THE POWER OF PLAY IN PEDIATRIC NURSING: THE PERSPECTIVES OF NURSES PARTICIPATING IN FOCAL GROUPS

LA FUERZA DEL JUGAR-CUIDAR EN LA ENFERMERÍA PEDIÁTRICA: PERSPECTIVAS DE ENFERMEROS EN GRUPOS DE ENFOQUE

ABSTRACT

Objective:   to understand how nurses assess the implementation of therapeutic play by the nursing staff in the care provided to children.

Method:  qualitative study addressing nurses providing pediatric care in hospitals located in five Brazilian regions. Face-to-face meetings were held with nine focal groups between January and August 2018. The sessions lasted two hours on average and were audio-recorded and transcribed verbatim. Data were analyzed through inductive thematic analysis.

Results:  52 nurses reported their perspectives regarding play and therapeutic play implemented in the care provided to children, which revealed The power of Play-Care implemented in nursing care: advancements and challenges and its subthemes: using puppets/dolls and dramatizing procedures; using distraction strategies to perform the procedures; wearing colorful and fun uniforms; recognizing the power of play in nursing care; and barriers challenging the connection between play and care in nursing practice.

Conclusion:  the power of Play-Care is manifested in the routine of nursing care through playful attitudes; however, these attitudes appear to be individual initiatives rather than systematized in the nursing process. Hence, there is a need to expand the possibilities of teaching this topic by promoting training programs, including practical activities and virtual learning environments.

DESCRIPTORS: Child; hospitalized. Play and playthings. Pediatric nursing. Humanization of assistance. Organizational culture. Professional competence

RESUMEN

Objetivo:  comprender cómo los enfermeros evalúan la utilización del jugar e del juguete terapéutico, en el equipo de enfermería en el cuidado a niños.

Método:  estudio cualitativo con enfermeros actuantes en el cuidado pediátrico hospitalario de las cinco regiones de Brasil. Nueve grupos de enfoque presenciales fueron realizados entre enero y agosto de 2018. Las sesiones tuvieron duración media de dos horas, que fueron grabadas en audio, transcritas y analizadas según el análisis temático inductivo.

Resultados:  52 enfermeros relataron sus perspectivas sobre el jugar y el juguete terapéutico en el cuidado a niños, revelando La fuerza del Jugar-Cuidar en el cuidado de enfermería: avances y desafíos y, sus subtemas: uso de muñecos y la dramatización de procedimientos; uso de la distracción para realización de procedimientos; uso de uniformes coloridos y divertidos; reconocimiento de la potencia del jugar en el cuidado de enfermería y barreras desafiadoras de la conexión jugar-cuidar en enfermería.

Conclusión:  la fuerza del jugar-cuidar se revela en lo cotidiano del cuidar de la enfermería, por medio de actitudes lúdicas; sin embargo, fueron identificadas como individuales y no sistematizadas en el proceso de enfermería. Se revela la necesidad de ampliar las posibilidades de la enseñanza de la temática, en la forma de capacitaciones, incluyendo actividades prácticas o además, que se hagan disponibles cursos en ambientes virtuales de aprendizaje.

DESCRIPTORES: Niño hospitalizado; Juegos e implementos de juego; Enfermería pediátrica; Humanización de la atención; Cultura organizacional; Competencia profesional

RESUMO

Objetivo:  compreender como os enfermeiros avaliam a utilização do brincar e do brinquedo terapêutico pela equipe de enfermagem no cuidado à criança.

Método:  estudo qualitativo com enfermeiros atuantes no cuidado pediátrico hospitalar das cinco regiões do Brasil. O total de nove grupos focais presenciais foi realizado entre janeiro e agosto de 2018. As sessões tiveram duração média de duas horas, foram audiogravadas, transcritas e analisadas segundo a análise temática indutiva.

