Visiting a hospitalized child in intensive care: experiences of siblings revealed through the dramatic therapeutic play

Abstract

Objective:

to understand, by means of dramatic therapeutic play, the meaning, for the sibling, of visiting the child hospitalized in intensive care.

Method:

a qualitative research, phenomenological modality, which used the dramatic therapeutic play to access the siblings' experiences. It was carried out in a Pediatric Intensive Care Unit in the countryside of the State of São Paulo, Brazil. Eleven siblings under ten years of age participated in the therapeutic play sessions, which were analyzed in the light of the Theory of Maturation.

Results:

the siblings, having a place to play, dramatized previously lived situations, from their daily life and from the visit to the hospitalized child. By living creatively, they revealed that playing is to integrate the experiences of the “I”, favoring the continuity of being in the face of the situation lived.

Conclusions and implications for practice:

the Dramatic Therapeutic Play understood in the light of a theoretical framework allowed the sibling to mean the visit as an experience of integration of the “I”, revealing emotions, desires and preferences of daily life. In this sense, the care for the brother of the hospitalized child is defined by the offer of free play, so that he demonstrates the feeling of continuing to be in his interactions with the world, in which the hospital context has become part of reality.

Keywords:
Pediatric Nursing; Siblings; Play and Playthings; Intensive Care Units, Pediatric; Visitors to Patients

Resumo

Objetivo:

compreender, por meio do brinquedo terapêutico dramático, o significado, para o irmão, de visitar a criança hospitalizada em terapia intensiva.

Método:

pesquisa qualitativa, modalidade fenomenológica, que utilizou o brinquedo terapêutico dramático para acessar às experiências dos irmãos. Foi realizada em Unidade de Terapia Intensiva Pediátrica do interior do estado de São Paulo, Brasil. Participaram das sessões de brinquedo terapêutico 11 irmãos menores de 10 anos, as quais foram analisadas à luz da Teoria do Amadurecimento.

Resultados:

os irmãos, tendo um lugar para brincar, dramatizaram situações, anteriormente, vividas, de seu cotidiano e da visita à criança hospitalizada. Ao viver, criativamente, revelaram que brincar é fazer a integração das experiências do “eu”, favorecendo o continuar a ser diante da situação vivida.

Conclusões e implicações para a prática:

o Brinquedo Terapêutico Dramático compreendido à luz de um referencial teórico possibilitou que o irmão significasse a visita como uma experiência de integração do “eu”, revelando emoções, desejos e preferências do cotidiano. Nesse sentido, o cuidado ao irmão da criança hospitalizada define-se pela oferta do brincar livre, para que ele demonstre o sentimento de continuar a ser em suas interações com o mundo, no qual o contexto hospitalar tornou parte da realidade.

Palavras-chave:
Enfermagem Pediátrica; Irmãos; Jogos e Brinquedos; Unidades de Terapia Intensiva Pediátrica; Visitas a Pacientes

Resumen

Objeto:

Comprender por medio del juego terapéutico dramático el significado, para el hermano, de la visita al niño hospitalizado en Terapia Intensiva Pediátrica.

Método:

Investigación cualitativa, modalidad fenomenológica, que utilizó el juego terapéutico dramático para comprender la experiencia del hermano. Se realizó en Unidad de Terapia Intensiva Pediátrica del interior del Estado de São Paulo, Brasil. Participaron de las sesiones de juego terapéutico 11 hermanos con menos de 10 años, quienes fueron analizados a la luz de la Teoría de la Maduración.

Resultados:

Los hermanos, al tener un lugar para jugar, dramatizaron situaciones anteriormente vividas, de su cotidiano y de la visita al niño hospitalizado. Al vivir de forma creativa, revelaron que jugar es permitir la integración de las experiencias del “yo”, lo que favorece el concepto de seguir siendo, ante la situación vivida.

Conclusiones e implicaciones para la práctica:

El Juego Terapéutico Dramático comprendido a la luz de un referencial teórico hizo posible que el hermano entendiera la visita como una experiencia de integración del “yo”, revelando emociones, deseos y preferencias cotidianas. En este sentido, el cuidado del hermano del niño hospitalizado se define por la oferta de juego libre, para que pueda demostrar su sentimiento de seguir siendo en sus interacciones con el mundo, en el que el contexto hospitalario se ha convertido en parte de la realidad.

