Lúdico no cuidado à criança e ao adolescente com câncer: perspectivas da equipe de de enfermagem

Objetivo: Descrever a perspectiva da equipe de enfermagem sobre a utilizacao do ludico no cuidado a crianca e ao adolescente com câncer hospitalizada. Metodologia: Pesquisa descritiva exploratoria de abordagem qualitativa, realizada entre agosto de 2013 e julho de 2015, com 29 profissionais de enfermagem de uma Unidade de Internacao Onco-hematologica de um Hospital Pediatrico do Sul do Brasil. Os dados foram coletados por meio de entrevistas semiestruturadas, analisados e categorizados segundo Minayo, constituindo-se duas categorias, sendo apresentada aqui a segunda categoria denominada "no cuidar eu aproveito para brincar: tornando o hospital mais agradavel". Resultados: Os profissionais relataram a vivencia do ludico no cotidiano da enfermagem, enfocando seus beneficios, dificuldades e possibilidades no cuidado. Conclusao: Salienta-se que o ludico e uma ferramenta indispensavel para o cuidado, contudo necessita de maior preparacao teorica e pratica para efetiva-lo e vivencia-lo como uma estrategia de cuidado.


INTRODUCTION
Diseases and hospitalizations affect the entire family, resulting in difficult moments that involve developments and setbacks.These moments can become traumatizing experiences for children and adolescents, as they undergo several changes in their routine, such as the family environment, school and friends; suffer from restrictions; are the target of several invasive, uncomfortable and painful procedures; and encounter new and unknown experiences that arouse feelings of fear, anger, insecurity and uncertainty, among others 1,2 .
Changes in the life of sick children and/or adolescents and their families require readapting to a new situation.Additionally, their reactions will depend on the characteristics and complexity of the disease, as it causes families to restructure their routine and learn how to care for their son/daughter and themselves again.When this experience results from cancer, such issues involve an even broader scope of child, adolescent and family care, as this disease and treatment encompass certain specific aspects that are constant and intense at times 3 .
Thus, the use of playful activities is an important tool for health professionals involved in care to minimize the effects of hospitalization, as this is essential to help one overcome the negative aspects inherent in cancer.Playful activities in the hospital environment are a catalyst in the adaptation process, as they seek to achieve joy, entertainment and the creation of a more pleasant environment, promoting the integration among health professional, child, adolescent and their family, in addition to shifting the focus from the disease, even if momentarily, thus helping them to adapt to and face the health-disease process and hospitalization 4,3 .
Consequently, the benefits of playful activities stand out in the sphere of pediatrics, especially in oncology, in the sense of improving the way disease and hospitalization are handled and promoting the bond between child, adolescent, family and nursing staff.However, we could observe that the routine nursing practice of care for hospitalized children and adolescents with cancer rarely uses such resources.
This study is justified by the possibility of identifying aspects in the nursing routine that are associated with playful activities in health care for hospitalized children and adolescents with cancer.There is a gap between theory and practice, as professionals sometimes know and recognize the importance of these resources, although they rarely use them.We hope to contribute to nursing care, with the purpose of increasing the use of playful activities, as their positive effects have already been described in the literature.Therefore, the present study aimed to describe the perspective of the nursing staff on the use of playful activities in health care for children and adolescents with cancer throughout their hospitalization.

METHODS
A descriptive exploratory study with a qualitative approach was performed in an onco-hematology inpatient unit of a pediatric hospital in Southern Brazil, which includes several specialties and is a model hospital in its state that provides care for children and adolescents with onco-hematological disorders 5 .
Participants' selection was intentional, comprised of nursing professionals from this unit who were directly involved with child, adolescent and family care.The following inclusion criteria were used: to have an employment relationship with the institution and to be working in the Onco-Hematology Inpatient unit at the moment of data collection.
A total of 31 nursing professionals from both the day shift and night shift met the inclusion criteria.Of these, 29 participated in this study: six nurses, 18 nursing technicians and five nursing assistants.It should be noted that one nursing professional was on a sick leave and another refused to participate in this study.
Data collection was performed through semi-structured interviews between August 2013 and July 2015.After the Informed Consent Form was signed by participants, the audio was recorded at a reserved location in the institution, lasting 40 minutes on average.The guidelines followed were divided into two parts: the first one characterized participants, including questions about age, sex, level of education, occupation, length of time of work in the institution and number of employment relationships; and the second one included guiding questions about playful activities as a nursing care strategy for hospitalized children and/or adolescents with cancer.
Regarding data analysis, using Thematic Analysis, which starts with a pre-analysis, when the data collected through interviews was organized, followed by material exploration, when these data were codified and categories and sub-categories were grouped through the assimilation of concepts associated with the elements and ideas of the proposed study.Finally, treatment and interpretation of results were performed 6 .
The present research project was approved by the Research Ethics Committee of the hospital in question, under number 031/2013 and official opinion number 396,589 of Plataforma Brasil database.Professionals' anonymity was maintained as their real names were replaced by names of toys, games and characters selected by them, followed by their professional category.

