Contribution of structured therapeutic play in a nursing care model for hospitalised children

ABSTRACT

Objective

To analyse how therapeutic play structured in a nursing care model contributes to the care of hospitalised children.

Method

This is a qualitative study based on convergent care research (CCR). Seven children participated in the study. Data were collected in September and October of 2014 by means of interviews with open-end questions and participant observation of therapeutic and dramatic play sessions and/or instructional play sessions based on the stages “Welcoming/Playing/Concluding” of the nursing model Care with Play. Data were analysed according to the analysis and interpretation stages of the CCR.

Results

The following three categories emerged: Meanings attributed by the child to hospitalisation and its influence on nursing care; Perception of the therapeutic procedures through therapeutic play, and Importance of the family in care.

Final considerations

It is concluded that the application of therapeutic play structured in the care model contributes to systematic and specialised nursing care.

Play and playthings; Child, hospitalised; Paediatric nursing

RESUMO

Objetivo

Analisar como o Brinquedo Terapêutico estruturado em um Modelo de Cuidado de Enfermagem contribui no cuidado à criança hospitalizada.

Método

Trata-se de uma Pesquisa Convergente Assistencial (PCA), de abordagem qualitativa. Participaram do estudo sete crianças. A coleta de dados foi realizada entre setembro e outubro de 2014, por meio de entrevista aberta e de observação participante de sessões de BT dramático e/ou instrucional através das etapas “Acolhendo/Brincando/Finalizando” do Modelo de Cuidado de Enfermagem Cuidar Brincando. Os dados foram analisados de acordo com as fases de análise e interpretação da PCA.

Resultados

Três categorias: Significados atribuídos pela criança à hospitalização e sua influência no cuidado de enfermagem, Percepção quanto aos procedimentos terapêuticos por meio do brinquedo terapêutico e Importância da inserção da família no cuidado.

Considerações finais

Conclui-se que aplicar o BT estruturado em um Modelo de Cuidado pode contribuir para um cuidado de enfermagem sistematizado e especializado.

Jogos e brinquedos; Criança hospitalizada; Enfermagem pediátrica

RESUMEN

Objetivo

Objetivo de analizar como Juego Terapéutico estructurado en un modelo de atención de enfermería ayuda en el cuidado de niños hospitalizados.

Método

Se trata de una investigación cualitativa del tipo convergente asistencial. Participaron del estudio siete niños. Los datos fueron recolectados entre septiembre y octubre de 2014, por medio de entrevistas abiertas y observación participante de sesiones de juguete terapéutico dramático y de instrucción por los pasos “Acogiendo/Jugando/Finalizando” del Modelo de Atención de Enfermería Cuidar Jugando”. Los datos se analizaron de acuerdo a las fases de análisis e interpretación.

Resultados

Tres categorías: Significados atribuidos por el niño a la hospitalización y su influencia en los cuidados de enfermería, Percepción acerca de los procedimientos terapéuticos a través del juego y La Importancia de la inserción de la familia en la atención terapéutica.

Consideraciones finales

La aplicación de la BT estructurada en un modelo de atención puede contribuir a un cuidado de enfermería especializada y sistematizadas.

Juego y juguetes; Niño hospitalizado; Enfermería pediátrica

INTRODUCTION

The hospitalisation process is stressful and traumatic for children because it removes them from their daily, family environment and places them in an unknown location that is permeated by fear, a confrontation with pain, physical limitation, and passivity(¹). The anxiety and fear that children feel during procedures triggers a response of intense emotional distress that, in turn, leads to regression, separation anxiety, apathy, fear and sleep disturbances. These symptoms can continue in adult life and cause people to avoid medical care(²).

Children must be emotionally prepared for these moments through special and distinctive care that can acknowledge and meet their needs(³). Hospitalised children should be viewed as active and participating subjects of the hospitalisation process. In addition to meeting physical needs, the provided care should consider emotional and social needs and include techniques that enable communication and bonding, such as the use of play(⁴).

Play is a childhood activity that is related to the motor, emotional, mental and social development of children. Moreover, play helps children adapt and cope with reality, and serves as a means by which they can construct, maintain and recover their health. In the hospital environment, it facilitates communication, the comprehensiveness of care, the acceptance of treatment, the enforcement of children’s rights and the (re) signification of diseases(⁵-⁶).

