Abstract

The benefits of therapeutic play (TP) in pediatrics are widely reported in the literature, however its use by health professionals is still limited. The objective was to understand how professionals belonging to the BrinquEinstein group evaluate the process of systematic implementation of TP in hospital pediatric units. Exploratory study, with a qualitative approach, developed in the pediatric and intensive care units of extra-large general hospital in São Paulo. The sample consisted of 13 professionals from different categories belonging to BrinquEinstein. Data was collected through individual semi-structured and audio-recorded interviews, being analyzed based on the Inductive Thematic Analysis proposed by Braun and Clark. From the analysis of the interviews, five themes emerged: experiencing a transforming process; the benefits that strengthen the path; the facilities that encourage the walk; the barriers that challenge the process; the future prospects. For the interviewed professionals, it is essential that the use of TP becomes a routine practice in different contexts of the child´s healthcare, in which managers and institutions play a fundamental role in its implementation.

Key words:
Child; Hospitalization; Humanization of Assistance; Health Personnel

Introduction

The advantages of using therapeutic play in pediatric care are widely disseminated in the literature, which highlights their importance for children, recommending the systematic inclusion of this practice in pediatric care units. However, most institutions do not include the use of this playful strategy in their protocols¹1 Veiga MA, Sousa MC, Pereira RS. Enfermagem e o brinquedo terapêutico: vantagens do uso e dificuldades. Rev Eletron Atualiza Saude2016; 3(3):60-66..

The evidence supports the application of TP in the care of hospitalized children, positively impacting on the reduction of anxiety and fear, not only for them, but also for their families, contributing to the development of more humanized nursing care²2 Sousa CS, Barreto BC, Santana GA, Miguel JV, Braz LS, Lima LN, Melo MC. O brinquedo terapêutico e o impacto na hospitalização da criança: revisão de escopo. Rev Soc Bras Enferm Ped 2021; 21(2):173-180..

The World Health Organization recognizes play in hospital as a child’s right and stresses that the provision of recreational play and its therapeutic use by professionals is an attribute of quality care³3 World Health Organization (WHO). Standards for improving the quality of care for children and young adolescents in health facilities [Internet]. Geneva: WHO; 2018 [cited 2023 abr 8]. Available from: https://www.who.int/publications/i/item/9789241565554..

Some of the factors that hinder the inclusion of TP and play in clinical practice by the nursing and interdisciplinary team are: lack of time, overload of activities and the work context, which often doesn’t value the initiative or provide the conditions to carry it out⁴4 Chiavon SD, Brum CN, Santos E, Sartoretto EA, Zuge SS, Gaio G, Trentin PA, Potrich T. Utilização do brinquedo terapêutico para a criança que vivencia o processo de hospitalização: uma revisão narrativa. Braz J Health Rev 2021; 4(1)382-398.^,55 Claus MIS, Maia EBS, Oliveira AIB, Ramos AL, Dias PLM, Wernet M. A inserção do brincar e brinquedo nas práticas de enfermagem pediátrica: pesquisa convergente assistencial. Esc Anna Nery 2021; 25(3):e20200383..

Considering the situation of the implementation of TP in a pediatric hospital unit, some questions arose that guided this study: What is the perception of health professionals about the process of implementing TP in the BrinquEinstein program? What facilitating factors and barriers do they identify in relation to its use in hospital practice with children?

One of the initiatives adopted in the process of implementing TP was the training of professionals working in the pediatric hospital unit and the formation of a reference group for the use of TP (BrinquEinstein), with the aim of equipping the team to incorporate this proposal into their care⁶6 Miranda CB. Modelo de implementação sistemática da prática de brinquedo terapêutico em unidades hospitalares pediátricas [dissertação]. São Paulo: Faculdade Israelita de Ciências da Saúde Albert Einstein, Instituto Israelita de Ensino e Pesquisa Albert Einstein; 2022.. Knowing how this TP implementation experience was perceived by these professionals can contribute significantly to outlining future improvements in the continuity of this process.

