Nursing care through the perception of hospitalized children

Objective: to describe the perception of hospitalized children of school age, on nursing care and understand what are, from their perspective, the best ways to address it to when performing such care. Method: qualitative, descriptive, exploratory research, with concepts of Vygotsky used as theoretical framework. The data collection occurred through interviews mediated by drawings and was performed with ten school children, with the interview later transcribed and submitted to a thematic analysis. Results: showed the importance of playing during hospitalization, of a friendly and caring approach and providing explanations regarding the performed procedures. Conclusion: nursing professionals need to consider how the children would like to receive the care being provided, so that their singularities are respected, characterizing nursing actions according to a perspective of the whole human being. Descriptors: Hospitalized Child; Child Care; Nursing care; Pediatric Nursing; Professional-Patient Relationship. RESUMO Objetivo: descrever a percepção da criança hospitalizada, em idade escolar, acerca dos cuidados de enfermagem e compreender quais são, sob sua perspectiva, as melhores formas de abordá-la para a realização desses cuidados. Método: pesquisa qualitativa, descritiva, exploratória, que utilizou as concepções de Vygotsky como referencial teórico. A coleta de dados deu-se com a entrevista mediada por desenho e foi realizada com dez crianças em idade escolar, sendo a entrevista transcrita e submetida à análise temática. Resultados: sinalizaram para a importância do brincar durante a hospitalização, da abordagem cordial e carinhosa e das explicações quanto aos procedimentos realizados. Conclusão: os profi ssionais de enfermagem precisam levar em consideração a forma como as crianças gostariam de receber os cuidados de modo que suas singularidades sejam respeitadas, caracterizando as ações de enfermagem segundo uma perspectiva de ser humano integral. Descritores: Criança Hospitalizada; Cuidado da Criança; Cuidados de Enfermagem; Enfermagem Pediátrica; Relações Profi ssional-Paciente. RESUMEN Objetivo: describir la percepción del niño hospitalizado, en edad escolar, sobre los cuidados de enfermería y comprender cuáles son, bajo su perspectiva, las mejores formas de abordarlo para la realización de dichos cuidados. Método: investigación cualitativa, descriptiva y exploratoria, que utilizó los conceptos de Vygotsky como referencia teórica. La toma de datos se obtuvo con una entrevista mediada por un dibujo, realizada con diez niños en edad escolar, siendo la entrevista transcripta y sometida a análisis temático. Resultados: Señalaron la importancia del juego durante la hospitalización, sobre un abordaje cordial y cariñoso y sobre las explicaciones de los procedimientos realizados. Conclusión: los profesionales de enfermería necesitan tener en consideración la forma en cómo a los niños les gustaría recibir los cuidados, de modo que las singularidades sean respetadas, caracterizando las acciones de la enfermería según una perspectiva del ser humano como un todo. Descriptores: Niño Hospitalizado; Cuidado del Niño; Cuidados de Enfermería; Enfermería Pediátrica; Relaciones ProfesionalPaciente. RESEARCH Nursing care through the perception of hospitalized children Os cuidados de enfermagem na percepção da criança hospitalizada Los cuidados de enfermería en la percepción del niño hospitalizado Liliane Faria da Silva E-mail: lili.05@hotmail.com CORRESPONDING AUTHOR


