us if they could carry with them some of the toys used during the session.
Behaviors showing a decreased involvement of children in the play were less frequent such as: no participation in the play, limiting themselves by only observing the researcher (06; 20%) and concentrate on little activity due to pain or discomfort (03; 10%).
Behavior of children during the perioperative period
On admission to the SC, the majority (22; 73.3%) participated spontaneously, transported on stretchers. Behaviors indicating less cooperation were less frequent at this time such as the resistance of the separation from their mother (06; 20%), crying (04; 13%) and screaming (04; 7%).
Upon entering the operating room, most children remained quiet (26; 87%), collaborating with the anesthetist by holding the inhalation mask (16; 53%) and falling asleep quickly after anesthetic induction (22; 74%). Just some children cried (06, 20%) or became agitated during anesthetic induction (12; 4%), needing to be contained. Two children recognized the researcher who previously played with her, commenting with other professionals on the ITP session (02; 7%). After surgery, the majority of children woke up from the anesthesia quietly (26; 87%).
Discussion
Initially analyzing the behaviors presented by the children in ITP session before surgery, it appears that the children showed great interest in the play, participating actively by asking questions and repeating the play by dealing with hospital toys resourcefully.
These behaviors show that, when they play, the child is free to create and when they create, accomplish something, they express their being and are able to find themselves at that moment. Playing is always a creative and intensely real experience for the child(1818.Winnicott DW. O brincar e a realidade. Rio de Janeiro: Imago; 1975). In times when they play freely, as when they interrupt and ask or repeat the play, she/he takes the initiative, dominating the situation, and her/his ego becomes strengthened(1919.Almeida FA, Bomtempo E. O brinquedo terapêutico como apoio emocional à cirurgia cardíaca em crianças pequenas. Bol Acad Paul Psicol. 2004;24(1/4):35-40).
A study conducted with preschool children prepared with ITP before outpatient
chemotherapy showed that during the session, they also showed a very similar
behavior to those found in this study. They would carefully observe the
dramatization of the procedures by professional and ask questions, collaborating
with the professional, catering to their requests in the dramatization, and took the
initiative in the play. They would also verbalize what they felt when they were
undergoing the procedure in a real situation(2020. Artilheiro APS, Almeida FA, Chacon JMF. Use of therapeutic play
in preparing preschool children for outpatient chemotherapy. Acta Paul Enferm
[Internet] 2011 [cited 2014 Feb 5];24(5):611-6. Available from:
http://www.scielo.br/pdf/ape/v24n5/03v24n5.pdf
http://www.scielo.br/pdf/ape/v24n5/03v24...
).
Another study conducted with children prepared with ITP prior to cardiac surgery also pointed out that almost all children showed interest in playing before and after surgery. Only one struggled to play after surgery. Quite weakened by prolonged ICU stay due to postoperative complications, she seemed to have lost confidence in the environment, failing to play freely(1919.Almeida FA, Bomtempo E. O brinquedo terapêutico como apoio emocional à cirurgia cardíaca em crianças pequenas. Bol Acad Paul Psicol. 2004;24(1/4):35-40).
It was also found that children expressed the desire to carry some of the hospital toys used in play. This finding was also found in the aforementioned study(1919.Almeida FA, Bomtempo E. O brinquedo terapêutico como apoio emocional à cirurgia cardíaca em crianças pequenas. Bol Acad Paul Psicol. 2004;24(1/4):35-40). The intention of repeating a play that gave her/him great satisfaction, not only during the session, but at any time, may be related. It is emphasized that the repetition of a stressful event playfully brings stress relief, evidencing the therapeutic value of play in childhood. Asking to stay with the hospital toy after the session is a way for the child to carry part of something that brings her/him pleasure(1717.Almeida FA. Em busca da confiança necessária para viver criativamente pelo brincar: a criança diante da cirurgia cardíaca [tese]. São Paulo: Instituto de Psicologia, Universidade de São Paulo; 2003) and even the guarantee that other meetings will happen, in case she/he commits to return it later.
Although with less frequency, some behaviors showed that some children were not motivated during the play, who would only observe the researcher dramatizing the procedures, having difficulty concentrating or refusing to participate. The ability to focus is crucial if the child can play and for this, she/he must rely on the environment and people around her/him. However, the ability to trust others varies greatly from one child to another, depending on confidence experiences that each one has lived since birth(1818.Winnicott DW. O brincar e a realidade. Rio de Janeiro: Imago; 1975).