Resultados:  52 enfermeiros relataram suas perspectivas sobre o brincar e o brinquedo terapêutico no cuidado à criança, revelando A força do Brincar-Cuidar no cuidado de enfermagem: avanços e desafios e, seus subtemas: uso de bonecos e a dramatização de procedimentos; uso da distração para realização de procedimentos; uso de uniformes coloridos e divertidos; reconhecendo a potência do brincar no cuidado de enfermagem e barreiras desafiadoras da conexão brincar-cuidar em enfermagem.

Conclusão:  a força do brincar-cuidar se revela no cotidiano do cuidado de enfermagem por meio de atitudes lúdicas, no entanto, são identificadas como individuais e não sistematizadas no processo de enfermagem. Revela-se a necessidade de ampliação das possibilidades de ensino da temática na forma de capacitações, incluindo atividades práticas ou ainda, que sejam disponibilizados cursos em ambientes virtuais de aprendizagem.

DESCRITORES: Criança hospitalizada; Jogos e brinquedos; Enfermagem pediátrica; Humanização da assistência; Cultura organizacional; Competência profissional

INTRODUCTION

In general, the admission of a child to a hospital facility, whether to treat an acute or chronic illness, causes anxiety, fear, and insecurity, both in the child and family. In this context, nurses play a crucial role in helping them face the experience of illness and hospitalization safely, involving them in a friendly environment, and promoting the child’s well being and development, playfully and safely1^-2.

Giving opportunities for children to play provides a structured environment that helps them deal with the disease, the unexpected, and medical interventions2. Nurses should facilitate children’s games, and playful interventions should be part of nurses’ attributions when providing child care3^-4. Families of children admitted to a hospital and prepared in advance through therapeutic play (TP) were unanimous in stating that their children understood the admission better, and for this reason, changed their initial perception of the hospital and professionals, i.e., they were positively impressed and considered essential to incorporate TP in care delivery5^-6.

Thus, professionals need to master the practices that involve playful interventions, such as recreational games, distractions, and therapeutic play7^-8. Both therapeutic play and distractions are communication skills required from nurses in the countries that compose the United Kingdom3^-4 and also in Brazil, as provided for by COFEN Resolution No. 0546/20179. However, there is a concern in these countries with a current tendency for the teaching of therapeutic play in undergraduate nursing programs to be considered low priority compared to the teaching of other techniques5^,10^-11. Consequently, there is a risk of it disappearing from programs, and future generations of nurses become oblivious of their role in promoting play and therapeutic play in child care11.

Such a concern is relevant as scientific evidence shows that play and therapeutic play is essential for hospitalized children. Playing in a hospital environment promotes adaptation, well being, regulates negative effects and decreases stress, facilitating coping and helping children process new information. Besides, it is a safe way to experiment with new behaviors with creativity, fantasy, and empathy1^,5^-6^,12.

Therefore, knowing whether the nursing staff has incorporated play and TP in child care and how nurses assess them can help diagnose this practice in the pediatric clinic and guide the development of strategies to strengthen this knowledge as a systematic care action to be implemented by nurses and nursing staff. In this sense, this study’s objective was to understand how nurses assess play and therapeutic play implemented by the nursing staff in childcare.

METHOD

This is a qualitative study. Data originated from a matrix analysis-based study conducted within a post-doctoral program. The objective was to develop and validate an online course addressing therapeutic play implemented in pediatric nursing care directed to nurses.

Inclusion criteria were nurses working in a hospital pediatric care setting, with ≥1 years of clinical experience, regardless of prior knowledge or practice with the therapeutic play.

Initial contact was made with the hospitals’ nursing directors, who nominated potential nurses to participate in the study. An electronic invitation was sent to 62 nurses to participate in the study; seven did not reply, and 55 agreed to participate, though three missed the date scheduled for the meeting. After the participants’ consent, an informative text was sent in advance to support the discussion and reflection at the time of data collection. The content was extracted from research papers addressing the subject, and a summary of how therapeutic play is used in child nursing care was provided.