It is within this context that structured therapeutic play can help children reduce the anxiety that arises from threatening and atypical situations and should be implemented whenever children need to understand and cope with experiences of everyday life(⁷).

There are three types of therapeutic play: dramatic play, which provides emotional release and allows children to act out their feelings, desires and experiences by assuming social roles in which they can shift from passive to active participants in order to understand their current reality; therapeutic play that facilitates physiological functions, which helps children learn to use their physiological capabilities according to their new condition; and, instructional therapeutic play, which is used to show how each procedure is performed by handing the material before and after the procedures(⁸).

Therapeutic play in nursing care helps to establish a bond and a channel of communication with the children, know their feelings and concerns, alleviate their stress and anxiety, and prepare them for procedures(⁹).

It is worth mentioning that therapeutic play is a technique that has been applied with different participants and environments, although there is no description of its systematic use.

Furthermore, structuring therapeutic play using a care model provides a specific, systematised form of nursing care that promotes a uni-duality of science and practice. A care model is defined as a structure of knowledge that seeks to outline reality through conceptualisation and a care process guided by schematic models, thus proposing care modes associated to reality(¹⁰).

Given the gap in the application of therapeutic play in a care model, and the importance of play and its incorporation in the hospital environment to help patients cope with unpleasant situations, the guiding question of this study is: How does therapeutic play structured in a nursing care model contribute to the care of hospitalised children? Consequently, the aim is to analyse how structured therapeutic play in a nursing care model contributes the care of hospitalised children.

METHODOLOGY

This is qualitative study based on convergent-care research conducted at a paediatric inpatient unit in a public hospital of Greater Florianópolis, SC, Brazil, in September and October 2014. The study was submitted to the ethic committee for human research of the Universidade Federal de Santa Catarina in observance of resolution 466/12 of the National Health Council, and approved according to decision 763.809.

The subjects were seven children who complied with the following inclusion criteria: four to 12 years of age; admitted at least one day prior to participation; with the physical and mental conditions to participate in the study. The criterion for exclusion was to complete less than two of the model stages. The children were identified with a fictitious name of children’s characters and the statements were identified with the letters C (child) and P (researcher).

Data were collected in four stages: presentation of the study to nurses of the paediatric inpatient unit; identification and selection of the participants; signing of the informed consent statement and; application of the nursing care model Care with Play (Cuidar Brincando, in Portuguese)(¹¹) based on therapeutic play. Once the participants were identified by the researcher and nurses according to the inclusion and exclusion criteria, the study and the informed consent statement were presented to the chaperones. The chaperones were then asked to participate in the study and authorise the participation of the children. The study and the therapeutic play sessions were subsequently explained to the children, and the statement of acceptance was signed in the case of literate children. For the play sessions, we used toys and a series of other items, such as household objects, drawing and painting supplies, dolls representing the family and healthcare professionals, hospital supplies and two dolls adapted for procedures.

The nursing model Care with Play proposes therapeutic play as a care technology in order to immerse into the world of children, learn about the reality that surrounds them, and play with them in a therapeutic manner with a theoretical and methodological basis. It consists of three stages “Welcoming”, “Playing” and “Concluding”, which are directly related to a “Context”, and can occur simultaneously or not, in one or more sessions(¹¹).

The “Welcoming” step aims to establish a link between child and nurse and is considered a diagnostic step since it is used to determine the care required by each child. The “Playing” step provides a more direct interaction with the child and approaches the child’s universe in order to determine the care deficits and later referrals. And, the “Concluding” step occurs when the care deficits have been met or when there is a need to refer the child to another professional(¹¹).

Data were collected through interviews with open-end questions and participant observation of the dramatic and/or instructional therapeutic play sessions, which were recorded and subsequently transcribed and arranged in a field journal to list the main points. These categories and participant observation were then used to analyse the data according to the stages of convergent-care research: analysis and interpretation. The interpretation stage is subdividing into synthesis (gathering different elements and joining them into a coherent whole), theorisation (identification, definition and construction of relationships between the group of constructs to produce previsions of the investigated phenomenon), and transference (contextualisation of the results in similar situations to transfer and socialise them)(¹²).