A study conducted with children from 4 to 12 years old, who underwent palate cleft
lip repair, previously prepared with ITP, pointed out that the interest in handling
toys increases when the child is more familiar with the situation(2121.Fontes CMB, Mondini CCSD, Moraes MCAF, Bachega MI, Maximino NP.
Utilização do brinquedo terapêutico na assistência à criança hospitalizada. Rev
Bras Educ Espec [Internet]. 2010 [citado 2014 fev. 5];16(1):95-106. Disponível
em: http://www.scielo.br/pdf/rbee/v16n1/08.pdf
http://www.scielo.br/pdf/rbee/v16n1/08.p...
). The preparation took place in
two stages: the day before surgery, when the preoperative orientations were made to
the children and their family, and in the surgery day, while waiting to be sent to
pre-anesthesia care unit. They had contact with the same toys and playful scenario
in both situations, with a greater number of children handled the toys in the second
time, when they knew the material(2121.Fontes CMB, Mondini CCSD, Moraes MCAF, Bachega MI, Maximino NP.
Utilização do brinquedo terapêutico na assistência à criança hospitalizada. Rev
Bras Educ Espec [Internet]. 2010 [citado 2014 fev. 5];16(1):95-106. Disponível
em: http://www.scielo.br/pdf/rbee/v16n1/08.pdf
http://www.scielo.br/pdf/rbee/v16n1/08.p...
).
In the perioperative period, most children in this study proved to be calm, coming spontaneously to the SC, not resisting the separation from their mother and collaborating during anesthesia, sleeping quickly.
The scientific evidence indicates that the previous preparation of the child with
toys contributes significantly to the dominance indicative of acceptance and
adaptation to the situation of child behaviors, as seen in this study. In a study
conducted with children prepared with ITP prior to the post-surgical dressing, these
behaviors have become more frequent, compared with those who received no preparation
with the toy previously(2222.Kiche MT, Almeida FA. Brinquedo terapêutico: estratégia de alívio
da dor e tensão durante o curativo cirúrgico em crianças. Acta Paul Enferm
[Internet]. 2009 [citado 2014 fev. 5];22(2):125-30. Disponível em:
http://www.scielo.br/pdf/ape/v22n2/a02v22n2.pdf
http://www.scielo.br/pdf/ape/v22n2/a02v2...
). Among
these behaviors, we highlight the interest in playing, spontaneously helping the
professional and asking questions, which were also observed in this study.
Some children reported on the ITP session when they were in SC, when they realize the similarity between the actual situation and dramatization in the play, recognizing the researcher who played with them and that was present in the operating room. The child begins to trust people who play with her.
Although it is considered that the preparation with ITP positively influence the child’s behavior in the face of traumatic situations, other factors have also contribute to make it happen. The persistence of a significant person close to the child makes the surgical environment less frightening, allowing the child to feel safe.
At the institution where data were collected, the mother or another caregiver accompanies the child to the operating room, often lying on bed with them. At the end of the surgical procedure, that person is already waiting for her/him in the anesthetic recovery unit, remaining near the child until discharge.
Parental separation seems to be the event that generates more stress for the child, as they represent their safe haven(101 1.Sanders J. Cuidado centrado na família da criança durante a doença e hospitalização. In: Hockenberry MJ, Wilson D, Winkelstein ML, editores. Wong Fundamentos de Enfermagem Pediátrica. 8ª ed. Rio de Janeiro: Elsevier; 2011. p. 675-702.). Moreover, due to the magical thinking characteristic of this stage of development, they can understand surgery and hospitalization as a punishment for not behaving well or because their parents do not love them anymore(404 4.Ribeiro CA, Almeida FA, Borba RIH. A criança e o brinquedo no hospital. In: Almeida FA, Sabates AL, organizadoras. Enfermagem pediátrica: a criança, o adolescente e sua família no hospital. Barueri: Manole; 2008. p. 65-77-505 5.Ribeiro CA, Borba RIH, Rezende MA. O brinquedo na assistência à saúde da criança. In: Fujimori E, Ohara CVS, organizadoras. Enfermagem e a saúde da criança na atenção básica. Barueri: Manole; 2008. p. 287-327).
Another factor that contributes so that the moment of surgery is less stressful for the child and her/his family is the use of pre-anesthetic medication, routine practice in the institution where the research data were collected. This approach is effective in alleviating anxiety while promoting sedation of the child and facilitates the separation of families and the onset of anesthesia, without interfering in the time of post-anesthetic recovery(2323.Belzarena SDG. Pré-anestesia com midazolan em cirurgia pediátrica ambulatorial. Rev Bras Anestesiol. 1989;39(4):277-80.).