Thus, the study aims to understand how professionals who are members of the BrinquEinstein group evaluate the process of systematically implementing TP in pediatric hospital units, outlining the facilitating factors and barriers in this process.

Method

This is an exploratory study with a qualitative approach, carried out between November 2020 and April 2022. The data presented comes from a master’s thesis whose objective was to develop a model for the systematic implementation of TP in pediatric hospital units⁶6 Miranda CB. Modelo de implementação sistemática da prática de brinquedo terapêutico em unidades hospitalares pediátricas [dissertação]. São Paulo: Faculdade Israelita de Ciências da Saúde Albert Einstein, Instituto Israelita de Ensino e Pesquisa Albert Einstein; 2022..

The study was carried out in a pediatric hospital unit, including the respective wards and the intensive care unit (ICU) of a general hospital in the city of São Paulo. The sample consisted of 13 professionals, 8 of whom were nurses, two nursing technicians, a pedagogue and two toymakers, most of whom were women, who work in these units and are members of the TP reference group, called “BrinquEinstein”.

The systematic implementation of TP in the institution began in the two aforementioned units and followed the stages of the PDCA tool, which involves the following steps: Plan, Do, Check and Action⁷7 Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. Modelo de Melhoria: Uma abordagem prática para melhorar o desempenho organizacional. Campinas: Mercado de Letras; 2011.. In the “Do” stage, staff were trained to use the TP in clinical practice: nurses, nursing technicians, psychologists, toymakers, physiotherapists and a psycho-pedagogue, with a total of 44 participants. Those who showed the greatest interest in using TP in practice were invited to join the reference group, a total of 28 professionals⁶6 Miranda CB. Modelo de implementação sistemática da prática de brinquedo terapêutico em unidades hospitalares pediátricas [dissertação]. São Paulo: Faculdade Israelita de Ciências da Saúde Albert Einstein, Instituto Israelita de Ensino e Pesquisa Albert Einstein; 2022.^,88 Almeida FA, Miranda CB, Maia EBS. Implementação do Brinquedo Terapêutico em unidades pediátricas hospitalares: Perspectiva dos profissionais de saúde integrantes do BrinquEinstein. New Trend Qualitative Res 2022; 13:e-70.^,99 Miranda CB, Maia EBS, Almeida FA. Modelo de implementação sistemática do brinquedo terapêutico em unidades pediátricas hospitalares. Esc Anna Nery 2022; 26:e20220136..

Data was collected through a semi-structured, individual, audio-recorded interview, which lasted an average of 40 minutes. The following guiding questions were used to conduct the interview⁶6 Miranda CB. Modelo de implementação sistemática da prática de brinquedo terapêutico em unidades hospitalares pediátricas [dissertação]. São Paulo: Faculdade Israelita de Ciências da Saúde Albert Einstein, Instituto Israelita de Ensino e Pesquisa Albert Einstein; 2022.^,88 Almeida FA, Miranda CB, Maia EBS. Implementação do Brinquedo Terapêutico em unidades pediátricas hospitalares: Perspectiva dos profissionais de saúde integrantes do BrinquEinstein. New Trend Qualitative Res 2022; 13:e-70.: What has it been like for you to experience the process of implementing TP in pediatric units? How do you perceive your role as a member of the “BrinquEinstein” TP reference group?

The fully transcribed interviews were analyzed according to the precepts of Braun and Clark’s Inductive Thematic Analysis (apud Souza¹⁰10 Souza LK. Pesquisa com análise qualitativa de dados: conhecendo a Análise Temática. Arqu Bras Psicol 2019; 71(2):51-67.), consists of six phases: a) familiarization with the data, based on transcribing and reviewing the data, reading and re-reading; b) generation of initial codes with the aim of systematically coding the outstanding aspects of the discourses; c) gathering the codes into potential themes and all the data pertinent to each potential theme; d) reviewing the themes by checking their functionality in the extracts and the database; e) defining and naming the themes, refining the details of each theme and the story told by the analysis; and f) producing the report with the examples experienced by the participants, considering the relationship between the extracts chosen and the research question.

