Understanding nurses' awareness as to the use of therapeutic play in child care

Abstracts

Este estudo objetivou compreender como ocorre a sensibilização do enfermeiro para o uso do brinquedo terapêutico como instrumento de intervenção de enfermagem. O referencial teórico foi o Interacionismo Simbólico e o metodológico, além do Interacionismo Interpretativo. Participaram sete enfermeiras que atuavam em unidades pediátricas hospitalares e ambulatoriais, incluindo o brinquedo terapêutico em sua prática. Emergiram quatro temas representativos: ampliando seu olhar para a pessoa da criança, encantando-se com uma nova possibilidade de cuidar, percebendo sua ação revalidada e comprometendo-se com o desenvolvimento da temática. Estes revelaram que, ao conhecer o brinquedo terapêutico e utilizá-lo na assistência, a enfermeira inicia um caminhar no qual constata os benefícios dessa intervenção, o que revalida cada vez mais sua ação, passando a valorizá-lo como instrumento de intervenção de enfermagem. Os autores consideram que ensinar sobre o brinquedo e integrá-lo à assistência são desafios que ainda necessitam ser superados.

Jogos e brinquedos; Criança hospitalizada; Enfermagem pediátrica

ORIGINAL ARTICLE

Understanding nurses' awareness as to the use of therapeutic play in child care*

Comprendiendo la sensibilización del enfermero para el uso del juguete terapéutico en la práctica de atención al niño

Edmara Bazoni Soares Maia^I; Circéa Amália Ribeiro^II; Regina Issuzu Hirooka de Borba^III

^IM.Sc. in Nursing, Universidade Federal de São Paulo Faculty, Undergraduate Nursing Program. Professor, Nursing Department, Universidade Federal de São Paulo. Member of the Play Study Group - GEBrinq. São Paulo, SP, Brazil. [e-mail]

^IIPh.D. in Nursing. Associate Professor, Nursing Department, Universidade Federal de São Paulo. Lead Researcher, Play Study Group - GEBrinq. São Paulo, SP, Brazil. [e-mail]

^IIIPh.D. in Nursing. Adjunct Professor, Universidade Federal de São Paulo. Researcher, Play Study Group - GEBrinq. São Paulo, SP, Brazil. [e-mail]

ABSTRACT

The objective of this study was to understand how nurses become aware of the use of therapeutic play as a nursing intervention instrument. Symbolic Interactionism was the theoretical framework and Interpretive Interactionism was used as the methodological framework. Participants were seven nurses working at hospitals and outpatient pediatric units who used the therapeutic play in their practice. Four representative themes emerged: Expanding the way he/she sees the child; Becoming fascinated with a new possibility to provide care; Noticing his/her revalidated action; and Committing himself/herself to the theme development. Such themes revealed that when nurses become acquainted with therapeutic play and use it in his/her practice, they begin on a journey that allows him/her to recognize the benefits of this intervention. By doing so, nurses revalidate their actions more and more, thus valuing play as a nursing intervention tool. The authors believe that teaching about therapeutic play and integrating it to nurses' daily practice are challenges yet to be overcome.

Descriptors: Play and playthings.; Child, hospitalized.; Pediatric nursing

RESUMEN

Este estudio objetivó comprender cómo se produce la sensibilización del enfermero para el uso del juguete terapéutico como instrumento de intervención de enfermería. El referencial teórico fue el Interaccionismo Simbólico, y el metodológico el Interaccionismo Interpretativo. Participaron siete enfermeras que actuaban en unidades pediátricas hospitalarias y ambulatorias, incluyendo el juguete terapéutico en su práctica. Emergieron cuatro temas representativos: Ampliando su mirada al niño como persona, Encantándose con una nueva posibilidad de cuidar, Percibiendo su acción revalidada y Comprometiéndose con el desarrollo de la temática. Estos revelaron que al conocer el juguete terapéutico y utilizarlo en la atención, la enfermera inicia un camino en el que constata los beneficios de tal intervención, lo que revalida cada vez más su acción, pasando a valorizarlo como instrumento de intervención de enfermería. Los autores consideran que enseñar sobre el juguete e integrarlo a la atención son desafíos que aún necesitan ser superados.

