IN THE PLAYFUL UNIVERSE OF THERAPEUTIC PLAY: WHO AM I? NURSES ATTRIBUTING MEANING TO THEIR ROLE IN THIS PROCESS

EN EL UNIVERSO LÚDICO DE LOS JUEGOS TERAPÉUTICOS: ¿QUIÉN SOY? ENFERMEROS ATRIBUYENDO SIGNIFICADOS A SU ROL EN ESTE PROCESO

ABSTRACT

Objectives:

to understand how nurses attribute meaning to their role in the interaction with children while using Therapeutic Play and building a Theoretical Model, representative of that experience.

Method:

a qualitative research study conducted in the light of Symbolic Interactionism and the Grounded Theory. The participants were eleven nurses of both genders and with experience in the use/teaching of this playful approach. Data were collected by means of participant observation and semi-structured interviews completed by story-drawing, simultaneously to the analysis following these steps: initial coding, categorization, theoretical coding, and apprehension of the central category until reaching theoretical saturation, enabling creation of the Theoretical Model.

Results:

two interactive phenomena were revealed. Striving to offer children welcoming and effective assistance through Therapeutic Play, which unveils nurses' sensitization towards children's/adolescents' distress, recognizing their playful nature and games as essential to their work, leading them to “embrace this cause”. Implementing actions so that Therapeutic Play becomes a reality in the care of children/adolescents, which describes the nurses' actions when they start using it helping children to cope with difficulties, favoring bond, catharsis, protagonism, welcoming, facing difficulties or receiving support from the institution, becoming famous as “nurses that play” and feeling gratified. Its integration allowed creating the Theoretical Model: Feeling gratified and fulfilled for promoting qualified and humanized assistance for children/adolescents by means of Therapeutic Play, representing the essence of this experience.

Conclusion:

by interacting playfully with children, nurses recognize several feelings that mobilize them: satisfaction, sense of responsibility and reciprocity, in addition to perceiving themselves as agents of change in favor of qualified playful care.

DESCRIPTORS:
Play and playthings; Nurses; Pediatric Nursing; Professional competence; Nursing assistance; Mental health.

RESUMEN

Objetivos:

comprender qué significados atribuyen los enfermeros a su rol en la interacción con niños al utilizar Juegos Terapéuticos y diseñar un Modelo Teórico representativo de esa experiencia.

Método:

investigación cualitativa realizada a la luz del Interaccionismo Simbólico y la Teoría Fundamentada en los Datos. Los participantes fueron once enfermeros de ambos sexos con experiencia en la utilización/enseñanza de este enfoque lúdico. Los datos se recolectaron por medio de observación participante y entrevistas semiestructuradas que culminaron con una historia ilustrada, simultáneamente con el análisis siguiendo estos pasos: codificación inicial, categorización, codificación teórica y aprehensión de la categoría central hasta alcanzar la saturación teórica, permitiendo así elaborar el Modelo Teórico.

Resultados:

se revelaron dos fenómenos interactivos. Esforzarse por ofrecer a los niños una asistencia acogedora y efectiva por medio de Juegos Terapéuticos, que revela la sensibilización de los enfermeros con respecto al sufrimiento de los niños/adolescentes, reconociendo su naturaleza lúdica y los juegos como algo esencial en su trabajo, llevándolos a “abrazar la causa”. Implementar acciones para que los Juegos Terapéuticos sean una realidad en la atención de niños/adolescentes, donde se describen las acciones de los enfermeros cuando comienzan a utilizarlos para ayudar a los niños a enfrentar las dificultades, favoreciendo el vínculo, la catarsis, el protagonismo y el acogimiento, haciendo frente a dificultades o recibiendo apoyo de la institución, además de ganarse la fama de ser “enfermeros que juegan” y sentirse gratificados. Su integración permitió diseñar el Modelo Teórico: Sentirse gratificado y realizado por promover asistencia calificada y humanizada para niños/adolescentes por medio de Juegos Terapéuticos, que representa la esencia de esa experiencia.

Conclusión:

al interactuar en forma lúdica con niños, los enfermeros reconocen varios sentimientos que los movilizan: satisfacción y sentido de responsabilidad y reciprocidad, además de percibirse como agentes de cambio en pos de una atención lúdica calificada.

DESCRIPTORES:
Juegos y juguetes; Enfermeros y enfermeras; Enfermería pediátrica; Competencia profesional; Asistencia de Enfermería; Salud mental.

RESUMO

Objetivos:

Compreender como o enfermeiro significa seu papel na interação com a criança, durante a utilização do Brinquedo Terapêutico e Construir um Modelo Teórico representativo dessa vivência.

