The insertion of play and toys in Pediatric Nursing practices: A convergent care research

Abstract

Objective  to analyze the process of apprehension and transformation of the use of play and toys by the Nursing staff of a pediatric unit.

Method  a study supported by convergent care research, developed between December 2018 and May 2019 with 11 professionals of the Nursing team, through conversation circles.

Results  the participants recognize playing as inherent to the child and beneficial in the interaction with the child when hospitalized. They perceive the non-appropriation of structured play in their practices, look for expansion, but identify obstacles associated with little institutional support. From the developments, they decided to insert a puppet and get trained to the use structured play.

Conclusions and implications for the practice  The insertion of play in the hospital demands a break with the biomedical model in health and betting on an institutional culture of the recognition of playing. Playing throughout hospitalization integrates fair, humane and comprehensive care, which should be a reason for the Nursing team to fight and guarantee and, for institutions, the duty to provide support, both within the scope of work and permanent education.

Keywords:  Child Hospitalized; Pediatric Nursing; Play and Playthings; Professional Competence; Education Continuing

Resumo

Objetivo  analisar o processo de apreensão e transformação do uso do brincar e brinquedo pela equipe de enfermagem de uma unidade pediátrica.

Método  estudo apoiado na pesquisa convergente assistencial, envolvendo rodas de conversas com 11 profissionais de uma equipe de enfermagem, atuantes em uma unidade de internação pediátrica de um hospital de ensino. Foi desenvolvido entre Dezembro de 2018 e Maio de 2019.

Resultados  Houve reconhecimento do brincar como inerente à criança e benéfico na interação com esta, quando hospitalizada. Os participantes percebem a não apropriação do brincar estruturado em suas práticas, prospectam ampliação, porém identificam entraves associados ao pouco apoio institucional. Dos desdobramentos, decidiram por inserção do fantoche e capacitação para o uso do brincar estruturado.

Conclusões e implicações para a prática  a inserção do brincar no hospital demanda ruptura com o modelo biomédico em saúde e apostas em uma cultura institucional de reconhecimento do brincar. O brincar ao longo da hospitalização integra um cuidado justo, humano e integral, que deve ser para a equipe de enfermagem motivo de luta e garantia, correspondendo às instituições, o dever de dar suporte, tanto no âmbito dos processos de trabalho, quanto no da educação permanente.

Palavras-chave:  Criança Hospitalizada; Enfermagem Pediátrica; Jogos e Brinquedo; Competência Profissional; Educação Continuada

Resumen

Objetivo  analizar el proceso de aprehensión y transformación del uso de juegos y juguetes por parte del personal de Enfermería de una unidad pediátrica.

Método  estudio sustentado en investigación de cuidados convergentes, desarrollado entre diciembre de 2018 y mayo de 2019 con 11 profesionales del equipo de Enfermería, a través de círculos de conversación.

Resultados  los participantes reconocen el juego como algo inherente al niño y beneficioso en la interacción con el niño cuando está hospitalizado. Perciben la no apropiación del juego estructurado en sus prácticas, buscan expandirlo, pero identifican obstáculos asociados al limitado apoyo institucional. A partir de los desarrollos, decidieron insertar un títere y entrenarse para usar el juego estructurado.

Conclusiones e implicaciones para la práctica  la inserción del juego en el hospital exige romper con el modelo biomédico en salud y apostar por una cultura institucional de reconocimiento del juego. Jugar durante toda la hospitalización integra una atención justa, humana e integral, que debe ser motivo de lucha y garantía del equipo de Enfermería, correspondiendo a las instituciones el deber de brindar apoyo, ambos en el ámbito del trabajo y de la educación permanente.

