290 PLAYING IN THE WAITING ROOM OF AN INFANT OUTPATIENT CLINIC FROM THE PERSPECTIVE OF CHILDREN AND THEIR COMPANIONS

Playing is one way children use to communicate with the world that surrounds them. This descriptiveexploratory 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.


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 selfknowledge 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

METHODOLOGICAL COURSE
This is a descriptive-exploratory study (14) ..This 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 (.

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.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: According to the companions, other factors contributed to turn their stay at the clinic even more u n p l e a s a n t , s u c h a s : h e a t ; n o i s e ; f i n a n c i a l 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.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 - 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).
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 among others, are legitimate forms of games (13)   .

IMPLICATIONS FOR NURSING
Playing/toys can be used to help the children 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.
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.
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, 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, Playing in the waiting room... Pedro ICS, Nascimento LC, Poleti LC, Lima RAG, Mello DF, Luiz FMR.Rev Latino-am Enfermagem 2007 março-abril; 15(2):290-7 www.eerp.usp.br/rlae Playing in the waiting room... Pedro ICS, Nascimento LC, Poleti LC, Lima RAG, Mello DF, Luiz FMR.