Método:

Pesquisa qualitativa realizada à luz do Interacionismo Simbólico e da Teoria Fundamentada nos Dados. Participaram onze enfermeiros de ambos os sexos, com experiência no uso/ensino desse brincar. Coletaram-se dados por observação participante e entrevistas semiestruturadas finalizadas pelo desenho-estória, simultaneamente à análise seguindo os passos: codificação inicial, categorização, codificação teórica, apreensão da categoria central, até atingir-se saturação teórica, permitindo a construção do Modelo Teórico.

Resultados:

Revelaram dois fenômenos interativos. Empenhando-se para oferecer à criança uma assistência acolhedora e efetiva por meio do Brinquedo Terapêutico, desvela a sensibilização do enfermeiro pelo sofrimento da criança/adolescente, reconhecendo sua natureza lúdica e o brincar como essencial ao seu trabalho, levando-o a “abraçar essa causa”. Implementando ações para que o Brinquedo Terapêutico seja uma realidade no cuidado da criança/adolescente, descreve as ações do enfermeiro quando passa a utilizá-lo auxiliando a criança no enfrentamento das dificuldades, favorecendo vínculo, catarse, protagonismo, acolhimento, enfrentando dificuldades ou recebendo apoio da instituição, ficando com fama de “enfermeiro que brinca”, sentindo-se gratificado. Sua integração possibilitou a construção do Modelo Teórico: Sentindo-se gratificado e realizado por promover uma assistência qualificada e humanizada à criança/adolescente pelo Brinquedo Terapêutico, representativo da essência dessa vivência.

Conclusão:

Interagindo ludicamente com a criança, o enfermeiro reconhece vários sentimentos que o mobiliza: satisfação, senso de responsabilidade e reciprocidade e percebendo-se como agente de mudanças em prol de um cuidado lúdico qualificado.

DESCRITORES:
Jogos e brinquedos; Enfermeiro e enfermeira; Enfermagem pediátrica; Competência profissional; Assistência de enfermagem; Saúde mental

INTRODUCTION

The Brazilian public policies on playful activities 1 value playfulness in the Education and Health areas due to its effectiveness for comprehensive human development. The legal actions recommended assert children's/adolescents' right to remain playing in any environment, even when sick, having the support of the World Health Organization (WHO), which recognizes the practice of free and therapeutic play as a humanizing strategy and as an indicator of health care quality 2.

As a care technology, Therapeutic Play (TP) represents one of the actions recommended as a resource for pediatric clients to relieve the anxiety experienced in situations atypical for their age and considered threatening, in which recreation is not enough, in addition to being used to assist them in understanding how to deal with such experiences 3. TP involves three modalities: Dramatic Therapeutic Play (DTP), for children to relive facts, master the situation and relieve emotional stress; Instructional Therapeutic Play (ITP), for children to learn about a given procedure/event; and Therapeutic Play to Train Physiological Functions (TPTPFs), to favor/recover physiological functions through play 4.

Nurses' systematic use of TP with children is recommended by the recognition of its broad benefits, as it enables professionals to communicate with children, listening to them and understanding their needs and desires, in order to assist them with the respect and consideration they deserve. Although there is vast literature on the topic, such assistance still remains neglected in the clinical practice by the nursing and interdisciplinary teams, referring to the following: lack of time, overload of activities and the work context; that this initiative is not valued by the institution; and that it neither provides conditions for its implementation 5^- 7.

When we focus our attention on nurses who use this intervention, a conviction emerges that it enhances the care time; eases interaction, communication and bonding with children and their family 5^, 8; that they recognize it as valuable in child care 9; and that its results should overcome the reasons for its systematic non-inclusion in child care 8. We add the ethical issues inherent to the profession and the resolutions that legislate in favor of using TP as part of the list of competencies of nurses who assist children and adolescents, as established by the Federal Nursing Council 10.

However, the literature does not offer answers regarding questions related to how nurses define and experience their role related to the use of TP during their care practice, as well as to what mobilizes them for future actions aimed at implementing this playful care approach, that is, that type of care which involves games and fun and provides pleasure to people. Thus, the objectives of this study were as follows: to understand how nurses attribute meaning to their role in the interaction with children while using Therapeutic Play and to build a theoretical model representative of this experience.

METHOD

This is a qualitative study using Symbolic Interactionism as theoretical framework, whose studies focus on the nature of the interaction, that is, the social dynamics activities that occur between people, considering society as a set of individuals interacting dynamically with each other 11. The methodological framework was the Grounded Theory (GT), which guided a constant interactive process between data collection and analysis 12 when investigating the interactions experienced by nurses during their practice mediated by TP.

