Play in the care practices of licensed practical nurses with hospitalized childrenABSTRACT
Objective: to understand the use of play in the care practices of licensed practical nurses with hospitalized children.
Method: this is a qualitative, exploratory and descriptive study, based on the Symbolic Interactionism theoretical-methodological framework, developed in a pediatric inpatient unit of a university hospital located in the countryside of São Paulo. Data was collected from August to October 2023 using non-participant observation. The study included 25 licensed practical nurses working in the unit in question. Data analysis was based on reflective thematic analysis.
Results: play was primarily used to facilitate the execution of procedures. It was evident that participants did not link and integrate this resource into their care practices. Furthermore, the toy library was not understood as a space associated with licensed practical nurses. The themes “Play in care practices” and “Interactions with the hospital toy library” detail the professional practices observed.
Conclusion: the use of play in licensed practical nurses’ care practices was reinforced by the symbolism that play is not feasible during pediatric hospitalization and that using the toy library is not part of its scope, which determined the limited incorporation of this resource. Furthermore, the importance of play activities was not recognized by the participants.
Descriptors:
Play and Playthings; Pediatric Nursing; Hospitalization; Child; Licensed Practical Nurses
RESUMO
Objetivo: compreender o uso do brincar nas práticas assistenciais de técnicos de enfermagem junto à criança hospitalizada.
Método: estudo qualitativo, exploratório e descritivo, apoiado no referencial teórico-metodológico do Interacionismo Simbólico, desenvolvido em unidade de internação pediátrica de hospital universitário localizado no interior de São Paulo. A coleta de dados ocorreu de agosto a outubro de 2023 utilizando observação não participante. Integraram o estudo 25 técnicas de enfermagem atuantes na unidade em questão. A análise dos dados esteve apoiada na análise temática reflexiva.
Resultados: o uso do brincar foi utilizado, mais especificamente, para favorecer a execução de procedimentos. Evidenciou-se que as participantes não vinculavam e integravam este recurso às suas práticas assistenciais. Ainda, a brinquedoteca não foi compreendida como espaço associado ao técnico de enfermagem. Os temas “O brincar nas práticas assistenciais” e “Interações com a brinquedoteca hospitalar” detalham as práticas profissionais observadas.
Conclusão: o uso do brincar nas práticas assistências de técnicos de enfermagem esteve reforçado pelo simbolismo de que brincar não é viável durante a internação pediátrica e que utilizar a brinquedoteca não faz parte de seu escopo, o que determinou a incorporação lacunar desse recurso. Ademais, reforça-se que a importância da atividade lúdica não esteve reconhecida pelas participantes.
Descritores:
Jogos e Brinquedos; Enfermagem Pediátrica; Hospitalização; Criança; Técnicos de Enfermagem
RESUMEN
Objetivo: comprender el uso del juego en las prácticas de cuidado de los enfermeros no diplomados con niños hospitalizados.
Método: se trata de un estudio cualitativo, exploratorio y descriptivo, basado en el marco teórico-metodológico del Interaccionismo Simbólico, desarrollado en una unidad de internación pediátrica de un hospital universitario localizado en el interior de São Paulo. Los datos fueron recolectados de agosto a octubre de 2023 mediante observación no participante. Participaron del estudio 25 técnicos de enfermería que trabajaban en la unidad en cuestión. Los datos fueron analizados por medio del análisis temático reflexivo.
Resultados: el uso del juego se utilizó más específicamente para favorecer la ejecución de procedimientos. Se evidenció que los participantes no vincularon e integraban este recurso en sus prácticas de cuidado. Además, la ludoteca no fue entendida como un espacio asociado al enfermero no diplomado. Los temas “El juego en las prácticas de cuidado” e “Interacciones con la ludoteca hospitalaria” detallan las prácticas profesionales observadas.
Conclusión: el uso del juego en las prácticas asistenciales de los enfermeros no diplomados se vio reforzado por el simbolismo de que el juego no es viable durante la hospitalización pediátrica y que el uso de la ludoteca no forma parte de su ámbito, lo que determinó la incorporación lacunar de este recurso. Además, la importancia del juego no fue reconocida por los participantes.
Descriptores:
Juego e Implementos de Juego; Enfermería Pediátrica; Hospitalización; Niño; Enfermeros no Diplomados
INTRODUCTION
Hospitalization represents a complex and potentially stressful and traumatic experience for children, as well as for their companions. Both are exposed to an unfamiliar environment and have their daily lives changed1,2. Furthermore, during hospitalization, children may experience diagnostic and therapeutic procedures that cause pain, as well as being separated from friends and educational setting, being limited in their main occupation: play3,4. Thus, hospitalization can lead to distress, anguish and anxiety in children, with impacts in the affective, psychological and emotional spheres2.
Incorporating play in the hospital environment, besides being a child’s right5, is also a duty of the nursing team6. This resource provides a counterpoint to the environment and experiences, favors the assimilation of information, contributes to identifying strategies for coping with the disease and the hospitalization itself, and provides comprehensive, humanized and child-centered care that stimulates their autonomy4,7-9 and development.
Playing is a therapeutic activity capable of positively impacting the child’s clinical condition, acting as a distraction and pastime, promoting their recovery, and mediating positive relationships with professionals4,7-9. This set of activities supports the indication of its protection and intentional and deliberate use by those involved in their care. Furthermore, stands out its potential to alleviate the effects of hospitalization and provide coping, and adaptation of children, with possibilities of promoting their well-being8-10. Moreover, its benefits in reducing anxiety and fears derived from the hospitalization also are recognized by families10.
