Perception of Health Care Workers Regarding Ludic Activities in Pediatric Hospitals

1. Introduction

It is notorious that games can be developed in the most diverse environments, including locations where medical services are provided to children. When a sick child gets to a hospital, it is crucial to commence treatment as soon as possible. However, as Vasconcelos (2006) shows, sickness is not the only priority, but the child as a whole. Cunha (2001), Fonseca (2008) and Mota and Silva (2005) demonstrate that, if pediatric hospitals employ a ludic practice, the benefits of the medical treatment towards the child could be positive not only for the child but also for the family accompanying it and the hospital’s multidisciplinary health care team.

Playing is part of human life at all times, places and in its several forms, to the point that games represent to the child what work represents to an adult (Cunha, 2001). It is the most memorable part of a childhood. Generally, adults have fond memories of their childhoods, with an emphasis on their preferred games and memories that bring out other memorable elements of the environment where they were born and raised. These include their friends, their street, the candy at the end of the day, the Sunday outdoor activities, their favorite music, art, dance, life as a child itself (Mota & Silva, 2005).

During childhood, playtime is the most anticipated moment for a child. According to Vasconcelos (2006), children play always and live in an imaginary world where reality and imagination intermingle. It is common for children to demand long lists of toys to their parents, since the more toys they can collect the better. A toy has the power to make them happier, and to put a smile on a tired or even down face due to sickness.

Notwithstanding, being sick, consulting a doctor and staying in the hospital are stressful and often traumatizing processes for a child. However, if the child is surprised by a ludic treatment upon arrival to the health unit, it will likely externalize its fears and concerns. In this sense, Mitre (2000) states that a ludic treatment contributes for the child’s distraction and, consequently, eases its permanence at the hospital, thus favoring its development and cure.

Infant hospitalizations impact the child through new experiences, which are often threatening. According to Mitre (2000), the feeling of finitude of life constantly afflicts the child and its family and, in a more direct way, those who accompany it during hospitalization. In this sense, the daily activities in the hospital are marked by the imminent fear of death, missing family members outside the hospital and the fear of new characters that stage this environment: nurses, doctors, psychologists, physical therapists, etc.

In the hospital bed, the child goes through a depersonalization process, that is, according to Camon (2005), it materializes a feeling of being a stranger to itself, an idea that its body or a part of it are not the same unit. This feeling originates in the way how the multidisciplinary health team treats the child, since it is no longer called by its name, but instead by its medical record number, room or disease.

Regarding the contributions of ludic activities at the hospital, Cunha (2008) states that games become a strong ally to the child, the family, and the multidisciplinary health team. Through these activities the child can remain psychologically ready to resist the challenges caused by the hospital environment.

According to Cunha (2008), playing may speed up the healing process for the sick child. For the author, children that play in the hospital have higher chances of recovery if compared to those that are not stimulated to play during hospitalization. In this way, the application of ludic resources can booster the recovery process and the child’s adaptation capacity given the imminent transformations since its hospital admittance. Employing ludic activities at the hospital contributes to reduce the stress, fear, anxiety, and pain caused by hospitalization, as playing makes children calm and adaptable to the new environment. In the hospital context, games must be perceived as an intervention instrument and a way for the child to collaborate in the medical treatment.

In this sense, here we investigate the perceptions of the multidisciplinary health team regarding ludic activities in pediatric hospitals of São Luís, Maranhão state, Brazil. We hypothesize that although health care workers perceive the relevance of such activities in public pediatric hospitals of São Luís, these activities are not systematic and therefore not consolidated in the sick child’s routine. Therefore, these ludic activities constitute laconic practices.

To answer this research problem, our study aimed at investigating the perception of multidisciplinary health professionals about the development of ludic activities in pediatric public hospitals of São Luís, Maranhão. In this sense, our specific objectives are to a) characterize the public pediatric hospitals in São Luís that develop ludic activities for hospitalized children; b) identify health care workers within the multidisciplinary teams that are responsible for carrying out ludic activities in the pediatric public hospitals of São Luís; c) verify how these activities are developed in the routine of the pediatric public hospitals of São Luís with hospitalized children; d) observe which ludic activities are being developed in the pediatric public hospitals of São Luís; e) understand potential difficulties and/or opportunities, as well as challenges faced by these professionals regarding operationalizing ludic activities in such facilities; f) describe the perceptions of such professionals regarding the relevance of ludic activities in these hospitals, as well as potential suggestions about their development.