RESULTS AND DISCUSSION

Seven children participated in the research, five of which concluded the three stages of the care model. Two of the children participated in dramatic play and one participated in both types of play. One of the children did not finish the three stages due to discharge and one did not want to continue with the sessions.

The ages of the children varied from five to eight and most of the children had diagnosed respiratory problems. All the children were accompanied by their mothers (Chart 1).

Chart 1
– Characterisation of the research participants, Florianópolis, SC, Brazil, 2014

Fictitious name	Age	Medical diagnosis	Chaperone	Number of sessions	Stages completed	Type of therapeutic play	Prior admissions
Barbie	5 years	Asthma	Mother	One	Welcoming Playing Concluding	Dramatic Play	No
Hello Kitty	6 years	Asthma	Mother	One	Welcoming Playing	Dramatic Play	No
Sponge Bob	4 years	Tonsillitis	Mother	One	Welcoming Playing Concluding	Instructional Therapeutic Play	No
Cinderella	8 years	Asthma Pneumonia	Mother	Two	Welcoming Playing Concluding	Dramatic Play Instructional Therapeutic Play	No
Ben 10	7 years	Atopic dermatitis	Mother	One	Welcoming Playing	Dramatic Play	Yes
Spiderman	6 years	Pneumonia Gastroenteritis	Mother	One	Welcoming Playing Concluding	Instructional Therapeutic Play	Yes
Snow White	6 years	Asthma Pneumonia	Mother	One	Welcoming Playing Concluding	Dramatic Play	Yes

• Source: Research data, 2014.

The collected data resulted in three categories that were analysed from two perspectives, namely the use of therapeutic play during the hospital stay and the structured use of therapeutic play in the nursing care model Care with Play(¹¹). The categories include the following: Meanings attributed by the child to hospitalisation and its influence on nursing care; Perception of the therapeutic procedures through therapeutic play; and Importance of the family in care.

Due to the richness of the data, all the sessions were used to create the study categories, regardless of whether the children finished or did not finish the process. Moreover, no differences were observed during the creation of the categories between the dramatic and instructional therapeutic play sessions.

Meanings attributed by the children to hospitalisation and its influence on nursing care

Sickness and hospitalisation are considered critical moments in the lives of children. During hospital stays, the daily lives of hospitalised children are altered and they are distanced from their families, toys, objects and pets(¹³). Consequently, negative feelings related to the hospital environment and the desire to return to their homes and family routine were observed during the therapeutic play sessions, as follows:

C: she’s crying here

P: why are you crying Isabella?

C: I want to go back home, not stay in hospital (HELLO KITTY)

P: what’s it like in hospital?

C: bad

P: that that you [...] like the hospital?

C: no

P: oh yeah [...] and why not?

C: because it’s boring and bad

P: Hmm [...] and what do you want?

C: to go home (CINDERELLA)

In addition, negative consequences such as separation anxiety, loss of control, and fear of injury and pain interfere with child development and are minimised when the child is given the opportunity to play(¹⁴).

Therapeutic play makes hospitalisation less traumatic and allows the provision of a more specific care with recreation and dramatisation, which provide some relief for children(³).

A study conducted with nurses on their perception of the use of therapeutic play identified that when the child has the opportunity to play, aspects such as pain, loneliness, fear and crying are put into perspective(¹⁵). Similarly, in this study, when the children were given the opportunity to play, they had more positive things to say about playing in the hospital environment.

P: what do you think about this place? [referring to the playroom]

C: Um [...] a little good

C: there are toys (HELLO KITTY)

P: and here in the hospital? What does she do?

C: She plays with the toys

P: hmm

C: and then she can go there to the playroom

P: Uh-huh [...] and what does she think of the hospital?

C: Cool (SNOW WHITE)

Therapeutic play allows children to engage in non-verbal expression and manifest their desires and feelings through play without having to worry if the professional realises they are talking about themselves(¹⁴).

Therapeutic play entertains children and shows them that the “hospital world” is not as cruel as they initially thought. It also helps provide a more unique and specific care, as shown in their statements when they indicate that the environment is not that bad due to the availability of toys. The systematic use of therapeutic play helped us identify the behaviour and perception of the children regarding hospitalisation.