According to the literature, the nursing team can use play through playful language, dolls, games, toys, colorful uniforms and child-friendly accessories, which can facilitate and favor interactions8. Although there is wide scientific evidence that demonstrates the benefits of play in nursing team practices4,7,8,11-13, its incorporation into care practices has proven to be limited and fragile.
The Brazilian reality has also shown insufficient intentional and robust adoption of play by licensed practical nurses in the hospital setting8,10, which contributes to children associating these professionals with painful and unpleasant procedures10. Thus, changes are needed in the use of play by these healthcare professionals, so that this resource becomes central in their relationship with hospitalized children, ensuring their therapeutic potential8,10) and, consequently, favoring more positive hospitalization experiences.
This study aims to investigate the use of play in the care practices of licensed practical nurses working in a hospital pediatric unit, considering that these professionals provide direct and frequent care to children and their families, and to this activity included within the scope of their competencies6. For this reason, this resource should be understood as an inherent part to care. Thus, the question is: how do licensed practical nurses in pediatric hospital units understand the use of play in their care practices? The objective was to understand the use of play in the care practices of licensed practical nurses with hospitalized children.
METHOD
Qualitative research, developed from an interpretative and comprehensive perspective, focused on behaviors and meanings embedded in social contexts, subjectivities, meanings, values and beliefs14, in the present case, the incorporation of play and its variants in nursing technique practices. To support the construction and reporting of the study, the COnsolidated criteria for REporting Qualitative research (COREQ) checklist was used15.
It is noteworthy that this article addresses the first stage of a larger study, which aimed to understand the use of play in the care practices of licensed practical nurses working in a hospital pediatric unit and to learn about these professionals’ perceptions regarding the use of these resources in their daily activities with hospitalized children. To this end, two data collection strategies were selected. The first strategy, whose results are analyzed in this article, corresponds to non-participant observation, while the second strategy, to be addressed in another article, concerns semi-structured interviews.
The theoretical-methodological framework used was Symbolic Interactionism (SI), a perspective of social psychology focused on the nature of interactions, meanings, and social actions. SI understands that human beings, based on and from interactional processes, interpret and assess meanings to social objects, a process that reverberates in their social behavior. Moreover, this process and the meanings are constantly changing through and from social interactions16. Thus, the incorporation of play is related to the way nursing technicians conceive of themselves, the child, play, illness, hospitalization, among other constructs and their integration, behaving accordingly.
The study was developed in a city in the center-east region of the state of São Paulo, which had an estimated population of 254,857 inhabitants in 2022, with 16.97% represented by individuals aged 0 to 14 years17. The study setting was the pediatric inpatient unit of a university hospital which, along with another public hospital, are references for pediatric inpatient care in the city and region. The selected hospital has 12 inpatient beds in the pediatric unit for children up to 12 years of age18.
This unit has a toy library that contained instructions for its use, which were physically posted on the side of the entrance door. These instructions included the operation hours of the place, an indication that a staff member needed to unlock the door for use, as well as the recommendation that toys should be stored in their proper places, and that companions should take care of them so that they were not damaged. As for the toys inside, they were grouped between those that could be used extensively and others that were locked in cabinets, considered to be work material for other professionals (occupational therapist, pedagogue and psychologist).
At the time of the study, the nursing team consisted of 27 licensed practical nurses and 13 nurses, the latter divided between managerial and care roles. The working hours of the entire nursing team were 36 hours per week, in 12-hour shifts. The inclusion criteria for the study were to be a licensed practical nurse working in the pediatric unit listed for the study and to have worked there for at least one month. The exclusion criterion was the absence from the unit for more than three months during the period that the researcher was in the field, as preventing the observation of these individuals’ practices. It is worth noting here that the inclusion criterion of having worked in the unit for at least one month was chosen to ensure some degree of integration into the pediatric context, allowing the inclusion of both newly assigned and more experienced professionals in the unit.
All licensed practical nurses were invited to participate in the study, but two declined, stating that the hospital was already conducting several other studies and that they were not interested in participating in another one. The first author recruited potential participants in person during work shifts in two weeks. If they indicated interest, the Informed Consent Form (ICF) was read together to clarify any issues. Afterwards, participation was confirmed upon signing of the form.
For data collection, the strategy of non-participant observation was chosen, conducted by the first author, experienced in qualitative studies. In this type of data collection method, the researcher acts as an attentive spectator, focused on capturing as many occurrences related to the phenomenon under investigation19; in the case of this study, the use of play in the practices of licensed practical nurses working in a pediatric inpatient unit. It is important to highlight that, in this type of observation, there is a chance that the presence of the observer will influence the behaviors adopted by the observed individuals. However, the literature shows that, with the passage of time and increased trust between researchers and participants, the research tends to develop more effectively20.
These observations were developed exclusively by the first author from August to October 2023. During this period, the researcher was present for 12 hours per week, dedicating three hours to interacting with the four different teams on day and night shifts. This occurred over eight weeks, totaling 96 hours of observations. To assist in this process, a script was used with guidance for the observations. It included the following questions: Are there children playing? If so, are they accompanied? By whom? During interactions, do the licensed practical nurses notice, respect, and value play? Is the toy library open? Are there children in it? Does the practical nurse go there? For what? When interacting with the child, do they use some form of playful activity?
Based on the observations, field notes were prepared consisting of the records made. Initially, these notes can be more concise and later expanded. Regarding the content, they can be descriptive and/or reflective. These notes make up the field diary, a notebook in which the researcher records his/her insights, ideas, reflections, doubts and research strategies that can be explored later. It is also useful for describing people, objects, environments, events, occurrences, activities, conversations, voice tone, expressions, gestures and body movements of the participants, as well as allowing notes on the researcher’s feelings and impressions21.