Palabras clave:  Niño Hospitalizado; Enfermería Pediátrica; Juego e implementos de juego; Competencia Profesional; Educación Continua

INTRODUCTION

Hospitalization imputes to children the chances of experiencing traumatic and stressful situations, especially for taking them away from their daily lives and exposing them to an intimidating environment, with emphasis on diagnostic and therapeutic procedures.¹ The routine incorporation of playing as an assistance resource for the health team mitigates this effect^2,3 and favors child coping and adaptation, with emphasis on situations of chronic disease.³ Still, it represents alignment with integrality and humanization⁴ and recognition of children's rights.⁵ The World Health Organization (WHO) conceives the right of children to play in the hospital and recommends that health professionals promote it in every care context.⁶

Although indications for free and therapeutic play are considered in hospital settings,^2,6 their incorporation into Brazilian realities is timid, ineffective and not taken as a nurse's care resource.⁷ In many contexts, it is restricted to the existence of a playroom, in compliance with the legal provision.⁸

Children express the desire that the nurse includes playing in the clinical practice as a form of interaction and communication;^9-11 however, the work process of nurses in pediatric units shifts the relevance of this resource to a secondary place.¹² Since 2004, the use of play/therapeutic play has been treated as a competence of nurses and is legally supported by the Federal Nursing Council, specifically described in Resolution No. 295/2004, updated by Resolution No. 546/2017.¹³

It is urgent to discuss and transform the place of playing, toys, and playful interventions in Nursing care practices. This study explored playing and therapeutic play in the care practices of a Nursing team from a pediatric unit. The objective was to analyze the process of apprehension and transformation of the use of play and toys by the Nursing team of a pediatric unit.

METHOD

A study with a qualitative approach, supported by the methodological framework of Convergent Care Research (CCR), which has its origin in Nursing and is aimed at transforming the care practices. This framework seeks to develop the critical and liberating attitude of professionals towards the qualification of health care. It takes questions emerging from health care and seeks answers by those who produce and experience it, that is, care practice and reflection about it constitute the empirical data of research towards solving practical problems diagnosed by those who experience it. The CCR has the potential to generate assistance commitments by enabling the reconstruction of perspectives and knowledge.¹⁴

It takes as a research field the space where the practices take place and where the problem listed in the study occurs,¹⁴ which in the case of this study was a pediatric inpatient unit of a teaching hospital located in a city in the Mideast region of the inland of São Paulo. The unit has 12 beds with an occupancy rate, according to information from the nurse responsible for the sector, close to 90% over the data collection period in this study: December 2018-May 2019. The unit's Nursing team has 25 nursing technicians and 10 nurses, spread over 4 shifts, two during the day and two at night, with a 36-hour workweek in 12-hour shifts. The unit has a playroom, whose access is regulated by a professional from Occupational Therapy and one from Psychology; however, the nurse has the key to this space for use in need.

In the CCR “the researcher must necessarily be part of the practical context, even if temporarily, during the research”,^14:844 a fact contemplated with insertions of the first author throughout the four-month curriculum supervised internship and that took place prior to the study data collection. In addition, after the internship, she kept weekly insertions. It should be noted that the researcher simultaneously assumes the role of researcher and participant, he integrates himself with the other participants with contributions of information, reflection and criticism about the practice experienced.¹⁴

For data collection, the conversation circle based on problematization was adopted, with application of the five stages of the Maguerez Arch in Berbel's proposal.¹⁵ All conversation circles were conducted by the main researcher, first author of this article, focusing on the use of play by the Nursing team. In the first conversation circle, she proposed that they revisit their practices and narrate how they understand that playing/toys have been adopted by them and the determinants related to this use. What was exposed in the circles was taken for a dialogical reflection and at the end of each circle, collectively, deliberations were developed for the next circle.

As noted above, the mediation of all the circles was developed by the first author, who received training to do so, either from readings or practices, when she integrated circles developed by the last author of the study for the same purpose. Still, after each conversation circles developed for this study, there was a tutoring between the first, second and last author of the article.

Aligned with the structuring of the CCR, Permanent Education (PE) supported the study, given the intention of significant learning via critical reflection of the work, (re)meaning of the work and its determinants, with the intention of transforming the ways of doing health care.