Palabras clave:
Enfermería Pediátrica; Hermanos; Juego e Implementos de Juego; Unidades de Cuidado Intensivo Pediátrico; Visitas a Pacientes

INTRODUCTION

Visits to intensive care units are usually restricted and at pre-established times, and it is unusual for children under 12 years of age to be admitted. This is a very controversial issue, although scientific advances in recent decades show its importance for patient recovery^1,2.

The restrictions imposed on visitors are based on the risk of infection to patients and visitors, besides the possibility of emotional trauma due to the hostile and unknown environment. The lack of physical space and trained human resources are also justifications for preventing visitors in these units³.

However, since the 1980s, these aspects have been refuted by scholars who defend the open visit and the presence of the family during the hospitalization of children, including with current legislation^4,5.

Limiting or preventing visits in intensive care units can have a negative impact on the family, which is also affected by the disease situation and all the aspects arising from it, which can cause negative feelings, especially in the siblings of the sick child⁶.

Often, siblings are kept on the sidelines when a family member becomes ill in an attempt to spare them. Parents often withhold information and/or remove them from the care and support of the sick child^4,6. However, this goes against preserving their emotional health, because this conduct does not prevent them from being affected by everything that happens around them⁷.

Research on sibling visits to hospitalized children from the perspective of the siblings themselves is scarce. However, a study that sought to reflect on the visit of children to adults hospitalized in an intensive care unit, revealed that the visit favors the child's mourning process, although health professionals do not always have strategies to support this practice⁸.

Listening to the siblings, answering their questions and doubts about the hospitalized child, bringing them closer to the situation lived through the visit, if this is their wish, is important, and may reduce the stress of family separation, rescuing the feeling of belonging, which may be weakened and relieving fantasies related to the illness, also favoring the construction of reality, because generally, the imagination about the condition of the sick child may not represent the fact^4,6.

For this, the professional needs to have knowledge and be prepared to welcome the siblings. Among the resources available for communicating with them is the play, with emphasis on Therapeutic Play (TP). One of the TP modalities, the dramatic one, enables emotional discharge, because by playing, the child externalizes feelings and experiences, trying to understand them and also allowing the nurse to understand them⁹.

Considering that the TP is a care technology regulated in the professional practice of nursing staff^9-11 and that the DTP is used in studies with children to reveal diverse experiences, such as hospitalization, illness, and maternal deprivation^12-14, Among others, using it with siblings of hospitalized children to access their visiting experiences in the intensive care unit may bring relevant elements to broaden the discussions about visiting children in hospitals.

Thus, the objective of this study is to understand, through dramatic therapeutic play, the meaning, for the sibling, of visiting the child hospitalized in intensive care.

METHOD

Qualitative, phenomenological research. Studies of this nature have as their essence to understand the lived experience and the meaning given to it by those who experience it, considering its singularity, without formulating hypotheses or inferences. We adopted the Situated Phenomenon Structure Analysis as a methodological reference¹⁵ and D. W. Winnicott's Theory of Maturation^16-21, as a theoretical reference.

Phenomenology is the discipline that studies the description of what appears, that which appears to the consciousness and shows itself, manifests itself, unveils itself to the individual who interrogates. It is a descriptive, rigorous, and concrete science, which allows us to show and explain the being itself, in a concern with the essence of what is lived¹⁵.

The Situated Phenomenon Structure Analysis investigates, in a direct way, human experiences, seeking to build knowledge aimed at understanding the dynamics of meanings, without getting stuck in causal explanations or generalizations. The aim is to get to know the individual and understand the process by which he constructs and describes his meanings. As the researcher describes and interprets human phenomena in a broad way, decoding the complex system of meanings, he creates conditions for a reflection that aims at understanding the phenomenon¹⁵.

