The Voices of the Teachers in the Hospital Pedagogy: Unveiling Possibilities and Confrontations

ABSTRACT

This research seeks to deepen knowledge on the pedagogical education process in a hospital environment, in the teacher’s enactment, considering the specificities of children in healthcare treatment, in the city of Palmas, state of Tocantins, Brazil. This investigation was developed from a descriptive qualitative approach. As methodological strategy, a case study was used; and as a data collection technique, a semi-structured interview. In its development, the research was built giving voice to the teachers, following a path that covered issues related to the regulation of the health care system and teaching practice for the educational service to the children in hospital treatment. The results show that hospital education offers different educational possibilities for these children. In the research field, the existence of a toy library was identified, which, in its dynamics, allows to develop ludic-therapeutic actions, contributing to soften the suffering, reducing anxiety and raise the self-esteem of the children and their families. It was also noticed the importance of thinking about the implementation of hospital classes, a legal right, but not yet effective in the researched context. When knowing the hospital pedagogical process, it was also possible to observe the need for strengthening the bonds between hospital and school experiences, seeking to give children, in treatment, access to the typical activities of childhood.

KEYWORDS:
Education and health; Teaching practice; Toy library; Possibilities and confrontations

RESUMO

Esta pesquisa busca conhecer o processo pedagógico educacional em um ambiente hospitalar, na atuação das professoras, considerando as especificidades de crianças em tratamento de saúde, na cidade de Palmas, estado do Tocantins, Brasil. A investigação desenvolveu-se a partir da abordagem qualitativa de cunho descritivo. Como estratégia metodológica, utilizou-se o estudo de caso; e, como técnica de coleta de dados, a entrevista semiestruturada. No desenvolvimento, a pesquisa foi construída dando voz às professoras, em um caminhar que perpassou questões relativas à regulamentação e à prática docente para o atendimento educacional à criança hospitalizada. Os resultados obtidos demonstram que a educação hospitalar oferece diferentes possibilidades educativas para o atendimento a essa criança. No campo de pesquisa, identificou-se a existência da brinquedoteca, que, em sua dinâmica, possibilita desenvolver ações ludoterapêuticas, contribuindo para amenizar o sofrimento, diminuir a ansiedade e elevar a autoestima da criança e seus familiares. Percebeu-se, ainda, a importância de pensar sobre a implantação das classes hospitalares, um direito legal, mas ainda não efetivado no contexto pesquisado. Ao conhecer o processo pedagógico hospitalar também foi possível observar a necessidade de aproximação do hospital com as experiências escolares, buscando oportunizar para as crianças em tratamento o acesso às atividades típicas da infância.

PALAVRAS-CHAVE:
Educação e saúde; Prática docente; Brinquedoteca; Possibilidades e enfrentamentos

1 Introduction

Experiencing the hospital context with a focus on children in health care raises questions that concern the rights amassed to childhood over the years. Questions about disease and health, life and death, as well as about the right to education. In this process, reflections about childhood and illness are drawn upon, as well as concerns about educational pedagogical care in the context of the hospital.

The child, even hospitalized, maintains the will to be active and to live experiences common to his/her age group, a situation that is sometimes modified during hospitalization. The will is restrained and the typical childhood choices are exposed in the face of the limitations imposed by the treatment conditions.

In this direction, when we think about the child in health treatment, we see the need to consider his/her growth and development in a set of specific needs that correspond to each phase of life. The child, when entering the hospital, brings with him/her a constitution permeated by the socio-cultural experiences developed through his/her intersubjective relations.

Thus, the hospital space is a challenging environment for health restoration, but it is also a place for the development of childhood when we treat the child in hospital. To think about the child development of hospitalized children is to emphasize hospital pedagogy, an activity that opens space for a differentiated education to children who are away from school due to illness.

Locating the Hospital Pedagogy as fundamental for the development of the hospitalized child reveals a person of great importance: the teacher. It is about a professional who in the exercise of his/her activity, when enacting in the context of the hospital, will be moved from his/her routine space, the school, to an environment in which illness, pain and death are present. The teacher will be faced with the diversity of contradictory factors that involve the child in treatment, experiencing in his/her teaching the restrictions imposed by diagnosis and treatment, but also he/she will find possibilities in the opportunity of the child’s teaching and learning.

In this perspective, the hospital pedagogy is developed as a movement towards an education that serves the children away from the school context due to the disease. A walk that questions the work of the teachers seeking to recognize the context of the illness and to understand the dynamics developed in this process. It is about teaching practice that goes beyond the formal school environment.