The participants were 11 nurses (eight women and three men) who met the following selection criteria: being active or retired nurses and having interacted with TPs in their professional, care and/or teaching practice. They were recruited using the snowball sampling technique, which is a non-probability sampling method used in qualitative research indicated to reach specific groups of people using, in the initial samples, key informants to locate potential participants 13; this trigger was based on the Play Study Group ( Grupo de Estudos do Brinquedo, GEBrinq) indicating the first participants and, from them, other contacts were indicated and invitations were made via telephone calls. Consequently, there was no specific setting.

All guests agreed to participate and data collection took place between February 2018 and May 2020 through participant observation and semi-structured interviews, initiated by the following guiding question: “Tell me how do you mean your role when interacting with children while using TP”; it was ended by asking the nurses to make a drawing about how they perceived themselves in their interaction with TP and to talk about it, that is, with a Story-Drawing (S-D).

Four interviews were conducted in the work environment at times opposite to the nurses' shifts; the others took place online via Skype. All lasted between 50 and 100 minutes, took place in a single meeting, were audio-recorded in a cell phone or via Skype, and mediated by one of the researchers, a trained psychologist. The records were transcribed in full and analyzed in depth simultaneously with data collection, as recommended by the GT.

Notes were also made in a field diary and memos, focused on the researchers' insights and the records derived from participant observation, a strategy that took place on four occasions, with researcher's presence in hospital environments, which allowed her to experience in loco the everyday life of nurses and the use of TP in their clinical practice.

From the constant comparative analytical process and the continuous coming and going to the data and formulating hypotheses, the participants were selected and invited to take part, as proposed by the theoretical sampling that guided the simultaneous data collection and determination of the number of participants, until reaching theoretical saturation, that is, when more data are not required to develop new categories or theoretical intuitions 12. Thus, three sample groups were assembled .

The first one consisted of five PhD nurses who had been attending GEBrinq for years, had extensive clinical and theoretical-practical teaching experience on TP, had already carried out research studies with publications on the theme; and with vast theoretical and practical knowledge on the topic and a high level of involvement and sensitivity with the children and families. By appropriating all the information analyzed, we raised the following hypothesis: What would the perception of nurses without extensive previous experience about their interaction with TP be like?

Thus, the second group was comprised by three nurses, two MScs and one MSc student, also participating in GEBrinq and who worked in the clinical field of care or as Pediatric Nursing professors, using and teaching TP, but also building/improving their skills in using it. However, observing the composition of these two sample groups, we noticed that, until then, all the actors interviewed were women, traditionally considered sensitive, welcoming, maternal and intuitive 14. Thus, another reflection emerged: Which meaning do male nurses attribute to their role in the interaction with TP?

Thus, the third sample group was constituted by three male nurses (a PhD, an MSc and a specialist) with clinical and/or teaching experience in TP, who were not members or had ever attended GEBrinq.

Data analysis took place based on three stages: Open coding; Focused coding or categorization; and Theoretical coding 12. For this, Glaser's model called “Six Cs” (Cause, Context, Condition, Contingencies, Covariance and Consequence) was used. In addition to this, considered the general model for coding the codes, the family of Interactive Codes was used, which include mutual effects, reciprocity, mutual path, interdependence and interaction of effects 15.

The study was approved by the institution's Research Ethics Committee, following all the ethical principles that regulate research involving the participation of human beings, with signing of the Free and Informed Consent Form.

RESULTS

It was revealed that the nurses' effort to ensure that children receive Nursing care mediated by TP is the center of the experience, being marked by their constant movement in the search for being-a-playful-person and for a qualified playful care approach for children.

Such experience emerged in two interactive phenomena. The first one, Striving to offer children/adolescents welcoming and effective assistance through TP, reveals nurses' sensitization towards children's/adolescents’ distress, recognizing their playful nature, and play as essential to their work, starting to “embrace this cause”. During this process, they evoke positive past memories with playfulness experienced in their childhood, training and professional life alike, in addition to deepening their knowledge related to its use.

The second one, Implementing actions so that TP becomes a reality in child/adolescent care, narrates the nurses' interactive experience and their effort so that the planned actions come true, providing children/adolescents with opportunities to interact with TP, as part of qualified and playful Nursing care, while at times facing difficulties in using it and, at others, receiving support from the institution for their purpose. At the same time, they see themselves interacting with reactions of recognition from the clients, families, colleagues and even the institution, earning the reputation of “nurses that play”, in addition to feeling gratified as a person and for the professionals they have become as a result of using TP.