INTRODUCTION
The hospitalization of children is a stressful and traumatic event, since there is a break with their social environment, activities, habits, and customs.Children are immersed in a new environment, full of restrictions and routines, with unknown people and, moreover, being subjected to procedures that generate fear and pain (1) .
Hospitalized children experiences many hardships: separation, pain, physical discomfort due to intense manipulation and disease, which all influence the affective, psychological and emotional spheres, and it is important that nurses recognize this suffering.Therefore, it is necessary to listen to them, thus learning the extent of the disease in their life and how they live it, which are unique aspects to each child (2) .
By taking care of hospitalized children, we come across a human being and their family immersed in emotional, physical and social vulnerability, which demands from the nursing professional not only understanding of the disease, but also sensitivity to recognize its peculiarities.Therefore, it is necessary to include the children in the process, making them active subjects and valuing their desires (3) , as they tend to communicate in a pure and true form.
A national study found that nurses recognize the importance of preserving the autonomy of children, allowing the expression of feelings, respecting their time in a flexibly manner and meeting their wishes according to their clinical condition.This attitude facilitates the establishment of a partnership, contemplating their needs (4) .
Internationally, the study showed that most health professionals recognize the importance of including children in the decisions being made about their treatment, leading them to feel part of the process, and thus facilitating their collaboration (5) .Another study explored the experience of managing postoperative pain in schoolchildren showed that children are capable of managing pain itself, therefore, it is important for health care to enhance its role and use strategies that allow them freedom to communicate (6) .
Based on this, we can say that children are the best sources of information about their own experiences and feelings.They can express their thoughts in different ways (verbal and nonverbal) and, therefore, it is necessary for the nurse to enter the child's world and allow them to express the situations they experienced (7) .
In the quest to better understand the development of a child and the articulation of the experience of a sick and hospitalized child, this research used Vygotsky's views as theoretical framework (8)(9) .For him, child development is the ability of the child to move from a more basic level to a more elaborate one, performing tasks and understanding what happens around them (8) .
In the course of a child's development, experiences with the world and the people around them are gradually internalized, transforming their behavior (8) .Everything around them has a mediating function and interferes in their development: the people with whom the children are connected, the environment they live in, the equipment represented by instruments and some signs, all meanings the child comes to understand.
Vygotsky also conceptualized the human development zones, according to the following classification: the real development zone, linked to what has already been learned, in other words, that which the child is capable of performing alone; the potential development zone, related to what can still be learned with the help of another, whether an adult or a more experienced child; and the proximal development zone, the interval between the two development areas cited above (8) .
Considering that the role of evaluator belongs to the child being assisted, and that the child can express their perceptions and care needs, when addressed in a consistent manner with their level of development (10) , the question is: what is the perception of the hospitalized child regarding their nursing care?And what is the best approach to care in the perception of a hospitalized child?

OBJECTIVES
This study aimed to describe the perception of hospitalized children of school age about their nursing care and understand what, from their perspective, is the best ways to address it, when performing such care.

Type of research
Descriptive and exploratory research with a qualitative approach, concerned with a level of reality that cannot be quantified.The type of research adopted allowed for the description and exploration (11) of the meanings assigned by children to the care received during hospitalization.

Study's scenarios
The scenario was the playroom of the pediatric ward of a federal university hospital, located in Rio de Janeiro.The room has tables and chairs in a child's size, features colored pencils, colored pens, crayons, papers and some toys.Because it is a more private space, the noise level is low, allowing a clear recording, thus facilitating transcription.It also ensured the privacy of the child during the interview.

Source of data
Participants comprised of 10 school children, selected using the following inclusion criteria: school aged children of both sexes; hospitalized for three days or more, thus in contact with the six teams of nurses in staff, working in rotation.We excluded those who were unaccompanied during hospitalization or who failed to respond to the survey questions.
The number of participants was defined during the research, since the criterion for interrupting data collection was "data saturation", defined as the suspension of the inclusion of new participants, the moment that the data started to present some redundancy (12) .
Collection and organization of the data Data collection was conducted through semi-structured interviews mediated by design, from June to August, 2014.We used an interview script with open and closed questions.
Closed questions sought the characterization of children, and the open ones to meet the research objectives.
Regarding the use of the design, many current researchers who work with children seek assistance of recreational resources as a communication strategy during the interview to obtain data.This feature, therefore, was only used to assist communication between the researcher and the children (7)(8)(9)(10)(11)(12)(13) .
To operationalize the interview mediated by the design, at first, we provided each child with a variety of materials: pens, markers, colored pencils, crayons, pencils, ballpoint pens and a sheet of A4 paper.Then, we explained the possibility of using the desired material and we clarified that they could draw everything they considered important about the care provided by the nursing professionals and the way the nurses care for them.If they so preferred, they could respond without drawing, though all of them opted to draw.
They had some time to organize their thoughts and to express it through drawing.Afterwards, we exposed them to the semi-structured interview, according to the following questions: What do you know about the care that the nursing professionals perform for you?What do you think of this care?How would you like to be cared for?
For a full and accurate record of the speeches given by the subjects, the interviews were recorded with the help of a mp3 player.We maintained the anonymity of the participants at all times and, therefore, we adopted cartoon characters names to identify them.These names were chosen by the children themselves, and none of them needed to be changed due to repetition.