2 Methodology

When thinking about hospital education as a continuity and promotion of the student’s development in the health treatment phase, we were guided by the objective of knowing, through the teachers’ voice, the pedagogical educational process in a public hospital environment in the city of Palmas-Tocantins, Brazil, about the performance of the teachers, considering the specificities of children in health care.

In order to understand this reality, we defined as specific objectives: to understand the historical path of institutionalization of hospital education; to know the educational proposal for the student in health treatment in a public hospital environment in the city of Palmas-Tocantins; and to identify the contributions and the confrontations experienced by the teachers in the hospital educational service, considering the specificities of children in health care.

So as to reach the objectives of this research, we opted for the qualitative approach, a path that cares about the process, allows the understanding of the meanings and interpretations of the social phenomena and allows the perception of simultaneity and the interactions between the researched elements.

As a methodological strategy, we adopted the case study, which is a methodological process that will discover and indicate the theoretical supports of the study, and will clearly define the dimensions and perspectives presented by the problem (Triviños, 2006). The case study is a strategy that aims to understand complex social phenomena (Yin, 2010), in order to understand the meanings of real-life events within the individual cycle, and the behaviors of small groups.

From this perspective, we seek to understand the hospital environment considering its educational interfaces in the face of the challenges in the work of the teachers, as well as the possibilities and the confrontations in favor of the health of the child in treatment, in an approximation with the teaching-learning process.

2.1 Research stages

To reach our goal, the research was developed in stages. The first one had as its starting point the bibliographic review. The phase in which the approach and the delimitation of the theme were delineated and the objectives defined. The second stage advanced through the bibliographical and documentary studies, in order to understand the historical course of institutionalization of hospital pedagogy and the context of teaching in the space of the hospital.

According to Gil (1999), such a journey enables the researcher to cover a much broader range of the phenomena than he could research directly. In what specifically corresponds to the contributions of documentary research, Yin (2010) states that the most important use of documents is to corroborate and increase evidence from other sources. At that time, it was also possible to define the field research and the technique for data collection, participant institution, teachers and implementation schedule. A moment at which the research was submitted and approved by the ethics committee, an activity that supported the next stage of the study.

The third stage constituted a time for data collection and analysis. For the delimitation of the participants of the research, two criteria were adopted: training for teaching and developing pedagogical activity in the context of the hospital. For data collection, we used the semi-structured interview, which, according to Lakatos (2003), is an encounter between two people, so that one of them can obtain information about a certain subject through a conversation of a professional nature. It is a walk in partnership that has as direction the goal previously outlined. The interviews were recorded and transcribed, when the analyzes began to be developed. We also emphasize that the analyzes did not follow certain sequences, since they are interrelated, generating new questions and the need to resume data collection (Triviños, 2006).

2.2 Research space and participants: the outline

The field research was carried out in a public children’s hospital in the city of Palmas, capital of Tocantins, considering the provision of hospital educational services for children under treatment, as well as the teachers’ enactment in this context. The delimitation of the hospital was based on the survey of all the hospitals in the city of Palmas that catered to children and had, in their team, the education professional.

The hospital that met the research parameters was created in 2010, after the pediatrics activity was separated from the city’s Maternity Hospital. With a modest physical structure, the hospital provides a total of 51 beds for hospitalization, leaving the space for educational activity restricted to bedside service and the environment of the toy library that has approximately an area of 20 m².

The playroom space has open and closed cabinets, children’s tables and chairs, serum supports, a television, plastic boxes for toys that must be sterilized. Among the materials for school activities, we highlight: children’s films, books, comic books, folders with different coloring pictures and activities (made by the teachers), various toys, rubber mats and many pencils for writing or coloring. The hospital’s target population is, according to Souza (2016): Children aged 0 to 11 years and 11 months, from 139 municipalities in the State, as well as neighboring states such as Mato Grosso, Pará and Maranhão. Among the specificities treated in the hospital, the ones with the highest incidence are pediatric surgery, neurology, nephrology, hematology, dermatology, pneumology, orthopedic surgery, endocrinology, gastroenterology, inflammatory polyarthropathies, polyneuropathies, sickle-cell disease, diabetes mellitus, classic dengue, bacterial diseases, pulmonary cystic fibrosis and haemophilia.

The care of the children is done by the doctors and nurses in partnership with the multiprofessional team that involves psychologists, physiotherapists, occupational therapists, pedagogues, social workers, nutritionists and speech therapists.

To enter the space of the hospital, we had the research approved by the area of health and education. Contact with the teachers followed the guidelines of the Ethics Committee, and the interviews occurred only after reading the Free and Informed Consent Form, which was explained in detail in order to give the subjects the opportunity to know the research objective and to resolve any doubts. After that, the teachers who agreed to carry out the research and signed the terms, were further clarified about the freedom to withdraw at any time.