The inclusion criterion of the participants was being a member of the Nursing team of the pediatric unit selected for the study; and the exclusion criterion, professionals on leave due to vacation and leave provided for by law. The invitation was made personally to all of the daytime Nursing staff by the first author, consisting of 6 nursing assistants, 12 nursing technicians and the nurse who occupies the position of unit manager. Eleven of the 19 professionals agreed to join the study, seven of them willing to experience the process in conversation circles, and another four for the moment of returning to the collective construct. In other words, four participants integrated the moment of study return at the institution making notes and comments that integrated results and discussions. As for the refusals, they were justified by lack of interest in the subject matter to be discussed (n=2), lack of time (n=3) and concern to produce discomfort in the discussion (n=1), vacation or leave provided by law (n=2). Given the above, this is a sample of participants for convenience, but the density of the exposed and experienced favored the identification of constructs about the phenomenon and its relationships, with a saturation reach about the sense and meaning of the questions put into dialog.¹⁶

When taking the availability of the participants, two groups were formed that called themselves 'Cute Group', with four participants, and 'Group 2', with three participants. A total of seven conversation circles were held, three with ‘Cute Group’ and four with ‘Group 2’, all conducted by the first author, with a mean duration of 45 minutes. The circles were developed in the workplace, at a time contrary to the schedule, audio-recorded and later transcribed for analysis.

The systematic analysis of the data followed that recommended by the CCR, with reading and re-reading of the transcripts with a view to the global aspects that supported the participants' dialog. Alongside, new readings and re-readings were developed looking for groupings by thematic similarity. This set of groupings underwent deductive and subsequently inductive analytical processes, culminating in categories translating the process.¹⁴

The study was approved by the Human Research Ethics Committee under opinion No. 3,067,479 of 12/09/2018, CAAE No. 03476018.4.0000.5504. All the ethical precepts were respected. The excerpts are identified by the name of the referring group, followed by the word “circle” and a number, translator of the conversation circle in which the data emerged.

RESULTS

The data analysis process resulted in three thematic categories: “Between knowledge and systematic playing: ways to polish”, “Management, pairs and the use of play” and “Designing paths for transforming the practice”. The reasons that drive and collect the participants, in the search for the transformation of their practices, were treated under a fabric of appreciative comings and goings of the involved aspects and their relations. Despite the limitations, they agree on the transformation of practices.

The “Between knowledge and systematic playing: paths to be polished” category deals with the concepts that anchor the recognition of playing and the need to surpass the actors of its concreteness. They are: (1) playing is inherent to children, it is language through which they expresses their needs; (2) hospitalization and illness have an impact on children and the professional is responsible for their welcoming, when playing is a resource; (3) the daily Nursing practices reflect on a negative image, which has the possibility of transformation in play, and (4) reveal themselves to be intervening parties that hinder the concreteness of play by the team:

Playfulness is inherent to the work in Pediatrics, because it is within what belongs to my target audience. [...] In fact, we enter the children's world, not that we bring the child into our world, we enter the child's world. [...] So, I keep thinking that sometimes we think we do it and, in fact, we have a lot more to do with playfulness. And even in day-to-day life it is beaten and not done. I think it will be very good here (research) (Group 2 – Circle 1)

They consider the child as a person, with a different look from the adult, with the capacity to reveal perceptions and needs. They point out that, when experiencing relationships of openness, interest and efforts to grasp their perspective, it reveals itself. The adult's playfulness and ludic attitude favor these relationships.

I think that children have a side that we often don't see. They see the world in another way and, with that, we do learn things from them, even though they are children. Their own stuff. When you use play you have a moment of interaction there, you discover new things, you learn things from the children with them. (Group 2 – Circle 1)

Playing is an action with which children are naturally involved, given a minimum stimulus they are already directed to this activity. Children like to be in colorful environments, with children's decor, with activities for them to freely engage, portray their desires, that is, play. They recognize the playful ambience as a space familiar to the children.