Data analysis
Data were analyzed following the steps of a thematic analysis (11) .To implement the review process, after the transcription of the interviews, we began by reading the material for exploitation of the content, processing and interpreting the results.Thus, the classification of the speeches was done using the colorimetric method, in other words, the words and the phrases with the same meaning were colored with the same color; afterwards, we grouped them by color, generating by their specificity, two thematic units: the perception of the school age child about the nursing care and the best ways to accomplish care from the perspective of the hospitalized children.

Ethical aspects
The research was approved by the Ethics and Research Committee of the institution where it was performed and complied with all aspects contained in Resolution 466/12 of the National Health Council.Still in compliance with this resolution, the child's legal guardian signed an informed consent form, and the children signed an assent form.

Characterization of children participating in the research
Of the 10 children participating, 8 were male and 2 females, aged between 6 and 12 years.Regarding the number of days in hospitalization, there was a variation of 3 to 12 days, with 4 being hospitalized for 4 days; 2 for 3; 1 for 5; 1 for 7; 1 for 9; and 1 for 12 days.Several were the reasons that led to hospitalization -6 had a defined diagnosis, such as ankle torsion, periorbital edema, megacolon, anemia and urinary tract infection, myasthenia gravis, thyroid cyst, periocular abscess, tumor in the jaw and neck and cellulite in the lower limb.The other four children were hospitalized for diagnostic investigation.

The perception of children about the nursing care
In the perception of the school aged children, nursing professionals were those who medicated and cared for those who were sick.These precautions are necessary for a person to recover.For them, the nurse must have good communication with the physician and report the conditions of the children: During the interviews, the children talked about some cares and procedures performed by the nurses and highlighted the steps of the venipuncture procedure: the local antisepsis and the use of a tourniquet.They talked about what they felt during the administration of medication through the intravenous access and described the performance of bandages with the use of adhesive tape, expressing their discomfort at the time of withdrawal, when placed over hair: They (nursing professionals) do it like this: they clean and do so (child demonstrates arm antisepsis), then pushes like this (demonstrates the puncture).(Mônica) To draw blood and put medicine in the vein, it doesn't hurt, they put it here (child gesturing the use of a tourniquet), place it (the needle), and draw blood.(Hulk) To put medicine (venous), dipyrone, it hurts!I feel, like, pressure...And to make the dressing, they put cotton, then put the tape.But the tape is bad when taking off, it sticks to the hair!(Goku) The children described the ways they were approached when procedures were performed and identified as fundamental the explanations they received, because they understood that there should remain no doubts.They indicated as positive the use of playing strategies, like playing to prepare and calm the child before painful procedures such as puncture.They verbalized the importance of communication by the nursing professionals about the possibility of feeling pain: They ask to see my arm, look, put the medicine (venous access), like, normal.But they take very good care of us!They explain, and answer my questions.We can't have doubts!(Goku) They (the nursing professionals) were playing for me to calm down.They said: "relax, we are going to stick you only 5 times" (Laughing)!But they spoke just for fun, just to calm me down and then they said "it won't hurt..." (Naruto) The PPD (Purified Protein Derivative -tuberculin test, performed intradermally in the middle third of the anterior aspect of the left forearm) was normal.It didn't hurt...The lady (nurse) said that when they placed it, it wouldn't hurt, but then when you press (injects), it burns.Then, she said that it's just like this, like "Oh, it will hurt when I place it".That is a good one, she explained.(Cebolinha) On the other hand, the children expressed their dislike when professionals failed to talk to them, did not explain the procedures to be performed, and tell them in a peremptory way to remain still.One signaled that he would like to be greeted with a "good morning!", though not all professionals act in a friendly manner.Another said he did not understand very well how the drug was injected and what function it had in his body: To draw blood, they talk like this: "Stand still, boy".One says it like that.So I don't like it.(Cebolinha) They don't talk when they put medicine in, they just do and tell us "Be real quiet" (Transformer) They (nursing professionals) don't say anything when they make the bandage.They just take it, and then [.