The participants were recruited from eight public hospitals located in the five Brazilian regions: four children's hospitals, three university hospitals, and one general hospital. A total of 13 nurses from two facilities located in the south participated, in addition to 14 nurses from two facilities in the southeast, 12 nurses from two facilities in the midwest, six nurses from the northeast, and seven from the north, the two last regions with one facility each. Research funding granted for one year provided to travel expenses determined the number of hospitals visited.

Data were collected through Focal Groups, a method that encourages sharing attitudes and opinions regarding a given topic that is generally a sensitive subject for the group13.

Nine face-to-face meetings took place between January and August 2018 with the focal groups; the last group met twice. The primary author, who had no prior relationship with any of the participants, organized and held the meetings. The meetings lasted two hours on average and were moderated by the researcher and an observer responsible for taking notes in the field diary. Both researchers are nurses experienced with FG.

The meetings were held in a private room on the hospitals’ premises. All the nurses were invited to sit in a circle and were introduced to each other. Characterization information was collected from the nurses, and the researcher explained what the FG consisted of and presented the study’s objectives. The session started by refreshing the topic concerning play, and the participants were invited to recall their favorite childhood games, choosing the most significant one to share with the group.

After this initial moment, the topic of therapeutic play in nursing practice within childcare was introduced to the participants. Open-ended questions guided the group’s meeting: do you observe the nursing staff playing and/or using therapeutic play in their practice routine? How has this happened? In light of this finding, what outcomes do you perceive? All the nurses had the opportunity to express their opinions, ask and answer questions.

All the sessions were audio-recorded, and after each FG, the interviews and observation notes were transcribed verbatim. The research team conducted debriefing sessions and reviewed the questions as needed. As previously mentioned, two meetings were planned for the last institution. The first meeting was similar to the ones held in the other facilities, while the second meeting, held on the following day, was intended to present and discuss content discussed and produced by the previous groups. The topics were discussed and presented without adding any information, which allowed ceasing the collection of data.

Data were analyzed using the inductive thematic content analysis process14. This is a method of qualitative data analysis used to identify, analyze, interpret, and report patterns (themes) in qualitative data. It is a flexible and accessible method capable of supporting the management of both large and small databases in qualitative studies.

The inductive analysis occurred concomitantly with data collection and guided the subsequent steps, clarifying and deepening essential aspects related to the topic. First, the research team carefully transcribed the FG records, reading and rereading the transcriptions while highlighting initial ideas and looking for meanings and patterns to become familiarized with the text. Next, all codes were grouped into potential themes. The themes were then reviewed and refined for consistency across the dataset and grouped according to similarities.

In compliance with Resolution 466/12, the project was approved by the Research Ethics Committee at the hosting institution. Additionally, to ensure confidentiality of the nurses’ identities, the participants are identified by the letter “N” following by the number corresponding to the order in which the focal groups were held, for instance, N1, FG1 (nurse 1 from the first focal group from a total of eight).

This study complied with the guidelines regulating qualitative research provided by COREQ (Consolidated Criteria for Reporting Qualitative Studies).

RESULTS

Fifty-two nurses participated in the study; most were women (n=51). Years of clinical nursing experience ranged from four to 33, with a mean ± SD of 13.3 ± 7.3 years. Most were Nurse Specialists and worked in different fields, such as pediatric wards, emergency, pediatric intensive care units, or outpatient clinics. Years of clinical practice in pediatric nursing ranged from one to 25 years (8.5±6.3 years).

The following central theme emerged from the qualitative analysis: “The power of Play-Care in nursing care: advances and challenges,” which presents the nurses’ perspectives regarding the presence of free play encouraged by the nursing team, strong enough to mediate interaction and communication with children, promoting the establishment of bonds and trust, and enable playful, pleasurable, and effective care. However, barriers challenging the connection between play and care were identified, such as a lack of plural systematic actions and not incorporating this structuring element into the nursing process. Additionally, undergraduate nursing programs and specializations in pediatric nursing seldom address this topic, and nurses have to deal with an overload of tasks, lack of physical structure, human and material resources, which prevent play from being implemented systematically.