Descriptores: Juego e implementos de juego; Niño hospitalizado; Enfermería pediátrica

INTRODUCTION

In current literature, countless studies exist that aim to understand the playful as a trigger of child development, enhancing children's recreation, stimulation, socialization, creativity, autonomy and recovery, also in the hospitalization context. Independently of children's different care scenarios, they need to play, as this activity is very important for their lives, mainly when they are ill⁽¹⁾.

Nurses can use play as a care strategy for hospitalized children, mainly in three areas: during daily routine; to prepare children for surgery and invasive procedures and during painful and unpleasant procedures⁽²⁾.

In nursing care, Florence Nightingale already appointed the use of toys some decades ago⁽³⁾. In 1970, it was already emphasized that it is important for nurses to know how to use toys in pediatric nursing and to turn them into an important component of child care, for use during physical care, i.e. singing, telling stories, playing games with body segments and, also, using the different forms of therapeutic play (TP)⁽⁴⁾.

Among the countless functions attributed to play, the catharsis function should be highlighted, i.e. relief or purification, allowing individuals to relieve some anxiety; this function is extremely important because it constitutes the base for play therapy and therapeutic play⁽³⁾.

TP is play structured for children to relieve the anxiety produced by experiences atypical of their age, which tend to be threatening and demand more than recreation to solve associated anxiety, and should be used whenever they face difficulties to understand and deal with the experience⁽⁵⁾. Its goal is to provide nurses with a better understanding of the children's needs and to help to prepare them for therapeutic procedures, as well as to allow the children to their tension after these procedures^(6-7).

It differs from play therapy, which is a technique used to treat children with emotional disorders, applied in sessions conducted by a psychologist, physician or psychiatric nurse, aimed at enhancing the children's understanding of their own behaviors and feelings. Therefore, the therapist should reflect the children's verbal and non-verbal expressions and interpret them in their place. Sessions take place in a very well controlled environment and can take months⁽⁶⁾.

Health professionals' use of toys/TP is appointed as beneficial to the children, mainly because it makes the relationship between professional and child narrower and more affective. Besides, studies appoint playing as a facilitator in the communication process among children, professionals and companions. When this takes place, they underline that opposition to treatment decreases and that the child becomes more cooperative^(3,8-11).

Health professionals working with children need to be aware of the many possibilities playing can offer them and the children, also during their stay in hospital, including: tranquility, communication and the establishment of new friendship bonds⁽⁷⁾. Thus, they face the responsibility and challenge of learning and using toys in care, besides offering a play environment in hospital⁽¹²⁾.

Although studies appoint a trend for nurses to study and research on TP and professional entities recommend the inclusion of this theme in undergraduate nursing course curricula⁽¹³⁾, recent studies demonstrate that its use in care practice is still incipient^(13-16), which is also observed in care experience. According to one of these studies, although 88% out of 25 nurses from pediatric units at a university hospital in São Paulo indicate that they know TP, only 13.63% use it sporadically in care practice⁽¹⁴⁾. In the other research, involving 30 nurses working at pediatric units of general hospitals in a city in Greater São Paulo, 93% mentioned knowledge about TP, but only 7% apply it⁽¹⁵⁾.

This is a fact, although Brazilian professional legislation attributes legal competency for nurses to use toys / therapeutic play, according to Federal Nursing Council Resolution No 295/2004^(13-16).

As a result of our commitment to the theme, our role as nurses and nurse teachers who use toys and believe in its importance is that of active agents in the dissemination of this care practice, making this possibility real in daily care. In that sense, we believe that understanding how nurses are sensitized to the use of TP is an important step to find out how we can act as educators and disseminators of this intervention form.