Integrating these phenomena allowed identifying the Central Category and creating the Theoretical Model: Feeling gratified and fulfilled for promoting qualified and humanized assistance for children/adolescents through Therapeutic Play, representing the essence of this experience, as illustrated in Figure 1.

Figure 1 -
Theoretical Model - Feeling gratified and fulfilled for promoting qualified and humanized assistance for children/adolescents through Therapeutic Play.

Becoming sensitized towards children's/adolescents' distress is the causal condition of this process, as such empathy leads nurses to mobilize so that the use of TP becomes a reality in Pediatric Nursing care. They sympathize with the patients' distress and are moved when describing painful experiences in individuals who are in their early development stages.

Either in pain or not, children feel as they're inside an egg, and toys allow them to express themselves. The three children [in the drawing] represent the bond. The syringe and the serum device can stop being traumatizing if games are included... This Sun represents hope, life, that the world is not so bad, so full of violence [...]. But nurses who incorporate therapeutic play in the systematization of pediatric assistance are providing children and adolescents with strength to leave the “ enclosure” and feel free and happy! (S-D REGISTER - Fictitious name).

The cases that moved me the most were the games I played with children whose mothers were in prison, because I realized that they were totally different from the children I played with in the hospital. [...] It's as if they were sort of “ stuck” to say something and that the time had come! Then, at the same time that she explored the box [of toys] , she spoke, spoke about herself, about her life. I was used to those issues targeted at diseases! Then I found a routine quite marked by some deficit, both effective and social! (LUMIAR) .

In the first hospital it was that classic scene, when the venipuncture time came, the children made a scandal and the nurses didn't quite know what to do. [...] What's right there are the children, mainly because they're suffering and need to be welcomed. What drew my attention and sensitized me were precisely those first cases, that the children were suffering... (DIFFERENTIATE) .

All of the above leads nurses to continually reflect and, through the TP practice, they Recognize children/adolescents as playful beings, which can be identified by the attitudes of respect they have for them. From this condition, nurses recognize that playing is the essence of a child and, when the TP approach happens, they realize that it allows children to understand everything that surrounds them, as they use language that reaches children's Self, starting to recognize playing as the essence of their work.

When playing with a child, I see that it's in their essence. As this is children's essence, it's also in the essence of my work with them. It’ s very important: it’ s no use for you to work with a child without stimulating games in them. It’ s how they see things, how they see and understand the world. [...] That toys can be their reflection (SEE) .

At the same time that they gradually experience feelings of compassion towards the children, nurses perceive themselves Evoking positive memories about playfulness. In addition, when playing with children, nurses are faced with influential memories that refer to their past, to their childhood and to their interactions with playfulness, or to their education and academic life, which start to light their way during the process of waking up to playfulness. The memories of these situations are important because they favor not only the nurses' sensitization, but also their perception regarding the recognition of children as playful beings.

Ah! This [playing] came from my mother, I was very motivated. I had complete freedom to play; everything about make-believe was really important to me [...] Playing was always really present, my mother stimulated me a lot and encouraged me to give “ wings to my imagination” (JOIN) .

And my grandmother was also a person that always encouraged my creativity, buying me materials to draw [...]. I think that, for sure, this exerted an impact on the playful issue, on me being always involved, on liking and having this creativity [...] I started using TP in undergraduation, back there at the camp, when I was still an undergraduate student.[...], I remember very well what that meant to me! [...] I went back to college full of ideas! That was what I wanted! (REVEAL) .

Consequently, nurses gradually Deepen their knowledge for using TP and prepare to use them, being responsible for propagating it, as well as for deepening their studies and appropriating this knowledge, or awakening the knowledge already built.

I'm still in this principle undergoing training, doing things for TP to become a habit, just like washing your hands. From the middle of this year, we started the implementation and training. And TP caught on in the institution since then! (CARESS) .

As I've focused a lot now on punctures, I went a little deeper into this during construction of this protocol [ITP], type and which phases, for people to be able to pass on and to correctly apply therapeutic play (ILLUMINATE) .

In this context, nurses gradually reflect and recognize that it is practically impossible to practice the profession without playing, without the symbolism that TP permeates, when caring for a client experiencing childhood, as they recognize to which extent its use is an intervention means that collaborates in various ways and in varied situations, therefore Recognizing TP as essential for their work, even deserving to be placed at the top of the Nursing care pyramid.