The central theme comprises the following sub-themes: using puppets/dolls and dramatizing procedures; using distraction strategies to perform the procedures; wearing colorful and fun uniforms; recognizing the power of play in nursing care; and barriers challenging the connection between play and care in nursing practice, which are presented below.

Using puppets/dolls and dramatizing procedures

The nurses emphasized that play has been naturally incorporated into care through conversations established with the children and their dolls and dramatization of procedures. Therefore, the playful language that is natural during childhood establishes a friendly connection with nursing care:

It [play] often happens very naturally. At admission, children often say: “Ma’am, are you going to put my little friend by my side? And I’d ask: “what is your little friend’s name?, the child replies: “you don’t know?” Then, the child takes his doll (Cebolinha) out of his backpack: “look, this is my little friend!” So, everything I’d do on him, I’d do on his friend first. So, this is how we play (N7, FG8).

You can do it [play] every day, and that’s how we bond. Interaction is fun, and it happens naturally. For instance, there is this patient with cystic fibrosis. She got here with her doll and had an IV. Everything she had to do, she’d do on her doll, and we did the same (N2, FG5).

Here, we have this patient; she has a tracheostomy, gastrostomy, and her little doll has all these devices. She plays with her doll and does all the procedures we do on her. Everyone on the team uses her doll (N3, FG6).

The nurses reported that the dolls mediate and facilitate care. For example, when approaching a child to perform a procedure, such as physical examination, dressing, or venipuncture, the nurses improvise and use the child’s doll to dramatize the procedure and involve them through play:

In my experience, I think that play starts like that. Sometimes, a child needs a nebulizer, and the child doesn’t want to do it, so we take her doll, do it first with the doll, and then with the child, and it works really well. So, we use these resources (N6, FG7).

I have some strategies. If there’s a doll on the bed, a teddy bear, or something I can use to do the physical examination, I start with what the child has, with his doll, I’ll do an auscultation with the doll and then I let him do it with me. So, this is a strategy to approximate the child and make the procedure. This is how we do it... (N2, FG5).

It reminds me of stories. For instance, I’d already had teddy bears here at the unit. There were teddy bears with a scalp IV, a catheter, and the child brings her teddy bear and says: “Ma’am, I’m going to give you my little arm, but do it with my teddy bear first, and the teddy bear stays by his side all the time on the armchair (N7, FG8).

One nurse from the pediatric radiology sector referred to playthings as an ally in his practice. He said that in his experience, playing with children and simulating the exam on dolls first leads to positive outcomes because it decreases the need to sedate children for undergoing image exams such as CT scans:

In radiology, we realize how much a toy helps us. Sometimes, we let the child perform the exam on her doll, and she does it, plays with the transducer, examines her doll, and then allows me to do the exam with her. As a result, we decrease the need for anesthesia considerably in the CT scans. So, this is how we play in the image service (N3, FG8).

Such experience also occurs in other contexts, as one nurse from the outpatient clinic, who uses therapeutic play to prepare children and their families for bladder surgeries, reported. She notes that orientation mediated by a doll is positive for children because they enjoy it and learn about their new condition through playing:

A good strategy we adopt in the outpatient clinic is therapeutic play. For example, in urology, when a child will have bladder surgery or a mitrofanoff, you need to present this new condition to her. This nurse and I have practiced this technique a lot. We talk to the child with her surgery already scheduled; we talk to her mother and father and teach them how to provide care using an adapted doll. So, using therapeutic play in our outpatient practice in the preoperative of bladder interventions is 100%. We know it is positive because children enjoy and learn (N4, FG4).