Through this reality, some inquiries emerge when we try to find a route towards the incorporation of TP, in fact, in nurses' care practice. What interactions do nurses experience that make them sensitized to TP practice? What emotions permeate interactions between nurses and children while using TP? How do interactions among nurses, children and toys take place?

In the search for answers to these inquiries, this study was developed to understanding how nurses are sensitized to the use of TP as a nursing intervention instrument in childcare.

METHOD

As a theoretical framework, we used Symbolic Interactionism, which constitutes a perspective for the analysis of human experiences, focused on studying the nature of the interaction, i.e. the social dynamics activities that happen among people⁽¹⁷⁾. According to this perspective, the meaning nurses attributes to the experience of interacting with children through TP is constructed in the interaction they establish with themselves, the children, families and the entire health team. When assuming the other's role, nurses act and interact with different situations that get re-signified, according to how they assess the past, manipulate and plan the future, thus attributing a new meaning to their experience.

The methodological approach was Interpretative Interactionism, which acknowledge that the experience contains the meanings of the actions and that any situation is new, emerging and loaded with multiple and conflicting meanings and interpretations. It focuses on the experiences that alter or trigger meanings in the individual's being, admitting that individuals not only respond to, but also create their environment. For interpretative interactionists, these moments permit the transformation of experiences into so-called epiphanies, which occur in problematic situations of interaction, when subject confront and experience moments of crisis, in a sociocultural context and based on the person's experience, who will never be the same⁽¹⁸⁾.

To put the study in practice, nurses had to be located and delimited who used TP in their daily work and would thus permit our interaction with narratives that would allow us to understand how they had become sensitized, that is, how they had been touched for the use of toys/TP in childcare. Hence, the research did not take place in one single context or one specific institution. Subjects were located, independently of their place of work, through their acknowledged involvement with the theme, due to their use of TP in care practice, teaching or research development on the theme, based on the researchers' personal knowledge, scientific and academic production or participation in the activities of the Study Group on Toys - GEBrinq

Study participants were seven nurses. Three were clinical nurses, two of whom were specialists and Master's students in pediatric nursing, who had been working at a child hospitalization unit for five years; the third was a general cardiology specialist who had been working at hospitalization and outpatient units of a pediatric hospital for eight years. Three other nurses were pediatric nursing faculty and had been active in theoretical and practical teaching on PT for more than five years. Two of them held a Master's degree, one a Ph.D. degree and all of them possessed previous professional experience as pediatric nurses and used TP in childcare. The seventh participant also held a specialist and Master's degree and had been working as a nurse in pediatric contexts for 13 years, besides two years as a pediatric nursing faculty.

For data collection, individual, semistructured interviews were used, which started with the following guiding question: Tell me how you started to use therapeutic play in your practice. During the interview, other questions were asked with a view to a further understanding of the experience. Interviews were recorded and later fully transcribed for analysis. The interviews enhanced the recovery of dense narratives about how nurses are sensitized to the use of TP in their practice.

Data analysis took place at the same time as data collection and transcription, as recommended by Interpretative Interactionism, involving the phases of isolation, construction and contextualization⁽¹⁸⁾. In the isolation phase, during the intensive analysis of the stories told, the constituent elements and key-configurations of discourse were identified and their units of experience extracted.

Next, in the construction phase, the attribution map was elaborated per thematic categories. Thus, based on the elements isolated from individual discourse, the representative theme could be reconstructed, considered as the summarized expression of the subjectivity of nurses who use TP in their practice. As the final phase in the analysis, contextualization was performed, who aimed to bring the phenomenon to life in the nurses' words, unveiling their meaning, as a fundamental step in the interpretative process and understanding of the phenomenon.

Before data collection, approval for the research project was obtained from the Institutional Review Board at Universidade Federal de São Paulo - Brazil under Opinion No 1532/2003 and participants signed the Informed Consent Term.

