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Revista Latino-Americana de Enfermagem

On-line version ISSN 1518-8345

Rev. Latino-Am. Enfermagem vol.15 no.2 Ribeirão Preto Mar./Apr. 2007

http://dx.doi.org/10.1590/S0104-11692007000200015 

ORIGINAL ARTICLE

 

Playing in the waiting room of an infant outpatient clinic from the perspective of children and their companions1

 

 

Iara Cristina da Silva PedroI ; Lucila Castanheira NascimentoII ; Livia Capelani PoletiIII ; Regina Aparecida Garcia de LimaIV ; Débora Falleiros de MelloV ; Flávia Mendonça Rosa LuizIII

IUndergraduate student
IIAdvisor, PhD Professor , email: lucila@eerp.usp.br
IIIVolunteer of the extension project
IVAssociate Professor, e-mail: limare@eerp.usp.br
VPhD Professor, e-mail: defmello@eerp.usp.br. University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Center for Nursing Research Development

 

 


ABSTRACT

Playing is one way children use to communicate with the world that surrounds them. This descriptive-exploratory study aimed to understand the experience of playing for children and their companions in an outpatient waiting room. We performed semi-structured interviews with 12 children and those responsible for them. In the data analysis, three themes were identified: waiting time: "there is no other way, you have to wait"; using the time to play: turning the clinic into a more pleasant space; and the toy as a relations mediator. Playing is revealed to be an effective pediatric nursing intervention strategy in helping the child to overcome barriers imposed by the assistance. This resource favors the communication process among children, companions and professionals and, thus, greatly contributes to improve the care delivery.

Descriptors: child; play and playthings; outpatient clinics, hospital; pediatric nursing


 

 

INTRODUCTION

In general, children suffer from great changes in the environment, and arriving in hospital undoubtedly creates stress and fear. Whether for hospitalization or outpatient care, this activity demands that they establish new relations with other persons and with themselves, besides constant adaptations. Children in general and preschool children in particular face difficulties to deal with the unknown and, when exposed to situations of fear, they become insecure and anxious(1). To minimize these feelings, they seek help from people they trust, in this case their relatives. However, these do not always manage to attend to this demand, as they also feel threatened and unprotected due to being in a strange environment, in this case the hospital.

In the hospital, the children experience health service routines at the same time as their spontaneous development process(2). Therefore, health professionals should make efforts to avoid this experience from being traumatic or a possible cause of interruptions in this process, as well as to humanize care delivery. The goals of treatment should not be restricted to saving lives and curing diseases, but also to preventing sequelae and, in parallel, to stimulating neuropsychomotor and cognitive development, in a way that is adequate to health restoration and promotion, in a broader perspective. Thus, creative strategies like toys should be used to minimize the effects of hospitalization(3) and other outpatient care, as well as to help the child to overcome adversities. Moreover, playing can be seen as a resource capable of strengthening relations and narrowing human contact between health professionals and users, as proposed by one of the guiding axes of the National Care and Management Humanization Policy of the Single Health System implanted by the Ministry of Health in Brazil(4).

Through the toy, children start their self-knowledge and interact, primarily with the world that surrounds them, which makes them discover the different possibilities it offers; later, they interact with other people. In play, they relate with their circumstance and the moment experienced in a specific context(5). Moreover, handling toys releases fears, tensions, anxiety and frustration; promotes satisfaction, diversion and spontaneity(6-7). Hence, in playing, children exercise their potentialities and can relive circumstances that caused them great excitation and joy, some anxiety, fear or anger. In this magical and relaxed situation, they can express and work with different emotions. This duality between the real and the imaginary allows the children, in case of hospitalization(6) or outpatient care, to overcome their passive role and assume an active performance in their treatment. When we make room for children to make their choices and show what they like and know, they become an agent in their transformation(2).