As for the choice of Winnicott's Theory of Maturation, it allows answering the question of this study, insofar as it defines the health of the individual from his process of emotional development^16,18. It is founded on two basic principles: the innate tendency to maturation, which offers the subsidies for the reading of lived experience; and the continuous existence of a facilitating environment, which, through sufficiently good care, fosters the interpretation of the relationships that connect the experience of human beings¹⁷.

In the journey of maturation there are capacities to be conquered and experiences to be integrated, which depends on the process of constitution of reality, of which play is a part²⁰. Playing is a sophisticated activity, through which the child can convert his impulses into symbolic and creative activities, being able to deal with the anxieties arising from his experiences and also allows him to unveil the process of building his subjectivity, based on his relationships with others and with the world²¹.

The study was developed in a Pediatric Intensive Care Unit (ICU) of a large philanthropic hospital in the countryside of São Paulo state, with a total of seven beds, where the multi-professional team assists critically ill children, aged between 29 days and 14 years.

Visits to children are daily, in two periods, with the entry of two people over 12 years old, without relay. Visitation by minors is an exception, limited to siblings, only in response to the request of the parents or the hospitalized child, upon authorization by the nurse.

The inclusion criteria were siblings between 3 and 10 years old, as this is the recommended age group for the use of TP^9,22, the interest of the responsible person and the possibility of bringing the sibling to visit the hospitalized child and, furthermore, who had no previous visiting experience. Exclusion criteria were siblings with any health problem whose visit was contraindicated by the multi-professional team and who were already familiar with the intensive care unit environment.

Thus, 12 families were approached and informed about the objective of the study and how their children would participate. Of these, one refused because he believed that the visit to the hospitalized child would be harmful to his brother's health. Two other families, although they showed interest, could not bring their siblings to the hospital, one because of financial difficulties and the other because the child was transferred from the hospital. Those who agreed signed the Free and Informed Consent Term, keeping a copy, and scheduled a day and time for the sibling to visit the hospitalized child.

Before the visit, the main researcher, dressed in ordinary clothes and a lab coat, approached the sibling in the Unit's reception room, where there is a sofa and children's tables/chairs. By means of the Term of Assent (TA), a playful description elaborated especially for this purpose, the brother was invited to play after visiting the hospitalized child.

All siblings whose families signed the FICT, agreed to participate in the DTP session. Thus, 11 siblings of 9 hospitalized children participated in the study. The following table (Chart 1) presents the study participants. Data collection occurred in the period from December 2017 to January 2019.

Chart 1
Siblings participating in the study. Campinas, 2019.

Visiting sibling, Age	Child hospitalized, age	Diagnosis (Pediatric ICU Days); general condition, devices	Dramatic TP Duration
Jorel, 8 years	Jorel’s brother, 4 months	Myocardiopathy + Pneumonia (3)	37 minutes
		Good general condition, awake, interacts with family; oxygen therapy (nasal catheter), serotherapy, non-invasive monitoring
Peppa Pig, 3 years	George Pig, 5 months	Bronchiolitis (8)	37 minutes
		Good general condition, awake, interacts with family; oxygen therapy (face mask), serotherapy, non-invasive monitoring
Sitka, 10 years	Denahi, 8 years	Cystic fibrosis (23)	15 minutes
		Good general condition, awake, communicative; in protective isolation, serotherapy, non-invasive monitoring
Tommy, 9 years	Dil, 3 months	Pneumonia (1)	38 minutes
		Good general condition, awake, interacts with family; oxygen therapy (face mask), serotherapy, non-invasive monitoring
Bart, 9 years	Marggie, 3 years	Pneumonia + Pleural effusion (21)	27 minutes
		Good general condition, interacts with family; oxygen therapy (face mask), serum therapy, chest drain, non-invasive monitoring
Smurfinha, 9 years	Neném Smurf, 9 months	Pneumonia (15)	17 minutes
		Good general condition, active, interacts with family; oxygen therapy (face mask), serotherapy, non-invasive monitoring
Gumball, 9 years	Darwin, 9 years	Genetic Syndrome (9)	46 minutes
Anais, 5 years		In palliative care, stable, interacts with family; intubated, mechanical ventilation, serotherapy, non-invasive monitoring
Charlie, 7 years	Bebê, 2 months	Pneumonia (6)	48 minutes
Lola, 4 years		Good general condition, active, interacts with family; oxygen therapy (face mask), serotherapy, non-invasive monitoring
Elroy, 3 years	Judy, 9 years	Pneumonia + Pleural effusion (27)	50 minutes
		Good general condition, active, interacts with family; oxygen therapy (face mask), serum therapy, chest drain, non-invasive monitoring

• Source: Research data, 2019.