RESULTS

Data analysis led to the identification of four themes, representative of how nurses start to take interest in and use TP as a care practice. Three of these themes revealed themselves as epiphanies: Broadening one's look to the child's person, Enchanting oneself with a new care possibility, Perceiving one's action as revalidated. The fourth theme, Committing oneself to the development of the theme, revealed to be a consequence of this experience (Figure 1). These themes, as well as their component categories, will be explained and exemplified below, using phrases taken from the participating' nurses discourse.

1. Broadening your look to the child's person

This epiphany emerges from the situations nurses experience in their personal life and during their professional education in the Undergraduate or Stricto or Lato Sensu Graduate Nursing Program, when they are introduced to aspects of Nursing care for children, broaden their look to the child's person and re-signify their contents of what it means to be a child.

From that point onwards, when interacting with children in hospitalization situations or during some painful procedure, nurses acknowledge the range of their suffering and are sensitized to the extent to which these experiences can be traumatic. Thus, Understanding the child better constitutes the first category of this epiphany.

This category evidences nurses' perception that it is during their professional education that they build the image of what it means to be a nurse, influenced by their interactions with their teachers, at undergraduate as well as graduate level. Thus, they gradually learn that they need to take care of the child without detaching physical from emotional care. This gives rise to important changes in their way of relating with the child, transforming care into a more gentle relation, getting a better understanding of their behavior and concerned with the trauma and what the experiences mean to the children.

I think that much of what I am, it's logical that, later, we get other teachers who broaden our view; but, like in Pediatric Nursing, which is not only directed at physical care, but at emotional care, it was during the undergraduate program (E4).

After the specialization, I completely changed with the child... the way of dealing with her. I think that, before I was drier, didn't touch a lot, when there was a procedure, when she got agitated, nervous and I couldn't do it. So, there was that trauma for her, and I couldn't understand what it meant (E2).

Remembering Special Moments is another component category of this epiphany and evidences how nurses' personal life stories influence their way of looking at children. When interacting with their memories, they remember special moments, such as: birth of their children, having a sick child in the family, having experienced hospitalization in childhood and how pleasant playing was in their childhood.

I played a lot in childhood, I used to destroy my dolls. I used to break the dolls' legs to be able to put a bandage on afterwards and say that they had a broken leg (E7).

One important thing was my daughter's birth, which coincided with my entry in the Master's program. She was a baby and that helped a lot. The fact of being a mother also helped me a lot in this sensitization (E1).

I had a nephew who had health problems at the time and that made me try and find a method to be able to minimize his feelings. And that was very gratifying to me (E2).

I had a surgical experience in childhood. At the age of six, I had a correction for strabismus, and I've never forgotten the moment I got into the surgery room, ... So, at first, perhaps I awoke to prepare the children for surgery (using toys) (E 4).

2. Enchanting oneself with a new care possibility

This was the second epiphany identified, which reveals the impact nurses experience when they meet with TP in their professional education, at undergraduate as well as specialization or Master's level. At that time, besides knowing this new care instrument, they interact with the teacher's stimulus and commitment. Other routes revealed in this epiphany are: the fact that nurses start to value TP, when they have to choose a research object or when, while experiencing difficult situations with the children they take care of, they meet with TP as a nursing intervention possibility, as the component categories show.

Meeting with TP evidences the moment when nurses receive theoretical orientations and perform TP practice in their undergraduate or specialization program in Pediatric Nursing, which allows them to expand their knowledge and grants them the opportunity to interact with the children more easily. They find themselves enchanted and then acknowledge the importance of TP to minimize the impact hospitalization causes in the children and start to use it.

In fact, I think that, in class, I got enchanted, sensitized by the possibility of using a resource to help the child ... And when we went to the undergraduate training, I wanted to learn how to use toys, to prepare the children for the procedures, so the first time I used it was while preparing a six-year old girl to have a congenital hip dislocation correction (E4).