There were, however, some children who resisted the separation from their mother, crying or screaming from the entrance in SC, having to be restrained during anesthetic induction. These behaviors, characterized by lower acceptance and adaptation procedures, are expected from the hospitalized child, especially before they reach five years of life even when they have been previously prepared with the toy(101 1.Sanders J. Cuidado centrado na família da criança durante a doença e hospitalização. In: Hockenberry MJ, Wilson D, Winkelstein ML, editores. Wong Fundamentos de Enfermagem Pediátrica. 8ª ed. Rio de Janeiro: Elsevier; 2011. p. 675-702.-202 2.Sabates AL. Reações da criança e do adolescente e de sua família. In: Almeida FA, Sabates AL, organizadoras. Enfermagem pediátrica: a criança, o adolescente e sua família no hospital. Barueri: Manole; 2008. p. 49-56.).
After surgery, most children awoke quietly, once again reinforcing the findings of
the study cited above(2222.Kiche MT, Almeida FA. Brinquedo terapêutico: estratégia de alívio
da dor e tensão durante o curativo cirúrgico em crianças. Acta Paul Enferm
[Internet]. 2009 [citado 2014 fev. 5];22(2):125-30. Disponível em:
http://www.scielo.br/pdf/ape/v22n2/a02v22n2.pdf
http://www.scielo.br/pdf/ape/v22n2/a02v2...
) which
also identified more frequently behaviors indicative of greater acceptance and
adaptation of children in conducting post-surgical dressing after preparation with
ITP.
Newly admitted preschool children in an inpatient facility began to better interact
with the environment and adults after attending a session of TP, which dramatized
domestic and hospital situations, expressing feelings of anger and love. Before the
session, they did not play, interacting very little with the environment and
responding to some stimuli and requests. These findings confirm that the TP helps
children to better understand what is happening, coming to realize hospitalization
as less aggressive and collaborating more with the procedures(2424.Campos MC, Rodrigues KCS, Pinto MCM. Evaluation of the behavior
of the preschool one just admitted in the unit of pediatrics and the use of the
therapeutic toy. Einstein (São Paulo) [Internet]. 2010 [cited 2014 Fev 5];8(1
Pt1):10-7. Available from:
http://apps.einstein.br/revista/arquivos/PDF/1462-Einsteinv8n1p10-17.pdf
http://apps.einstein.br/revista/arquivos...
).
A literature review of 22 studies published between 2005 and 2011 also emphasizes
that the child contributes more during procedures after preparation with ITP. By
giving them the opportunity to externalize their feelings against threatening
situations, the toy promotes stress relief, evidencing as an essential instrument of
care in pediatrics(1212.Cruz DSM, Virgínio NA, Maia FSB, Martins DL, Oliveira AMS.
Therapeutic toy: integrative review. J Nurs UFPE on line [Internet]. 2013 [cited
2014 Jan 16];7(5):1443-8. Available from:
http://www.revista.ufpe.br/revistaenfermagem/index.php/revista/article/viewFile/2833/pdf_2557
http://www.revista.ufpe.br/revistaenferm...
).
The play, by itself, has a relaxing potential, which is very useful in the
hospitalization and healing, it reduces stress, anxiety and pain, normalizes vital
signs, besides that, the process favors the bond of trust with staff because it
facilitates communication and promotes entertainment, among other
benefits(2525.Tondatti PC, Correa I. Use of music and play in pediatric nursing
care in the hospital context. Invest Educ Enferm [Internet]. 2012 [cited 2014
Fev 5];30(3):362-70. Available from:
http://www.scielo.org.co/pdf/iee/v30n3/v30n3a09.pdf
http://www.scielo.org.co/pdf/iee/v30n3/v...
).
A study aiming to identify the benefits of the TP for the child by the nursing staff
of the pediatric unit also emphasizes its value in improving the communication and
strengthen the bond between children and professionals, it also enables them to
verbalize their feelings. Professionals observe a more positive response from the
child about the procedure and the team itself, as well as significant improvement in
both emotional and clinical aspects. Also emphasizing that the family comes to trust
the team(2626.Souza LPS, Silva CC, Brito JCA, Santos APO, Fonseca ADG, Lopes
JR, et al. O brinquedo terapêutico e o lúdico na visão da equipe de enfermagem.
J Health Sci Inst [Internet]. 2012 [citado 2014 fev. 5];2012;30(4):354-8.