The “Welcoming” step allowed us to understand how to interact with the children as professionals and how the children perceive the process of hospitalisation. This step is also crucial for the interaction between health professionals, the children and their families to occur.

It is the moment that the children start to express their fears and anxieties and how they understand hospitalisation through fantasy and reality, which reveals the care they require.

At some moments during the sessions, the children spoke of the dolls when they referred to situations that were similar to those they were experiencing, and, in some cases, they used medical terms to express the need for hospitalisation.

P: and is she sick?

C: uh-huh

P: what’s wrong with her?

C: she has bronchitis

C: she´s going to have to stay until Monday morning (BARBIE)

P: um.... what medicine do you want to give her?

C: penicillin

P: um [...] and how many days will she have to take penicillin? Do you know?

C: 24 days

P: yes [...] and what does Beatrice have?

C: atopic dermatitis (BEN 10)

The importance of using a care model during the application of therapeutic play became evident as the sessions proceeded and the children talked about the improved health status of the “dolls”, which reflected their understanding of the length of the hospital stay and its relationship with the improving health status.

C: Maisa is a lot better and can go home today.

C: Now let’s take the oxygen out to go home. (BARBIE)

C: tomorrow she’ll be better already

C: done [...] you can go home now (SNOW WHITE)

The three stages of the model helped the children gradually understand the hospitalisation process and, consequently, improved the quality of nursing care.

The “Playing” step is essential for the evolution of this process since it is during play that the children manage to grasp the hospitalisation process, assimilate what is happening, express their opinion and prepare for the situations they must face, as shown in the statements. Thus, this is the step of the model in which the nurse must be attentive to the evolution of the child and perform the diagnosis and correct prescriptions for the child and the child’s family.

Furthermore, the “Playing” step can consist of one or more sessions, depending on the needs and development of the child. This study shows that the children generally managed to show and quickly realise their needs and the hospitalisation process.

Therefore, structuring therapeutic play in a care model allowed the nurses to acknowledge the real needs and difficulties of the children and implement measures to solve them or mitigate them.

Perception of the therapeutic procedures through therapeutic play

One of the most stressful situations that the children must endure during their hospital stay are the procedures, which cause anxiety, insecurity and fear that are expressed through crying, anger and aggression(¹⁶). Fear of the unknown and new experiences cause discomfort, anticipation and anxiety in children, which reinforces the need to prepare for procedures(¹⁷). During the sessions, the children made some negative statements about these procedures and crying was the prevailing behaviour.

P: what is Beatrice feeling?

C: pain

P: pain, but why is she feeling pain?

C: because of the injection

P: she cried, but why does she cry?

C: because of the pain (BEN 10)

P: um [...] what is she like when she takes the medicine?

C: she cries a little

P: she cries [...] why does she cry?

C: because she feels a little pain (SNOW WHITE)

When children play they are free to create, realise something, express their being and fund themselves. By playing freely, they interrupt and ask or repeat the game, take the initiative, control the situation and strengthen their ego(¹⁵). In this study, the children were involved and interested in handling the hospital supplies during the instructional play sessions. They also asked questions and quenched their curiosity, and showed that they could communicate more easily through play.

C: what is that? [referring to the multiple infusion]

C: hmm [...] where do I put this? [needle felt catheter]

C: how do I put the glove on? (BARBIE)

C: is this a real needle?

C: do you use all this here?

C: can I really do that? (SNOW WHITE)

Therapeutic play serves as an instrument of communication through which children hear explanations from the professionals and ask questions, thus decreasing the negative effects that hospitalisation and procedures have on them(⁵). By representing the procedure with the toy, the children shift from passive to active subjects, which mitigates the stressful effects and decreases their anxiety and fear(¹³). During the sessions, it was observed that the children understood the importance and necessity of the procedures and performed these procedures on the “dolls” in the same manner in which they are carried out on them.

P: what are you doing now?

C: I’m putting solution in her nose

P: why are you putting solution?

C: it helps her stop with the oxygen (BARBIE)

P: puff? For what?

P: why are you doing that?

C: because it’s her inhaler

P: Um [...] and what’s the inhaler for?