Using distraction strategies to perform the procedures

The nurses reported that another playful activity implemented is distractions. For example, the participants working in Intensive Care Units noted that the nursing staff has become concerned with distracting children when performing procedures, so they use videos, books, toys, and songs, so the children play while they provide nursing care:

We always try to distract children in the ICU, put a video with songs and when the mothers mention what the children like, we put for instance, “Pepa Pig”, and we distract them and play (N7, FG1).

We use some artifices in the ICU with children to explain the procedures. We play while doing the auscultation, use toys, put a movie on the cell phone, give them a book… We always use something to distract the children (N4, FG6).

The nurses in other clinical settings noted that distracting a child with a toy while performing procedures is also a practice adopted in the routine of the nursing staff. They verified that, in general, the resource that has mediated this interaction is the workers’ cell phones. The workers access the children’s preferred videos or songs whenever they need to perform procedures, such a venipuncture:

Here in the ward, playing takes place while we provide care. Some workers play videos on their cell phones at the time of a puncture. If it’s an infant or younger child who pays attention, they use it; some even sing… so, free play happens (N1, FG3).

This little thing here [showing her cell phone] is handy, especially at the time of a puncture; there’s Lottie Dottie Chicken, among so many videos. We use it a lot in the procedure room (N3, FG5).

I use it (play) almost every day [...] I download videos for the younger children and show them Lottie Dottie Chicken. Everyone loves it (N1,2, FG4).

Wearing colorful and fun uniforms

In addition to playing with dolls, dramatizing procedures, and using distractions, nurses reported that colorful and fun uniforms also show that playfulness is present in the routine of the nursing team. For example, the nurses from one of the hospitals were enthusiastic with the possibility of wearing fun caps with children’s motifs, or a touch of fantasy, wearing superhero costumes. These work as an invitation for children to interact with nursing care, and the nurses deem it to be effective:

There is something else we play here, and we find it really cool. We wear fun caps. The hospital’s nursing staff wear really fun caps, so some people are known by their caps; there is Superman, Batman, Arrow, you know, a cap for the entire team. There is a nurse known as Batman. So, it’s something we play with and it works (N7, FG8).

This (shows a picture) is a nursing technician from the outpatient clinic, and he usually wears a Batman cape and cap on Fridays. This new coordinator allows us to wear something fun and colorful on Fridays. [...] Look this (picture) with the entire team; there is everything here, Green Lantern, Spiderman, the entire team! (N2,7, FG8).

I recall that there is a group of people in the nursing staff who always dress as Superman, superheroes, Wonder Woman on children’s day [...] We do it too! We work dressed as superheroes for the children on that day! So, there are the things that we, from the nursing staff, come up with, and it works out really well (N3, 4, FG8).

Recognizing the power of play in nursing care

Thus, the nurses recognize the power of play to transform the hospital routine into something more familiar for children, allowing them to enjoy some sense of normality and continuity of life even when hospitalized. Providing care that value playfulness allows children to enjoy “being children”, especially when experiencing critical situations due to their health and the need to stay in a hospital:

At the hospital, I guess it’s important to think about the healthy side of children, the one that needs to play [...] when a child plays, she’s being a child! [...] And, the fact they are hospitalized does not interrupt childhood (N1,3, FG1).

Play is important. We need to realize that when children get better and are no longer in a critical condition, they are practically healthy children and want to run and play. They want to experience the joy of being a child, even at a hospital (N3, FG5).

When the participants were asked about what they perceived from playing while providing care, they highlighted that play has a relaxing effect and helps children deal with their conflicts, working as an escape valve, which helps and protects them during hospitalization. When recalling a case, a nurse noted how much dolls support children, which children signify as part of their family:

I guess that promoting play is important because many times it calms children’s conflicts, considering a hospital is an environment with many different people. We also encourage them to bring a toy they like from home, so they feel cozier, calm down as their toys represent something they are familiar with (N4, FG7).

Being in a hospital, I guess that sick children have their limitations, but there has to be some form of escape. I guess that play can help children in this situation (N3, FG2).