There were 11 DTP sessions initiated with the guiding question, “Are we going to play a child who visited his brother in the Pediatric ICU?” At this point, the time of the session was agreed upon by showing the hands of the clock to indicate the allotted time, but explained that play could be stopped at any time.

The time of the DTP session can vary between 15 and 45 minutes⁹, however the child may request some more time to finish the game, which happened with four siblings. Thus, the time of each session varied between 15 and 59 minutes.

The selection of toys followed the recommendations in the literature^9,22, and a plastic box contained dolls representing the family, health professionals, animals, and household and everyday objects, such as various foods, cars, tools, and hospital supplies (syringe, needle, medicine bottles, thermometer, electrodes, stethoscope, mask, glove, among others). Also, colored pencils and a pad of paper.

The records were recorded on digital audio and in a field journal, where general impressions and perceptions about the siblings' behavior were described, helping to clarify the moment of play, and subsidizing the analysis of the play. Considering the principle of phenomenological research that the phenomenon to be unveiled happens at the moment of the manifestations of the participants and not afterwards²³ it was decided not to film the DTP sessions.

The transcription of the audios occurred soon after the end of each DTP session, and the sessions were closed when the speeches showed consistency, that is, when theoretical saturation was reached, meaning that from a constant analytical process, the researchers observed that new elements no longer appeared in the jokes²⁴.

The analysis followed the steps recommended by the Situated Phenomenon Structure Analysis: global reading of the total content of the sessions together with the information in the field diary in order to apprehend its global configuration; attentive rereading in order to identify the significant statements (units of meaning); search for convergences and divergences for the construction of the thematic categories and elaboration of the descriptive synthesis¹⁵ carried out in the light of Winnicott's theory of maturation^16-21.

Ensuring the privacy of the participants and the protection of their identity, we chose to use names of children's animation characters, chosen by the main researcher. The study followed the recommendations established by Resolution No. 466 of December 12, 2012, and was approved by the Research Ethics Committee of the State University of Campinas under opinion No. 2,652,332 and CAAE No. 65571417.1.0000.5404 of May 14, 2018.

RESULTS

In understanding the experience of the siblings who visited children hospitalized in the intensive care unit, two categories emerged: “Having a place to play” and “Living creatively: playing is doing”. These categories will be presented below and illustrated through the siblings' speeches extracted during the DTP session, followed by their fictitious name and age.

Having a place to play

The siblings recognized the play environment as good enough capable of receiving their play. Thus, accepting the invitation to play, they explored the environment looking for elements for play and recognizing objects available for play.

When selecting toys they initially preferred those that alluded to the experience of the visit; but they were also interested in other elements of the box.

Bart explores the box. Now I need to find a visitor! Over here! Got it! A little baby! Here... inside. [Placing the baby doll on the bed of the Pediatric ICU set; goes back to exploring] I found it! [I'll put it on the bed... this one... like this... [Humming puts the blanket over the baby on the bed; goes back to exploring] (Bart, 9 years old)

Smurfette finds colorful plates and arranges them one in front of her and one in front of the researcher. She finds a fried egg. Egg. Puts it on the plate [removes other household utensils from the box - pots, cutlery, cups, grouping them by similarities]. (Smurfette, 9 years old)

Peppa Pig explores the box; she finds a pad of paper and a case with crayons. 'Qué quevê' (trying to say “I want to write” in Brazilian portuguese) here... [picks up a pencil and scribbles on the paper] (Peppa Pig, age 3))

It was also observed that the siblings were interested in a certain toy when they recognized the possibility of this toy performing another function.