RESULTS
A total of 29 nursing professionals participated in this study, of which six were nurses and 23, nursing technicians.All those interviewed were females.Mean length of time of work in the unit ranged from three months to 23 years; 11 had two employment

Playful in pediatric oncology
Marques EP, Garcia TMB, Anders JC, Luz JH, Rocha PK, Souza S relationships and one had three or more.In addition, mean age was 34.5 years, varying between 22 and 50 years.
Based on the interviews with nursing professional, two categories were formed, although only one was described in this study: "When providing care, I take advantage to play, allowing the hospital environment to be more agreeable", revealing the experience of playful activities in the nursing routine, focusing on its benefits, difficulties and possibilities when caring for children and adolescents with cancer.
Nursing professionals showed their reality with regard to the use of playful activities, varying between being often used, sometimes used and not used at all, as observed respectively in their dialogues:

Yes, I use them a lot. (Cinderella, nursing technician) I use them whenever possible, because we usually can't, but when it's possible, we do it. (Magali, nursing technician) I've never had this experience. (Hello Kitty, nurse)
Based on participants' speech, playful activities were identified as a tool that can: turn the care process into a less traumatic experience, even when dealing with all their routine tasks; generate a bond between child, adolescent, family and health professional; reduce children and adolescents' fear of health professionals; allow the family to be involved; and enable the work environment to be more pleasant.This could be observed through the following reports:

This makes children feel they're receiving care, it makes them feel better. (Galinha Pintadinha, nursing technician)
Children come here and they get afraid, especially in the beginning of the treatment, they're afraid of us, they're afraid of everything [..

.], so we need to change this and playful activities help a lot. It's much easier once they begin to trust us. (Barbie, nursing technician) When they are undergoing a painful procedure and professionals also play, this reduces pain and suffering. (Snow White, nurse)
In the perception of nursing professionals, when playful activities are included in the care routine, there is a change in the mood caused by a smile on the face, the recurring satisfaction, and the joy experienced, resulting in positive responses to treatment, apart from reducing the negative feelings generated by the clinical picture, "strange" environment and pain, an aspect revealed in Sponge Bob's report: They're happy and this increases their immunity and helps fight the disease.The organism itself does this.Especially among adolescents, this is also important, because they get sad and depressed, it's harder for them because they know what they're losing, they're more aware of this disease.So, if we can change the environment and shift the focus, I think this is very important, because we see such great improvement!(Sponge Bob, nursing technician).
Additionally, nursing professionals also mentioned that playful activities create a bond between professional, child, adolescent and their family, as observed in the following reports:

Because we can only win a child over through this [playful activities]. There's no other way to get closer to them, only through such activities. (She-Ra, nursing technician)
I think this ends up bringing the child and professional closer together, so this professional can get into their little world for a while and so they can accept nursing care, medications and this situation more easily.(Hide-andseek, nursing technician)

When you work in this way, it's easier to bring family and children closer together. (Uniqua, nursing technician)
Through playful activities, children and adolescents can change the way they see a health professional, from a stranger who invades their privacy to someone who cares for them by playing, helping them to cope with the health and disease process.

They [the children] are suspicious of us, mostly because of the venipunctures. So, they associate us with pain, people who make you suffer and cry. This is quite depressing, we wouldn't like to be seen like that. (Mônica, nursing technician).
As playful activities facilitate the hospitalization of children and adolescents with cancer, their positive effects can also be seen by the family, who feel included, accepted and strengthened, because they undergo countless changes due to their son's/ daughter's health-disease process.