Another cool thing was also the drawings (decoration of the unit), because there were no drawings. It was cute! In fact, they (children) painted the wall, did you see the doll? When we (professionals) saw it, the doll was ready! (they all laugh). [...] The mother was nervous and upset that she (child) did that (drew on the wall). Then I said: “Mom, stay calm, look at the wall, she thought she could too, because she is all scratched!” [...] I look at that wall and I feel happy! Because I think they (children) were able to express themselves. Represent themselves in that drawing. I think I shouldn't paint this wall, this wall should look like this: “Look! There are children here!” Understood? (Cute Group – Circle 1)

Playing is being discussed as an assistance practice. They identify as professionals with welcoming efforts, including from the use of play and revisit their use, identified the prevalence of the adoption of music and drawings with collaboration and distraction intentions during procedures and evaluations. They reinforce an intrinsic playful attitude and that many of the strategies that they use are popular knowledge, of common use.

So the professional who is already in Pediatrics, he already does many things. He already has skills in handling the child, the way of talking, the game that does not even need anything like that, but that he manages to conquer the child with. So this professional, he already has some personal and professional characteristics that facilitate, right? From the adult professional to the ludic that takes the child. (Group 2 – Circle 1)

Every time you go in to make a sign, to make a medication, you have to distract, play, with the child. Put on a little song, play hide and seek, for example, we are there trying to see the child's breathing. Then the child is agitated, then we (think) there is little, little time, but we put on the music and then calm the child down! (Cute Group – Circle 2)

But now that it comes to me that we really use music. (laughs) we use music in vital signs, I think it’s one of the strategies that the team ends up using, to be able to do some procedures. [...] We bring songs that are popular knowledge because, really, it makes these children calmer. [...] We play games with the children, in the procedure itself, when you play with the child or the drawings, when we bring drawings to them. (Group 2 – Circle 1)

In the end, I think we do a lot. It doesn't seem like when we think and when we speak, but when we write, we even have interesting (playful) strategies that we already put into practice. (Cute Group – Circle 2)

They constantly reinforced the need to incorporate play in a structured manner in the environment and in the hospital practices, underlining the possibility of revelations regarding the child's uniqueness and needs. With this intention, they acknowledge incipiences and trigger the non-systematic practice, pondered their real alignment with the idea of welcoming the uniqueness of each child and their situation.

I think it can be planned too (use of play), and at that point we do little. [...] The child is hospitalized, a demand appears, demands that we need to talk with the child, better investigate some point, and then we can play for that, right? So, to evaluate some things, because the children playing, they say things that they don't say if they are not playing. [...] I, as a nurse, used this planned play strategy little, really intending to investigate or treat something in the child. But that possibility exists, I think it exists. (Cute Group – Circle 3)

The professional needs to get involved, because otherwise, it won't work! Even playing can come out mechanically! (thinks) I believe it has to do with the relationship I make with how the child sees the world, health professionals and the hospital environment. So, I need to know what world this child lives in. All of this is put into play in games, in the relationship with them. So I think this is extremely related to how I see the child. In addition to understanding what it is to be a child and how they see things, I also have to know the specifics. And humanization in care, it really involves this, you understand what it is to be a child, you understand why they are that way, why they accept or not and has structured work strategies, such as playing. Something structured, this is missing. (Group 2 – Circle 4)

The discussion focused on a more structured and expanded use of playing, lack of time is pointed out in an articulated way to an initial concept of being an 'extra' doing, not part of the responsibility of doing Nursing and dissociate it from the role of the nurse, as if this activity was not included in the list of competences.

It would be interesting, but we don't have time for that. Because there is a routine, that we don't have to stop doing the care actions, but then, I think it would be interesting to associate this. But it is the question of time, that not even (the name nurse) spoke of, we also cannot fail to do our responsibilities to be playing with the children. Yes, I think that one of the issues I see is Nursing, it is really overloaded with other roles! (Group 2 – Circle 1)

Initially, they deposit play with the actions of other professions, but the dialogs on the circles reallocate playing as an action also inherent to Nursing. They recognize that, by maintaining the children's fundamental occupation, playing, they start to give a sense of normality to life, even experiencing the hospital routine.