2.2.1 Moment of interview

The meetings for the interviews were defined according to the availability and scale of the work of the teachers, being recorded individually, transcribed, analyzed and approved by the teachers. The subjects who volunteered to participate in the research were two teachers who worked in the space of the toy library and developed, together with the multiprofessional team, pedagogical activities for children in health care.

To preserve the interviewees identities, we chose to designate fictional names in a way that made it possible to differentiate the subjects without revealing who they were; action also used for the research institution. Female names were assigned to the respondents because they were both women. In this case, the subjects were denominated Atena and Métis, and the space investigated was called Quíron Public Children Hospital

The initial moment of the interview was preceded by the visit to the spaces of the hospital and the presentation of the research to the multiprofessionals that composed the team of the toy library. At this stage, the documents that contain the basic guidelines for measures to protect the safety of health service workers were provided by the coordinator of the toy library in order to adjust the research activities. In this context, the interviews were initiated in movements that were interrelated to the documentary and theoretical studies in search of the objectives intended with this research, which will be discussed below.

3 Results and discussions

This section is divided into three parts: Hospital education: construction of rights; Between hospitals and schools: hospital pedagogy; and Unveiling the context: voices that echo.

3.1 Hospital education: construction of rights

Reflecting on hospital education involves concerns about the child and their development in order to recognize full rights to health and education. Proposals that consider compliance with laws that ensure care in the hospital and school context.

Understanding hospital education involves questions about the possibilities of the learner experiencing the disease situation to continue the educational process in line with the age group and school stage, even in hospitalization. This movement goes through the recognition that the child is a subject of rights and, even hospitalized, maintains the need to live experiences common to his/her age, such as playing and studying.

Recognizing the child’s right to development and school learning, even in a situation of infirmity, is construction outlined over the years; a process of conquests that is gradually taking place in search of the full development of the child.

The first actions in the direction of the maintenance of the rights of the children in situation of illness that we have registry are related to the creation of the Centro Nacional de Estudos e de Formação para a Infância Inadaptada4 [CNEFEI], in the city of Suresnes, France, for children with physical specificities. It was set up in 1939 with the objective of providing training to teachers in order to work in special institutes and hospitals. In that same year, the position of hospital teacher was created, through the Ministry of Education of France (Oliveira, 2013).

In Brazil, the first official initiatives were registered in 1950, with the creation of the Jesus hospital class, in Rio de Janeiro (Fonseca, 1999), followed by, according to Souza (2016), the Santa Casa de Misericórdia, created in 1953, in São Paulo. In the 1960’s, the hospital class was officialized at the Barata Ribeiro Hospital, with only the support of the management of Santa Casa de Misericórdia. Only in the 1980’s did the hospital education advance more expressively to the South and Midwest of Brazil.

As for the legal norms regarding the educational right of the person in health treatment, we have as reference the Decree nº 1,044 (1969): Art. 1 - Students of any level of education are considered worthy of exceptional treatment when they present congenital or acquired conditions, infections, trauma or other morbid conditions, determining acute or exacerbated disorders, characterized by: a) relative physical incapacity, incompatible with attendance at school; provided that the intellectual and emotional conditions necessary for the continuation of school activity in new ways are preserved; b) isolated or sporadic occurrence; c) duration not exceeding the maximum permissible, in each case, for the continuity of the pedagogical process of learning, given that such characteristics are found, among others, in cases of hemorrhagic syndromes (such as hemophilia), asthma, cartids, pericarditis, osteoarticular conditions submitted to orthopedic corrections, acute or subacute nephropathies, rheumatic conditions, etc. Art. 2 - To assign to these students, as compensation of the absence to classes, homework with accompaniment of the school, whenever compatible with their state of health and the possibilities of the establishment.

The right of all to education is reinforced by strengthening the movement to recognize hospital education as the right of children in situation of illness. Right highlighted in Title VIII - Social order, Chapter III - Education, Culture and Sport, Section I of 1988 Federal Constitution: Art. 205. Education is a right for all and the duty of the state and the family, it will be promoted and encouraged with the collaboration of society, aiming at the full development of the person, his/her preparation for the exercise of citizenship and his/her qualification for work (Constituição Federal, 1988). However, the non-regulation of specific legislation has contributed to the implementation of school-based procedures in the context of hospitals being weakened, and the child who was hospitalized remained excluded from the school process and his/her educational rights restricted.