Perceiving the value of teachers' activities pictures situations in nurses' academic lives, during which they interacted with teachers, identifying their true commitment to the theme and, mainly, to children and students. These interactions results in one of the most important stimuli for learning on the theme and for their sensitization, especially when they felt welcomed by the teachers, when they took interest in the results of their preparation and pleasantly discussed with them the meaning they attributed to the situation experienced when using TP.

I remember that the teacher was always asking us how the preparation had been and what that moment meant to us. I felt welcomed by her. I am sure that she liked toys and childcare, the emotional aspect (E4).

Choosing a study problem. This category reveals how nurses, when they start a Master's program and reflect on their research problem, are faced with the TP theme, deepening their knowledge and acknowledging the theme as a route towards comprehensive childcare and research development.

I started my Master's, then I thought seriously about playing. I thought what am I gonna do? What is going to be my study theme? And, literally, I went to the library and started to look for books, I kept looking, to see what theme I was going to follow and suddenly something like playing came up, and I thought: Look what an interesting theme! (E6).

Experiencing difficulties in professional practice reveals experiences in the care scenario when nurses perceive the children's needs and are sensitized to their suffering due to the hospitalization experience and procedures. In this painful experience, they reflect on the need to do something for the child, help them to conquer their wellbeing by using TP.

I observed the children's behavior in the postoperative period: they got back so traumatized, rebelling towards their mother, looking scared. I think that increased my desire to prepare the children for the procedures and use toys (E4).

The start of using toys was when we experienced difficulties with the children, mainly with the young ones and when you're gonna do invasive procedures and that's quite aggressive. So, I started to think how I could mitigate the suffering. Then we started to use toys. Ah! Let's do it on the doll first (E7).

3. Perceiving one's action as revalidated

This third epiphany reveals that, when starting the process of using TP in their care practice, nurses establish a trajectory permeated by the observation of countless benefits, but also by the experience of multiple difficulties and conflicts. Driven by a greater force, however, they do not let difficulties bring them down; they redirect their actions to overcome them, believing in the meaning of TP-mediated care.

Along this trajectory, significant interactions happen among nurses, team, children and families, perceived as great benefits to all and granting great pleasure. Nurses also perceive transformations in the environment and acknowledge that a support network is being established for the use of TP. Receiving this support and experiencing the benefits of using toys revalidates the practice of their use and drives nurses to increasingly use them, despite having to overcome difficulties.

Experiencing the benefits of TP is the first category in this epiphany. It pictures the situations nurses experiences when they develop actions involving TP in care practice and observe countless benefits for the children, such as wellbeing and tranquility, associated with decreased fear inherent in the hospitalization process, as well as enhanced child development, among others.

When you get a toy, a drawing and give it to the child, I think that her eyes say something else, the eyes kind of shine, because then she sees you with other eyes, it's not just to do something bad, playing is a good thing, positive to her (E5).

She's gonna play with me, so there's not that distance, that fear among us (E2).

At the same time, I was playing with the toy and also with the child's imaginary. I think that was a good experience, it helped the child and the family a lot (E1).

The interactions established at that time also benefit the nurses, who find themselves tightening the relation with families and starting to understand the children better. They also feel they are valued when they perceive acknowledgement by stakeholders along this trajectory, besides experiencing pleasant feelings deriving from the possibility of playing with the child.

But, mainly the relation with the family, I think that, for the family, it's more important than for the child himself and the parents start to get involved with you, with a closer relation of great mutual trust (E4).

When I used the toy, it was a very rich experience, I could understand things that were happening with the child, things that happened and she didn't demonstrate and, in play, she did... It's good, it's a feeling like, kind of peace. I love it, when I can feel with the children and play, I think that's the best time (E5).

Today, I am applying much as a preparation for surgery. So the surgeons themselves forward them and say: look, prepare him before going to surgery. So, they schedule it to get in one hour before the surgery, and they already ask us - have you been there already for the orientation? (E2).

I feel professionally accomplished. I think the greatest response we can have is the child and the family's retribution really. It's a personal accomplishment! (E4).