Disponível em:
http://www.unip.br/comunicacao/publicacoes/ics/edicoes/2012/04_out-dez/V30_n4_2012_p354a358.pdf
http://www.unip.br/comunicacao/publicaco...
).
During data collection, it was observed that some parents feared that the child was afraid to hear about the surgical procedure in the ITP session. However, they are reassured when they see how the child showed increasingly interested in the story and the dramatization with toys.
A research was developed with parents and caregivers of children undergoing
outpatient venipuncture in order to understand their perception regarding the use of
ITP in preparation for the procedure(2727.Conceição CM, Ribeiro CA, Borba RIH, Ohara CVS, Andrade PR.
Brinquedo terapêutico no prepare da criança para punção venosa ambulatorial:
percepção dos pais e acompanhantes. Esc Anna Nery Rev Enferm [Internet].
2011[citado 2014 fev. 5]; 15(2):346-353. Disponível em:
http://www.redalyc.org/pdf/1277/127719099018.pdf
http://www.redalyc.org/pdf/1277/12771909...
). The results showed that they are favorable to the strategy
because they believe it reduces fear, calms the child and promotes the safety of
both. According to them, there is no need to restrict it because usually the child
is more collaborative, causing a puncture be performed more easily, increasing the
chances of success in the first attempt and in less time(2727.Conceição CM, Ribeiro CA, Borba RIH, Ohara CVS, Andrade PR.
Brinquedo terapêutico no prepare da criança para punção venosa ambulatorial:
percepção dos pais e acompanhantes. Esc Anna Nery Rev Enferm [Internet].
2011[citado 2014 fev. 5]; 15(2):346-353. Disponível em:
http://www.redalyc.org/pdf/1277/127719099018.pdf
http://www.redalyc.org/pdf/1277/12771909...
).
Concerned with not hiding the truth from the child, the family of one of them had already talked to her about the surgery using the toy. Upon entering this girl’s room, who would undergo an orthopedic surgery, the researcher found a doll dressed in apron, cap, slippers, identification bracelet and a bandaged arms the same in which the child would have in surgery. It was made by the child’s grandmother, who had performed a surgical procedure and realized the importance of preparing her granddaughter to cope with that.
It is important that parents are involved in the preparation of the child, because it will validate the information received with them, which are their source of security. Therefore, they should be encouraged to participate in the ITP session, they also benefit from the information transmitted during the play, clarifying the doubts that they had no courage to ask the professionals.
The results of this study contribute to reinforce the importance of the routine use of ITP in preparing children for hospital procedures. However, further research is needed to prove the effectiveness of this practice in the situation studied.
The development of experimental studies, with larger samples, comparing the use of ITP in the preparation of children in these same conditions with situations in which the ITP is not usually applied may help clarify whether this practice contributes significantly to the prevalence of behaviors of adaptation in the perioperative period or if these results come from concomitant adoption of other humanized strategies.
Conclusion
Preparation for surgery with ITP proved to be a pleasurable experience in itself for most children, who attended the session effectively, interrupting the play to make questions, interested in repeating the play after hearing the story that was told by the researcher and reproducing the information assimilated during preparation. In the SC, most of them spontaneously entered the operating room, keeping calm in the operating room, collaborating in anesthetic procedure and awakening calmly after surgery.
The reduced or absent number of behaviors that show fear and stress among children, such as crying, being agitated, struggling or screaming, enhances the beneficial effects of ITP in preparing the child for the surgical procedure. However, we must consider adopting other strategies that also contribute to alleviate fear and childhood stress, as the permanence of a significant person and anesthetic medication.
The importance of involving the family in the preparation of children is reinforced by encouraging families to participate in the TP sessions. It is for the truly committed professional to recognize the insecurity of parents to talk about the subject with their children and instrumentalize them with additional information when necessary, so that they can consistently help the child to face new and challenging situations.
-
*
Extracted from the graduation final paper "Benefícios do brinquedo terapêutico no período perioperatório" Certified Specialization in Surgical Center, Anesthetic Recovery and Material and Sterilization Center, School of Nursing, Albert Einstein Jewish Hospital, 2010.
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-
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» http://www.scielo.org.co/pdf/iee/v30n3/v30n3a09.pdf -
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» http://www.unip.br/comunicacao/publicacoes/ics/edicoes/2012/04_out-dez/V30_n4_2012_p354a358.pdf -
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» http://www.redalyc.org/pdf/1277/127719099018.pdf
Publication Dates
-
Publication in this collection
June 2014
History
-
Received
18 July 2013 -
Accepted
24 Feb 2014