Faced with a gradual process of recognition of the educational rights of these children, in 1994, a document that guided the hospital education was issued, ensuring a hospital environment that enables the educational attendance of hospitalized children and youngsters who need special education and are in hospital treatment (Política Nacional de Educação Especial, 1994 ⁵). This document gains space with the inclusion of Special Education as a principle of equality of conditions based on the Lei de Diretrizes e Bases da Educação - National Education Guidelines and Framework Law - Law 9,394, of December 20, 1996, advancing with the guarantee of three basic principles: right to education; impossibility of observing the minimum attendance limits to school due to unfavorable health conditions; and admissibility of adopting an exceptional regime of care for the student, according to Opinion No. 06 (1998). Thus, with the recognition of educational rights even in a situation of illness, the barriers that separate and the spaces of health and disease are sketching a new outline.

This understanding gains another outline with the publication of the Ministry of Education in 2002, entitled “Classe Hospitalar e Atendimento Pedagógico Domiciliar: estratégias e orientações” (2002) ⁶. In this document, the hospitalized child must have guaranteed the continuity of their educational development, either in the circumstance of hospitalization or attendance in hospital-day and hospital-week, or at home, or even in outpatient care. According to the document, hospital educational services and home educational services should be linked to educational systems as a unit of pedagogical work of the State, Federal District and Municipal Education Departments, as well as the Clinical departments of the health systems and services in which they are located. In addition, the document points out that it is the responsibility of the Education Secretariats to meet the request of the hospitals for the hospital and home teaching service, the hiring and training of the teachers, the provision of financial resources and materials for these services (Classe Hospitalar e atendimento pedagógico domiciliar - estratégias e orientações, 2002).

In the referrals of the documents, we see that the organization of the proposal to be implemented in the hospital context considers the educational development and the particularities experienced by the child and understands the disease in its multifactorial aspect, so as to consider the child’s readaptation to his/her conviviality and enable the approach to the infantile world from which he/she was removed because of illness. In this scenario, hospitalized children should be offered, according to the document of the Ministry of Education, the pedagogical-educational accompaniment of the process of development and construction of knowledge of children, young people and adults enrolled or not in regular education systems and who are unable to attend school, temporarily or permanently, and the maintenance of the link with schools through a flexible and/or adapted curriculum, favoring their entry, return or proper integration with their corresponding school group, as part of the right to integral care must also be ensured (Classe Hospitalar e atendimento pedagógico domiciliar - estratégias e orientações, 2002).

After three years of the publication of the document, the law regulating the implementation of hospital toy libraries in Brazil, an action linked to the Programa Nacional de Humanização da Assistência Hospitalar⁷ (PNHAH) - Law no. 11,104, 2005 - was approved, aiming at maintaining the rights to education and the development of children who undergo medical treatment and experience hospitalization. Its implementation, according to the Law No. 11,104 (2005), is based on the compulsory installation of toy libraries in health units that offer pediatric care in hospitalization. Article 1 of this law points out that hospitals that offer pediatric care will be required to have toys in their facilities, which provision applies to any health unit that offers pediatric care in hospitalization. Article 2 affirms that this law considers a toy library a space provided with toys and educational games designed to encourage children and their accompanying persons to play (Law no.11,104, 2005).

We emphasize that the advances in the proposals elaborated are mainly related to the necessary link between the hospital and the educational system, different spaces that, in the quest for child development, need to be found in order to offer health treatment and also the approximation with the spaces of the infantile context.

We also highlight the current amendment of Law 9,394, dated December 20, 1996, with the addition of article 4-A, which regulates the educational service of the student of Basic Education in long-term health treatment. Article 1 points out: Law No. 9,394, of December 20, 1996 becomes effective with the addition of the following article: Art. 4-A. During the period of hospitalization, educational care is provided to the student of Basic Education who is subjected to a long-term hospital or home health treatment, as provided by the Government in regulation, within the sphere of its federal competence (Law no. 9,394, 1996).

The documents sanctioned so far, especially Law no. 13.716 (2018), bring advances on the guarantees of educational care in a hospital environment, as well as indicating the need to provide adequate spaces for care, training of professionals working in the area and the curriculum adapted to the conditions experienced by the student; however, its effectiveness is still in process in the Brazilian scenario.

This process is being developed slowly and gradually, since, even the first initiatives in 1950 and the legislation and regulations that followed to guarantee the right to health and education of children, the proposals are not yet a reality in most of the hospitals that attend children. The legal norms are accompanied by challenges that involve the few investments in the area of Education and Health by the Public Power, and this lack of resources is accompanied by indefiniteness regarding the responsibilities of schools and hospitals, a context that has made difficult the effectiveness of the pedagogical service for children in health treatment.