I think caring becomes lighter for both the children and those accompanying them, sometimes the treatment is not so hard or tiring for these children, but it is for these people, who end up interfering with them. (Spider Man, nurse)
Playful in pediatric oncology Marques EP, Garcia TMB, Anders JC, Luz JH, Rocha PK, Souza S Acceptance, even from mothers, is different, it's better.They see that we're truly trying to win the children over and so the mothers begin to trust us, really trust us!(Barbie, nursing technician).
Moreover, the data showed that the benefits can also be experienced by the nursing professionals, as playing while caring enables them to feel grateful and happy.This is because children and adolescents recognize this unique care that softens the hospital environment, a place where there are inner conflicts at times due to the daily failure and perspective of death.The following reports revealed this: Even though they understood the benefits that playful activities bring not only to the children and adolescents, but also to their family and even health professionals themselves, participants recognized that there are innumerable barriers that hinder and even prevent the use of this tool in their routine.
In their view, the main problem that hinders the use of playful activities is time, or rather lack of time: At times, we have little time for everything we would like to do.Things are very busy, patients need much medication and care, so I think our time is a little short for this.(Buttercup, nursing technician)

I think the greatest difficulty we have is time. We have willpower, because I think they [patients] inspire us to do this. But the main problem is the time you need and can't commit to. (Tasha, nursing technician).
This obstacle is associated with innumerable others that, when put together, have a negative influence on playful care, among which the great demand for care in the Oncology Unit should be emphasized.This reality interferes with the care routine, causing nursing professionals to be more distant from the experience of playful care, stifling their creativity and causing them to feel tension and fear that, added to the onco-hematological environment, interfere with nursing care planning in terms of bringing something new and playful to the daily routine.

To me it'd be essential to have time, because we work on something while thinking about what's next, like medication and care, so you stick to this routine and don't have any spare time. I can see that we sometimes have time, but we're so used to our service that we sometimes forget to do something different to entertain children. (Ferris wheel, nursing technician).
Apart from these aspects, there is the lack of materials and resources for playful activities.

Now we have a playroom which is very limited, there isn't much there. (Minnie, nursing technician).
Another aspect found to hinder the use of playful activities was the small number of nursing team professionals.Participants pointed to a lack of personnel, given the complexity and specificity of the Onco-Hematology Unit.

There are days when we basically give the kids their meds, but no attention at all. It's a bit complicated, but I think it's because there aren't enough workers. (Ferris wheel, nursing technician) Maybe if we had an adequate number of nurses, we could use this strategy better. (Snow White, nurse).
The issue of the night shift time was also considered to be an obstacle, as children and adolescents are asleep most of the time, reducing the possibility of interaction and use of playful activities.

At night, I can't always use playful activities, they usually go to sleep early. So we end up not doing this. (Tinkerbell, nursing technician)
Another challenge for the use of playful activities is the moment children and adolescents are experiencing, in other words, the stage of the disease itself, the hospitalization, the personality, the culture, i.e. intrinsic factors of each child and adolescent.Aiming to better illustrate and understand the perception of nursing professionals, these moments are emphasized individually as follows: Some children and adolescents cannot get into the world of imagination:

Playful in pediatric oncology
Marques EP, Garcia TMB, Anders JC, Luz JH, Rocha PK, Souza S At some moments, adolescents have less interaction with the social environment and specific interests, especially due to the current individualistic technological era: Teenagers are more rebellious and don't usually get in touch or speak much.(Carocha, nursing technician) Adolescents seem to pay more attention to individual technology these days.(Snow White, nurse) The clinical condition of children and adolescents can also hinder the use of playful activities:

When children are feeling very sick or unconscious, we obviously end up not using this much, we have little contact. (Carocha, nursing technician)
In addition, another obstacle that affects this use is the nursing professionals' lack of qualification and the resulting lack of knowledge about this theme.