C: to breathe better (HELLO KITTY)

Therapeutic play helps children express what they are going through and allows the professionals to understand and help them in the best possible way(⁴). When therapeutic play is applied through a care model, it also helps professionals to understand the needs of children, plan and execute the needed actions and assess whether these needs were met. Incorporating a care model into the nursing practice provides a reflexive nature to the care by creating modes that are firmly anchored in reality and enable the assessment of actions(¹⁰).

The application of the nursing care model Care with Play allowed the nurses to provide a specific and efficient care, as observed in this study when the children expressed the procedures to the nurses and asked questions about the procedures to reduce their fear and pain. Moreover, the statements showed that the model can be applied to other forms of existing therapeutic play insofar as the steps and the numbers of stages for each child are respected.

Nurses can use therapeutic play during their daily routines, that is, before the procedures, and add new sessions to precisely prescribe care according to the children’s needs..

The importance of the family in care

The families of hospitalised children also demand attention. The well-being of one depends on the well-being of the other, so the family must be fully involved in the entire process(¹³). During the sessions all the children mentioned their families, whether in relation to the hospital care or in relation to their home lives, which reinforces the importance of including the families in nursing care.

P: who is this?

C: her father

C: her father’s home [...] he´s not working, right. (CINDERELLA)

P: what does she do at home?

C: she has her milk, her yogurt

C: baby can’t come visit, can she?

P: why, who do you want to come visit you?

C: my niece, baby girl, Maria Clara, not this one (SNOW WHITE)

When dealing with hospitalised children, the mother is the most frequently mentioned member of the family. Consequently, the family bond must be valued to maintain a warm, close and continuous relationship with the children, especially due to their heightened sense of insecurity during hospitalisation(¹⁵). During the sessions it was observed that the mother carried the most weight, and was the family member who stayed with the children.

P: who takes care of Elis?

C: the mother

P: who’s going to sleep with her here?

C: the mother (BARBIE)

P: and who is going to stay with her?

C: the mother (BEN 10)

The presence of the mother makes the child feel safe and protected in the face of adversity. Including the family in therapeutic care also helps the family members understand the importance of the sessions and encourage the children to show their fears and concerns regarding hospitalisation. The importance of using toys for the families was observed in another study, in which the mothers felt safe and calm when they saw how the toys triggered feelings of joy and helped the children overcome hospitalisation by momentarily forgetting the hospital environment(¹³).

The involvement of the children’s parents is important because they can validate the received information and make the children feel more confident. In addition to the mutual benefits, the parents can ask their own questions and participate in the provided care(¹⁵).

The presence of the mothers during the first sessions has a soothing effect on the children and helps them get involved quicker, as observed in the sessions.

Another observation was that the family members became gradually less important as the sessions progressed. Once the children had established a bond with the nurse, some of the children even dismissed the mothers.

Also, as the children established a bond and trust in the nurses during therapeutic play in the care model, the mothers chose whether they preferred to stay or not, while, in the first sessions, the children requested the presence of their mothers during the entire session.

The conclusion of the therapeutic sessions should therefore be considered to maintain the bond between the children/mothers and the nurses. The “Concluding” step is the moment when the nurses close the sessions only after having reached the goal regarding the children’s care. This moment was calm and easily accepted by the children since they had evidently understood the hospitalisation process and the need to remain in hospital.

CONCLUSIONS

Structured therapeutic play in the nursing care model applied to hospitalised children was analysed to determine whether it can reduce the negative effects of the hospitalisation process among children.

It was found that playing diminished the negative views the children regarding the hospital environment and health professionals and the effects of a bad hospital experience. The use of therapeutic play showed that the children can understand the need for hospitalisation and experience this moment in a calmer, more peaceful way.

Once they were given the opportunity to play with the hospital supplies and perform the same procedures that are performed on them, they felt free to ask questions that helped them diminish their fears and understand the need to carry out these procedures.

The importance of the family as a source of security was also observed during the sessions, and should therefore be included in nursing care and therapeutic play to ensure that the children feel calmer and more eager to participate.

The application of therapeutic play through the nursing care model Care with Play revealed its potential for the provision of comprehensive nursing care directed toward the needs of each child. Moreover, therapeutic play allows the nurses to get to know the children and their needs, and gives them time to plan and provide the needed care and assess the effectiveness of their actions.