Reflexive thematic analysis proposed by Braun and Clarke guided the analysis of the observations. The analytical process involved the familiarization stage, in which the field notes were read repeatedly, highlighting elements related to the phenomenon under analysis. Next, coding was performed, with the field notes coded considering the research question and objectives. In the theme search phase, the codes from the previous phase were grouped into themes based on the thematic core related to the use of play by licensed practical nurses. In the theme review stage, they were validated. Afterwards, the themes were defined and named, involving the detailed writing of the analysis of each one. Finally, the writing was done, integrating the analytical narrative in an articulated manner with the literature22.
The study was submitted to and approved by the Research Ethics Committee for Human Beings, under Opinion No. 5,983,460 and Certificate of Presentation for Ethical Consideration No. 67333623,0,0000,5504. All ethical precepts were respected, in compliance with Resolution No. 510 of 2016 of the National Health Council. It is worth highlighting that all scientific rigor was met. The participants’ identities were preserved, and they were identified with the letter “P”, referring to the word “participant”, followed by an Arabic numeral representing the order of their participation in the study.
RESULTS
The practices of 25 licensed practical nurses were observed, all were female, working in the four shifts, two day shifts and two night shifts. The minimum age was 27 years old, and the maximum was 57 years old, with an average of 43 years old. A more detailed characterization can be observed in Chart 1.
Regarding higher education, nine of them (36%) reported having a degree in nursing, while two (8%) had a degree in pedagogy. Other degrees reported, less frequently, included languages (4%), design (4%), food science (4%) and physical education (4%). It is worth noting that four participants (16%) have already completed postgraduate studies and/or specialization courses. On the other hand, 11 participants (44%) had not completed a degree at the time of the study.
When asked about continuing education through advanced and/or specialization courses in pediatrics, ten participants (40%) reported that they attended courses provided by the hospital. Three (12%) reported also taking some update courses in the area. Others, taken less frequently, included courses in pediatrics (4%), specialization in Pediatric Intensive Care Unit (4%), specialization in neonatal emergency (4%), specialization in pediatrics (4%), post-technical training in urgency and emergency in the Neonatal Intensive Care Unit (4%) and post-technical training in neonatology (4%). However, ten of them (36%) reported not participating in any type of continuing education.
The non-participant observation revealed a predominance of the use of play with the aim of facilitating nursing procedures. It was evident that licensed practical nurses did not integrate play as care. Those who understood it and recognized it as relevant to children took advantage of it and created opportunities to incorporate it into their practices. Specifically, regarding the toy library, it was not associated with these professionals’ practices, largely because it was transmitted in the social context of the hospital, through its norms and interactions with other professionals working in the pediatric unit. Their relationship with this space included activities that they disagreed with being within their professional scope. The themes “Play in care practices” and “Interactions with the hospital toy library” encompass the use of play in the observed practices of licensed practical nurses.
Theme: Play in care practices
Subtheme: Play as a mediator of nursing procedures
Among the licensed practical nurses who incorporated play into their practices, the predominant intention was to favor the development of nursing procedures, especially checking vital signs and administering medications. The goal was to promote the execution of these and, thus, promote less discomfort and distress. The meaning is that the playful attitude can distract the child and take their focus away from the procedure.
From the beginning of the observations, it was noted that the technicians who incorporate play into the procedures do so with the intention of distracting and attempting to open a relational channel throughout the procedure. There are those who modify their voice, who speak in a childish way, who use words from the world of children, try to be funny and those who sing. Based on what was observed, it is believed that the efforts to distract and create an interactive context favor the relationship with the child for the execution of procedures. (Reflective field note, week 5)
A licensed practical nurse (P19) was observed performing a nasal wash on a child. Before starting the procedure, she asked the patient: “Do you want to see the little bug that will come out of your nose?”, and immediately after it was done, showing what she removed from the cloth used to contain the discharge, she said: “Look at the size of the bug that came out of your nose! The nurse did this to make you feel better.” Afterwards, she also interacted and praised the child’s toys: “Look at all these beautiful toys. Who is this? And this one? Now they know how brave you are!”. (Descriptive field note (P19), night shift 2, week 2)
The practices of a licensed practical nurse (P5) who was responsible for the care of a three-year-old child were observed. She entered the room, greeted the child by calling by name, and the child started crying. In response to this behavior, the practical nurse showed that she had seen the toys in the room and said: “So many beautiful toys.” She physically approached the child and said that she would check the child’s vital signs and give him medication. She set up the medication and, at the same time, continued to comment on the toys. The child continued to cry, and the technician also maintained the relational narrative. (Descriptive field note (P5), day shift 2, week 8)
During care for an eight-month-old infant, the technician (P13) adopted a higher-pitched voice, diminutives, sang little songs and played with him. (Descriptive field note (P13), night shift 2, week 8)
During a venous puncture procedure with a nine-year-old child, the nursing technicians (P2 and P22) adopted a loving tone when explaining the procedure and moved on to verbal statements based on play when the vein had already been punctured and the blood had been drawn: “We are vampires here, we draw a lot of blood to then share it with each other”. (Descriptive field note (P2, P22), day shift 1, week 5)
Subtheme: Determinants of the incorporating play
The regulations regarding play in the hospital and the nurses’ position on this topic influenced the licensed practical nurses’ behavior in relation to this practice. In the unit observed, they were predominantly restrictive, however the personal value they assessed when playing provided a counterpoint and supported its incorporation within the scope of autonomy and personal commitment, with impacts on professional actions.