Tommy pulls out of the box a drill. A gun! Yeah, yeah, yeah... [simulates shots] But strange... [looking at its tip] the tip looks like glue... is it a glue gun? (Tommy, 9 years old)

The siblings recognized the objects provided, which was shown when they named toys, objects and characters and when they played simulating their use.

Lola explores the box and takes out the stethoscope: Let's listen to Aunt P's heart (name of researcher) [puts the stethoscope on the bench and takes out of the box a pair of gloves] Put the glove here for me? [stretches out his hands to P and hands over the gloves]

P: Where do you want me to put the glove?

Lola: On the hand! On this one... [stretches out one hand] Now this one... [stretches out the other one] (Lola, 4 years old)

Upon finding medical supplies, he recognized them and declared that they were not for playing with.

Charlie finds an oral medication kit in the box. That's no joke! [...] [Explores the box and finds syringes, ampoule of SF0.9%. He picks them up and places them on the countertop]. There are so many doctor's things here... Don't you use these things?

Q: Don't we?

Charlie: No... because it's here in the box... so... in here with the toys. But... but do they work?

Q: They do?

Charlie: Yes! [pushing and pulling on the syringe plunger] (Charlie, age 7))

The siblings related the toys and characters in the box to the experience of the visit, as an example they associate the doll in white with the research nurse.

Bart explores the box; finds the doll representing the researcher. Oh, the nurse... [shows the researcher a doll dressed in white] Here it is... [arranging the doll in the Pediatric ICU setting] What best suits you goes... White... you know... because you're wearing white! (Bart, 9 years old))

Creative living: playing is doing

Bringing to play elements alluding to their daily life, experiences and lived reality, they used them, dramatizing old memories and the situation of the visit; recreating, destroying and rebuilding the intensive care environment. Still, they showed to realize about themselves, to have a look at the other, and to act according to their will. The toys mobilized memories of situations previously lived, and these were dramatized in play.

Lola picks up a dog from the Dog Patrol on the counter: Look! Let's cut Zuma! Cut Zuma! I'm going to cut Zuma! I'm going to cut Zuma's foot off. Zuma will get a boo-boo! [singing] Because she had to get a few stitches... Just like Charlie did here. [touching his brother's forehead, where there was a discreet scar] Pin! First he put it on his forehead. [puts a gauze pad on the brother's forehead and holds it up with the support of the scissors] And he did, right? And I cried!

Charlie: Did I put the scissors on my forehead? The 'nurse!

Lola: The 'nurse' put it on... and then I saw Charlie, and then I cried... (Charlie, 7 years; Lola, 4 years)

They also dramatized the experience of visiting the hospitalized child.

Sitka opens the box and finds the objects that refer to the experience of the visit, takes them and puts them on the counter. Do I have to demonstrate how I got there? I will demonstrate how I got there. How I went to see my brother. [takes a doll to represent him] I got here, then I washed my hand, went in there. My father stayed here, with my mother. [shows the scenario where the parents stayed inside the pediatric ICU] I arrived, hugged Denahi, told him I missed him; he told me he missed me too. Then he asked me if I wanted to draw. Then we were drawing. We drew and then you came. (Sitka, 10 years)

The siblings' capacity to play allowed them to recreate the Pediatric ICU scenario, inserting new elements into this environment.

Bart explores the box and finds a toilet: Bathroom... where do you put that? [Asks himself; immediately places it in the Pediatric ICU setting. Explores the box again]. More... [finds a detergent dispenser package] Get alcohol, here... it's important! Tchii... [simulates putting on hands, rubs and puts on the Pediatric ICU scenario] (Bart, 9 years)

Playing, the siblings built, destroyed and rebuilt the scenario representative of the intensive care environment.

Charlie: I'm going to set up the hos-pi-tal! [removes the set from the box, places it on the countertop and watches] What was the game again?

Q: Let's play a child who went to visit her sister in the ICU.

Charlie takes a hammer out of the box; begins to tap the walls of the set, gently] I'm remaking the ICU... remaking ... the ICU. (Charlie, 7 years old)

Some toys available in the box, when found, allowed the siblings to reveal their preferences.