It's fundamental to use play with children; it's no use thinking about caring for a child without any toy involved. Especially therapeutic play, which give you tools [for care] (SEE) .

I needed something that helped me educate about the disease and TP was the best tool I could find. For me, depending on the indication, TP should be included in nurses' activities with the same relevance as a dressing. It's just like any other Nursing care measure (REVEAL).

It's a pyramid, like the importance pyramid. [...] I put it [playing] at the top of the Nursing care measures. [The pyramid offers] Everything children need in their hospitalization. Then, the other care measures are not more or less than playing. I believe that they're linked and are like priorities for pediatric treatments (S-D CARESS).

Continuing in their path with greater foundation and confidence to achieve their goals, nurses then gradually Embrace the TP cause by recognizing the good it produces. As a consequence of establishing this commitment with their Self, they are now getting involved with the multiprofessional team, or with the Nursing team, in order to promote knowledge about games and TP and a friendly climate for employing them with children to ease their use by them.

I adopted and embraced that cause. Then I started to create a group of professionals from the hospital, we assembled a study group. [...], we didn't stay just with TP, because we were also working with the Play Room. But the focus was on playing and on TP, which were part of this group (REGISTER) .

The second (step) was introducing TP, making people understand that it should be part of our daily practice. Then I made a project, part of implementing TP in my unit, which started with the training. I trained the employees so that they also understood the importance of TP, before they started implementing it (CARESS).

By embracing the cause, the nurses' attitude leaves marks in the institution, creating a therapeutic philosophy and a playful culture and feeling responsible for the existence of games and TP within the organization.

Because they [nurses] work so that the children in that institution can play, providing the physical structure, training and, above all, the work philosophy [...]. They allow, drive, ensure that [the team] understands playing! The person who should guarantee that is the nurse. [...] even when not in direct contact with a child, nurses work for that structure to be installed (SEE).

Faced with this decision, nurses find themselves in a continuous flow of actions, more motivated to the support-promoting actions, when Using TP to help children/adolescents. In this sense, they recognize themselves preparing them for the procedures and getting to know them better. This gradually instigates them to identify the interesting experiences that occur when using TP because, in addition to approaching children in distress, they also become aware of facts about them at their homes and of their socioeconomic, cultural and affective conditions, including information that was not learned in the initial interview with the families.

I had a cancer patient aged 8. She was very depressed and was really quiet. I started some drama TP with her and noticed that she had a family issue. She missed her mother, who was a working nurse; she spent a lot of time with her grandparents... [the “mother doll’’ always isolated]. Then, with the dolls, she showed me what her family structure was like (CARESS).

A nurse recalls the emotion she felt when receiving an affectionate hug from a child after playing with her and noticing that a positive bond had been established between them.

And after [TP], when I went out for a walk with the mother [through the hospital's corridor], the child came running to hug me. It was at the end of the shift. I was emotionally shaken and I thought: this you call a bond! (ROTATE).

By using TP, nurses also recognize that they are favoring children's protagonism, so that they may act spontaneously for themselves, assuming the role of the main characters of the game and, thus, controlling the playful staging, favoring catharsis. They identify that, when leaving a passive state to enter an active one in a situation where they experience feelings and emotions, children gradually assume the power to control the situation.

Then I like it very much to see that children have a moment to “ be themselves” ! People don't let them do anything, they do everything for them at the hospital. Children are very happy to be able to command, to have control over the situation [while playing] (LUMIAR).

You put the material there for them (children), they're the first ones to get the insulin, get the diabetes stuff, do the procedure on the doll. This invasive thing for children with diabetes is really strong! (REVEAL).

During a DTP session, the child (three years old) hands in a syringe for the nurse to fill it again. When the nurse sees the child putting more “ medication” in the syringe, she asks: -You put more? Do you want to me to do it? The child confirms with a nod and delivers it, making the first eye contact with the nurse; gives a very deep sigh, showing to be very engaged and repeating the sonorous sigh a few times. [...] The nurse asks: She's hurting where, in the belly? The child immediately lifts the doll's dress to uncover her chest. The nurse says: -And it's here in the chest that she's hurting? The child confirms with a nod and cleans the doll's chest with gauze and alcohol, insistently..., an area where she had received a lot of cleaning, as she had undergone a liver transplant, staying in the Pediatric ICU for some time (ROTATE - Observation Note).

When I notice, I'm just a coadjuvant because it's the child that plays, she conducts the toy session and she sometimes ends it before I realize so. Or, else, the child picks up the dolls and plays with them in a different way, [.. .] children conduct everything in the best way for them (TAKE-CARE-OF).