Upon a child destabilized after being told by the nurse in charge of the shift that the toy library would only be open at 9:00 AM., the nursing technician (P4) responsible for the child intervened with the proposal that they play in the room until the toy library was opened and that, when the time came, she would open it promptly. The child, upset, accepted the suggestion. Silence filled the nursing station. Every now and then, the licensed practical nurse (P4) looked at the clock, and as soon as 9:00 AM struck, she took the key from where it was kept, opened the toy library, called the child and stayed there playing with her until the occupational therapist arrived to attend to her. (Descriptive field note (P4), day shift 2, week 2)
The licensed practical nurse (P8) was seen taking chalk from her makeup bag and giving it to the child to color, asking the child to return it after using it. (Descriptive field note (P8), day shift 2, week 1)
Over the weeks, it was observed that there were licensed practical nurses (P1, P3, P4, P7 and P8) who protected play time. They even sought to promote it, especially by avoiding interruptions due to technical care. Some of them worked on strategies to perform nursing procedures in the place where the child was playing. The same occurred when some play-related activity occurred in the unit. (Reflective field note at the end of the 8th week of observation of all shifts)
Specifically this week, “Play Week” was taking place. One licensed practical nurse (P3), as soon as she saw the proponents of the day's activity arriving, went to the doctor and asked if she could interrupt the therapy for a while so that the child could enjoy the activity. (...) when the Play Week activity was held in the toy library, the technician (P3) went there and, discreetly, brought the stand and delicately handled the distal tip of the nasoenteric tube, installing the enteral diet in an infant who was focused on the activity. Clearly, she intended to keep the child there, protecting her participation and interaction with the activity. (Descriptive field note (P3), day shift 1, week 8)
Children were playing in the courtyard with their companions. The licensed practical nurse (P13) approached with a tray, sat near where the patients were, waited, apparently observing the scene, and, at a certain point, went over and said to a child: “I'm just going to check your vital signs quickly, then you can continue playing”. The child ran to the professional, who performed the check, and said: “Go back and play”, with a smile on her face. (Descriptive field note (P13), night shift 2, week 4)
During the observation period of the four shifts, seven licensed practical nurses revealed the behavior described above. The act of playing was understood by them as important to the sick and hospitalized child and, therefore, they made decisions to include it in the scope of their professional actions.
From the group of scenes observed, seven licensed practical nurses stood out in terms of their own initiative and effort to provide toys and games for children. They sought and brought toys from the rooms with greater intensity, sometimes at the request of the child and/or companion, sometimes not. These licensed practical nurses seemed to value play. Two of them were from night shift 2 (P13 and P19) and five were from day shifts 1 and 2 (P1, P3, P4, P7 and P8). Some even made themselves available to be partners during play. (Reflective field note at the end of the observation)
The observations suggested that nurses recognized the importance of play and, for this reason, encouraged and supported the licensed practical nurses to use this technology in interacting with the children. Similarly, those who did not value it had an impact on their team. In one of the shifts observed, no licensed practical nurse showed evidence of using play during the observations.
After a few weeks of observations, the impression was that the nurse was a guide for this behavior, since, depending on the nurse on duty, there was a whole team attitude that favored or not the use of play in relationships. There were nurses who recognized its importance and took a stand, encouraging them to use this technology. However, there were other nurses who did not understand its significance and did not encourage it. (Descriptive field note, week 4) Throughout the observations, it was noticed that, on night shift 1, there was no licensed practical nurses who used play in their practices. Some try to speak kindly to the mothers, explaining procedures, but do not use playful attitudes during interaction with the child. (Reflective field note, week 5)
On the other hand, there were participants who stated that play was not a priority or a relevant activity to the child when they are sick and/or hospitalized.
From the start of the study, one of the licensed practical nurses (P6) said that “play doesn’t exist in the hospital”. She explained that children usually arrive quite debilitated and that, for this reason, they were not used to play with them. However, she agreed to participate in the study and was later seen using a playful attitude when interacting with the child, talking in a relaxed manner, entertaining her and making her laugh. (Reflective field note, week 1) A licensed practical nurse (P25) was observed during medication administration and vital sign measurements. No use of play was identified in her interactions. Apparently, completing the procedures was on the technician’s horizon and guided her actions, because when she handled the newborn and he started to cry, she remained silent and measured the signs while the baby was crying excessively. She performed the procedures mechanically and promptly, then left the room and went to the nursing station to handle her cellphone. (Reflective field note, week 5)
Subtheme: Play as care
During the observations, few licensed practical nurses observed play in a structured way with the child, indicating that they consider that engaging in play is also part of their professional role, a way of caring for the child.
On this day, a licensed practical nurse (P19) was observed actively playing soccer with the child in the hallways. When they got tired, they went into the toy library and continued playing there for another hour. (Descriptive field note (P19), night shift 2, week 3) The licensed practical nurse (P19) stands out from the others due to her intense and routine use of play. It seemed that this was an intentional, purposeful use that went through different incorporations, including play as a shared occupation. (Reflective field note, night shift 2, week 3)
It was noted that professionals who adopted play in their professional practices achieved recognition from children and, therefore, were frequently sought out by them.
One child was seen calling the licensed practical nurse (P8) to go to her room to see the drawings she had drawn. She promptly went to the room, and the child presented her with a drawing, including both of their names. The practical nurse thanked her, praised her and hugged her. Throughout the observation, every time they met in the hallways, the practical nurse would make comments and jokes with her. (Descriptive field note, (P8), day shift 2, week 5)
Theme: Interactions with the hospital toy library
Subtheme: Space of the toy library
The observations allowed us to infer that the toy library held the symbolism of being a place for occupational therapy and psychopedagogy and was not recognized as part of the care process for the child. Thus, the participants rarely used the space and interacted with it by opening the door at the designated times and opening cabinets containing toys with restricted access.