Besides these advantages, the nurse finds out, by using toys, the environment itself and care delivery transform, opening up for playfulness.

I always use toys. Even the other day, there was a child in coma and I said: people, this is very sad! I went to the room, got toys and filled the cradle! The workers said: Ah! Only you could do this (E2).

In addition to these benefits, there is the acknowledgement that the use of TP as an intervention instrument enhances interdisciplinarity, which shows to be important for nurses to experience the countless benefits of its use and perceives their action as revalidated.

The idea of the toy came up to me and the speech therapist, who was facing difficulties to work with the child... I made the puppet and put in what I had, and they (speech therapists) take it whenever they need it (E7).

Overcoming difficulties. A continuous movement of support and help for the child and family marks the route nurses follow who attempt to incorporate TP into their care. It is the pleasure of helping them and the finding of benefits in using toys that considerably raises their strengths to continue. This route, however, is marked by countless difficulties they need to overcome, such as: not having institutional support, facing difficulties with the nursing team itself and, also, with other professionals who are not always sensitized to the use of TP.

The fact that the hospital is not a pediatric hospital, it was a specialized cardiology hospital, so, there were few people with a child-oriented background. The approach was disease-centered and that was bad and hampered things so much (E6).

The workers don't know what it is, they think that you are not working, that you are playing and losing time. People end up calling you - look, there are things to do, you can't sit here and play! (E6).

Despite experiencing countless difficulties, along their trajectory, the nurses find that the benefits resulting from this practice outweigh these situations and, thus, feel driven to continue using them because they perceive their action as revalidated.

There is time, I think it varies a lot between when you prepare the child with the toy and the benefit it offers compensates for the time you're going to spend... you can use toys. I believe it is a tool the nurse has at her disposal (E2).

Perceiving oneself as supported. This category pictures situations that permit the understanding that, despite these difficulties the nurses face, they feel supported by the interactions, when they perceive that a support network is being constituted for the use of TP, involving the institution, the health team and the child's family. So, they feel more strengthened, perceive their action as revalidated and feel driven to continue.

There at the hospital, we have puppets, I asked to buy them, there's also an excellent puppet, large, more or less the size of a four-year-old child, with all parts removable, proper for orientation. As for the material, there's enough (E2).

But none of the physicians came to question me, about the therapeutic toy. On the opposite, when I asked a pediatric surgeon, to collect my data (for a research) at her private practice, she loved the idea and encouraged me and gave me the opportunity to apply toys and always referred to this as a benefit (E4).

In general, the family is present, if it's for a puncture or a fluid collection, the family is very interested and, sometimes, the family wants us to explain on the puppet where they're gonna puncture, you know, they want to get to puppet (E3).

4. Commitment to the development of the theme

As a consequence of this sensitization, nurses start to value and use TP as a nursing intervention instrument. They incorporate the commitment to enhance teaching on the theme, to put it in practice in care and to seek answers to their inquiries regarding theoretical foundations and knowledge construction on toys/TP, through research development. In addition, nurses make efforts to disseminate this knowledge during events and by publishing scientific papers, attempting to disseminate knowledge and enhancing information exchange with other professionals.

Trying to put TP in practice in care is a category that pictures how the nurses, driven by the will to help children through toys, get mobilized in the search for strategies to sensitize the people involved in the care area, so that they start to use it, so that therapeutic toys are systematically implanted in care.

We are in the phase of setting up the project and forwarding it to the ethics committee. We have weekly meetings at the hospital to discuss about toys and offer advice, we're starting (E2).

Enhancing TP teaching pictures the commitment of nurse faculty with permitting students to experience TP use, going beyond classroom limits and enhancing a link between theory and practice.

Today, we use the toys during training and teach the students, in theory, how to apply Therapeutic Play, how to use play systematically, using adequate techniques in practice (E1).

Researching on and disseminating the theme reveals nurses' commitment and investment in furthering their knowledge and seeking answers to their concerns regarding the theme. In this attempt, nurses interact with other sciences to consolidate and broaden their concepts.