In this scenario, a situation is posed because the child in a hospital treatment situation maintains the rights to development, which includes health care and the educational process, a right in which hospital pedagogy is instituted as a necessity.

3.2 Between hospitals and schools: hospital pedagogy

The approximation of the school contexts of the hospitals is a challenging movement that involves the search for the reestablishment of health and the search for the psychic, social and cognitive development of the child. Entering a hospital is walking in an inhospitable environment with a monochrome appearance, strong odors and ceaseless moans. Space in which concerns about health, life and fear of death present themselves. It is a place where sorrows and fears cohabit. To place a child in this space is to attend to biological aspects in search of treatment and reestablishment of health, but it is also investing in the continuity of life, a movement that places education as a necessity. With this recognition, hospital pedagogy is established as a right.

It is important to highlight that the hospital pedagogy recognizes the specificities of both elements, that is, of the areas of Health and Education. We are in a specific environment in the area of Health, which places the development of school activities in spaces different from those in school settings. Thus, pedagogical activities developed in hospitals can be located in defined educational spaces, such as designated places for toy libraries and hospital classes, but may also occur in waiting rooms, outpatient clinics, desks, hospital beds, hospital wards or bedrooms, in which the child can remain for long periods of time or only for one day.

It is a dynamic environment that demands attention to the specificities of treatment, as well as to educational development. In this context, the importance of planning stands out, in order to allow the appropriation of the meanings of educational activities, considering different time and spaces. Thus, hospital pedagogy aims to, according to Menezes (2004), promote integration between the child, the family, the school and the hospital, mitigating the trauma of hospitalization and contributing to social interaction; approach the child’s experience in the hospital to his/her daily routine prior to hospitalization, using knowledge as a form of emancipation and human formation; provide the hospitalized child with the possibility of having access to education even in a hospital environment; contribute to the reintegration of the hospitalized child in his/her school of origin or to his/her insertion after receiving a clean bill of health, since many of them, even of compulsory school age, do not go to school.

These objectives are not limited to the schooling of the hospitalized child, since it is an investment in life. In addition to aiming to develop strategies and advance in school contents, allowing at the end of treatment the return of the student to the school context, it is sought to integrate children to the processes of health treatment and minimize the impacts arising from the removal of the routine to which the child had the right to.

Hospital pedagogy involves the understanding of the context, its routine, its protocols and its peculiarities, in order to make the hospital language closer to the child’s understanding and thus ease the anxiety, because, with this understanding, the child accepts better the treatment. The pedagogical attention, through communication and dialogue, so essential in the educational act, proposes to help the sick child or adult so that, immersed in the negative situation that he/she goes through, he/she can continue to develop in all his/her personal dimensions, with the greatest possible normality (Gonzáles-Simancas & Polaino-Lorente, 1990). Thus, hospital pedagogy, according to Nascimento and Freitas (2010), is based on the principle of inclusive education and overcoming, presupposing communication, dialogue and playful elements as main pedagogical tools for the continuity of educational development.

We understand that educational monitoring is, in addition, a right of all children and should be provided even when hospitalized. It is in the context of the hospitalization, as the child remains hospitalized, that the desire for the activities lived in the school environment is (re)signified, revealing that the search for learning is a search for maintaining the role of student. Thus, we are faced with the desire to resume life, the childhood that was outside the hospital (Rolim, 2015).

In this perspective, we emphasize that the desire to learn is related mainly to social and cultural aspects, to the values that the child develops throughout the family experience and the social group, highlighting the school as an investment in the future of the child, a proposal that carries the perspective of continuity, a fundamental part of the socio-cultural development process of the subject (Vygotsky, 1997).

The fact of being sick cannot be a condition for silencing the protagonism of the child. In this sense, hospital pedagogy is an important tool for approaching the sick child with the universe of a healthy childhood, sometimes taken away by the disease.

Giving the opportunity for school activity for the children who are experiencing illness and hospital treatment initially represents the possibility of continuity of the school process, but as it is invested in learning situations, as a right to development and life, its representativeness surpasses the limits of learning as curricular content. Hospital pedagogy establishes itself as a link with the world outside the hospital, a search for the child to maintain his/her social place, to be a student among students. Thus, understanding hospital pedagogy as a legally established right, we enter the context of Palmas.

3.3 Unveiling the context: voices that echo

In order to understand the hospital pedagogy developed in the context of Palmas-capital of the state of Tocantins, we surveyed the city so as to identify which hospitals performed the treatment with hospitalization of children. Four hospitals with pediatric care were identified, three of which were public and one private, which carried out the hospitalization of sick children. Of these four hospitals none offer the hospital class and two have toy libraries. However, only one hospital has pedagogical attention to the child; the other has only the physical space, but does not rely on professional education for assistance. In this scenario, the field research was carried out in a public hospital in the city of Palmas, considering the existence of hospital educational services and the performance of the teachers in this context. The delimitation of this space was based on the survey of the hospitals in the city that had, in their team, the education professional.