The observation suggested that the toy library had the meaning of being a place for therapeutic interventions by occupational therapy and psychopedagogy. During the observation periods, the access door to the toy library remained closed, sometimes locked. Furthermore, many of the toys were locked in cabinets, and the licensed practical nurses were sought out by the children or caregivers to open the cabinets and find toys that interested them. Apparently, they had the role of being the people who opened the doors to those who gave access to space and its toys. (Reflective field note after the 3rd week of observation) During the reading of the ICF, several licensed practical nurses made comments that they did not usually play in their practices, since the toy library was not the space for their work, but rather for occupational therapy and psychopedagogy. They seemed surprised that the topic had been proposed to them and immediately decided to play with the toy library. (Reflective field note after completing all study invitations) On that day, a child asked the nursing technician (P1) to watch a movie on the television in the toy library. The nursing technician (P1) explained to her that the occupational therapy team was the one authorizing this activity and, therefore, she could not put the movie on. (Descriptive field note (P1), day shift 1, week 2)
It was observed that some practical nurses acted as mediators for access to the toys. It was not uncommon for children to approach them to ask them to open cabinets, allowing access to the toys. Some promptly went to the toy library and mediated their access, while others said they would go later, but ended up not going. The most common thing was that, with the cystic toy in their possession, the child would go to their room to play and the nurse would say that, when finished, they should call them so they could put it away. (Reflective field note, day shift 1, week 6)
Subtheme: Relationship with the toy library
Mediating access to toys in the toy library cabinets was a daily activity of the licensed practical nurses, as well as helping ensure that the space was used in accordance with the established rules. There was a great concern in rigorously following the rules established for the space, although they disagreed with having been given this responsibility, since it was not a space considered for their professional role.
A licensed practical nurse (P8) told another that she agreed with the need to control over the use of the toy library, since the toys belonged to the hospital and many children and caregivers would either damage or take them. They then discussed who should be responsible for this and disagreed with the fact that they and the nurse had been given such responsibility, since they were not the ones using the space, and the activity was overwhelming them. (Descriptive field note (P8), day shift 2, week 5) A licensed practical nurse (P2) walked down the unit hallway and a child asked her, pointing to the toy library, which had its door closed and the lights off (10:00 a.m.), if she could go in. The technician looked at her watch and said yes, and the caregiver asked, “Can we use it?” The professional shook her head and asked, “Did you check if the door is already open?” (Descriptive field note (P2), day shift 1, week 5) At the nursing station, the practical nurse (P2) asked the other (P1) if she could get colored pencils from the toy library and take them to the child in the room. She replied: “I think so, better ask (nurse’s name)”. (Descriptive field note (P1, P2), day shift 1, week 3)
During night shifts, the mediation of the licensed practical nurses to search for toys in the toy library was lower compared to the day shifts. Few professionals did this task or encouraged the use of the space by the child and their companions. Furthermore, the fact that the toy library was locked made the children look for other places and other ways to spend the time.
During the observation period that night (8:00 p.m. to 11:00 p.m.), the toy library remained locked, drawing attention to the absence of children walking around the hallways. (Descriptive field note, night shift, week 1, similar to some other night observations) Toy library locked (8 p.m.). Children who were not sleeping played in the open area in front of their rooms, some doing activities, such as painting, with their companions. This external area had built-in concrete benches surrounding the garden. It was a large and airy space, with no chairs or tables for activities. Therefore, the children and their companions sat on the benches mentioned. It was noted that they invented games to play in the space outside their rooms, such as playing ball, coloring, playing tag and hide-and-seek. (Descriptive field note, night shift, week 2)
DISCUSSION
Play is inherent to children and has positive effects on their development, life and well-being, and should be considered in all contexts, including illness and hospitalization. It is a right of the child recognized and recommended by the World Health Organization23. Furthermore, according to the legislation6, it is the responsibility of the nursing team working in the pediatric area to use play in caring for children and their families. Thus, all professionals who care for children in this space are committed to supporting and integrating play into their practices. This study revealed that nursing techniques do not see that the protection and promotion of play is a part of their profession. Some expressed a symbolism that the hospital is not the setting for play, based on the understanding that the children are ill.
According to a study24, play in the hospital is valuable because it regulates negative feelings and reduces stress, contributing to coping with adverse events and situations. It is useful for processing information, being a safe way to practice new behaviors and solutions, stimulating fantasy and creative thinking, and favoring the development of empathy. However, in this article, only seven of the 23 participants showed behaviors of protection and promotion of the activity, with emphasis on encouraging them to go to the toy library, draw, providing access to toys stored in locked cabinets, not interrupting play for procedures, play with the child, among others.
The results reinforce the importance of incorporating play into procedures, aiming to alleviate the trauma of the event, anxiety, pain and distress, as pointed out in another study25. The identification of positive outcomes of this incorporation reinforces and promotes its use16. On the other hand, in the observed reality, there was no clear evidence of developments in the use and its benefits to foster the incorporation of this resource in the practice of professionals who either did not use it or only used it occasionally and sporadically.
Among the group of participants, few used the resource intentionally. This may be associated with the identification of a context that did not encourage or promote use, suggesting the possibility of an understanding that the resource was not part of the licensed practical nurse's care practice. The main restrictive factors identified in the observation, were the nurse's unsupportive attitude regarding play and toys, the social interactions in the unit, emphasizing the occupational therapy and psychopedagogy professions with those to whom the resource was referred, and the way in which the toy library was regulated and its use controlled. Interaction with these factors socially reinforces the meaning that play is not perceived as a form of care.
Similar results have been found in the literature10,13, indicating that insufficient institutional support weakens the adoption and incorporation of play into the daily care provided in hospitals. Furthermore, national and international studies show that the prioritization of other interventions, the lack of time for play due to the structured work process, the lack of infrastructure and training, the routine of procedures and the mechanical performance of care10,13 stand out as limiting factors to the incorporation of this resource by Nursing. This article also addressed these limiting factors, adding social interactions, under meanings that do not refer the resource to the scope of nursing practice.