However, conflicting situations gradually arise in the path of nurses that play, certain contingencies that are not always facilitating factors, disturbing their progress. And when they see themselves Having to face difficulties to use TP, a number of confrontations arise that start challenging their routine. Among them, they perceive themselves interacting with certain inaction from the Nursing team and with the absence of a care philosophy centered on children's needs.

I have really chronic cases, very heavy, complex! So, scheduling exams and procedures is all at the last minute, we can't go with the child beforehand, to apply TP. Then, the procedure already took place in the morning many times. And I wasn't there. Then I see the child only after the procedure [to apply TP] ! [...] It's how approached it... My colleagues don't apply TP. They have the knowledge in the unit, we know they have it, but they don't apply them! (ROTATE).

And, in that place [hospital] people saw me with 'evil eyes', they thought I was a weirdo, where nobody talked about children's reactions and stress during procedures and I invaded that space to introduce TP, a new technique, a new approach, a new look at welcoming hospitalized sick children... (ILLUMINATE).

In addition, nurses oftentimes find themselves without the support required to fulfill what they consider to be in the high hierarchy of care, precisely because TP is not valued and, even when it is already systematized in the place as a practice, it is still invisible to the Nursing team's eyes, not being demanded by nurses, unlike other procedures.

But if the day went by, if your shift was over and you didn't apply a dressing, someone would demand your attention, that would be demanded, but if you spent your shift without playing with a child, without preparing them for a venipuncture, nobody would even notice. Then there's some hierarchy of Nursing activities within the hospital where TP is not included, although it's systematized there (REVEAL).

A very embarrassing fact for nurses is when they claim that the organization is unable to implement play, then blaming both the philosophy that does not meet the professional contingent to provide care in Pediatrics, and the non-provision of material and recreational resources for using TP.

What is it that I think is missing in the hospital? Toys, they should provide those materials. It's us that buy some. They don't provide... There's no structure or policy here. I consider that all procedures are important, but there's no mobilization to have TP (ROTATE).

[...] it has to do with the institutions' problems, having a small proportion of nurses for the large demand of children. They prioritize other activities over TP (DIFFERENTIATE).

On the other hand, persevering in what they believe, a conviction that is based on their professional experiences and on published scientific evidence, nurses eventually stand out in their image through the use of this playful technology, so that they end up Receiving institutional support to use TP with children/adolescents. Therefore, under organizational support, nurses assert that TP becomes a common care resource for them, as it is already systematized in the hospital where they work, or when the coordination of the pediatric unit in which they work allows and encourages its use.

Then, kind of, I liked it, I believe, I was lucky to work in a hospital where this was included in the systematization of Nursing assistance [...] . Then this discourse, this policy that TP is a nurses' activity, it was something natural for me, because I went to a hospital where it was already implemented (REVEAL).

My coordinator knew that I had skills for TP and she bet some money on me. Now we have TP. There's also the factor that my institution is motivating, because my coordinator, from the beginning, always motivated me to apply TP, always opened the field for me, gave me opportunities in this regard (CARESS).

In this context, nurses gradually Interact with reactions of recognition after applying TP. They experience different situations regarding how children, families and Nursing colleagues show attitudes of recognition for the positive result of TP, either because of the parents' surprise with the child's behavioral change, or because of their emotion, being happy with the effect of this technology.

A three-year-old boy was on diagnostic investigation when we applied TP, for him to represent the hospitalization. Then a week went by and I met the mother, she said: -What did you do? Because my son was so much calmer! Because he only shouted before, only cried, only kicked, and now he's so calm! (REGISTER).

The mothers thanked a lot the collection I made that week. A child's mother thanked me, she took my hand and said: -You helped me a lot today! She has a girl that was diagnosed with Sickle-Cell Anemia at the age of one and a half years old; now she's seven (TAKE-CARE-OF).

With this, the image the family had about the nurse ends up being modified after applying TP, earning the reputation of a nurse that plays. The nurse is even awarded a prize for his work with TP, after being indicated by a child's mother. In addition, he begins to interact with surprise reactions from Nursing team colleagues due to the behavioral change that the children show after participating in the TP session he performed.

It’ s very important to think how a child changes their image about me from the moment I start playing with them (JOIN).

Then she [the mother] says: -You're the nurse that plays then? [...] That’ s right, other mothers already told me that this is a very good place for children! (LUMIAR).

I had a case in which I was honored, I was awarded a Nursing recognition prize thanks to a mother's report [...] . She said that her daughter was going through a bad phase, they had discovered leukemia; and the TP work that I had done with the daughter made the girl not think that she was in a hospital (CARESS).