The data was analyzed at the same time as it was collected. The transcribed interviews were carefully read to identify the initial ideas, looking for meanings and familiar patterns in the text. Codes were created to identify them, grouped into potential themes, reviewed and refined in search of coherence throughout the data set. All themes and codings were discussed and confirmed by the research team⁸8 Almeida FA, Miranda CB, Maia EBS. Implementação do Brinquedo Terapêutico em unidades pediátricas hospitalares: Perspectiva dos profissionais de saúde integrantes do BrinquEinstein. New Trend Qualitative Res 2022; 13:e-70..

The preparation of this study followed the recommendations for preparing qualitative research from COREQ (Consolidated Criteria for Reporting Qualitative Research)¹¹11 Souza VR, Marziale MH, Silva GT, Nascimento PL. Tradução e validação para a língua portuguesa e avaliação do guia COREQ. Acta Paul Enferm 2021; 34:eAPE02631.. The project was approved by the Research Ethics Committee of the proposing institution, under number 4.376.155 (CAAE: 38581120.6.0000.0071).

Results

Thirteen members of the BrinquEinstein reference group took part in the study, the majority of whom were female (92.3%) and members of the nursing team (76.9%). The time they had been working in pediatrics ranged from two to 24 years and 69% of them had been working in this area for more than 10 years. The majority received theoretical information about TP during their undergraduate studies (61%), while 23% had the opportunity to use it during their practical academic activities.

From the analysis of the interviews, five themes emerged which represent the perspective of BrinquEinstein members on the TP implementation process. These themes will be described below, accompanied by excerpts from the participants’ speeches, identified in the text with the letter A and an Arabic numeral, which represents the interview number (A1, A2, A3...).

Experiencing a transformative process

This theme shows how taking part in the process of implementing TP was transformative for the professional, who began to perceive himself as a better person, becoming more empathetic and involved with the emotional issues that permeate care:

A nurse who worked in the ICU recounts her experience of using TP, being delighted with this new possibility and starting to use it and encourage its use by her colleagues:

Another transformative aspect for the professional was the opportunity to broaden his knowledge through the exchange of information between team members and participation in training activities, helping him to better understand children’s play:

The benefits that strengthen the path to effective use of TP

The benefits obtained from implementing TP are recognized by the professionals as being related to themselves, the child and their family.

As for the benefits for the professional, there are many relevant aspects. One professional said that once the process of implementing the TP had started, he felt closer to the child and their family, strengthening the bond with them, as well as feeling gratified by the positive results obtained.

For the professional, some daily activities can now be carried out more easily, more safely and in less time, especially when carrying out procedures:

When they start using TP, professionals report that they sometimes feel more valued and recognized in the sector they work in, because they are able to ease the anxiety of the family and the child.

The benefits seen by professionals in relation to the gains for the child and their family from using TP are many, culminating in the perception of an improved hospital experience for both:

The speeches revealed how the use of TP provides a welcome in moments of suffering and estrangement, increasing the child’s trust in professionals and having a positive impact on their recovery:

The facilities that drive the TP implementation journey

Among the factors driving professional performance in the use of TP, the following stand out: the formation of the BrinquEinstein reference group, the establishment of a WhatsApp communication channel between members of this group, staff training and support from the institution.

For one of the participants, the creation of the BrinquEinstein group was “a watershed” for the consolidation and strengthening of the TP implementation process at the institution:

The speeches showed how the involvement of the multidisciplinary team can enhance childcare actions with different perspectives to achieve a certain common goal. One participant reported that he felt encouraged when he learned that the people on duty would continue with the play proposal he had developed for the child:

Training the entire team to use the TP was a facilitator during its implementation, as it broadened the professionals’ perception of the value of this initiative. By covering the different work shifts, it helped the whole team to “speak the same language”, increasing their commitment to applying the TP in the unit:

One participant highlighted the importance of the support offered by the nurse leader of the TP implementation project when she began to apply it in her clinical practice:

The support of the institution’s board of directors and managers and the consequent recognition of the work carried out with TP, which was also pointed out as a facilitating factor in its implementation, came from the praise of the children’s families referred to the SAC (Citizen Service) and the actions awarded at the institution:

The availability of hospital materials provided by the institution itself and the acquisition of toys for TP was also a facilitating factor during implementation:

The barriers that challenge the TP implementation process

With regard to the barriers that have been imposed on the process of implementing TP, we would highlight the persistence of its lack of appreciation as a care action by some professionals, associated with work overload, especially in the ICU:

Regardless of the sector in which they work, whether in pediatrics or the ICU, the professionals recognize that the team still doesn’t see TP as a priority in care:

Other barriers identified by professionals working in the ICU refer to the difficulty of applying the TP when the child is admitted, due to clinical instability and parental tension, or when the child develops limitations in playing:

Another issue identified as a barrier refers to the position of parents/family members in relation to the TP activity. Professionals perceive a lack of knowledge on the part of the child’s companions regarding the objectives of using TP in hospital and its benefits:

The work shift was also identified as a barrier to performing TP, as it becomes more difficult to apply it with the child at night.

Despite the availability of toys, often obtained by the BrinquEinstein nurses themselves, and the hospital materials offered by the institution itself for the application of TP in the sector, the lack of material was pointed out as a barrier, due to the need for a diversity of toys to meet the different needs of the child.

The professional considers it difficult not only to implement TP, but also to ensure that the practice is maintained.

Establishing future prospects

This theme covers the expectations of the professional regarding the implementation of TP, such as the expansion of its use to other sectors of the hospital and external units of the institution.

There was evidence of the participant’s motivation to expand the TP implementation process as a model for other institutions.

The professionals also expressed concern about the continuity of the BrinquEinstein group and pointed to the implementation process as a motivator for the participation of other professionals from the multi-professional team.

The professionals point out the importance of the BrinquEinstein group continuing to invest in training employees to use TP, with the prospect of increasing the number of people involved in this initiative, including the offer of distance learning courses.

The professional also believes it is important to make parents aware of the benefits of TP for the child and of the group’s work, proposing some strategies for this purpose.

Discussion

The findings of the study allowed us to identify that the process of implementing TP from the perspective of the professionals has proved to be successful and relevant to the integration and transformation of the interprofessional team, as well as to the satisfaction of the child and the family, by providing welcoming, humanized care centered on the pediatric patient, improving their experience when mediated by playful interactions.

In fact, play offers opportunities for interpersonal interactions that are attuned to a strong and trusting environment, resulting in a secure relationship between the players, in this case the child and the professional. This empathetic attunement is reflected in the personal relationship. When professionals are kind and sensitive to the feelings of others during play, there is resonance, an increase in oxytocin and the establishment of a social bond¹²12 Stewart AL, Field TA, Echterling LG. Neuroscience and the magic of play therapy. Int J Play Therapy 2016; 25(1):4-13.. These aspects were reported by the participants in this study.

This important gain characterizes one of the standards for improving the quality of care for children and adolescents in health units, as advocated by the World Health Organization (WHO), ensuring that their needs and rights are met, such as playing in health care scenarios and the right to be cared for by professionals qualified to do so³3 World Health Organization (WHO). Standards for improving the quality of care for children and young adolescents in health facilities [Internet]. Geneva: WHO; 2018 [cited 2023 abr 8]. Available from: https://www.who.int/publications/i/item/9789241565554..

As the implementation of the TP program progressed, the benefits recognized as strengthening the process gained prominence, such as the team’s finding that play strategies permeate the establishment of bonds, trust and greater closeness with clients. The children’s behavioral change in the face of the procedures was noteworthy, as they became more collaborative after playing. And the professionals, in turn, noticed a reduction in the time spent carrying out these procedures, increasing the chances of success and safety in their execution. These aspects are discussed in three systematic reviews¹³13 Silva RD, Austregésilo SC, Ithamar L, Lima LS. Therapeutic play to prepare children for invasive procedures: a systematic review. J Pediatr 2017; 93:6-16.