Guided by the functions of playing as a resource to promote child development and to contribute to the rescue and strengthening of the humanization process, particularly looking at the child's interaction with the toy in the outpatient context, we organized and implemented a nursing intervention project that uses recreational activities as a technology for care delivery to children in an outpatient waiting room of a university hospital. This research aims to understand the experience of playing, from the perspective of children and their companions, after having participated in the activities of this intervention project. In this study, we justify the focus on playing in the outpatient context, as most research reported in literature(2, 6-13) refers to the use of this resource in hospitalization situations only. However, care delivery to children in outpatient clinics should also incorporate interventions that value humanization and the child development process.

 

METHODOLOGICAL COURSE

This is a descriptive-exploratory study(14). Due to the study's object and objectives, it is supported by the premises of the qualitative approach. It was carried out at the Pediatric Outpatient Clinic of the University of São Paulo at Ribeirão Preto Medical School Hospital das Clínicas (HCFMRP-USP), at the unit located on the university campus. As it involved human beings, the research project was submitted to ethical review and follow-up and approved by the Ethics Committee of the study institution.

Study participants were twelve children waiting for outpatient care together with their twelve companions: one uncle, one grandmother, one father and the rest mothers. To select the participants, we established the following inclusion criteria: children who participated in the extension project* "Playing/toys in the waiting room of an infant outpatient clinic", carried out at the outpatient clinic of the study institution; children aged seven or older, as they have verbal communication skills at this age and are able to understand and express their feelings orally, in function of the development stage they are in(15). This extension project has been implemented by undergraduate students since May 2003.

Initially, we explored the study site to get acquainted with the children and their companions and to participate with the group of students who have developed the extension project at the clinic. This activity routine occurs three times per week, during the interval before the afternoon care period.

Data were collected from July 2004 to January 2005. During the meeting with the children and their companions, the researchers read the "Free and Informed Consent Term" and, after clarifying doubts, handed it over to the person responsible for the child, who agreed to participate. The goal of the research was carefully explained to the children and their responsibles. On this occasion, the researchers guaranteed the anonymity and secrecy of the collected information. Moreover, they guaranteed the right to participate or not without impairing care delivery in any way. Next, the responsible and child were asked to sign the term and received a copy. On the same occasion, permission was asked to record the interview.

Semistructured interviews were used to collect empirical data. For this activity, we elaborated two instruments, one applied to the child and another to the companion, at different moments, inside the outpatient clinic, before or after care delivery, in accordance with the participants' availability. To complement the interviews, we also used a field diary where we recorded observations and impressions for each meeting, with special attention to the children's and their responsibles' non-verbal communication, such as pauses, posture, expression and interactions with other persons and the environment.

As we were already involved in the process of developing the activities related to the extension project, at first, we used this strategy as an approach and warm-up resource to hold the interviews. This activity allowed us to participate in the playing and observe the children's behavior; interactions with the toys, with the researchers and with other children; talking and silence. These factors enriched data and were registered at the end of each meeting, so as not to lose details.

Next, that is, when the child returned to the outpatient service, we interviewed the companion and the child, oriented by guiding questions that helped to keep the conversation centered on the study goals. To the companions, we asked "What would you like to tell me about the time you and your child spent waiting to receive medical care at the outpatient clinic?" and "Do you perceive any difference in your child's behavior when he plays at the outpatient clinic before care delivery?" With the children, the question that started the conversation was "What would you like to tell me about the time we spent together at the outpatient clinic before you received medical care?" It should be added that, at this second data collection moment, the recreational activities of the extension project took place normally, so that the children could participate in the games while their responsibles were being interviewed, and were only interviewed at the end of their activities. In general, we only interviewed each child and each responsible once. However, on certain occasions, we felt the need to return to the study field and complement some information certain children and/or companions had given as, during the first analysis, new reflections arose that needed to be looked at more in depth or doubts that needed to be clarified.

The interviews were transcribed soon after they had ended so as not to lose valuable details for analysis. For the transcription process, we adopted the criterion of preserving the participants' statements; although we made some corrections, these did not change the contents of the phrases and preserved the message. Codes C1, C2, C3 up to C12 were used to identify the children and A1, A2, A3 up to A12 for the accompanying persons, with a view to maintaining the research subjects' anonymity.