The most picturesque thing is that you're identified [by the team] as the nurse that plays, the “ nurse that cares while playing” (DIFFERENTIATE).

With the reputation of a nurse that plays, she gradually becomes known not only among the mothers and the health team, who ask to use TP with other clients, but also among the children assisted, who very much appreciate her and request her presence, even complaining when they are not hospitalized in the unit where she works, justifying that it is “ Because she can play!” .

Another nurse asked him [child] : -You only want to come here because of the Auntie [nurse that plays] , don't you? He said: -No. It's because of everyone. But more for her. -But, why do you like her so much? -Ah!! Because she can play! (JOIN).

Another consequence of experiencing this process is that nurses that play gradually Feel gratified as a person and as a professional as a result of using TP, revealing themselves to be satisfied with this situation, both personally and professionally, identifying feelings in themselves manifested during the exercise of their role in the interaction with TP and by the benefit-return to the families and their children.

I believe that it's a really big satisfaction to be able to communicate with children through toys, because it’ s at that moment that I “ get inside” their world. I think that what helps me play is the will to have that positive interaction with a child, that start-up! (REVEAL).

The mother thanked me so much! And the child asking: -Auntie, you come back later?; you come back tomorrow? That’ s really cool, that affection, that bond they create with me. That’ s another thing that I think nurses are losing (TAKE-CARE-OF).

TP gave me professional fulfillment as a pediatric nurse. It's as if I said: -Mission accomplished today! That [the child's proactivity discharging the doll from the hospital] was very gratifying for me, I was emotionally shaken then. I remember that I hugged the child because that made me happy. I thought: -It's only too good that this child is going home happier! (ROTATE).

DISCUSSION

The theory elaborated in this study allowed understanding the nurses' performance, actions that are defined and redefined in defense of playful care and the incorporation of TP in their clinical practice with children, satisfactorily becoming “nurses that play!”.

Being a nurse that plays corroborates the concept of the “good nurse”, who, in order to meet a demand from a child, such as the need to play, makes use of their creativity, seeking playful strategies as a way to minimize stress from the hospital environment and alleviate children's/adolescents' distress 16, decisions that, in this study, proved to be mobilizing forces for nurses to use TP.

For the participants, having a playful attitude means responding not only to children's demands (the promotion of free play) but also accessing their essence; in other words, recognizing play as a therapeutic language and, through it, more easily accessing the children's universe, their wishes and pressing needs.

Being a “nurse that plays” and recognizing play as fundamental and essential to their role means being a sower of ludic interventions in health care and, therefore, by behaving in this way and using TP in their clinical practice, nurses perform, in our view, evidence-based care, whose results point to efficiency in their objectives. In particular, they meet what the literature has been highlighting for some time about the importance that playful activities, whether structured or not, should be prioritized in child care due to the beneficial potential for their health, as well as that of their family 17.

However, in addition to sowing seeds, nurses that play experience the effects of this playful interaction, which mobilizes feelings and senses. This is because, when new meanings are attributed to their role, they become chosen/selected by children and families, conferring them a sense of satisfaction, key to continuity in defense of this care. This harvest results in effective communication, creation of ties and bonds, trust, confidence and comfort 18, aspects that are also strongly highlighted in our research.

Bonding between nurse and child during TP sessions is an aspect highlighted in a study that sought to understand how the sessions take place. It points out that this result is only possible because, while playing, children watch nurses and gradually internalize the concept that these professionals are adults in whom they can trust to expose their thoughts, feelings, fears and emotions because they respect them, as well as their decisions 19.

In this study, sensitization towards sick and/or hospitalized children, who experience procedures that cause pain and therefore need to express themselves about and understand the care measures, proved to be a trigger for nurses to plan playful actions. These concerns mobilize scholars around the world, as the systematic review points out about the effectiveness of using playful programs involving TP on well-being and improvement in the health outcomes of children and, although they recommend it, the articles reiterate the need for studies with more robust methodological designs 20.

Other studies corroborate this, presenting similar results in the reduction of fear, anxiety and pain during the postoperative period of children undergoing surgeries 21^- 22, as well as a positive impact on emotions and behaviors with a reduction of anxiety and an expansion in the knowledge level on children's health 20.