I think we work a little less with playing (compared to occupational therapy and psychology), our interaction with toys with the child is limited. This is limited to some members of the team, such as the occupational therapist, who is the one who ends up using the most. And we realize that children love the occupational therapist because he is a professional who will provide care based on toys, on playful strategies. [...] So it's something that I really needed to get married to. So, I have to do such a thing, but I also have another part of my job which is to work on the playful. Especially because, many times, we have different demands. Because the Nursing professional has a very high demand! So, when there are a lot of hospitalized children, who have several sick patients, they have several medications. These are very high responsibilities. (Group 2 – Circle 1)

At the hospital, she (child) left her field, went to the hospital. Only in the hospital we bring the play, bring the toy, bring the dynamics. And that makes her go back to her environment or be more or less as close to her environment as possible! [...] I think, in fact, nothing more necessary than keeping her (the child) in her normal environment, in her natural environment and in her usual occupation, right? Playing. (Group 2 – Circle 4)

The discussions focused on the social constructions related to playing and the hospital/hospitalization/Nursing. They identified that the image the child establishes of them has a direct relationship with the actions they take and that these reflect the care focus of the unit/hospital and the role placed on Nursing. They recognize that, when playing with the nurse, children (re)signify their image to someone more welcoming and playful.

Children look at us with different eyes after that (using play). Exactly! It is looking and talking like this: “Ah, it's that girl who came to play here, so I won't be afraid of her anymore. I will no longer look at her as if she were a monster that will only sting, perform a painful procedure.” Like, a venipuncture, give an injection. They end up realizing that the professionals are also engaged in some playful attitudes. There is a child who sees us in white and starts to cry. (Group 2 – Circle 1)

We print drawings for them (children) to paint and they love it. So much so that sometimes, when they leave the hospital, they deliver letters with drawings to us. Thus, it shows the world that the hospital is not that seven-headed animal that you, that they (children) see. Even something that I find very interesting is the children drawing for the employees! This is very good, we see that children smile, draw pictures for us and even help with the procedure. I like it! (Group 2 – Circle 1)

They are clarifying more and more that, in the reality where they work, playing is not used by Nursing and that it has a secondary place in relation to the execution of procedures linked to medical treatment. They want transformation, in addition to identifying in play the construction of a more positive image. Thus, they reinforce the need to assume playing as inherent to Nursing too, highlighting that it is something good for everyone, it brings recognition and motivation to the professional.

Playing is a work strategy in Pediatrics, including Nursing. The professional who uses play and interacts with the children learns from them and is simultaneously motivated. Using play is motivating. It is good for us as well as a professional and as a person too, to take it to our personal life. (One participant intervenes) I think this is good for both, for the children and for the person who is doing it. It's group therapy! (jokingly) (everyone laughs). (Group 2 – Circle 4)

In this context, they focus on the conception that Nursing itself makes about the use of playing and consider that disseminating understanding in the category itself is fundamental to expand its use in a more intentional and deliberate manner.

So this (reflecting on their use of playing/the ludic) is a strategy to reinforce the work of the Nursing team. Which I think is one of the things we need to work on a lot. (silence) And we realize that the Nursing team would have ample space in this (use of playfulness and games), right? Because, really, it is something that is extremely important, and Nursing is the area that works the most with the child. But, even so, it is insufficient, because, really, for us there is a very bad part left, which is necessary, but which is also heavy for children. (Group 2 – Circle 4)

The “Management, pairs and the use of play and toys” category deals with reflections about the viability of using play, especially when the unit is highly occupied, seasonally. They report not identifying great efforts by institutional management to look at these times differently. Tiredness and stress are referred to as conditions that restrict involvement with the child and, thus, the use of play and the attitudinal playful behavior. They feel frustrated in view of the development of this for the quality of Nursing care. The Cute Group addressed this issue with greater intensity, being reflected in greater return of its transformation bets.