In the analysis, we systematically organized the empirical data collected in the interviews and, after exhaustive reading, we classified the subjects' statements in groups, according to the similarities we found(14). After this phase, data were categorized and separated in three themes, which allowed us to understand the experience of playing for children who await outpatient care in the waiting room as well as for their companions. In the presentation of statements selected to illustrate the themes, we used the following standardization: parentheses (...) indicated cuts inside the same statement and information between square brackets [ ] referred to important observations, which contextualized the statements or expressed the participants' non-verbal behaviors.

 

RESULTS

The qualitative data analysis process allowed for the identification of three themes, around which we organized the empirical material: waiting time: "there's no other way, you have to wait"; using the opportunity to play: turning the outpatient clinic into a pleasant space and, finally, the toy as a mediator in relations. Next, we will present the theme areas.

Waiting time: "there's no other way, you have to wait"

The study results evidenced that the waiting time, during which the children and their companions awaited for outpatient medical care, was a factor that caused situations, most of which were hard to manage for both. In the children, waiting caused anxiety, agitation/restlessness, nervousness, impatience, crying, irritation, aggressiveness and tiredness. However, these repercussions went beyond the situations experienced in the waiting room because, when they felt the need to return to the outpatient clinic for new medical care, they declared that they did not feel motivated to do this, as shown by the following statements:

Ah, there's nothing to do, you have to sit there and wait for the doctor. That's irritating, you know? (C2).

When I come here and when you come, we even forget. When you come, time goes by faster and, when you don't, time goes by slower. It goes slow, then there's a problem, right? Then it goes slow, we get bored. (...) Sitting down and waiting, we get tired, hungry and there's no way you can keep sitting. Your legs, your back hurt, then, playing, it gets much better (C7).

(...) Sometimes I'm tired and I don't want to come (C1).

Moreover, the children seemed to have the feeling of being stuck at the clinic, without being able to explore this constantly changing environment. They frequently revealed the desire to their companions to go home or explore other spaces, as illustrated by the statements below:

He likes to walk around. The last time I came, the doctor called him, I couldn't find him. He didn't go in to the doctor's office. Then I talked to the doctor and she let me go. I couldn't find him in the hospital. Today, I told him not to walk, but then there are the games (...) He doesn't like to sit still! (A11).

She's agitated. She doesn't like to sit still in one single place. Because she wants to walk all over: wants to go to the bathroom, drink water, leave. And she can't (A13).

If she had to sit still, she's impatient, then she would ask to leave. She was restless just now, then she saw you there in the back, and said "mom, I'm gonna play" (A9).

Oh dear, I want to leave soon [from the appointment, when he doesn't play before]. I turn into something, something bad, because I don't want to stay here [at the clinic] (C5).

For the companions, the developments related to waiting time were also present, although in another dimension. Besides manifesting dissatisfaction about the long period they awaited care, the companions showed their involvement in the task of trying to contain the children, or at least minimizing the situation, staying constantly alert. In this sense, they reported:

Ah, waiting is not easy, no matter what you're going to do. It's not easy to wait, but you have to wait, what are you going to do? So there's no other way. Sometimes I come here and it's past five o'clock when I leave. Sometimes, everybody has already been attended there, in the other sectors and they leave. And sometimes I'm the last, you know? But there's no other way. I can't leave without the appointment, because that's what I came for, right? (A6).

(...) Sometimes, with other children, he gets aggressive, like, you have to be more careful to look after him, right? (A4).

According to the companions, other factors contributed to turn their stay at the clinic even more unpleasant, such as: heat; noise; financial problems, due to food expenses while at the hospital and difficulties to have the child await care. Besides these factors, they mentioned difficulties to leave the waiting room, even to attend to basic needs, either because they did not feel secure to leave their children unattended or because they feared not being present when they were called to start the appointment.

Sometimes it was really hard to keep him quiet, for him to be quiet and wait for his turn. He gets impatient. (...) Now, I think that what's kind of bad is this financial thing. Because we have to bring all kinds of things, and for him even more, because if he wants to eat things, you always have to choose to see what he can eat [the child was allergic to different kinds of food]. But also, before, it was difficult to go to the bathroom, because I left him alone. Not now, because he's much bigger, right? But that's one difficulty I had before. And this heat, right? (A1).