Play supports children at a hospital. We had this little girl who had her little doll with her all the time. She’d take the doll with her wherever she’d go and used to say it was her twin sister. So, the doll calmed her down and represented a close relationship she kept with her family (N3, FG5).

The nurses consider that when the workers are willing to play, in addition to meeting the children’s needs and promoting interactions, they go down to the child’s level of thinking. They consider that when this happens, they are as equals, so the child becomes interested and transforms the situation, from being lonely with a cell phone to an opportunity to play with the professionals:

Playing enables us to establish a better interaction when providing care. We can provide care and play at the same time because they are children, they need it, and we do too (N2, FG1).

Using a doll, a car toy, it’s a way to interact and communicate with children through the toy. I recognize that there are more IPads, iPhones, Smartphones, but the interaction with a toy is different because in this case, you and the child are equals; she’ll immediately put the cell phone away to play with you (N2, FG4).

One participant acknowledged that when using play, nurses have their care practice facilitated. As a result, they can break relational barriers, establish trust, and promote positive bonds that permeate the health system, i.e., children can benefit in the future when seeking a health care service:

We manage to break many barriers with a child when we use therapeutic play in health care and are willing to play. Next time they’ll come back, they’ll be more open and will even collaborate during care. We notice that the relationship with them improves a lot, and they start trusting you. Therapeutic play helps us a lot (N6, FG7).

Barriers challenging the connection between play and care in nursing practice

Although nurses recognize the use of playful strategies and the power of play and therapeutic play in their practice, they revealed that barriers challenge the connection between play and care. These barriers include the fact that these strategies are not systematically adopted in the nursing process of the facilities addressed in the study:

Nothing is documented here at the hospital; I mean, we don’t say, “Ah, we systematically use therapeutic play in nursing care,” but we do it! We, the nurses working with pediatric patients, do it, only that it is not formally integrated into the nursing process (N7, FG8).

Here, toys help us reproduce and understand what children are experiencing, though we do not systematically implement therapeutic play in care delivery (N2, FG5).

What emerged from a reflection about this aspect and potential causes is that this topic is not included in the training provided to nurses, not during the undergraduate program or pediatric nursing specialization. When it is included, only theoretical aspects are addressed to the detriment of practical interventions:

I attended a specialization in pediatrics and didn’t receive training in therapeutic play. Actually, I only had a single theoretical class at college (N5, FG3).

I also had TP at college, but it was really superficial because I never saw it like real-world practice. I only saw the theoretical aspect of it during the program (N3, FG1).

I didn’t have theoretical nor practical classes addressing TP. I didn’t see TP during the undergraduate program or specialization program (N1, FG5).

The nurses reported that the work process, in general, is focused on technical and procedural aspects, and play would be another side of care as if these two sides never connect. The overload of tasks is a barrier that impedes integration between play and care; though they recognize it as something joyful, play is put in the background, implemented only when it is possible to do it:

What happens? We are overwhelmed, so, the workers are concerned with work processes. They administer medication, do dressings, so there's this other side [play] and nursing workers end up missing it a little [...] I guess that we fail and forget this other side [pause] we fail to pay attention to this (play), you know? (N2,4, FG2).

Nurses deal with an overload of tasks; sometimes, it doesn’t allow us [to play], which is fun, you know? So, we do it but can’t implement it every day (N1, FG4).

Another aspect concerns the difficulty of promoting play in pediatric wards because there is a lack of physical structure and human and material resources, such as toys. Additionally, therapeutic play is not valued, and the playrooms are remodeled and used for other functions, or simply “cease to exist”:

There is some room for children to play, but it is small. We have a playroom, but not all children can go. There is no longer the employee who used to stay there… The units other than the pediatrics, which also have children hospitalized, are even worse, there are no toys, no access, it is complicated, there is nothing! (N4, FG2)

My unit [burn treatment center] is different from the pediatrics, but it provides care to children. There was a playroom when it was inaugurated, but then it was replaced by an anesthesiologist room, and then, the playroom ceased to exist… now it’s missing… there is a lack of places for children to play (N3, FG2).