..] then I'll sleep. (Scooby Doo)
To make the clyster, she (nursing professional) put ointment on the thingie (enema probe) and put it in.She never explained (the procedure).(Mônica) To put the medicine in, serum, to draw blood, they (nursing professionals) have to make a hole to access it.But I don't know how they put the medicine in.(Goku) I think this care is terrible!I can't explain... they aren't treating me right.Oh, there are some who speak, say "good morning, Cebolinha", but some don't say it.(Cebolinha) The best ways to approach nursing care in the perception of hospitalized children In this thematic unit, we will present the best ways to approach, through the hospitalized children's perspective, for performing nursing care.The subjects indicated that nursing professionals need to play, and not mistreat.It is necessary to be careful in how to approach the child, to talk fondly.Some indicated they would like to be called "little friend", and others by their own names: Hum... to take care of children you have to be funny, to play!Be good.You can't mistreat!Or hit, or be bad.(Mônica) Some nurses asks us for our arm, "little friend", but others talk like, normal with us.I would like to always be called "little friend", to be called fondly.Some don't call me that.(Goku)

Nurses need to be careful. I would like to be taken care of with affection, treat myself well, call me by name. (Hulk)
When carrying out the procedures, professionals must guide and explain about the procedures, what they are for and how they work.They should be more careful, act more slowly and use recreational resources to prepare the child.
To take good care, you have to talk, explain and treat people well... these things.(Cebolinha)

I don't know how they (nursing professionals) put the medicine in through the access (venous) [...] I wanted to know. (Goku)
To give injection and make a dressing, you have to do it slowly, righ !? [...]More slowly...More slowly.(Ben 10) It's nice when they played to make me feel calmer, not nervous.(Naruto) Some highlighted also that they would like the nurses to care for them, so they might be healed, and then be discharged:

DISCUSSION
With the experience of hospitalization, the school aged child internalizes (8) the role of nursing professionals, who act as mediators in the child development zones, teaching them what can be learned with the help of someone more experienced (8) .They also recognize that they use verbal and nonverbal communication to provide care, and that these actions are focused on their recovery.
In the stage of development where the child is, where language has already been conquered and therefore is able to understand what is being spoken (8) , the child understands that nursing professionals are there to help them face the stage of disease and hospitalization.Moreover, the child has internalized the possibility of affection and exchange of experiences.Similarly, the proximity between nurse and child favors the identification of their health needs while hospitalized (13) .In this sense, the children argue that nurses taking an interest in their health, with frequent visits, is a demonstration of empathy, affection, and they value these professionals and realize the attitudes nurses assumes in their care (14) .
With the social interaction of the child in the hospital environment, the child watches closely the actions of the nurse.The instruments and signs used by the professionals -such as syringes, bandages, among others -specific to this environment, are internalized and gradually start to have meaning due to the frequency with which the procedures are performed during hospitalization (8) .
Due to this watchful gaze, care and nursing procedures in pediatric patients require specific actions for the protection of the child.Nurses must be aware of the uniqueness of each body and, in the case of venipuncture, they should employ methods to minimize the pain, such as previous use of anesthetic cream to minimize the painful sensation during the invasive procedure, according to the reports of children (15) .
Another method that can be used for this purpose is playing, which may not prevent the pain, but offers the child a way to release feelings of anger, anxiety, hostility, thus enabling the inner expression of fear and despair.This is an option that minimizes the negative feelings of hospitalization and enhances the recovery of the child (16) .
Regarding the statements of the respondents about the importance of the nurse explaining the procedures that will be performed and answering questions, and because they are complex issues and a little difficult to be imagined by children, the professional needs to act taking into consideration the potential development zone, which is linked to what can be learned with the help of another (8) .Therefore, the nurses needs to convey this information in the clearest way possible, helping them to move from one level of basic understanding to a more elaborate one (8) .It is also important to inquire if the children understood the explanations to confirm that the message was well assimilated.
The children can already understand their disease and its treatment, know themselves and have the foresight to notice when something is out of the ordinary, since they are already able of having more abstract thoughts and their understanding is not limited to factual information (8) .So, it is essential that the nursing team talk, orient, explain, consider their complaints and use them as guides to care during hospitalization and invasive procedures (17) .
Regarding playing, cited by one of the children, this refers to a strategy routinely used in hospitals to calm children down.It is scientifically shown that, when used according to the child's stage of development, playing reduces pain and promotes more cooperation during the procedure (18) .In addition, the toy plays an important role in child development because it acts as a mediator, thus transforming the elementary psychological basic functions such as reflex action and crying, into more elaborate functions such as the development of abstract thinking (8) .
To help children cope with periods of hospitalization, hospital researchers in the United States conducted a randomized study whose purpose was to build a snowman with unused socks and buttons.The aim was to encourage children to understand the hospitalization situation, and help them in difficult times to express their feelings.The results showed that the preparation of the material helped not only during the therapy session, but throughout period of hospitalization (19) .
Therefore, it is possible to make use of creativity and permeate the children's universe, to help them cope with hospitalization.It is noteworthy that invasive procedures are often causes of stress in children and to mitigate them, there are several strategies: use of toys, of touch, of guidance, always to distract and mitigate the likely suffering that will be caused.
The act of playing is important for the child, and the nursing staff must recognize this need, provide means for its implementation and use it in daily care.The Resolution of the Federal Council of Nursing (COFEN) No. 295/2004 of 2004, in Article 1 st , claims to be the competence of nurses who work in pediatrics to use toys/therapeutic toys in nursing care for hospitalized children and their families (20) .This expresses the recognition that such methods reduce the stressor agents during the course of care for these patients.However, since its use depends on nurses, it is up to them to identify the most effective strategy for each situation to make assistance considerably easier and humanized (18,21) .
Thus, the use of playful strategies, be it expressed through play, toy/therapeutic toy, or through storytelling, act as a beneficial tool for both the child and the family, favoring communication with the health professional (20)(21)(22) .The toy allows children to resolve doubts about hospital procedures and their health; aims to clarify concepts and fantasies, which are part of the imaginary world of school, especially when faced with something unknown and threatening.In addition, it allows nurses to better understand the child's needs and feelings, helping to face hospitalization in a more peaceful way (20,22) .
The dislike of children with professionals who did not explain the procedures to be performed, who acted in an authoritarian manner, giving orders on how to behave during the invasive procedure and that, often enough, failed to even greet them, was noticeable.A study described the experience of children in their interaction with the nursing professionals during their hospital stay, and brought this understanding that children, while observing these attitudes of members of the nursing team, qualify them as "good" or "bad" (14) or even "terrible", as seen in the speech of Cebolinha.
Professionals need to reflect and understand their role as mediating agents in the child's development zones (8) , for they can and should help children to better understand the processes of the disease, hospitalization and the treatment they are receiving, through an approach that addresses their needs and singularities.It is essential that the child understands the intentionality of the nursing actions, through explanations and guidance using appropriate language, so they feel respected by the adults who are part of their routine, follow-ups and who represent authority (14) .
Regarding the speech of Goku, about not understanding how the drug "gets" inside the body, we can see that the child feels more secure when nursing professionals adopt strategies to facilitate their understanding of the reality and function of treatment.For this to occur, an effective communication should be used in the nurse's relationship with the child, conveying respect and safety to meet their level of understanding.They must also consider the moments, showing the necessity for treatment.This set of actions alleviates suffering incurred with hospitalization and strengthens the bond of trust between the individuals (13) .
It is, therefore, possible to understand that in order to establish communication with the child, it is important to use strategies such as proper instruments and signs of the child's universe, such as playing, which is full of sense already internalized and already a part of their lives (8) , to facilitate the contact, show security and respect, thus enabling changes in their behavior.Thus, the child can accept, more peacefully, the hospital procedures that need to be performed.Playing becomes a tool that allows nurses to better understand the needs and feelings of the children, helping to assimilate new situations and understand what is happening around them (23) .
We saw that children crave care in an environment filled with respect, consideration and affection, amusing them and distracting them during the hospitalization period.However, they still face professionals without these qualities during care.
Encouraging the child to laugh, to rejoice, substantially favors their healthy growth and development, adding also the benefits of learning, social interaction and promoting positive behaviors (14) .The results of this study showed that the affective interaction of the nursing staff is key to a good relationship with the child.
Those who feel welcomed by the nurse begin to express this feeling through their behavior, greeting, dispelling their doubts, cooperating with the procedures.However, this freedom of interaction occurs only after thoroughly assessing the body language and verbal and non-verbal language of the professional during therapeutic interventions.The moment they consider that this interaction will be beneficial, these children build emotional bonds with ease (14) .
We can infer, given the results shown, that in some moments the children reported having received explanations during their hospitalization and not in others.In these reports, they wanted the nurses to tell them about their health or procedures that would be performed.They are satisfied these actions occur.Thus, it is possible to understand that children want the professionals to take charge, in fact, of the role of learning mediator in children's potential development zone, thus assisting them in what can be learned with the help of the other (8) .
Thus, the act of explaining and cautiously performing procedures are linked to the respect that this professional should have with the hospitalized child.A study whose objective was understanding the ethical aspects that guide the care provided by nurses to hospitalized children showed the importance of exchanging information while this professional performs the care, so that actions can be performed humanly (24) .Some children have internalized the thought, through their experiences with the world and people (8) , that nursing professionals are responsible for healing their disease, for allowing them to eventually return to their homes.What they still do not understand, however, is the fact that hospital discharge is a term used by health professionals to describe the care started with hospitalization, including the period prior to their discharge from the hospital and the period that comes afterwards, in their place of residence (25) .
This process involves all members of the hospital multidisciplinary team and each one is responsible for promoting children's health, including nurses, with their work process and their assistance to their health (25) .