There's a lot of noise! It's impossible here [to watch TV] (A13).

Based on the above examples, we observe that the origin of the problems both the children and the companions experience is the long waiting time. The waiting time to be attended varies and there are no prescheduled appointments, that is, all children are scheduled for one single time.

Using the opportunity to play: turning the hospital into a pleasant space

The waiting time for the outpatient appointment presented different meanings for the children and companions. It could represent an eternity, something far from over, due to the absence of games, or the feeling that hours passed like seconds, when they participated in the recreational activities the extension project offered. In this respect, the participants gave detailed examples of this difference:

It's hard [without the games], because there's nothing for us to have fun and spend time. Sometimes, I bring a story book, but sometimes I forget, and that's bad (C6).

It's because when we come here [participate in the games], time goes by faster. We play and do not even see time go by. The doctor calls, we don't even have to stop playing. Then he keeps yelling here. And something else, when you sit down, your head starts to hurt. So, when you make drawings, you don't even see anything (C7).

When she's playing, she's quiet. When she's sitting, she gets nervous. She talks about the delay, wants to leave. When she's playing you can leave her here until tomorrow. Then she's in no hurry (A10).

(...) [When she's playing] she gets calm, she keeps quiet, she knows how to wait for the doctor. It doesn't matter! It doesn't matter for her if the doctor calls today or not, it's just fine (A3).

I notice, like, that, when she's playing she gets quiet and when there's nothing to do she gets in a bad mood, she's got a terrible bad mood, she gets annoyed. Then her face is closed, there's nothing for her to do (A12).

The companions also mentioned the repercussions of offering games in the waiting room when they described that the recreational activities turned them more relaxed, calmer and less tense. Holding these activities in the waiting room, that is, in the same environment where the companions were, was indicated as positive, as it contributed to increase the companions' security, to the extent that they saw that their children were being "looked after", however, without losing their roles as caregivers and protectors; observing them at a distance, they were always ready whenever necessary.

While there are these games, for example, it's important because he stays, like, we relax, relax our head, sit down, calmer. Then he plays and we see it at a distance, if everything's OK (A4).

(...) because if he's playing there, we're here too, relaxed. We may even doze off a bit (A7).

(...) but just the fact of me being here, without concern about her, that she's playing there, it's so good, right? Otherwise she'd be crying and asking to leave. You stay still for a long time, right? So that's very good (A8).

At the same time as the children and their companions acknowledge the benefits the games provide, they are also aware that the resource is not always available, as the extension project activities are developed at preset times. Hence, many times, children and companions use their own means to handle the waiting, with the available resources: they watch TV; talk to other people; do crochet; find distraction through magazines, books, crosswords and toys they bring from their homes, and some children pass their time by listening to songs on their walkman.

Sometimes I do embroidery, sometimes I do crochet, sometimes I don't do anything. We do not always bring something, right? So, it's like, we wait like this, without actually doing anything (A6).

[When there are no games] I play with my sister. If I come alone with my mother, then I bring something, some book for me to read. Just today I didn't bring anything (...) (C11).

The participants mentioned other activities volunteers develop at the clinic and, after they experienced them, they demonstrated that they acknowledged their important as a differentiated care form. One of the children who participated in the research illustrated how the involvement with games could relax the environment and could even make her forget why she was at the hospital. There were toys everywhere. In this respect, she mentioned:

Ah, I liked it when there was this park, because then I came and there were so many toys and games. When those clowns came too. Then it was a lot better. Then we arrived here, the doctor yelled in our ears, we didn't even listen. There were toys everywhere. Then it was better (C7).

The toy as a mediator in relations

Data analysis evidenced that the companions perceived that, when the children participated in the recreational activities before the doctor's appointment, their willingness to start receiving care was different. When used to provide a relaxed and happy environment, the waiting time minimizes the negative feelings both children and companions experience, and gives room to establish harmonious relations between them and health professionals. Consequently, interaction among the people who make up these distinct worlds child, companion and professionals is facilitated by the opportunity of an open dialogue, which goes beyond information transmission, in the search for effective communication. The companions' statements illustrate this benefit:

With the games, he's more of the doctor's friend. He's already more relaxed when he arrives (A1).