Therefore, we emphasize that sick children can be attended through ludic activities in pediatric public hospitals, developing an intense knowledge exchange, partnerships, friendships, and self-motivation, which are relevant factors for recovery (Mitre, 2000).

This theme is relevant as it provides a description of how a child, while a developing human being, is being cared for in the public health system at Maranhão state’s capital. Once knowing how this child is attended to, actions could be articulated to improve such attendance, as preconized by the Constitution of the Federative Republic of Brazil (1988), the Statute of the Child and Adolescent (ECA) (Law n. 8.069/1990), Resolution nº 41 of the National Council for the Rights of Children and Adolescents (1995) of Hospitalized Children and Adolescents, National Education Base and Guidelines Law.

 

2. Methods

We developed an exploratory and descriptive research priming for a qualitative approach, in two pediatric hospitals of São Luís: Dr. Odorico Mattos, commonly known as Children’s Hospital located at the Franceses Avenue, Alemanha, São Luís, and the Infant Maternal Hospital, located at the Silva Jardim street, Downtown, São Luís.

We chose these locations not only for the high rate of attendances for children from the São Luís metropolitan area but also for being the largest public pediatric hospital of the São Luís municipality and the only federal hospital of Maranhão state, respectively. Additionally, they also develop ludic activities with hospitalized children and have toy rooms in their facilities, which enables the ludic to become an ally in the attendance process of the sick child.

Participants comprised eight workers from the multidisciplinary health care team, including two doctors, two psychologists, and two occupational therapists. Among these, six were women and two were men, with an average of six years of professional experience in pediatric hospitals.

The criteria for inclusion of the participants were: to integrate the multidisciplinary health team of the researched hospitals; be in the pediatric hospitalization sector; have at least six months experience at this sector. Exclusion criteria included not integrating the multidisciplinary health team of the researched hospitals; having less than six months experience in this sector, and not accepting to participate in the research.

Sampling instruments comprised of semi-structured interviews applied through a script with 9 questions approaching the following subjects: ludic activities performed with hospitalized children; the goals of such activities; the professionals that develop these activities; temporality; frequency and space for the development of ludic activities; hygiene of the toy and materials used for playing; risks associated with playing at the hospital; challenges to perform the ludic activities with children at the hospitals; main difficulties regarding the operationalization of such activities and their relevance at the hospital environment.

The data collection procedures were in accordance with the ethical standards for research involving human subjects. Our research was approved by the Scientific Commission of Research and Teaching (COMIC/HUUFMA) (nº 23523.006439/2016-18). We explained the study phases to the participants and their guaranteed rights. All of them signed a free and informed consent form agreeing to participate in this research and acknowledging that the results would be communicated through talks, conferences, and scientific journals with their preserved identities. Interviews were previously scheduled and occurred within the hospitals. All interviews were recorded and subsequently transcribed, categorized and qualitatively analyzed.

 

3. Results, Analysis and Discussion

Here we present the results, analyses, and discussions needed. Regarding the questionnaires not only about the ludic activities developed with hospitalized children but also about the experiences of participants at the studied area, four out of the eight workers of the multidisciplinary health team reported that the ludic activities carried out at the hospital contribute to the socialization and interaction of the child to its new environment. Three participants also stated that these activities are important for the recovery process of the child by optimizing disease treatment. Finally, one participant stated that these activities contribute to the child’s psychological equilibrium in the hospital.

Therefore, our data suggest that ludic activities developed with hospitalized children are important for the socialization and integration process according to the multidisciplinary health team, which is in accordance with Cunha (2008), Fonseca (2008) and Velasco (1996). Social isolation is inherent to a hospital. It is as if two worlds with distinct rules and ideas were created: the hospital world and the real world. The first is isolated by walls, which is the opposite of what the child knows, since in there it is obligated to refrain from social contact and integration with its peers. The second is its home, where it lives, and interacts with friends and toys. At the hospital even the number of visiting family members is limited (Mitre, 2000).

Therefore, ludic activities are bonding mechanisms between children sharing the hospital experience. Although it is possible to play by yourself, games are much more entertaining in a collective environment (Lima, 2014). Thus, the moment of approaching the other child essentially happens in the hospital through the ludic experiences during playtime.