Charlie explores the box and finds an ice cream carton: Yes! [excitedly; takes the ice cream carton from the box] It's an ice cream carton! [speaks enthusiastically]

Lola: I like ice cream too, but it's lego. [Gets the princess Elsa doll, squeezes it, making it play the song “Let it go”] I like that song “Lerisgou...” [humming] I have an Olaf in my house.... I don't have the doll... but I have the movie! And that one... “Lerisgou”! [referring to the song] (Charlie, age 7; Lola, age 4)

During playtime, the siblings also made considerations about the hospitalized child, asked about her and the hospital being able to meet her needs.

Sitka tells the researcher that her father bought a new cell phone for Denahi: [...] Actually, my father already bought it, right, but it's just at home. Because he said, if there is wi-fi here... because he wants to use the wi-fi; also because he is addicted to it. [...] Denahi is addicted to it [wi-fi] Back home he doesn't stop messing with the cell phone... he spends five-four hours [emphasis added] messing with it... He would only stop like this, to eat, drink water, like this... these things... Is there wi-fi here? He [refers to the father] hasn't asked yet, because after he broke it, he didn't bring it... [refers to the cell phone] (Sitka, 10 years old)

The siblings decided to continue playing or end the game even though they knew the combined time of the TP session.

Q: Elroy, we're going to have to put the toys away, because, oh, the hand on the clock is already on time. [shows the clock and the indication of the hand at the agreed time for the end of the game]

Elroy: It's not! I have to play yet... I haven't played yet... [and continues playing, ignoring what the researcher had said] (Elroy, 3 years old)

DISCUSSION

The way the child can express the meanings of his lived experience is through play²⁰. Therefore, by accepting the invitation to play, the siblings were able to signify their confidence in the play environment, that is, they recognized this environment as good enough, capable of welcoming their play. The sufficiently good environment has the character of allowing the child to enter the real world, helping the child to differentiate fantasy from reality, integrating as a being in a unity²¹.

A study on the dynamics and structure of DTP revealed that the session is a process with four interdependent and complementary stages. Accepting the invitation to play is part of the first stage, named 'establishing a bond', which occurs gradually, but is essential for the child to expose feelings and emotions. Moreover, this stage supports the next one, 'exploring'²⁵, a movement also observed in the siblings of hospitalized children.

The siblings explored the box and the toys by observing, handling, asking, trying to discover and recognize what was available to play with. Exploring is an activity that belongs to external reality; through it, it is possible to get in touch with what is real²⁰.

Initially, they selected elements that referred to the experience of the visit to play. Children with cancer brought to play what they considered of greater impact in their new realities, that is, the illness and the painful procedures, showing difficulties in extrapolating the difficult moments¹³.

However, the siblings went beyond the moment of the visit. The DTP session provided the opportunity to become interested in other toys in the box, according to the need to conceive, as real, the experience lived, integrating it to the “I”, which may favor their journey toward maturation^16,17.

The TP, conceived as a sufficiently good environment, is capable of promoting the siblings' courage to play to the extent that it offers emotional support, freedom of expression and experimentation, a starting point for the experience of new discoveries and the conception of reality^22,26.

In some situations, the siblings were interested in the possibility of the toy performing another function. In this context, one cannot view the preferences and interests of the siblings in a naive way, because the moment of the TP awakens possibilities to reflect, react, and act. Playing is not only a spontaneous act; it facilitates the access to symbolic activity and the psychic elaboration of daily experiences, such as the experience of visiting a hospitalized child. Thus, more important than the object played with is the way it is used and the relationship the child establishes with it. Relating to the object, here represented by the toy, gives it the characteristic of being recognized by the child as real²⁰.

During the play, the siblings found medical-hospital supplies and, in front of them, recognized their function, identifying that they were not for playing, which may mean the use of their repertoire prior to the experience of visiting the hospitalized child, differentiating these supplies from those toys that they have confidence and courage to play with, replacing their initial function. However, such prohibitive act with a category of objects may indicate that the child has already conquered the ability to symbolize, since there is no longer the need for its use in play, because it is already named, characterized, and constituted in the lived reality¹⁹.