We have periods of seasonality [...] There is talk on humanization. You will not be able to have humanization with the child and the mother if you are not having humanization with you! You are overworked and this will put an end to your disposition. Because you end up getting frustrated, you're not doing it the way you wanted to, you know you're better than that. You can provide better service than that. Tired because you're overwhelmed. So it's kind of traumatic. [...] difficult to use play in these conditions. (Cute Group – Circle 1)

The restrictive scenario to playing is the institutional care philosophy, centered on illness, with a conception of the use of playing not being integrated by Nursing, doing something more in a movement dissociated from systematized care, in which the technicist and bureaucratic approach prevails in the relationship with the other.

Often, what is required from us (institutionally) are very bureaucratic and very technical issues. Obviously there is a question of patient safety, these issues are extremely important, but I am asked for techniques that I have to do, precise techniques. Because of the number of procedures I do, the amount of bureaucratic procedures that we end up doing. But, even so, we have a very technical historical question. (about the hospital) And, that is why, sometimes, it seems that we have to fit the playful question. [...] So, sometimes, we think of play, or other issues within our work process as extra work, and not as work that is already mine, right? So I try to work with the child, the playful thing has to be in my work, but, often, due to the technicist history, we end up leaving it a little aside (Group 2 – Circle 1)

In the “Designing paths for transforming the practice” category, the focus was on the discussion that reinforces the relevance of welcoming children as a playful individuals and their unfolding to the recognition of the professional, with a renewed belief in these care goals. They return to the cohesion of the Nursing team to maintain their commitment to transforming their practices in terms of using play. They give visibility to the perception that incipient management support affects, but it cannot hinder them in the movement.

Thus, they select the following as referrals: (1) inserting a puppet into the Nursing practices, a resource of greatest interest to Group 2, in which one of the participants bought a set of puppets and donated them to the unit; (2) developing training in directive play and therapeutic play for the unit's Nursing team; (3) betting individually on a more deliberate and intentional use of playing in the care practices with the child.

If the team is a team that has cohesion on the subject matter and that thinks, for example: “Ah, let's create a group of puppets.” This, really, I think motivates other playful strategies. So the puppet group was an initial ‘start’, but it was a trigger for several other strategies. [...] The team is cohesive, they are people who already have affinities, we have worked together for a long time, so I think that makes the job much easier. [...] Because I think the awareness that the use of toys, the playroom, the use of playfulness is important for Pediatrics, I think that everyone who works with Pediatrics has this awareness. (Group 2 – Circle 2)

And I also think that therapeutic play, it is something that would really need better training for the team. [...] There is also this question... (Cute Group – Circle 3)

In the line of training, they asked for the opportunity to share experiences with the use of playing with other nurses/Nursing staff. As a referral, a video recorded with the last author of this study was shared about her experiences with playing as a nurse. It was assisted individually and discussed in circle 3 of both groups. The effect was motivating and considering new possibilities for using play and toys.

Because we realize that it was something that in her experience (external guest video) worked very well. And our tendency, when seeing an experience that worked, is to use it too. So I think it strengthens the idea. After I saw this video, my way of thinking changed a lot. But like this, I think it opens our minds to see people who have had experiences about it [...] I really liked this video and I think my head has expanded. I remember that when we watched, I was like: “Wow!” The feeling I got was exactly that! (laughs). [...] And motivation, I found that I felt motivated to think about the possibilities, what happened to her, the experiences she went through and the things we go through on a daily basis. I liked very much. (Group 2 – Circle 4)

DISCUSSION

The literature emphasizes that playing is fundamental for full and humanized care. Through this instrument, the dialog and the relationship between the child and the Nursing team are enhanced, generating safety and comfort, in addition to helping the children overcome their negative fantasies and relieve tension, fears and anxiety.¹⁷ Hospitalization impacts children and their families and requires professionals to understand not only the disease, but also the other impacts, when it is essential to include the children and their notes.¹¹

With this understanding and the conception of playing as inherent to childhood and a means of expression par excellence, the participants experience a dilemma between knowing what they must do and what they can achieve, they know the benefits of systematic playing for the child and experience the adversities that prevent its concreteness, among which the current model of hospital assistance stands out.