It is necessary to highlight the nurse’s role in shaping the team’s attitudes. The nurse needs to overcome unintentional use and be trained to develop intentional, planned and integrated play actions into the care plan for positive outcomes, as well as encouraging and maintaining their team trained for care. This fact is evidenced in scientific articles and in the legislation7,8. In the present study, few nurses acknowledged and valued play, which influenced the behavior of licensed practical nurses regarding the devaluation of this resource. It was observed that the meaning the nurse attributes to play can, through social interactions, reshape the meanings held by their team, potentially leading to behavioral changes16.
When talking about the toy library, it was noted that licensed practical nurses went there, mainly to provide access to the toys that were locked inside the cabinets. Therefore, it was noted that nursing technicians understood that this is an environment designated to the duty of other professionals, such as occupational therapists, psychopedagogues and psychologists. In this regard, findings obtained in international studies3 are in line with those of this article, as they indicate that, due to routine, the nursing team ends up transferring the responsibility for playful care to other professional teams.
According to the legislation, the presence of a toy library is mandatory in hospitals that provide pediatric care26. It helps children go through the hospitalization process, facilitating their adaptation and minimizing their suffering. It also supports children and family members to get closer together and facilitates the execution of procedures, contributing to treatment adherence and increasing the child’s chances of recovery27,28. Despite the benefits highlighted in the literature, our research showed that the use of this environment was limited to professionals other than licensed practical nurses. It is evident that these professionals need to empower themselves and redefine the toy library as a space that should be used in their professional practices. By changing and reconstructing the meaning of the toy library, new behaviors can be established16. For this to happen, institutional policy must take a clear stance.
Regarding the hours of operation, the law states that they should be defined by the hospital management but ensuring broad and free access29. However, in this study, it was observed that, often, the door was closed, even during opening hours, which limited the access of the child and the licensed practical nurse to the place. Additionally, keeping the toys locked in the cabinets posed another barrier to play and access to toys. The licensed practical nurses were positioned, by institutional norms, as mediators of access to the cabinets and toys. These conditions led to limited intentional use of the space as a place to be with children or to be offered to them.
Moreover, the participants were professionally working as licensed practical nurses but either held or were pursuing higher education degrees. In this regard, a study29 showed that these professionals feel greater satisfaction, as they seek quality of care based on their qualifications, recognizing contributions to a broader and more critical view of their work. In this specific article, it was evident that having higher education in nursing corroborated, in some cases, greater use of play in their professional practices. Higher education may have contributed to changes in the meanings attributed, determining different behaviors among these professionals16.
The search for professional development and postgraduate courses becomes necessary for professionals to stay up to date. However, in the present study, it was found that few licensed practical nurses sought courses beyond those provided by the institution. Among those who did, the use of play in care practices was not a topic of focus. Thus, it is recommended that institutions address play in the continuing education offered and promote it in social spaces as a duty and commitment of all professionals who work with hospitalized children, as even stated in legislation6.
Interviews with some nursing professionals30 showed that, after motherhood, the way they care for and look at patients became more refined, in addition to awakening a sense of empathy. Among the participants in this study, almost all had at least one child and, in some cases, this fact acted as an incentive to use play. Regarding the length of service, it was noted that the longer the period of work in pediatrics, the more the licensed practical nurses interacted with each other and with the children, which made them reflect and reconstruct meanings16, starting to recognize the importance of play and, consequently, to include it more intensely in their care practices.
By providing evidence based on the voices of licensed practical nurses in pediatric units, this study contributes to raising awareness among professionals and managers of these hospital units about play, with the possibility of reverberating in changes. Furthermore, the results obtained have the potential to foster a playful attitude and the intentional adoption of play in nursing care performed by licensed practical nurses, with consequences for humanization, rights and quality of pediatric care.
As a limitation of this study stands out the potential influence of the observer on the behavior of licensed practical nurses, who could simulate greater use of play in their care practices, since they knew they were being observed. Additionally, there is the fact that data collection was supported by only one strategy: observation. However, almost all licensed practical nurses in the unit were observed, on different days and for a considerable amount of hours. These aspects counter the limitations and contribute to the strength of the evidence presented. Furthermore, the results reinforce, and advance to the existing evidence on the subject.
CONCLUSION
From the observations, it was possible to understand the use of play in the care practices of nursing technicians with hospitalized children. It was noted that play was symbolically not seen as part of these professionals’ care practices, being associated with the meaning of the child being limited in engaging in it due to illness and hospitalization. Therefore, behaviors that promoted and supported the occurrence of play in the studied setting were rare. Moreover, the toy library was not understood as a space in which technicians can work, since institutional rules and social interactions in the pediatric unit suggested that it was not a space for licensed practical nurses’ activities. Despite this, there were professionals who countered the messages conveyed by social interactions in the unit and invested in play, signifying its relevance and benefits for the child.
Thus, it is concluded that the use of play in the hospital environment needs to be renewed in terms of the meaning to be understood as a care activity, which is also the responsibility of the nursing team. Daily commitments to educational practices that support play, toys and toy libraries as children's rights are essential and, therefore, all professionals are responsible for protecting, promoting and offering them in hospital pediatric units. Future studies are recommended to address how the theme of play in care practices is presented and included in professional training courses and also in continuing education provided by institutions.
Acknowledgments
This work was conducted with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES) - Funding Code 001. Likewise, we are grateful to the University Hospital of the Universidade Federal de São Carlos- SP (HU-UFSCar), Brazilian Company of Hospital Services (Empresa Brasileira de Serviços Hospitalares - EBSERH).