Here, it seems that they're treating us like we're really part of the family. It makes, makes [a difference to be treated like this] for the child and for the parents, because the child feels more at ease, has the freedom to play with the doctor. So it really makes a difference (A7).

The report about the companions' observations with respect to the children's positive behavior during the doctor's appointment, after they had participated in the extension project activities, and also the children's opinions demonstrated that they valued the use of strategies to "break the ice" and facilitate communication during the appointment. The children and companions revealed that they prefer care delivered by health professionals who try to establish relations with both, who go beyond the care act in itself or the reason why they are at the outpatient clinic. Perceiving that the professional is open to dialogue and cares about the child and companion seems to serve as a parameter to assess the quality of the care they receive. In this respect, we transcribed the extracts that highlight the professionals' qualities, in accordance with the children's and companions' preferences:

(...) I prefer playful ones, because it's nicer. They do games, ask, ask how I am doing, if I'm there just to see girls. She [the doctor] played, she liked to talk to me. The male doctors don't play, they ask some things and that's all. (C1).

(...) C1 liked her [a doctor] a lot. She left. She used to play with him a lot. She used to see him from outside [in the waiting room] and said that her cute boy was coming. It were these kinds of things, compliments to him. Some doctors are really like that, more quiet, they don't like to play, but they're nice. But I prefer the more playful ones! Then the child feels more at ease. The appointment gets different (A1).

Ah, [I prefer] those who play more, leave the child more at ease. The children get more at ease, even we, like, to talk. If there's a doctor with a kind of bad, closed face, we're even afraid of talking, even ashamed of talking to the doctor (A7).

The companions' opportunity to observe the children, during the extension project activities, allowed them to reflect on the possibility of expanding the use of toys to other hospital spaces. The companions acknowledged that children would be more accessible to health professionals if games were used to mediate the interaction between these two worlds. They exemplified that, through games, the children's natural language, it would be easier to approach them, mainly when certain invasive procedures are carried out, such as venipuncture for blood collection. Companion A1's report illustrates the importance of the professionals' abilities to develop the work with children and the benefits of introducing toys beyond the outpatient clinic. In this sense, she reported that:

He's afraid [of taking blood]. His body gets stiff like this. Ah, I try to calm him down, that it's just a prick, right? That it's gonna be over soon. That's what I tell him. Then, he ends up losing the fear and letting them take blood. The one-but-last time he came to take blood there was a boy who came like, that he [the child] cried and he was impatient with him. I thought that was, like, that he's a child and is scared. There is no way to do it, even we adults are [scared]. Then the boy told him to stop crying and be quiet, because he had to relax, or they couldn't take the blood. Then it even turned blue and hurt him a lot that day (...) I didn't like that! I think they should put some people playing for blood collection. That would be much better! I think the children would like it more (A1).

 

DISCUSSION

Playing is one of the forms through which the child can communicate with the surrounding world. Countless studies(2,6-13) have focused on the promotion of playing and toys as a therapeutic resource, and it can be an instrument to facilitate the integrality of care, treatment adherence, maintaining the child's rights(7) and establishing more appropriate communication channels(7,16). As the organization of child health care should contemplate different scenarios, in this study, we attempted to look at children in an outpatient waiting room.

In understanding children's experience in recreational activities implemented in an extension project, from the perspectives of these children and their companions, waiting time revealed to be an important factor that can interfere in the quality of the delivered care. The children's dissatisfaction is evident, who mostly find themselves impeded from exploring new spaces and exercising what is characteristic of their age, which is playing. Demanding that children remain seated waiting for care is asking something that may often go beyond their chronological age. Thus, they may feel discouraged for future visits to the service, which would exert a negative effect on the interaction between professionals, children and companions and impair care quality itself.