The Public Children’s Hospital, called here 'Quíron', was created in 2010, after the pediatric nucleus was dismembered from a Hospital and Maternity ward located in Palmas. In this research, we move forward with Fonseca (2008), Rolim (2015) and through legislation in search of an approach with the pedagogical proposal in the hospital educational service in Palmas.

Locating the educational proposal developed at the Quíron Public Children’s Hospital, we observed that it seeks to comply with that proposed in Law no. 11,104, of March 21, 2005, which regulates the compulsory installation of toy libraries in health units that offer pediatric care under hospitalization. This process involves the multiprofessional team of the hospitals, mainly the figure of the teachers.

In this Hospital, the hospital pedagogical proposal developed is aimed mainly at the students in the Infant Education phase and attends the children who are in the first grades of Elementary School. However, the activities are related to the playful perspectives, focusing on the emotional aspects of the child, without the commitment to the school continuity as proposed by the hospital class.

The installation of the toy library took place in 2010 and was accompanied by Professor Atena, who participated in all phases of the process, as follows:

Everything that is to be deployed is not easy at all. You do not have a team ready, you have nothing ready. What we had was space, some toys, we had the furniture and the desire to work and to think through the toy library. So come on, behind people and human resources, let’s study; read articles about toy libraries, we did not have training in the State, we were not trained, we will understand what it is to work with the hospitalized child. We did not know what the hospital environment required, so we researched, wrote the project, imagined, reviewed, thought about, what kind of toy library we wanted, how we wanted it and what our vision was. (Atena).

Her speech reveals, in addition to the challenges of the process of implementing the proposal, a search, sometimes solitary, of the team, to think about the space of the child in the hospital. One of the actions was the creation of a study group for further clarification on care, with issues related to the importance of playing in the hospital environment, care for children in situations of violence, as well as death and mourning, recurring subjects in context of pediatrics.

The educational service developed in the context of the hospital requires more than adequate space for activities, the meeting of health and education professionals for the benefit of the child. To Teacher Athena, an effort that

requires time, persistence, patience tolerance, a lot of dialogue, a lot of talk, and also to sensitize people of the hospital, the medical team, the nursing team, direction. I always say that we need to raise awareness, use our own work, mark the territory. We came here and people said NO. ‘We cannot release the child, she has medication’. So we studied to gain knowledge, argument and say: “Listen, play decreases the stress hormone, there are scientific articles that prove it’. So the child needs it, it’s a form of treatment, they also had knowledge about it, because it has in their discipline description, nursing school has it, but here they did not want to release very much. Until we got it, it took time and we got there, marking territory, with persistence. (Atena).

Throughout its history, the hospital has the function of health care, dedicating efforts to physical and biological aspects, a characteristic presented in the teacher’s speech, highlighting the need to raise awareness in the team so that, little by little, education can conquer its space.

Even the toy library that has been deployed to provide care for children hospitalized or being treated still has the difficulty of associating education and health. This difficulty is evidenced in the teacher’s emphasis on the need for persistence, patience, tolerance and the need for a lot of dialogue between the teachers and the hospital staff. It is a stage of convincing, so that it is possible to offer educational actions that will also contribute to the improvement of the health framework, so as to consider the overall development of the child.

Searching for the pedagogical proposal approved and in operation, we had access to the documents that indicated the implantation of the toy library as the educational action in execution in the hospital. We verified that the Regimento interno brinquedoteca (Toy Library Internal Regulation), among other things, consists of the purpose of the attendance and the attributions of all the members of the team acting in the proposal. As a main goal, the document aims to develop a program of playful, cultural and socio-educational actions, with the purpose of alleviating the suffering caused by hospitalization, raising the quality of life of children and their families (Regimento interno brinquedoteca, 2013).

The Internal Regulation recognizes that the child, when faced with hospitalization, experiences uncertainties during the period of hospital stay. The detachment of social, family, friends and school life is also evidenced, highlighting the importance of considering the integrality of the child and the need for proposals that minimize the distance from the social context and daily activities typical of childhood. In this sense, the play proposed in the Internal Regulation is aimed mainly at the playful movements of relaxation, imagination, interactivity and well-being, but this play also makes the work with the internal and external reality of the children’s world possible, an important element for the continuity of development in the inhospitable context of the hospital.