This imposes, in terms of the nurse's responsibility and demands, the technicality and medicalization of care; however, the participants perceive the need to overcome this care model. The Nursing professional is expected to make the movement towards the child, with recognition of the ludic attitude and play/toys as a means of approximation, given the chances of dialog between the professional and the child occurring from it.

Playing and the therapeutic play are resources of Pediatric Nursing to cope with the process of illness and hospitalization¹⁸ and favor children to deal with adversities, in addition to being means of communication that reveal uniqueness and provide professional-child-family confidence. The families themselves recognize the strength of the therapeutic play as an ally for the child to feel safer in the face of hospital admission and the fears inherent in the hospitalization situation.^19,20

Playing is manifested as a childhood demand and, when valuing comprehensive and humanistic assistance, nurses naturally resort to ludic strategies, when playing, motivated from their creative skills,²¹ an aspect also identified in the participants of this study. However, research indicates that, despite this, their inclusion in care is not routine, which denotes certain devaluation in the incorporation of this knowledge¹⁷ or limits to use it. In the case of this study, the current care model and the lack of recognition of playing between genuine and integral Nursing care practices was a limiting aspect.

When the Nursing practice is restricted to performing procedures and actions considered invasive and is reduced to technical and bureaucratic tasks, the establishment of interactions with the child is limited and the construction of therapeutic bonds is hindered. As pointed out by the participants, culturally the child makes a negative image of the Nursing professional as being the performer of painful and unpleasant procedures and sees in the adoption of play and toys the possibility for the transformation of this image into a more positive one.

Play and toys favor a fuller professional-child relationship and qualify communication, since it is a children's language, they express and show themselves while playing. In a study that addressed the concept of hospitalized children in relation to Nursing care, the students' disapproval of the professionals who did not explain the procedures and who acted in an authoritarian manner was highlighted; they stated that, to take care of children, professionals need to be funny and play, which denotes the need to include playfulness in Nursing care.¹¹

The adoption of play proved to be timid in the reality of the participants, highlighting the centrality placed on the routine practices of hospitalization and in the treatment of the child's disease, when playing and games are in the background. This confirms that, although the literature is vast with regard to the advantages and benefits of playing in the hospital, it is little used in the Nursing care routine, due to lack of time and of preparation for the use of the therapeutic play,¹⁷ also present in this study. Regarding therapeutic play, despite the regularization and incentive for the theme to be inserted in professional training, there is an inconsistency of this issue around the world, both in terms of quality and content.²²

The scarcity of infrastructure, skilled workforce and time pressure can make therapeutic interventions through play less feasible in places with limited resources,²² revealing the impact of the institutional culture on the use of play and toys by Nursing. Thus, we suggest that the perspective of managers be apprehended in future studies, especially with regard to understanding and support about the use of play.

In this study, the use of a playful attitude by Nursing prevailed, especially with the exploration of playing in the interaction with the child through singing, mimes with hands or showing music videos via cell phones. This use intended to collaborate during the procedure via distraction, which corroborates with the literature, in which systematic distraction has been effective in reducing pain and fear in the face of painful procedures¹⁸ although without considering their stimulus functions in the scope of motor and cognitive development.

In a more advanced movement of reflections in the conversation circles, involvement as a necessary condition to approach the child and meet their needs emerges and strengthens the desire to have greater awareness and intentionality in the use of play; to create a bond and minimize the impact of hospitalization.²³ Throughout the discussions, the use of structured and intentional play on their feasibility is discussed, when they focus on the puppet and its benefits, as well as the therapeutic play.