In the Master's program, I remember a child who had been submitted to a Postectomy, and he had cut the puppet's hair. And he was quite aggressive with the girl doll and, when I looked for an explanation in psychoanalysis, we can detect the meaning of the fear of castration, so, I think that marked me (E4).

DISCUSSION

This study permitted understanding the route of nurses who teach and use TP, as well as to visualize noteworthy moments in this trajectory, regarding their sensitization to its use. Data do not only underline the benefits of using TP in childcare, but also broaden this understanding, revealing that their sensitization to the use of this intervention is enhanced when the contents are part of the undergraduate curriculum and offer students practical experiences with this instrument.

The São Paulo Regional Nursing Council has recommended the inclusion of contents on toys/TP in undergraduate curricula and has issued a favorable opinion regarding the use of this intervention as a nursing care instrument, recommending that these contents be compulsory in Undergraduate Nursing Course curricula, which teaching institutions have been complying with⁽¹⁶⁾. Other authors reaffirm that playing should be inserted in different professional health education programs, including mutual discussions on specific study programs for children through games and toys^(2,7).

We have found, however, that the teachers' facilitating and stimulating attitude is as important as offering TP contents, permitting students to experience the therapeutic action of this intervention and enhancing discussions on the meaning of this experience for students and the benefits of this practical experience.

We have found that, on this sensitization trajectory, despite the limitations and difficulties faced, when touched by the perceived benefits of their activities, nurses redirect their actions and start to believe in TP-mediated care.

Based on the results, it can be confirmed that TP is an adequate strategy for nurses to approach children, establishing bonding, empathy and trust relations. Besides, by understanding the meaning of some experiences for children through toys, nurses expand and qualify care in any context children receive care in. Other studies support this fact, which using interviews with games to understand the meaning children attributed to some situations they experienced, furthering nurses' understanding of the children's experience^(19-20).

Parents are also benefitted when they receive care through TP, as this intervention favors their perception of professionals' competent and high-quality care delivery to their children, consequently contributing to decrease the anxiety the experience produces⁽¹⁾, as the nurses who participated in the present research also experienced. Also, the benefits the nurses experience in preparing children for surgical procedures, such as decreased anxiety, recovery of self-control and decreased negative emotional reactions, revealed in this study, are similar to other research results^(1,21-22).

When reflecting on these findings, we can understand that, in nurses' trajectory towards sensitization for TP use, interactions are observed that grant a new meaning to the childcare process and feed these professionals' continuation to put its use in practice in childcare. Thus, they reveal that it is by Valuing TP as a nursing intervention instrument that nurses start to use it, opening up a new form of child and family care.

CONCLUSION

These study results offer contributions by motivating nurses that are not familiar with TP use yet to start using it systematically, with a view to benefiting all stakeholders in the care context. They also reveal the importance of teaching aimed at understanding the particularities of children and playing as a basic childhood need, as well as the importance of teaching and practicing TP in the academy, so that nursing students can verify its effects and experience its benefits already during their undergraduate program and, thus, start to value it as a nursing intervention instrument.

We believe nurses are responsible for putting in practice and providing means for toys/TP to be truly incorporated in nursing care, out of respect for the children and families who need healthcare, including hospitalization, so that they can continue growing up healthily, reverting this traumatic experience into benefits for their maturing. In addition, we consider it important to accomplish research focusing on faculty and students' experiences related to teaching and learning on toys/TP, as well as on experiences of implanting this care form in different care scenarios.