This term wasn't very popular when I was in university. (Strawberry shortcake, nurse) I didn't see the theory behind this, we didn't study this. (Beauty, nursing technician) I don't know... It was the first time I heard about this [playful activities] I know very little about this. What exactly is this? (Rapunzel, nursing technician) You got me! I don't know [what playful activities are]. [...] It's not a word we use in our routine. (Hide-and-seek, nursing technician)
Another difficulty pointed out as a limiting factor for the use of playful activities is associated with the personality of professionals and affinity with the area of pediatrics.The following reports revealed this:

I'm not cut out to be in pediatrics, I think I have an adult profile. And children are different. (Minnie, nursing technician) It's not that people don't work or treat children well, it's just their personality. (Fiona, nursing technician)
After nursing professionals revealed the difficulties for the use of playful activities in health care, they described means that can promote playful care.One of the main points, regardless of level of education, was the need for a qualification process, when they could grasp not only the theoretical aspects, but also understand questions about child and adolescent psycho-biological development according to their health and disease condition, aiming to provide effective playful care: Given the magnitude of care for children and adolescents with cancer, professionals frequently choose not to have sufficient time for the development of any playful activities, often creating a mechanical work environment.Thus, they emphasized the importance of an adequate number of professionals to meet the work demand, considering the complexity of children and adolescents undergoing cancer treatment, varying from intermediate to semi-intensive care.If this proposal was achieved, they say they would have more time to provide playful care: I'd be good to have a technician for every one or two patients, for example, and time available for them to play, talk, watch and paint.So, if we had the opportunity, this would certainly improve things and, depending on the situation, even lower the risk.Actually, not the risk, but the hospitalization and recovery time, especially for patients.(Gloria from Madagascar, nursing technician)

Maybe a training program or a specific qualification course would be more interesting, because what we do
Resources are another strategy that can enable playful care, in terms of adequate work materials being available for children and adolescents, such as stethoscopes with child themes, chemotherapy infusion equipment with popular characters in the media, and dolls to explain procedures and diseases.This would help professionals, as such materials are ready to use: Maybe if we had a doll here, something washable that we could be using more.(

Minnie, nursing technician)
There are also the boxes.I brought the chemo bags.

Playful in pediatric oncology
Marques EP, Garcia TMB, Anders JC, Luz JH, Rocha PK, Souza S Considering the fact that playful activities are not part of routine care, nor are they recommended, the proposal of regarding such activities as "required care" was made, so that professionals would have the responsibility of providing playful care as something intrinsic.

I think it's your job to work on this [playful activities]. [...]
We've never done it, like, "Hey, let's do it!Let's put this into practice!".[...] I think the question is that we never stopped to do this.So, I think that if we managed to implement this, it would work out.(Strawberry shortcake, nurse) We must use this here.It's essential, we have to do it.(Carocha, nursing technician)