FINAL CONSIDERATIONS
The children recognize the role of nursing professionals in the care they receive during hospitalization and the importance of that to their recovery.For them, nursing care is directly related to hospital discharge, and they ask that this care be executed quickly and appropriately so they can get better and return to their own homes.
The children also highlight the importance of care being performed with tenderness, affection and respect.In addition, they emphasize the need for these professionals to explain each step of the procedures, so they can understand their purpose and feel safer.Also, they consider cordiality to be essential for them to feel comfortable in the hospital.They verbalized that, sometimes, the simple procedures end up causing pain, which requires greater attention and sensitivity of the professional.
Playing was identified as a resource able to minimize anxiety and fear during these moments.The individuals also stated that, to care for children, the nursing professionals need to be funny and play, which shows the need to include recreational activities while assistance is being provided.
This study showed the importance of a child's view of the care offered through the various actions of the nursing activities during hospitalization.Thus, it contributes to the professionals of the pediatric unit being able to provide care to hospitalized children while considering the way they would like to be cared for.
We must give voice to children so that their singularities are respected, characterizing nursing actions according to a perspective of a human being as a whole.We recommend new studies focused on the perception of children about nursing care, since most research on the care of hospitalized children addresses the issue from the perspective of caregivers or nursing professionals.
Ah! Get my foot and my knee well and do my test soon.And go away soon.(Cebolinha)I wanted the nurses to send me to discharge, so I could go home.Take care of me so I can go... take away what I have.I want to get well so I can go.(Scooby Doo) They (nursing professionals) give the children medicine, because the children are sick.(Power Ranger) Nurses do the activities to care, to care for everyone.The nurse takes care, because if we do not receive care, we will not get better, if not for the care.(Transformer) I think it's the care (of the nurses) that we require, that we need.They can't not treat, care for us, otherwise we get worse.The nurse can't stop talking about how we are to the doctor.Because he (doctor) has to know how we are.(Goku)