The professionals from the multidisciplinary health team interviewed during this study highlighted that ludic activities are important in the recovery process of the child by optimizing disease treatment. This agrees with what Taam (2004) postulated by stating that children use play times as a way of making the hospitalization experience less traumatizing. In the case of the health care workers who assist the child, turning ludic activities into a technique to reduce the anxiety caused by both the disease and the hospitalization process.

In our context, the participants unanimously emphasized that ludic activities developed in pediatric hospitals corroborate with the psychological equilibrium of the child. In this sense, Paula et al. (2009) and Vasconcelos (2006) reinforce that ludic activities or just the act of playing contribute to the equilibrium development and give a new meaning to the emotions lived by children. Therefore, our data demonstrate the complexity involved in the ludic activities (Freidmann, 1966).

In this sense, such activities include plays, games, and toys, as well as several benefits to those who use it as a source of socialization, thus constituting an important technique in children’s recovery process as a way to optimize treatment and to their psychological equilibrium.

Regarding our second question, we asked the components of the multidisciplinary health team which ludic activities were developed with the children at the studied hospitals. Six workers reported expressive activities such as drawing, playing, painting, cutting, and collaging, while two mentioned rhythmic ones such as music, theatrical plays, and dances.

Given these facts, among the ludic activities developed with hospitalized children, we highlight expressive and rhythmic activities which include painting, drawing, dancing, music, etc.

In this regard, Mota and Silva (2005) reinforce that ludic activities are crucial for the inclusion of the sick child, since it uses drawing, dancing, and singing to demonstrate the child’s wishes and desires along the health-sickness process. It is worth mentioning Law nº 11.104 (2005), which treats the promotion of hospitalized playing.

In this sense, all staff engaged in assisting the child must not to refrain it from any of its rights, specifically that of playing, even if it is within the hospital (National Council for the Rights of Children and Adolescents, 1995).

We also verified the approximation and interaction of professionals and the children through games at the hospital. Additionally, the toy room provided a tender and respectful environment for the hospitalized children. Therefore, ludic activities are beneficial for the sick child, its family members and/or companions, as well as the medical staff that provide this moment to the child. In fact, according to Almeida (2011), collective playing is involving, making everybody strip themselves from the adult and become children for a while.

Regarding the motivation for developing ludic activities with hospitalized children, five of the eight medical staff interviewed stated that these are related to fighting and/or easing the stress caused by the hospitalization process for the children, the companions, and the health care workers. Furthermore, one reinforces that ludic activities help children accept the health procedures performed by the staff more easily, while another interviewee observed that ludic activities are meaningful for the child’s cognitive development, and another medical staff interviewed stated that these activities are equivalent to social interaction means for the children.

Therefore, our data demonstrate that ludic activities developed with hospitalized children aim at fighting or easing the stress caused by the hospitalization process, contributing to the health recovery process and to an easier acceptance of the necessary medical procedures, helping with the cognitive development of the children and, finally, enabling social interactions.

The hospitalization process is hard for a child since it is related to several losses and traumas. For the adult, hospitalization is not necessarily a choice but a decision that needs to be made for the child’s sake.

In the interviewees’ opinions, ludic activities should be fomented during the whole child’s stay at the hospital due to its therapeutical function. Thus, each child should be individually accompanied by a professional, respecting the policies that assure such individuality, which is the ECA in this case (Law n. 8.069/1990).

In this context, the hospitalized child has a higher acceptance towards the medical treatment if it goes through a certain level of playfulness since, according to Kishimoto and Friedmann (1998), in the hospital context, playing helps with the recovery of the sick child and the eases the psychological traumas caused by hospitalization.

For the multidisciplinary health staff, ludic activities are of the utmost importance for the child’s cognitive development because, as stated by Lima and Oliveira (2014), these enable the development of imagination, creativity, communication, social skills, memory, capacity of following rules, self-esteem, and learning how to identify their emotions and understand the other’s point of view. In this sense, cognitive functions are still being developed despite hospitalization. Given this, although the main goal of hospitalization is to treat the child’s disease, it is possible to use playfulness as an ally in several areas that need to be developed with the sick child.

The last aspect regarding the goals of ludic activities developed with hospitalized children is that such activities are means for social interactions, since those interactions happen through playing. Therefore, according to Collet et al. (2009), interacting with a playmate is highly important in a child’s life. In this context, the medical staff considers that being close to a playmate makes the child feel as much as a human as it did before it was hospitalized.