Playing with medical-hospital supplies by dramatizing procedures is not something uncommon for children who experience the context of illness and hospitalization. It is an excellent opportunity to understand feelings such as anxiety, anguish, loneliness, and fear^27,28.

At the same time that there are hospital supplies that were named, characterized, and constituted in the reality experienced, in some situations, the siblings established a relationship between the toys-personages available in the box and people around them, who are part of their daily life or the experience of the visit. Such inclusion may indicate the symbolic game existing in the very act of playing, as there are objects that are external to the child²⁹, which at different times are chosen to be part of the game and, at another time, emerge bringing the lived context, especially the hospital visit.

The play between exteriority and the internalization of the objects that prompt the visit to the hospitalized child, shows the play in the potential or transitional space²⁹. This is not an area of conscious and reflective understanding, but of experimentation in which the process of symbolization is based, in which the symbols have value and exist as such. Thus, playing is assured as a facilitating resource for symbolic activity²⁰ which can contribute to the meaning given by the siblings to the experience of the visit. A similar behavior was observed in children of incarcerated women who participated in DTP sessions¹⁴.

The siblings dramatized, in play, situations that they had experienced some time ago, which allows us to consider that the dramatic play session mobilized memories and provided a moment to represent what was significant to them. Remembering is a way to experience in the present what has happened in the past¹⁷. Sometimes, impacting situations can make it difficult for the child to rescue his story through play. Children in oncologic treatment demonstrated, even if briefly, a willingness to go beyond the issues surrounding their illness, which brought them well-being¹³.

The siblings could enjoy the opportunity to relive moments that were significant to them, dramatizing the experience of visiting the hospitalized child, signifying it in the continuity of living, without the experience of the disease being determinant for the discontinuity in their maturing process. In the light of the maturation theory, the origin of symbolization lies in the experience with transitional phenomena and objects, and its achievement comes from the differentiation between what is internal and what is external, from the clear distinction between what is fantasy and what is fact, between what is created and what is found, which occurs in the play¹⁶.

From this perspective it is possible to conceive that the dramatic TP as a care technology that promotes play⁹, is a mediator to symbolic activity once it provides the dimension of transitionality, in which it is possible to have experiences and use creativity¹⁹ to conceive reality.

Reliving the experiences in play represents the free and creative doing (playing) as a result of a situation and/or the environment.²⁰ It translates into the movement of encountering life and others, that is, the experience of encountering external reality from one's own spontaneity¹⁸.

Playing, the siblings recreated the scenario of the Pediatric ICU, bringing to this environment, new elements, which may point out that the sibings meant the visit as a space to use creativity to develop their maturation incorporating such experience to the task of conceiving reality, since, who is creative can bring new elements to play and do in it. In Winnicott's conception, the creative phenomenon is an activity of experimentation and is related to the feeling of reality and not to an action or unpublished act¹⁶.

Thus, by creatively living the play, it is possible to have a new contact with the experience, take a new look at it and, from then on, elaborate what was significant to him, contributing to the experience being conceived as real¹⁶.

However, creativity is an action that presupposes destructiveness, that is, it is necessary to promote the destruction, in the unconscious fantasy, of what is subjective in order to conceive what is objective, real^17,19. This movement could be perceived when the siblings built, destroyed and rebuilt the representative scenario of the intensive care environment, which again corroborates the meaning of the visiting experience as a moment of integration of reality and not of rupture.

When the child experiences play in all possible ways, he builds contact with reality and experiences the continuity of being¹⁷. Providing a play environment that allows the siblings to let their creativity and the experience lived through it, are the beginning for them to conceive the continuity of their existence. It is only possible to have the feeling of continuing to be who has the feeling of existing^17,18.

Thus, when the siblings, during play reveal their preferences, they signify the visit, distinguishing themselves from it, because they recognize themselves as an “I”, separate from a “non-I”, because only those who exist are able to perceive themselves and the world¹⁶. This ability is also revealed when siblings make considerations about the hospitalized child, and signify the visit as a moment to express concern about meeting the needs of the hospitalized child in the hospital.