REFERENCES
-
1. Bezerra AM, Marques FRB, Marcheti MA, Luizari MRF. Triggering and mitigating factors of maternal overload in the hospital environment during child hospitalization. Cogitare Enferm. 2021;26: e72634. https://doi.org/10.5380/ce.v26i0.72634
» https://doi.org/10.5380/ce.v26i0.72634 -
2. Ahmed EA. Psychological impact of hospitalization on child and family and the role of nursing care. Int J Psychol Sci. 2024;6(1):97-102. https://doi.org/10.33545/26648377.2024.v6.i1b.48
» https://doi.org/10.33545/26648377.2024.v6.i1b.48 -
3. Gjarde LK, Hybschmann J, Dybdal D, Topperzer MK, Schroder MA, Gibson JL, et al. Play interventions for paediatric patients in hospital: a scoping review. BMJ Open. 2021;11(7): e051957. https://doi.org/10.1136/bmjopen-2021-051957
» https://doi.org/10.1136/bmjopen-2021-051957 -
4. Santos ACCD, Coutinho PC, Nogueira A. Cuidar em Parceria: o uso da brincadeira terapêutica na criança na hospitalização. Acta Farmac Port [Internet]. 2023 [cited 2024 Sep 24];12(2):14-8. Available from: https://actafarmaceuticaportuguesa.com/index.php/afp/article/view/409
» https://actafarmaceuticaportuguesa.com/index.php/afp/article/view/409 -
5. Ministério da Saúde (BR). Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências [Internet]. 1990 [cited 2024 Sep 24]. Available from: https://www.planalto.gov.br/ccivil_03/leis/l8069.htm
» https://www.planalto.gov.br/ccivil_03/leis/l8069.htm -
6. Conselho Federal de Enfermagem (COFEN). Resolução COFEN nº 546/2017. Atualiza norma para utilização da técnica do Brinquedo/Brinquedo Terapêutico pela Equipe de Enfermagem na assistência à criança hospitalizada [Internet]. 2017 [cited 2025 Jan 21]. Available from: https://www.cofen.gov.br/resolucao-cofen-no-05462017/
» https://www.cofen.gov.br/resolucao-cofen-no-05462017/ -
7. Godino-Iáñez MJ, Martos-Cabrera MB, Suleiman-Martos N, Gómez-Urquiza JL, Vargas-Román K, Membrive-Jiménez MJ, et al. Play therapy as an intervention in hospitalized children: a systematic review. Healthcare (Basel). 2020;8(3): 01-12. https://doi.org/10.3390/healthcare8030239
» https://doi.org/10.3390/healthcare8030239 -
8. Maia EBS, Banca ROL, Rodrigues S, Pontes EDCD, Sulino MC, Lima RAGD. The power of play in pediatric nursing: the perspectives of nurses participating in focal groups. Texto Contexto Enferm. 2022;31: e20210170. https://doi.org/10.1590/1980-265X-TCE-2021-0170
» https://doi.org/10.1590/1980-265X-TCE-2021-0170 -
9. Graber K, O’Farrelly C, Ramchandani P. Centring children’s lived experiences in understanding importance of play in hospitals. Child Care Health Dev. 2024;50:e13287. https://doi.org/10.1111/cch.13287
» https://doi.org/10.1111/cch.13287 -
10. Claus MIS, Maia EBS, Oliveira AIBD, Ramos AL, Dias PLM, Wernet M. The insertion of play and toys in Pediatric Nursing practices: a convergent care research. Esc Anna Nery. 2021;25(3): e20200383. https://doi.org/10.1590/2177-9465-EAN-2020-0383
» https://doi.org/10.1590/2177-9465-EAN-2020-0383 -
11. Darko EK, Senoo-Dogbey VE, Ohene LA. Play for hospitalized children: a qualitative enquiry of behavior and motivation of nurses in a secondary level healthcare setting in Ghana. J Pediatr Nurs. 2024;77: e1-e7. https://doi.org/10.1016/j.pedn.2024.02.027
» https://doi.org/10.1016/j.pedn.2024.02.027 -
12. Yogman M, Garner A, Hutchinson J, Hirsh-Pasek K, Golinkoff RM. The power of play: a pediatric role in enhancing development in young children. Pediatrics. 2018;142(3):e20182058. https://doi.org/10.1542/peds.2018-2058
» https://doi.org/10.1542/peds.2018-2058 -
13. Ciuffo LL, Souza TVD, Freitas TMD, Moraes JRMMD, Santos KCOD, Santos RDOKFLD. The use of toys by nursing as a therapeutic resource in the care of hospitalized children. Rev Bras Enferm. 2023;76(2):e20220433, 2023. https://doi.org/10.1590/0034-7167-2022-0433pt
» https://doi.org/10.1590/0034-7167-2022-0433pt -
14. Minayo MCS. Ética das pesquisas qualitativas segundo suas características. Rev Pesq Qual. 2021;9(22):521-39. https://doi.org/10.33361/RPQ.2021.v.9.n.22.506
» https://doi.org/10.33361/RPQ.2021.v.9.n.22.506 -
15. Souza VRDS, Marziale MHP, Silva GTR, Nascimento PL. Translation and validation into Brazilian Portuguese and assessment of the COREQ checklist. Acta Paul Enferm. 2021;34: eAPE02631. https://doi.org/10.37689/acta-ape/2021AO02631
» https://doi.org/10.37689/acta-ape/2021AO02631 - 16. Charon JM. Symbolic Interactionism: an introduction, an interpretation, an integration. Boston: Prentice Hall; 2010.