Furthermore, when interviewees were questioned about which health care workers develop ludic activities in the studied hospitals, eight staff members mentioned occupational therapists, doctors, psychologists, and physical therapists, besides toy librarians, recreators, speech therapists, social workers, educators, librarians, and nursing technicians.

Therefore, our data reinforce that a hospital team comprises several types of health care workers, including those that do not directly assist hospitalized people such as the cleaning, maintenance, and security staff, among others. However, the multidisciplinary health team is the staff who directly works with hospitalized children, including doctors, nurses, psychologists, occupational therapists, physical therapists, nutritionists, social workers, nurses, radiologists, and laboratory technicians, among others. We also highlight that this multidisciplinary team is formed focused on the necessities of the people, thus it is not previously organized. The sick child’s necessities are what will lead the health staff to integrate to satisfy the person’s global needs, enabling its wellbeing (Tavares, 2001).

We know that, during hospitalization, a child’s main desire is to return home to its family, no matter how good it is being treated. Thus, our study provides evidence of how these are committed to the professional network established on the child’s behalf aiming for the noble ending of sending the child back home and recovered.

When asked about the ludic activities carried out in pediatric public hospitals in São Luís, Maranhão, six interviewees stated that such activities have been performed in the hospitals they work for a while, while four answered that they did not know how to answer this question.

It is important to register that we had difficulties obtaining information regarding the history of ludic activities in the hospital since the beginning of this research. This happened because even though we found workers with over thirty years of experience in health services, information was not systematized, which hampered us from getting basic data. Therefore, the question regarding since when ludic activities have been developed in these hospitals did not reach a satisfactory number of answers from the interviewees.

In this sense, Lima (2014) emphasizes that the essentiality of information about the work environment should be the domain of all workers and not only administrative sectors. Having a deep knowledge about the work institution creates a feeling of belonging, which may directly reflect on how the patients are treated. When relevant information circulates in collective environments people can listen and develop a higher social interaction and participation (Fonseca, 2008).

Regarding the frequency of these activities and the spaces they are developed at, as well as toy hygiene and/or the risks associated with playing in the hospital, seven workers reported that activities happen almost every day or, in some cases weekly, both in the hospital’s toy room or in patients’ rooms. According to the answers, toys are cleaned daily with 70% alcohol, but staff still consider that there are many other risks associated with playing at a hospital. Only one worker said that there are no risks for this activity.

As verified, most ludic activities done in the hospitals studied are developed in hospital toy rooms, with only secondary activities occurring in the hospital beds. These include activities for children who cannot move along the hospital, such as those that need to stay in isolation because of the risk they may pose to other children due to contagious diseases (Boretti & Corrêa, 2014).

In both hospitals studied, the toy room attends children with different pathologies on a daily basis. However, those that are hospitalized with contagious diseases are not authorized to play in the same environment as the other children due to the constant risk of contamination. The health team then takes all precautions needed to prevent infections from spreading. They are vigilant of playing to prevent the toy from becoming a transmission vector. That is why all toys are rigorously cleaned with 70% alcohol periodically and washed with soap and water weekly. Only after this process they can be released for children to play (Boretti & Corrêa, 2014).

To avoid contamination and decrease the risk associated with playing, one of the studied hospitals created a second toy room in its dependencies in 2012 to exclusively attend children that need to be hospitalized and isolated in the hospital. Toys used in this toy room are of restricted use, as is the access to them: only the children in isolation can play with them. This enables children who were previously prevented from playing to have a specific place to do it, thus enjoying the benefits provided by ludic activities as the other sick children, since a toy room is a right assured by federal law since 2005 (Law n. 11.104/2005).

That is why playing at the hospital is considered a way for the hospitalized child to overcome its physical and psychological limitations. However, the medical staff are also alert to potential risks produced by ludic moments, since they can also spread diseases. Therefore, medical staff need to be alert to any potential contamination focus involved in playing at the hospital and that can be avoided (Chiattone, 2009).

Regarding the challenges faced to promote ludic activities at the public pediatric hospitals in São Luís/MA, six interviewees said that the main types of challenges are material, financial, as well as of human resources and the physical structure. Two of them did not know what to say about this matter but acknowledged that such challenges must exist.

As verified, the main challenges for performing ludic activities in this context are related to the physical structure where these activities are developed, more specifically at the toy rooms and hospital beds. During our interviews, we observed several precarities in the nursing rooms regarding what is stated by the ECA, in which hospital places where playing occurs must be suitable and equipped for these activities (Law n. 11.104/2005).