Regarding the use of a puppet, a number of studies have shown it as an excellent resource to be used by health professionals with the intention of promoting communication, allowing understanding the reactions and feelings manifested by children and encouraging a rapprochement relationship between professionals and children.²⁴

However, the participants reveal the need to expand knowledge and skills for their adoption, when they want continuing education. Thus, we question: ‘Are the technical and undergraduate courses focusing on the subject matter? To what extent and depth? And in-service training, how are you addressing this issue?’ We suggest explorations in these directions.

In addition, it is worth mentioning about the lack of in-depth themes of the playroom by the participants, questioning whether they perceive it as a place for Nursing. To refer it to exclusive uses of professional categories is to deny the essence of space and its purpose and legal warranty⁸ with the purpose of protecting play, the child's natural occupation, during the hospitalization period.

According to a number of studies, in the daily practice of Nursing professionals, due to the need to meet the child's physiological demands, they devote little or no attention to the child's psychological issues, which often limits the use of the playroom.²⁵ It is important to note that, despite its importance, the playroom should not be the only space in which playing activities are developed, as it would condition the act to restricted and fragmented moments.²⁶

In this study, the participants recognized and valued the ambience of the pediatric unit, understanding that a hospital environment in which there is pediatric care must be differentiated so that it becomes more welcoming and less frightening to the child. They argue that this environment should be more colorful, cheerful, with playful themes and drawings, in order to advertise and allude to children. A literature review highlights the imperative to build welcoming environments, structured to assist the child in a comprehensive manner, providing the best coping with hospitalization and guaranteeing play as a child's right during hospitalization.²⁷

Finally, we extol the fact that playing throughout hospitalization, both in recreational and therapeutic modes, integrates fair, humane and comprehensive care. The Nursing team is among the professionals who must fight and guarantee this incorporation through the development of ludic competence.²¹ And the institutions have a duty to provide support, both in the scope of work processes and in the area of​ permanent education and all issues addressed in this study.

CONCLUSION AND IMPLICATIONS FOR THE PRACTICE

The study described the participants' recognition and desire in the use of play in their care practices; however, the institutional context that underestimates this assistance structure hinders them from using the playful attitude, with a view to the child's collaboration and distraction in procedures.

Becoming aware of this scenario propelled them into criticism and struggle to transform the situation. The proposal for advances was limited to the autonomy of the Nursing team, when they decided to incorporate the puppet and bet on training for the use of directive and therapeutic play. However, they announce desires to tension the assistance philosophy, an issue initiated by the researchers in the return of the study to the institution. The culture of playing in hospitals still has a gap in terms of articulation with care practices, when critical training is indicated.

The methodological framework selected was powerful for the purpose of the study, since the openness and willingness of the participants to make revelations and notes allowed aspects related to the context to come to light, signaling important critical nodes for the implementation of practices of incorporating play and toys. It enabled the practical application of the essence of permanent education in health, promoting the generation of scientific knowledge from the reality experienced, favoring professional attitudes towards continuous improvement and promoting a critical questioning of the practices, such as collaborative and enriching discussion and significant learning of those involved.

The limited number of participants stands out, but the density of the process handled contrasts this aspect, allowing what is revealed to be taken into account in other pediatric hospitalization scenarios. In any case, it is recommended that further research studies be carried out under the focus of the promoters and stakeholders on the use of play by the Nursing team, especially nurses.

• FINANCIAL SUPPORT
  Scientific Initiation Scholarship - FAPESP - Process No. 2018/14455-3. Awarded to student Maria Izabel Sartori Claus, under the guidance of professor Monika Wernet. The present paper had the support of the Coordination for the Improvement of Higher Level Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, CAPES) – Brazil – Funding Code 001.

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Edited by

• ASSOCIATE EDITOR
  Beatriz Toso

Publication Dates

• Publication in this collection
  24 Feb 2021
• Date of issue
  2021

History

• Received
  14 Sept 2020
• Accepted
  21 Dec 2020