The dissatisfaction the companions manifested reveals feelings of impotence and, often, lack of control of the situation, naturally changing their responsibilities as caregivers. These events cause effects that make it difficult for the children as well as the companions to stay at the clinic. Consequently, this physical and emotional exhaustion can interfere in the companions' and the children's willingness when establishing effective communication with health professionals. Hence, the main goal of these subjects' visit to the clinic is no longer the child's health. Instead, what prevails is their desire for care to end. That is the only way for them to get rid of that situation.

The long waiting time has been considered a dehumanizing aspect in health services for decades as, among other inconveniences interfering in their rights, in the patient's singularity and integrality, it also has a negative influence on their comfort and well-being(17). In this sense, projects valuing the communication process and the better welcoming of users inside the services, such as the introduction of playing/toys in the outpatient waiting room, qualify the delivered care.

In the attempt to transform this whole scenario, games emerge as a resource that helps children and their companions to overcome the inconveniences and make better use of the period during which they wait for their doctor's appointment, turning their stay at the clinic more pleasant and less tense. In this sense, the time they spent in this environment became more pleasant and relaxed, leading to changes in the children's behavior, such as decreased anxiety and demonstration of joy and good mood, besides acting as a facilitator for interaction and communication among health professionals, children and their companions. Hence, the play starts to be considered as a possibility to gain or construct something positive at a time of losses(7) or also, indirectly, to grant companions the benefit of feeling supported and "cared for" in an environment that, in itself, represents a threat to their protective role.

Through playing, a language that children master, they relate with others and, therefore, it is natural for them to express themselves through these symbols, and they prefer the world to act in the same way. A study carried out in Finland, involving 20 preschool and 20 school children and aimed at examining these children's expectations about the quality of care delivery by pediatric nurses, showed that they expected the nurses to be human, reliable, happy, fun and with a sense of humor. It also showed that these professionals should create awareness about the importance of toys and use them more frequently when giving instructions to children or when informing them about treatments and care(9). This study presents evidence that the child acknowledges and values professionals who use games as a resource to get closer to them and address them.

The assessment of the experience of introducing recreational activities for children in an outpatient waiting room, according to the children and their companions, entailed direct positive repercussions for the children and indirectly for the companions. Moreover, although that was not the focus of this study, we perceived that some professionals' attitude when interacting with children can be influenced by involving them in recreational activities in the waiting room. In other words, professionals observing the child playing before the appointment can make use of the "contamination of the climate" to use this same resource, in due time, to modify the quality of the delivered care. The different ways of getting close to a child: in a playful way, talking, stimulating them to perform recreational activities, offering them objects, among others, are legitimate forms of games(13).

 

IMPLICATIONS FOR NURSING

Playing/toys can be used to help the children to expand its capacity of relating with the external reality, establishing a bridge between their own world and the hospital world. In playing, children modify the environment in the waiting room and bring it closer to their daily reality, which may be a positive strategy to cope with the situation they are experiencing. The activities related to playing/toys are resources that value the development process of children and their well-being.

Successful experiences in using playing/toys support the implementation of this kind of interventions by pediatric nursing, including in the outpatient context. Moreover, considering that this should not be an exclusive nursing practice, other health professionals, in partnership, can contribute to improve care delivery to this clientele. In addition, future studies should look at the impact of using playing/toys in situations involving child care, in disease and health circumstances, from health professionals' perspective.

In this new scenario, the act of playing constitutes a viable and adequate resource for the pediatric nursing team. However, it is essential for the team to know the benefits of this strategy and advance in the construction of intuitive knowledge, guided by daily practice, towards another conceptual level, at which the systematization of nursing care, the incorporation of research results and reflections on the child's singularity and the care context are taken into account.

 

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Recebido em: 24.11.2005
Aprovado em: 29.5.2006

 

1 Study extracted from project inserted in the Group of studies in Children and Adolescent Health, University of São Paulo at Ribeirão Preto College of Nursing WHO Collaborating Center Nursing Research Development
* Poleti LC, Nascimento LC, Pedro ICS, Gomes TPS, Luís FMR. Recreação para crianças em sala de espera de um ambulatório infantil. Rev Bras Enfermagem 2005 [enviado para apreciação em fevereiro de 2005]

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