REFERENCES

• 1. Li HC, Lopez V. Effectiveness and appropriateness of therapeutic play intervention in preparing children for surgery: a randomized controlled trial study. J Spec Pediatr Nurs. 2008;13(2):63-73.
• 2. Haiat H, Bar-Mor G, Shochat M. The world of the child: a world of play even in the hospital. J Pediatr Nurs. 2003;18(3):209-14.
• 3. Ribeiro CA, Maia EBS, Sabatés AL, Borba RIH, Rezende MA, Almeida FA. O brinquedo e a assistência de enfermagem à criança. Enferm Atual. 2002;2(24):6-17.
• 4. Hot J. Rx: play PRN in pediatric nursing. Nurs Forum. 1970;9(3):288-309.
• 5. Steele S. Child health and family. Concept of communication. New York: Masson; 1981.
• 6. Green CS. Understanding children's needs through therapeutic play. Nursing. 1974;4(10): 31-2.
• 7. Hall C, Reet M. Enhancing the state of play in children's nursing. J Child Health Care. 2000;4(2):49-54.
• 8. Martins MR, Ribeiro CA, Borba RIH, Silva CV. Protocolo de preparo da criança pré-escolar para punção venosa, com a utilização do brinquedo terapêutico. Rev Latino Am Enferm. 2001;9(2):76-85.
• 9. Ribeiro PJ, Sabatés AL, Ribeiro CA. Utilização do brinquedo terapêutico, como um instrumento de intervenção de enfermagem, no preparo de crianças submetidas à coleta de sangue. Rev Esc Enferm USP. 2001;35(4):420-8.
• 10. Maia EBS, Guimarães RN, Ribeiro CA. O significado da medicação intratecal para a criança pré-escolar, expresso em sua brincadeira. Rev Paul Enferm. 2003;22(3):268-76.
• 11. Maia EBS, Ribeiro CA, Borba RIH. Brinquedo Terapêutico: benefícios vivenciados por enfermeiras na prática assistencial à criança e família. Rev Gaucha Enferm. 2008;29(1):39-46.
• 12. D'Antonio IJ. Therapeutic use of play in hospitals. Nurs Clin North Am. 1984;19(2):351-9.
• 13. Leite TMC, Shimo AKK. Uso do brinquedo no hospital: o que os enfermeiros brasileiros estão estudando? Rev Esc Enferm USP. 2008;42(2):389-95.
• 14. Oliveira CS. Brinquedo terapêutico na assistência a criança e família: percepção dos enfermeiros pediatras do Hospital São Paulo [monografia]. São Paulo: Universidade Federal de São Paulo; 2009.
• 15. Amans NSS. Brinquedo terapêutico: conhecimento e prática de enfermeiras que atuam em pediatria no município de Guarulhos - SP [dissertação]. Guarulhos: Universidade Guarulhos; 2008.
• 16. Cintra SM, Silva CV, Ribeiro CA. O ensino do brinquedo/brinquedo terapêutico nos cursos de graduação em enfermagem do estado de São Paulo. Rev Bras Enferm. 2006;59(4):497-501.
• 17. Charon JM. Symbolic interacionism: an introduction, an interpretation, an integration. Englewood Cliffs (NJ): Prentice-Hall; 2009.
• 18. Denzin NK. Interpretive interactionism. London: Sage; 1989. (Applied Social Research Methods Series; v.16).
• 19. Borba RIH, Sarti CA. A asma infantil e o mundo social e familiar da criança. Rev Bras Alerg Imunopatol. 2005;28(5):249-54.
• 20. Ribeiro CA, Angelo, M. O significado da hospitalização para a criança pré-escolar: um modelo teórico. Rev Esc Enferm. USP. 2005;39(04):391-9.
• 21. Castro AS, Silva CV, Ribeiro CA. Tentando readquirir o controle: a vivência do pré-escolar no pós-operatório de postectomia. Rev Latino Am Enferm. 2004;2(5):797-805.
• 22. Li HC. Evaluating the effectiveness of preoperative interventions: the appropriateness of using the Children's Emotional Manifestation Scale. J Clin Nurs. 2007;16(10):1919-26.

Correspondence addressed to:

^(a)

, which the researchers are also members of.

Publication Dates

• Publication in this collection
  25 Nov 2011
• Date of issue
  Aug 2011

History

• Received
  06 Apr 2010
• Accepted
  17 Nov 2010