-
17. Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico 2022: panorama [Internet]. 2023 [cited 2024 Sep 24]. Available from: https://censo2022.ibge.gov.br/panorama/?utm_source=ibge&utm_medium=home&utm_campaign=portal
» https://censo2022.ibge.gov.br/panorama/?utm_source=ibge&utm_medium=home&utm_campaign=portal -
18. Empresa Brasileira de Serviços Hospitalares (EBSERH). Plano de Dados Abertos do Hospital Universitário da Universidade Federal de São Carlos - SP [Internet]. 2023 [cited 2024 Sep 24]. Available from: https://www.gov.br/ebserh/pt-br/hospitais-universitarios/regiao-sudeste/hu-ufscar/acesso-a-informacao/dados-abertos/PDA20232025HUUFSCarFinalValidadoCGU.pdf
» https://www.gov.br/ebserh/pt-br/hospitais-universitarios/regiao-sudeste/hu-ufscar/acesso-a-informacao/dados-abertos/PDA20232025HUUFSCarFinalValidadoCGU.pdf -
19. Marietto ML. Observação participante e não participante: contextualização teórica e sugestão de roteiro para aplicação dos métodos. Rev Ibero-Am Estratég [Internet]. 2018 [cited 2024 Sep 24];17(4):05-18. Available from: https://www.redalyc.org/journal/3312/331259758002/html/
» https://www.redalyc.org/journal/3312/331259758002/html/ -
20. Berkhout C, Berbra O, Favre J, Collins C, Calafiore M, Peremans L, et al. Defining and evaluating the Hawthorne effect in primary care, a systematic review and meta-analysis. Front Med (Lausanne). 2022;9. https://doi.org/10.3389/fmed.2022.1033486
» https://doi.org/10.3389/fmed.2022.1033486 - 21. Velloso ISC, Duarte ED, Chianca TCM. O diário de campo e suas potencialidades como instrumento investigativo nas pesquisas. In: Silva Neto, BR, organizador. Ciências médicas: campo teórico, métodos, aplicabilidade e limitações. Ponta Grossa: Atena; 2021, p. 212-23.
-
22. Naeem M, Ozuem W, Howell K, Ranfagni S. A step-by-step process of thematic analysis to develop a conceptual model in qualitative research. Int J Qual Methods. 2023;22:1-18. https://doi.org/10.1177/16094069231205789
» https://doi.org/10.1177/16094069231205789 -
23. Yu C, Weaver S, Walker M, Hess J, Mac A, Ross T. Opportunities for play in paediatric healthcare environments: a scoping review. Front Rehabil Sci. 2024;5:1415609. https://doi.org/10.3389/fresc.2024.1415609
» https://doi.org/10.3389/fresc.2024.1415609 -
24. Nijhof SL, Vinkers CH, van Geelen SM, Duijff SN, Achterberg EJM, van der Net J, et al. Healthy play, better coping: the importance of play for the development of children in health and disease. Neurosci Biobehav Rev. 2018;95:421-9. https://doi.org/10.1016/j.neubiorev.2018.09.024
» https://doi.org/10.1016/j.neubiorev.2018.09.024 -
25. Correio JFDA, Barbosa AB, Sena MLMD, Margotti E, Silva TFD, Nascimento VFD. O cuidado lúdico pela enfermagem em pediatria: conhecimento e dificuldades para sua utilização. Rev Enferm Atual Derme [Internet]. 2022[cited 2024 Sep 24];96(39). Available from: https://pesquisa.bvsalud.org/portal/resource/pt/biblio-1417512
» https://pesquisa.bvsalud.org/portal/resource/pt/biblio-1417512 -
26. Ministério da Saúde (BR). Subchefia para Assuntos Jurídicos. Lei nº 11.104, de 21 de março de 2005. Dispõe sobre a obrigatoriedade de instalação de brinquedotecas nas unidades de saúde que ofereçam atendimento pediátrico em regime de internação [Internet]. 2005 [cited 2024 Sep 24]. Available from: https://www.planalto.gov.br/ccivil_03/_ato2004-2006/2005/lei/l11104.htm
» https://www.planalto.gov.br/ccivil_03/_ato2004-2006/2005/lei/l11104.htm -
27. Cesário F, Pinto S, Aniceto T, Jardim A, Araújo C, Torres L. Parents’ perception of the hospital playroom as a therapeutic resource. Millenium. 2022;2(17):81-8. https://doi.org/10.29352/mill0217.22494
» https://doi.org/10.29352/mill0217.22494 -
28. Kelada L, Wakefield CE, Graves SD, Treadgold C, Dumlao G, Schaffer M, et al. Evaluation of an In-Hospital Recreation Room for Hospitalised Children and Their Families. J Pediatr Nurs. 2021; 61:191-8. https://doi.org/10.1016/j.pedn.2021.05.017
» https://doi.org/10.1016/j.pedn.2021.05.017 -
29. Ministério da Saúde (BR). Gabinete do Ministro . Portaria nº 2.261, de 23 de novembro de 2005. Aprova o Regulamento que estabelece as diretrizes de instalação e funcionamento das brinquedotecas nas unidades de saúde que ofereçam atendimento pediátrico em regime de internação [Internet]. 2005 [cited 2024 Sep 24]. Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2005/prt2261_23_11_2005.html
» https://bvsms.saude.gov.br/bvs/saudelegis/gm/2005/prt2261_23_11_2005.html -
30. Gimenes BP, Maia EBS, Ribeiro CA. In the playful universe of therapeutic play: who am I? Nurses attributing meaning to their role in this process. Texto Contexto Enferm. 2023;32:e20230056. https://doi.org/10.1590/1980-265X-TCE-2023-0056pt
» https://doi.org/10.1590/1980-265X-TCE-2023-0056pt
Access to the dataset can be obtained upon request to the corresponding author.