DISCUSSION
One of the main benefits of playful activities is to provide care without trauma, a way to minimize inner and outer suffering experienced throughout hospitalization, contributing to the maintenance of one's physical and emotional balance [7][8][9] .
Playing in itself is pleasurable and joyful, apart from bringing back the feeling of being a child/adolescent, which reduces fear, organizes one's feelings and calms one down during hospitalization 2,6,7,[10][11][12] .In this sense, playful activities are considered as a means to recover the neurological, endocrine and immunological imbalance caused by aggressors involved in hospitalizations, improving one's capacity to respond to treatment and, consequently, to overcome this disease 2,13 .
The literature corroborates professionals' speech about the importance of playful activities for children.The present study mentions the value of understanding playing as a key aspect in child care.Furthermore, it emphasizes the fact that playing is part of being a child, an essential aspect for their mental, emotional and social well-being.Thus, playing must continue when children fall ill or are hospitalized, just like other needs for development that cannot stop 14 .
The particularities of children with cancer must also be taken into consideration, as the treatment itself reduces their immunity.For this reason, children often stay in isolated rooms or interact with each other very rarely.This results in feelings of loneliness, in an environment that children are not familiar with and where there are only adults who are not always available or willing to play or interact with them.In view of what has been described and understanding the importance of the relationship aspect of hospitalizations, playing can help this process, providing an opportunity of closeness and interaction among hospitalized children with cancer 15 .
However, the benefits reported are not restricted to the children.Similarly to what professionals mentioned in their reports, families must also be seen and included in nursing care.A study performed with children and parents in two oncology services in Portugal found that these parents revealed a lower quality of life associated with health than that reported by children.This fact is related to the stress, concern and weariness experienced by parents of children diagnosed with cancer 16 .
When using playful activities, nursing professionals not only come closer to children and adolescents, but also their families, forming a bond and breaking barriers between them.In this sense, professionals can become familiar with the reality of each individual and their current needs and anxieties, enabling care to be physically and emotionally comprehensive and complete 2,10,17 .
Thus, professionals themselves agree that playful care is an instrument that supports this process, as it connects professionals and those accompanying patients, it allows the routine in the units to be more bearable and it shows its value.Consequently, nursing care is more accepted by families, who understand the commitment of professionals to provide comprehensive care.This shows the families' view of playful activities, i.e. an important component of nursing care, as they see that their children are being cared for adequately, allowing them to feel safer with the nursing staff 12,18,19 .
For nursing professionals, the use of playful activities strengthens their job satisfaction, as it enables the work environment to be more agreeable and as they are recognized by those cared for them, i.e. patients and their families 7 .
On the other hand, even considering the benefits resulting from the use of playful activities, there are obstacles that hinder playful care in practice, as observed in the interviews.In the nursing routine, the justification for lack of time has always been one of the main problems for different practical contexts.Several authors mention the lack of time, apart from the inadequate number of professionals, lack of qualification and insufficient resources associated with it, as the main obstacle for them to provide increasingly better care that takes into consideration all child and adolescent needs 3,7,20 .
Thus, we should emphasize the need for better technicalscientific preparation of nursing professionals to provide care to the families of children undergoing treatment, in addition to the greater effort that must be made by institutions to restructure inpatient units, aiming to improve infrastructure and to qualify professionals for more humane care.However, the difficulties found should not be a reason for children to be prevented from the right to play and receive more affectionate and humane care 21 .
In this sense, considering the fact that playful activities are not part of routine care, nor are they recommended, the proposal of regarding such activities as "required care" was made, so that nursing professionals would have the responsibility of providing playful care as something intrinsic.
Presenting the solutions offered by nursing professionals and, in this sense, broadening the view of this theme and encouraging those working in the area of pediatrics to think about strategies, allows them the opportunity to change the current Playful in pediatric oncology Marques EP, Garcia TMB, Anders JC, Luz JH, Rocha PK, Souza S reality of their workplaces.It is understood that changes not only depend on professionals, but also on institutions, in the sense of hiring an adequate number of professionals and purchasing suitable materials.Apart from promoting qualification courses and understanding that the use of playful activities is as important for children and adolescents as other types of nursing care 22 .
Despite the difficulties encountered, the successful experiences with playful activities showed the importance of their implementation by pediatric nursing in the hospital context.In this perspective, playful care enables the hospital environment to change, as there is a proximity with the child context, providing a positive strategy to cope with situations resulting from the cancer process, thus overcoming the barriers of disease.

FINAL CONSIDERATIONS
The present study emphasizes the fact that playful activities are a key instrument in nursing care for children and adolescents with cancer.The data found in this study show that such activities can be primarily used in two ways: as a facilitator for children and adolescents to experience different situations in view of their disease and hospitalization; and as specific care, considering the importance of playing for children and adolescents, thus being as essential as other types of nursing care.
However, it should be emphasized that playful care is a strategy that values the development process of children and adolescents with cancer and their well-being.Furthermore, using playful activities in the routine practice is in accordance with the comprehensive child/adolescent care approach that emphasizes the humanization of health.Additionally, such activities can be experienced in different areas of pediatric nursing, exploring the creativity of professionals and providing the benefits of playful care.
Difficulties were found in the use of playful activities in nursing care.Nonetheless, the present study provided some possibilities that can contribute to the transformation of such reality.One of the challenges of nursing care is to overcome the dichotomy between care and playful activities, because, although professionals understand and affirm that such activities are a care strategy, they often have a limited view of how to incorporate this into nursing care.
flows better, because children don't look at you in a desperate way, you're there to help them and play with them [...].Work is more pleasant and satisfying.(Fiona, nursing technician).You get into their world and this doesn't only make them feel good, it makes the team feel good, we get happy and so do they.So, it's entirely positive.(Barney, nursing technician).