The importance of the creation of toy libraries in a hospital environment brings in essence the purpose of playing and socializing, highlighting the development of the child. However, we must emphasize that in the child’s life there are social and cultural processes that involve the desire to learn and to know as a constitutive movement of human development, which leads us to think of the guarantee of continuity of school learning.

In the interview, Atena and Métis highlight the role of the toy library, but both point out the limitations of their care when they think about the educational process of the child in the context of the hospital.

The work of education is very broad, it cannot be said that only the toy library permeates its entirety. The toy library does an educational and also social work. But it is interesting to expand this view of the education because education runs through the corridors, the rooms and all the teams. (Atena).

In the hospital, the toy library works. It is only for fun to play with the toys, but the goal is that through play, which is part of the essence of the child, he/she gets better. Because he/she loses his/her identity, space. When hospitalized, the child receives many traumas, many fears and the toy library came to soften that, to help in this process of recovery of the child. So that he/she does not lose his/her child’s identity. (Métis).

In the intersection of these excerpts, it is possible to observe that the toy library is not established as a systematic space for schooling, as is the case of the hospital class. However, we identified a subtle relationship between the educational process and the work developed by the teachers in the context of the hospital’s toy library. It is through the teachers’ view that the concern with development and with learning presents itself.

A look that considers the specifics of the child in treatment, it does not lose sight of the adversities experienced in the contact with the disease and hospitalization, but its guiding element is the right to full development, since it involves health and education. In this movement, we are driven to seek the Internal Regulation of the toy library that proposes to develop in children the playful aspects of childhood, considering that this proposal has as its final activity the search for recovery of the child and his/her return to social life, as described in its goals, according to the Toy Library Internal Regulation (Regimento interno brinquedoteca, 2013, p. 2):

• Encourage and make parents and/or caregivers aware of the importance of playfulness in the recovery and physical and psychological development of the children;

• Stimulate by playing the recovery of the self-esteem and confidence of the hospitalized child;

• Enable the play of the expression of an inner reality that may be blocked by the need to adjust to hospital expectations;

• Stimulate creativity, allowing the child to use and understand his/her potential;

• Provide activities and mediation to read children’s stories, as an instrument of entertainment for the child, companions and professionals in various sectors of the hospital;

• Stimulate the ability to concentrate;

• Develop a sense of initiative, responsibility, organization and respect for others in a collective environment;

• Reduce rejection of routine treatment procedures;

• Demystify the fear of the hospital;

• Contribute to greater adherence and compliance to treatment by the patient and the family.

When analyzing the toy library regiment, we highlight the objectives elucidated, in the use of playfulness and play, as stimuli for the expression of the child’s inner reality, which may have been blocked due to the contact with the hospital’s invasive practices, as well as actions that provide the recovery of self-esteem and the development of creativity.

The implantation of the toy library is a step towards guaranteeing the rights of the full development of the child, regardless of the space that he/she experiences; it is to move towards humanizing proposals in hospital spaces, as described by Costa, Ribeiro, Borba and Sanna (2014). However, it is necessary to emphasize that access to the space of the toy library is also regulated, respecting the pathological condition and hospital times.

The hospital already has an organization, it divides the patients by pathology, it’s a technical job. The hospital has these regulations, then we schedule and we go to the child, inside the room, we meet the child, the specificity and how he/she is. Because each pathology has a specificity, hospitalization for surgery is one, and pneumonia is another. Every room, we usually say, has its own dynamics that it is important to observe. After this survey, we scheduled the child to come to the toy library. (Atena).

It has a whole team, psychologist, pedagogue, social worker, occupational therapist. Before attending, professionals go to the patient room, talk to the mother with the medical record, to see what the child has, if he/she can go to the toy library. Because sometimes he/she is so weak, or he/she has a pathology that he/she cannot have contact with other people [due to the risk of contagion from other children]. Then the professionals take them to the children’s room, play in that hospital bed because they cannot be attended there in the toy library at the scheduled time. (Métis).

The speeches reveal the search for educational assistance for the child, however the discomforts that occur in the hospital are explained, the fear of injections is present. The pedagogical attendance given at the hospital is a possibility for development, but it is an action subordinated to the compliance with norms and standards listed for each hospital space, being these involved in the dynamics attributed to each specificity diagnosed.

Faced with the contradictions that the environment imposes, we questioned Atena and Métis about the objectives of the educational proposal implemented in the Hospital. We consider it important to emphasize that the teachers answered the question after a long pause, stating:

The goal is to ease the suffering of the child and his/her family, try to reduce anxiety, because anxiety does not end and it has a very strong impact. He/she has to stay here and has to adapt to the space, which is collective, different from the family structure. The child needs to leave the family at home, leaves school, he/she misses everybody; so everything is very new, very invasive. Everything in the hospital is invasive, people do not have their intimacy preserved because here everyone enters the room. [Pause]. We try to open a channel of affection with the child so that it is possible to ease the suffering, reduce the impact, his/her and the family anguish. (Atena).