We believe that this model of care can be applied outside the hospital environment, possibly in nursing education, although its application would require further studies with the model.

The limitation of this study was the limited number of participants in each type of therapeutic play and the failure to conclude all the steps of the model with some of the participants, which suggests the replication of this model.

REFERÊNCIAS

• ¹
  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. 2012;30(4):354-8.
• ²
  Gomes AVO, Nascimento MAL, Christoffel MM, Antunes JCP, Araújo MC, Cardim MG. Punção venosa periférica: uma análise crítica a partir da experiência do cuidar em enfermagem. Enferm Global. 2011;(23):287-97.
• ³
  Ferrari R, Alencar GB, Viana DV. Análise das produções literárias sobre o uso do brinquedo terapêutico nos procedimentos clínicos infantis. Rev Eletr Gest Saude. 2012;3(2):660-73.
• ⁴
  Bento APD, Amorim HCC, Aquino Filho MB, Oliveira CS. Brinquedo terapêutico: uma análise da produção literária dos enfermeiros. Rev Eletr Gest Saude. 2011;2(1):208-23.
• ⁵
  Fontes CMB, Mondini CCSD, Moraes MCAF, Bachega MI, Maximino NP. Utilização do brinquedo terapêutico na assistência à criança hospitalizada. Rev Bras Educ Espec. 2010;16(1):95-106.
• ⁶
  Sousa LC, De Vitta A, Lima JM, De Vitta FCF. The act of playing within the hospital context in the vision of the accompanying persons of the hospitalised children. J Human Growth Develop. 2015;25(1):41-9.
• ⁷
  Maia EBS, Ribeiro CA, Borba RIH. Compreendendo a sensibilização do enfermeiro para o uso do brinquedo terapêutico na prática assistencial à criança. Rev Esc Enferm USP. 2011;45(4):839-46.
• ⁸
  Ribeiro CA, Maia EB, Sabatés AL, Borba RIH, Rezende MA, Amorim FA. Mesa redonda: o brinquedo e a assistência de enfermagem à criança. Enferm Atual. 20022(24):6-17.
• ⁹
  Buyuk ET, Bolişik, B. The effect of preoperative training and therapeutic play on children’s anxiety, fear, and pain. J Pediatr Surg Nurs. 2015;4(2):78-85.
• ¹⁰
  Rocha PK, Prado ML, Silva DMGV. Pesquisa convergente assistencial: uso na elaboração de modelos de cuidado de enfermagem. Rev Bras Enferm. 2012;65(6):1019-25.
• ¹¹
  Rocha PK. Crianças vítimas de violência: cuidar brincando. Blumenau: Nova Letra, 2006.
• ¹²
  Trentini, M. O processo convergente assistencial. In: Trentini, M. Paim, L. Silva, DMG. Pesquisa convergente assistencial: delineamento provocador de mudanças nas práticas de saúde. Porto Alegre: Morin; 2014. p.31-62.
• ¹³
  Castro DP, Andrade CUB, Luiz E, Mendes M, Barbosa D, Santos LHG. Brincar como instrumento terapêutico. Pediatria. 2010;32(4):246-54.
• ¹⁴
  Paladino CM, Carvalho R, Almeida FA. Brinquedo terapêutico no preparo para a cirurgia: comportamentos de pré-escolares no período transoperatório. Rev Esc Enferm USP. 2014;48(3):423-9.
• ¹⁵
  Francischinelli AGB, Almeida FA, Fernandes DMSO. Uso rotineiro do brinquedo terapêutico na assistência a crianças hospitalizadas: percepção de enfermeiros. Acta Paul Enferm. 2012;25(1):18-23.
• ¹⁶
  Jansen MF, Santos RM, Favero L. Benefícios da utilização do brinquedo terapêutico durante o cuidado de enfermagem prestado à criança hospitalizada. Rev Gaucha Enferm. 2010;31(2):247-53.
• ¹⁷
  Marques DA, Silva KLB, Cruz DSM, Souza IVB. Benefícios da aplicação do brinquedo terapêutico: visão dos enfermeiros de um hospital infantil. Arq Ciênc Saúde. 2015;22(13):64-8.

Publication Dates

• Publication in this collection
  2016

History

• Received
  28 Aug 2015
• Accepted
  08 Apr 2016