When I got here, it was an old hospital, and it had a playroom, and a little square, which was very nice and children loved it… but now, there is no longer this space in this new building, there is no playroom or a square, they did not include it in the blueprint (N6, FG6).

DISCUSSION

This study’s findings show that nurses acknowledge the power of play to promote playful, fun, and effective nursing care. Furthermore, this practice is implemented by those who naturally overcome barriers and allow the essence of play to guide the interaction between nurse and child. Hence, using a language inherent to childhood, mediated by dolls, toys, colorful uniforms, and playthings, nurses connect play to care in a unique action that results in an encounter that is both fun and serious and effective.

Brazilian and international studies highlight the connection between play and care and its effectiveness in nursing care provided to hospitalized children1^,15. Puppets and dolls play a role in make believe/pretend play and is also a communication resource that prepares children for medical procedures and mediates the relationships between children and the health staff16^-17. A commitment to help children understand the aspects of their conditions and the need to perform procedures encouraged the participants to use their creativity and create and adapt dolls to mediate communication.

Through improvising and customizing dolls and puppets, nurses can star in stories in which children can play an active role, providing interesting information regarding their concerns, fears, and points of view, which soothes their emotional distress and minimizes hierarchical relations between children and adults at the hospital environment, as one of the participants report, when both become equals16^,18.

The nurses reported that dolls mediate and facilitate care. In fact, evidence shows that when children are prepared for hospitalization, surgery, or other potentially painful procedure mediated by therapeutic play and dramatization with dolls, outcomes are positive in terms of learning about painful procedures19, decreasing anxiety, fear, and pain20^-21.

On the other hand, one study shows that children still find it difficult to access, understand, and use information during healthcare, impacting their health literacy. Lack of clear, honest, and accessible information results in children having a low level of understanding, which favors anxiety, fear and limits the development of coping strategies before, during, or after procedures. All the children, parents, and health professionals reported that information and preparation are essential to decrease uncertainties and anxiety toward the procedures22.

Another aspect worth noting is that nurses distract the children with toys, videos, applications, or books. The nurses reported that playing while providing care is considered a natural behavior. One study found similar results, reporting that nurses considered distractions to happen naturally and usually in partnership with Child Life Specialists. They often did not even realize they were doing it, though they considered it an integral part of their role as pediatric nurses; hence it was not an intentional or planned action23.

Note that distractions are a non-pharmacological effective method indicated to alleviate pain. Sound scientific evidence shows it decreases pain and negative behavior when in the face of potentially painful procedures4^,24. However, the participants did not mention these conditions or observed these outcomes.

The nurses mentioned that play was something that happened naturally. This notion is worth noting and raises the question of whether this playful attitude results from something they were “born” with or a skill acquired and developed during academic training or yet, their institutions provided training. However, the reports reveal weaknesses during undergraduate training; that is, this topic was seldom or only superficially addressed in their training. Furthermore, a lack of knowledge becomes apparent in the reports in which the participants confused concepts and terminologies involving play, playthings, and therapeutic play.

Nurses need to overcome the unintentional use of these practices and be qualified to implement intentional and planned playful actions integrated into care plans to achieve positive outcomes, whether they use distractions, free or therapeutic play.

Who is responsible for this process? Educational institutions are expected to integrate play linearly into the curricula, emphasizing theoretical and practical aspects, as studies show this topic is not a priority in training programs. When it is addressed, content is primarily theoretical and does not allow students to experience its benefits in clinical practice. It is considered an obstacle to learning, and the participants reinforced this aspect5^,10^-11. However, there is a positive movement led by motivated professors to teach this topic. Hence, they use didactic strategies they consider adequate to sensitize students and promote significant learning of theoretical and clinical practice25.