14 Rashid AA, Cheong AT, Hisham R, Shamsuddin NH, Roslan D. Effectiveness of pretend medical play in improving children's health outcomes and well-being: a systematic review. BMJ Open 2021; 11:e041506.^-1515 Godino-Iáñez M J, Martos-Cabrera MB, Suleiman-Martos N, Gómez-Urquiza JL, Vargas-Román K, Membrive-Jiménez MJ, Albendín-García L. Play Therapy as an Intervention in Hospitalized Children: A Systematic Review. Healthcare (Basel) 2020; 8(3):239. on the use of TP and its action in reducing anxiety and pain and improving children’s health knowledge.

A scoping review¹⁶16 Gjærde LK, Hybschmann J, Dybdal D, Topperzer MK, Schrøder MA, Gibson JL, Ramchandani P, Ginsberg EI, Ottesen B, Frandsen TL, Sørensen JL. Play interventions for paediatric patients in hospital: a scoping review. BMJ Open 2021; 11:e051957. identified that playful interventions have been used in four areas to support children: in situations involving procedures and diagnostic tests, in patient education, in treatment and recovery, and in favoring adaptation to the hospital environment. In another study¹⁷17 Zengin M, Yayan EH, Düken ME. The effects of a therapeutic play/play therapy program on the fear and anxiety levels of hospitalized children after liver transplantation. J Perianesth Nurs 2021; 36(1):81-85., are indicated as a non-pharmacological method due to their potential to reduce pain, fear, stress and anxiety as a result of painful procedures.

Still about the benefits of TP, the families’ perspectives have been explored in national¹⁸18 Aranha BF, Souza MA, Pedroso GER, Maia EBS, Melo LL. Using the instructional therapeutic play during admission of children to hospital: the perception of the family. Rev Gaucha Enferm 2020; 41:e20180413. and international¹⁹19 He HG, Zhu LX, Chan WC, Liam JL, Ko SS, Li HC, Wang W, Yobas P. A mixed-method study of effects of a therapeutic play intervention for children on parental anxiety and parents' perceptions of the intervention. J AdvNurs 2015; 71(7):1539-1551.^,2020 Yayan EH, Zegin M, Düken ME, Dag YS. Reducing children's pain and parents' anxiety in the postoperative period: A therapeutic model in Turkish sample. J Pediatr Nurs 2019; 51:e33-e38. studies and their results reiterate the power of this intervention to improve the healthcare experience of both child and family, a fact reiterated in this study.

The barriers initially identified by the professionals in this study to the implementation of TP in the unit, such as its lack of appreciation as a care action, especially in the context of intensive care, and work overload, are also highlighted in the literature. The overload of activities, the lack of time, material and an appropriate environment, the lack of knowledge and devaluation of play by colleagues and the institution are some of these barriers, as well as the failure to systematically include play strategies in the nursing process²¹21 Baldan JM, Santos CP, Matos APK, Wernet, M. Introduction of play/playthings in the assistance practice to the hospitalized child: nurses' trajectory. Cien Cuid Saude 2014; 13(2):228-235.^,2222 Maia EBS, La Banca RO, Rodrigues S, Pontes ED, Sulino MC, Lima RAG. A força brincar-cuidar na enfermagem pediátrica: perspectivas de enfermeiros em grupos focais. Texto Contexto Enferm 2022; 31:e20210170..

Despite the barriers to the use of TP, the results of its implementation are optimistic. There was a movement towards incorporating the planning of the TP practice into the team’s work routine and, in particular, the concern with systematization in the continuity of playful care. In this sense, it is worth highlighting the value of the information on how to do TP with children during the nursing team’s shift, which is also shared in the reference group. This action is important because it complies with COFEN regulations on the responsibility of the nursing team to incorporate TP into the nursing process²³23 Caleffi CCF, Rocha PK, Anders JC, Souza AIJ, Burciaga VB, Serapião LS. Contribuição do brinquedo terapêutico estruturado em um modelo de cuidado de enfermagem para crianças hospitalizadas. Rev Gaucha Enferm 2016; 37(2):e58131..