Having the awareness of being “self”, is a capacity to be conquered in the journey of maturation, which involves the relationship between the singularity of “self” and the encounter with “the other” (“non-self”) and the consequent integration of new experiences, such as the visit in the Pediatric ICU. “I am, I exist, I acquire experiences, I enrich myself and have an introjective and projective interaction with the “not-me”, the real world of shared reality”^16:60.

The movement of doing for themselves can be perceived when they decide to continue playing or to stop playing and it meant that the hospital visit is an experience that reinforces the sense of “self”, which leads them to make for themselves the choice of ending or continuing in the game.

The feeling of existing must be maintained throughout life, yet continuing to be, even in the face of adversity, is a great challenge. By acting according to their will, regardless of the limits of the environment, the siblings have imposed themselves as a being that exists. This capacity that the brother has corresponds to a healthy emotional state and reveals the creative living of who has the freedom to be and to do, of who perceives himself, the other, and the world, of who has the “feeling of existing” and of “being”¹⁸.

The creative way of living results in free and spontaneous actions in the face of life's circumstances, providing support for the individual to maintain a sense of being “oneself” in interactions with the world. These actions are called “spontaneous gestures”, which is one of the many ways in which the true self can express itself. It represents one's own authenticity and genuineness. Through genuine actions the child can enjoy the experiences of life without fear of annihilation, and thus continue to be¹⁶.

The play provided by the nurse could favor the siblings to live creatively, giving meaning to their experiences, such as the visit to the hospitalized child, allowing them to be conceived as real and integrated to the “I”. By playing, the sibling signified, through the feelings expressed in the results, that life is real, that it is worth living, and that it is possible to continue to be, even in the face of difficulties that may present themselves.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The DTP made it possible to play that, understood in the light of the theory of maturation, revealed that the brother meant the visit as an experience of integration of the “I”, to the extent that they incorporated the visit to the games, besides revealing emotions, desires and preferences of the daily life, mobilized memories of lived situations, showed the ability to destroy and reconstruct the object in order to constitute the reality in a creative way, demonstrating the feeling of continuing to be in interactions with the world, which reveals the creative living of the one who is “self”.

The visit seems not to have meant, to the siblings in this study, a traumatic experience, capable of interfering or interrupting the continuity of being, because they were able to signify the adverse situations, showing confidence, courage, and replacing the original function of the toy by another that responded to their need to communicate and constitute reality. This capacity for meaning was made possible by the implementation of an appropriate language for them and by offering them the opportunity to promote the elaboration of the hospitalization experience, which in this study was developed by the DTP.

It is worth noting that this study demonstrates to the nurse the need to care for the sibling, considering them as part of the family of the hospitalized child, including them in the context of hospitalization, which does not imply only allowing visitation, but also understanding what the visit means to them. For this, it is recommended to organize a favorable environment for play, characterized by free, non-directed play, in which the nurse has a posture that welcomes and supports play, without judgments or inferences, so that the sibling conceives reality mediated by the potential space in order to symbolize the experience lived, as occurred in this study.

Regarding the limitations of the study, the intervention with DTP proved to be relevant to understand the siblings' experience, but it may not be enough to promote changes in visitation policies because it represents a select group of participants, although they can raise relevant discussions and reflections.

This study brought the importance of, in the care to the family, to glimpse the brother of the hospitalized child, understanding that this care is characterized as the possibility of signification of the lived experience and for such, it is recommended the adoption of a theoretical proposal for the reading of the experience of the visit, when admitted the use of the TP to the brother of the hospitalized child.

• FINANCIAL SUPPORT

  “This work was carried out with support from the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Funding Code 001, Doctoral Scholarship granted to Glicinia Elaine Rosilho Pedroso), Process No. 38P-4071/2019.

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Edited by

EDITOR ASSOCIADO

EDITOR CIENTÍFICO

Publication Dates

• Publication in this collection
  27 Sept 2021
• Date of issue
  2022

History

• Received
  06 Apr 2021
• Accepted
  12 Aug 2021