In turn, health institutions are expected to acknowledge that playing is a right of children and part of the philosophy of care. Hence, health institutions need to ensure that play is a care action implemented by the multidisciplinary team to improve practices and assume its role in managing, qualifying and promoting a playful environment integrating actions between play and care in the health care provided to children. Additionally, these institutions are supposed to disseminate research in this field of knowledge26.

Researchers reinforce the role of health institutions in supporting systematic play, both in the context of work processes and in continuing education14. Nurses, on the other hand, should be motivated by the positive effects of play/therapeutic play, seeking training and incorporating them as constituting practices in their routine, becoming competent to implement playful interventions, as this requires training, patience, and willlingness15^,19.

In any case, teaching and health institutions need to establish a partnership and share what they consider essential in pediatric care and seek to overcome the barriers that proliferate, fragmenting care and play, such as lack of knowledge and resources13. If play and therapeutic play are considered one of the best practices to provide care to this population8^,26, wouldn't it be urgent for these institutions to pay attention to these practices? Moreover, wouldn't it be their responsibility to provide human and playthings and resources, such as dolls and toys, for these playful interventions to occur?

We reaffirm that it is essential to overcome the concept of play as something simple, only a source of leisure and a way to mitigate boredom. Much more than a “simple” game, play is an important source of learning, through which children learn content, concepts, and alternative solutions for problems, and improves their health literacy16^,19.

Additionally, play is a source of flow experiences, hope, and resilience for children, highlighting the seriousness and urgency of the Play-Care connection in pediatrics. Therefore, it is essential to comply with the children’s right to play and help them in their healing processes, so they experience less pain, feel more confident, and become more willing to relate to health professionals, their families, and also with themselves16. In general, these were the perceptions of the nurses addressed in this study.

Only the nurses’ perspectives were addressed here; other nursing staff members, such as technicians, were not included, which constitutes a limitation. On the other hand, we highlight the breadth of data collection, i.e., at least one or two representatives of each Brazilian region were included.

We emphasize the need to advance in knowledge by expanding the possibilities of teaching this subject through training programs, including practical activities, or even providing courses in virtual learning environments, which are more freely and easily accessed, regardless of time and place. Further studies are needed to give a voice to all the members of the nursing team to understand existing barriers better and identify the effects of implementing systematic therapeutic play in the pediatric health system, such as its impact on the time spent to provide care, costs, patients’ recovery, and on the level of satisfaction of patients and families, and quality of nursing care.

CONCLUSION

The conclusion is that nurses acknowledge the power of play in nursing care by implementing playful activities, using improvised dolls adapted to the children's needs, using distractions, and wearing colorful uniforms. However, they note that these actions are not intentional or systematized in the nursing process. Barriers that hinder the connection between play and care were reported, such as lack of physical and human resources, excessive workload, and a lack of a play culture in the institutions, not only healthcare facilities, such as hospitals but also teaching institutions.

ACKNOWLEDGMENT

The authors thank the participating hospitals and nurses for the rich exchange of experiences, knowledge, perceptions, and encouragement.

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NOTES

• ORIGIN OF THE ARTICLE
  Extracted from a post-doctoral report - Development and content and face validity of an online course addressing Therapeutic Play in child care: nurses’ contributions, presented to the Post-Doctoral Program, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, in 2018.
• FUNDING INFORMATION
  This study was financially supported by the National Council for Scientific and Technological Development, Brazil (Process number 168093 / 2017-0).
• APPROVAL OF ETHICS COMMITTEE IN RESEARCH
  Approved by the Ethics Committee in Research with Human Beings of the Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, opinion Report No. 2.393.143/2017, Certification of Presentation for Ethical Appreciation 79685317.0.0000.5393.

Edited by

• EDITORS
  Associated Editors: Laura Cavalcanti de Farias Brehmer, Monica Motta Lino. Editor-in-chief: Roberta Costa.

Publication Dates

• Publication in this collection
  11 Feb 2022
• Date of issue
  2022

History

• Received
  27 May 2021
• Accepted
  24 Aug 2021