Studies²⁴24 Pedrinho LR, Shibukawa BMC, Rissi GP, Uema RTB, Merino MFGL, Higarashi IH. O brinquedo terapêutico na atenção primária: contribuições para a sistematização da assistência de enfermagem. Enferm 2021; 30:20200616.^,2525 Drayton NA, Waddups S, Walker T. Exploring distraction and the impact of child life specialists: Perception from nurses in a pediatric setting. J Spec Pediatr Nurs 2019; 24:e12242. reinforce the importance of systematizing playful care, since its structured implementation in a care model contributes to reducing the negative effects of hospitalization by fostering the establishment of bonds between the team and the child, stimulating a more active participation of the child in the coping process.

The plan put in place to overcome these barriers, such as training the interdisciplinary team and involving its members by forming an interdisciplinary reference group on play and TP was considered essential by the participants for the successful implementation of TP.

The importance of teamwork is emphasized in another qualitative study²⁶26 Conselho Federal de Enfermagem (COFEN). Resolução 546/2017 - Revoga a Resolução Cofen nº 295/2004 - Utilização da técnica de brinquedo terapêutico pela Enfermagem [Internet]. 2017 [acessado 2023 abr 8]. Disponível em: http://www.cofen.gov.br/resolucao-cofen-no-05462017_52036.html.
http://www.cofen.gov.br/resolucao-cofen-... , which discusses the perception of 18 Australian nurses in relation to the partnership established with Child Life Specialists in the use of distraction for children undergoing painful procedures. The results emphasize how beneficial this partnership was for them, who highlight the value of the integrated work of the interdisciplinary team.

The findings of this study reveal that, for the participants, the implementation process triggered a feeling of pride in the recognition of the work with TP developed in the sector by the institution. This has generated even more satisfaction among the employees involved in adhering to playful practices, including not only TP, but others, such as games and games that distract the child. In this context, one of the main expectations pointed out by the professionals is the expansion of the use of TP to other pediatric care sectors of the hospital and also to other health institutions in Brazil.

The study had an important limitation, related to the occurrence of the COVID-19 pandemic, which had a significant impact on the interviews with professionals who had experienced the implementation process. This was due to the fact that the team had to be resized, due to the high demand for adults affected by the disease and the reduction in hospitalizations of children and adolescents.

This context led to demotivation on the part of the group with regard to continuing to implement TP. However, as the pandemic stabilized in the city of São Paulo, the team of professionals returned to their activities in child and adolescent care. And surprisingly, they became interested in the practice of play and TP again.

Another issue to consider is that the study only looked at the perception of the TP implementation process of the members of the BrinquEinstein group. Future studies with the team’s professionals who are not yet part of this group could provide additional information, especially in relation to the barriers to the implementation of TP and strategies for dealing with them. Furthermore, the replication of this study in other institutional contexts and at different levels of health care can help consolidate these results on the implementation of TP in pediatric practice.

Final considerations

The study highlights the importance of integrating TP into the planning of care for children, due to the benefits resulting from its use. The implementation of this practice brought benefits for the children, who began to show reactions that showed greater acceptance and collaboration during the procedures, becoming calmer and understanding the hospitalization situation better. It also brought benefits to the professionals, such as an increased bond with the children and their families, as well as satisfaction in minimizing suffering and providing atraumatic care. There were also benefits for the family, who began to trust the performance of the healthcare team more, directing complimentary comments towards the customer service and the coordination of the service.

The professionals highlighted the feeling of recognition, as they were able to offer humanized care, a fact that served as a springboard for continuing the practice, as well as the involvement of more collaborators, who were interested in the results obtained.

It is essential that the use of the TP becomes a systematic practice in the different contexts of child health care. Unit managers, as well as institutions, have a fundamental role to play in implementing this practice, and it is up to them to identify the needs for its implementation, seek solutions and offer all the necessary support for its inclusion in care.

References

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