Attention and care in listening to children about what they have to say, through playfulness, is a desired attitude of nurses when using TP. Qualitative studies have evidenced this high strategic potential of “conferring voice to children”, as expressed in a research study that, through DTP, sought to understand children's experiences while their mothers were in prison. From children's play, the tortuous path they experienced after conviction of their mothers was revealed, sometimes with sadness, distress and a tendency to early maturity, calling for the urgency of programs that advocate maintenance of the bond between mothers and children, who need to be and grow as dignified individuals with comprehensive care 23.

In addition to that, the relationship established between nurses and children in games makes it possible for the autonomy developed in children to emerge through freedom actions eased by the adults, providing answers with decision-making while playing because, when playing games with a doll, affirmation of their Self is favored by the manifestation of their desires, redefining themselves subjectively 24. Thus, through indirect expression in games, children become aware of affective percepts and problematic memories, self-promoting in the healing process 25.

Winnicot, an important play theorist, points out the need for children to participate in interactive play with their guardians from an early age 26^- 27, which corroborates with the SI theoretical concepts 11 since, when an adult, in this case a nurse that plays, interacts with a child through TP, this promotes the expansion of their “world view and actions”, as emphasized in this reference 11.

With TP, nurses take on the role of “stimulus-support person” in the process because, when playing, the very creative games of their initial life phase are evoked and enhanced before their clients, causing them to end up presenting themselves, becoming more confident and determined in their playful attitudes 26. Thus, the importance of rescuing nurses' playful experiences as students 28 makes them aware of the effective strategy for such training and the stimulus to rescue themselves as “playful people”.

Another feeling perceived in itself by nurses is “feeling surprised” when verifying the effect of TP on children's behaviors, which stems from their awareness of the potential action of TP on children they take care of while playing, in terms of feeling and cognition, that is, in feeling, thinking and acting 27.

Consequently, in their playful path, nurses feel gratified to be recognized as people that play, as they are moved by a feeling of compassionate empathy in their interaction with children. This consists in being sensitive to the feelings of others and their needs, as they have already experienced similar sensations, or knowing how to put themselves in the other's shoes, as everything nurses have and do at the TP moment for/by sick children is seeking to reduce their distress 29^, 30.

It is known that, although play is children's language, TP is still little included in the Pediatric Nursing language 28. Thus, we hope that, by exposing the “nurses’ voice” about their role in the application of TP as a Nursing care action, this study offers a significant contribution to knowledge advancement, especially in the field of teaching this care technology, revealing characteristics of their person, which can be enhanced during their education and in training processes, aiming to qualify Nursing care for children efficiently in any care setting.

We also emphasize that the model prepared is not a closed Theoretical Model, and that it can be expanded based on new research studies carried out with other actors in the child care universe, who interact with nurses in performing this action of playing through TP, as well as with other professionals and clients since, in this study, we were determined to know the meaning attributed to this process only by nurses who experience it consciously and fully.

CONCLUSION

This study allowed understanding that, when interacting playfully with children, nurses perceive and declare themselves as involved in several feelings, such as satisfaction or sense of responsibility and reciprocity, when empathically putting themselves in the place of the person to whom they should provide care, also offering them clarity about the situations resulting from the health-disease-hospitalization process.

It also revealed the qualities of a nurse that plays, defined as follows: an agent of changes, favoring moments of freedom to play and happiness for children/adolescents; an effective contact agent, easing communication between them; a professional who guarantees the necessary arrangements for using TP in the health institution; an agent that generates willpower and optimism, as they provide a healthy climate for the playful session to take place satisfactorily; and finally, a promoter and facilitator of the playful session, conducting it and, simultaneously, ensuring that children/adolescents are the protagonists and that they can play in the health care context.

ACKNOWLEDGMENT

The authors would like to thank the participating nurses for their time, for the rich exchange of diverse experiences and knowledge, and for the personal learning opportunity.

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NOTES

• ORIGIN OF THE ARTICLE

  Extracted from the thesis - Feeling gratified and fulfilled for promoting qualified and humanized assistance for children/adolescents through Therapeutic Play: Nurses attributing meaning to their role in this playful universe, presented at the Graduate Program of the Paulista Nursing School, Universidade Federal de São Paulo, in 2021

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Ethics Committee in Research of the Universidade Federal de São Paulo under Opinion No. 1,573/2017 and Certificate of Presentation for Ethical Appraisal No. 81597617.5.0000.5505.

Edited by

EDITORS

Associated Editors: Luciara Fabiane Sebold, Maria Lígia dos Reis Bellaguarda. Editor-in-chief: Elisiane Lorenzini

Publication Dates

• Publication in this collection
  28 July 2023
• Date of issue
  2023

History

• Received
  16 Mar 2023
• Accepted
  29 May 2023