The main objective is to soften, so that he/she accepts the treatment, so that he/she does not escape the essence of a child, so that he/she does not have that right usurped. Even if we do not have the school focus, we end up educating, because everyone ends up educating the child, even the nurses, in a way, educate. (Métis).

The speeches of both teachers, just like the toy library regiment, highlight the importance of pedagogical activities in the hospital environment, acting as an investment in the continuity and quality of the child’s life. However, the interviewees also explain that school attendance is not being developed, even in the case of children of school age.

We consider that the pedagogical-educational service that takes place in the hospital space is fundamental for the child, and despite the importance of the toy library, the hospital class is necessary to guarantee the continuity of learning and to act in the development of it, which is assured as a right also by the 1988 Federal Constitution (Fonseca, 2008).

When interlacing the statements and the documentary and theoretical propositions, we observe that the toy library and the hospital class are spaces for the development of hospital pedagogy, a construction of rights, essential elements that need to be provided to the child in the hospital space.

4 Conclusions

When crossing the information obtained, we observed that entering the hospital context through pedagogy is a challenging proposition. Challenges that permeate the understanding of this context, an environment that, in its characteristic, presents organic weakness, physical and social space constraints, but, at the same time, thinks about the child and his/her development, then it seeks life. It is important to emphasize that the data are punctual and the analyzes cannot be generalized, but they bring clues from a context in which the rights to education remain neglected.

In view of this context, we noticed, through the statements of the teachers, that, even though the need for pedagogical support in the hospital was recognized, the first initiatives came amidst resistance from health professionals. We believe that greater value is attributed to clinical practices, disregarding the relevance of pedagogical activities for the child’s development. It is important to retake, in the teachers’ speeches, the quest for the effectiveness of educational work, so that efforts were made to “demarcate territory”.

In the structural aspects of the proposal, we observed the layout of the physical and furniture space, but for the accomplishment of the pedagogical activities, materials characteristic of the age group of the child are necessary and appropriate to the proposal foreseen in the Internal Regiment, such as games, toys, crayons, among others. According to the reports, these teaching materials have not been made available, which makes carrying out the activities difficult; with this, the team, throughout the year, promotes bazaars, feijoadas (a typical Brazilian dish) to meet the needs of the toy library.

This situation reveals, between the lines of the process, the lack of recognition of education as essential to child development. Even though the toy library is established by law, its activity in the hospital still goes through recognition of necessary space. In this scenario, we observed that the hospital class did not even achieve a space in the hospital environment.

In this process, we understand that the toy library in the hospital environment is essential, as well as the teachers who work in their space, since the activity of education cannot be replaced by the area of Health. Health and Education need to be intertwined as a right of the child being treated, which must be provided.

Placing children in the hospital space as subjects of rights obliges us to look at an exclusionary society which, in contradictory movements, recognizes the educational rights for all school-age children, but continues to exclude them by failing to ensure that these rights become reality in the hospital context.

Hospitalized children are placed outside the educational system, as if the situation of illness cancels out the right to continuity in school. Thus, a process of exclusion and segregation of the patients is accentuated. In this context, the interviewed teachers reveal that, in recognition of the right to education, health and education professionals are starting to take the first steps in the hospital investigated, but there is still a lot to be done, to ensure attention to space of the play as well as to create opportunities to the right to school continuity through the hospital classes. We see, then, that hospital pedagogy, in the spaces of the toy library and in the hospital classes, needs to be provided in the hospital environment as a right.

Hospital pedagogy shows its relevance in this process as it makes us think that the school process in the context of the hospital is possible, a perspective that does not leave aside the attention to organic aspects, health care, but carries the investment in education. This movement goes beyond supplying the absence of school content, it is the process that invests in the continuity of life.

• 4
  Possible translation: National Center of Studies and Education for the Inadapted Childhood.
• 5
  National Policy of Special Education issued by the Ministry of Education.
• 6
  Possible translation: Hospital Class and Pedagogic Home Care: Strategies and Orientations.
• 7
  Possible translation: National Program for Humanization of Hospital Care.

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Publication Dates

• Publication in this collection
  12 Sept 2019
• Date of issue
  Jul-Sep 2019

History

• Received
  03 Apr 2019
• Reviewed
  23 May 2019
• Accepted
  24 May 2019