These places often have few toys and are improvised, small, and with a limited physical structure to host children, their parents and/or legal guardians and the health care workers themselves, hampering a good development of activities and actions with children and their peers.

Health care workers reported that the entire toy and book collection came from donations, because there were no specific resources destined to meet this demand at the hospital. Indeed, hospital managers always prioritize other demands of the hospital, and mostly see toy rooms and ludic activities as palliative.

With this secondary bias, the staff designated to play with the children is small. Another critical factor pointed in this research is the educational background of the workers engaged in playing with the children, since several of them do not seem to have a lot of skill, which makes playing somewhat boring and prevent it from reaching the desired effects for the patient.

One of the studied hospitals was going through a major renewal but the multidisciplinary health staff did not know if that would contemplate a toy room in the future installations. This shows that these health care workers were not heard in terms of demands for the physical space to develop ludic activities. Even so, the team interviewed eagerly awaits the opening of the new space to better attend the sick children that play in the hospital.

The data demonstrate that, even without an adequate physical space for these activities, together with a bad financial situation, insufficient human resources, and impoverished material means, playing still occurs in the public pediatric hospitals of São Luís/MA. However, it is important to highlight that a small room and a few toys are not enough for these activities to occur. They require qualified staff members who are committed to the child and the games. According to Cunha (2008), wherever there is a child willing to play, there will be a playful adult apt to develop ludic activities and make the sick child play.

At the counterpart of the daily routine, playing at the hospital is a children’s right guaranteed by federal law. When questioned about the relevance of hospital games, four staff members answered that it contributes to the child’s global development, one said that it is relevant for the psychological stability by bringing joy and tranquility to the child. Another interviewee said that playing potentializes cognitive abilities, and another one reported that playing is a condition for a healthy life.

Therefore, we consider that playing in the hospital is relevant for the child since it eases the hospitalization effects, reducing stress and minimizing fear, anxiety and, in some cases, the pain caused by being hospitalized. Playing makes the child calm, thus making it more receptive of its surrounding reality (Maluf, 2004).

The multidisciplinary health staff was categorical when stating that the act of playing is relevant and promotes the child’s global development. It involves neurological, cognitive, affective, physical, emotional, and social aspects, since children are known for learning by experience (Vygotsky, 1994). Therefore, playing is needed to demonstrate important attitudes for the child’s health recovery. One of these attitudes would be to explain that even some procedures such as drawing blood, no matter how painful, are needed for recovery and a speedy return home.

The child’s psychological stability was also highlighted by the medical staff as being one of the relevant outcomes of ludic activities. In this context, hospitalization itself is quite abusive for a child, potentially causing serious wear, which can range from nightmares to deep insomnia (Collet et al., 2009).

In this aspect, ludic activities can create mechanisms for children to face and overcome barriers imposed by the sickness, since they exteriorize their fears and desires through playing, and thus activities may effectively contribute to treatment (Cunha, 2008).

Therefore, as stated by Brougère (1997), joy is one of the medicines that should never be missing from a child’s routine. For the medical staff interviewed, joy is one of the relevant things of playing at a hospital. Thus, we consider that joy is more than a polite smile, which reinforces the need to create mechanisms for these sick children to have their rights assured. In this specific case, the right to play, which is universal to children (Mitre, 2000).

A ludic activity leads to emotional stability, widens cognitive abilities, favors a healthy life. These were some of the statements made about the relevance of playing at the hospital. Such points of view agree with the results of research carried out in Brazil (Fonseca, 2008).

A hospital represents a unique world, and many things may cause fear during a shift due to the unpredictability of life and death. When a hospitalized child can play at the hospital, it is stimulated to listen to several overcoming stories potentialized by the ludic. In this aspect, we asked the medical staff to report cases of sick children whose recovery significantly improved through playing at the hospital.

All eight health care workers interviewed reported cases they witnessed during their professional care. Each one discussed how important this activity was in the children’s lives and the professionals that made the ludic something important and decisive in the lives of children they cared for.

The first case is a report of a child who was hospitalized in an intensive care unit (ICU) and spent a long time in the hospital. The staff reinforced how much the child loved superheroes. When the medical staff noticed it, they used ludic activities as a technique, which fomented the child’s interest in the treatment to the point that, when it recovered, it already had all the superheroes it wished.

The medical staff’s attitude of using ludic methodologies in the child’s treatment reveals the correct procedure to better attend and approximate the ludic world where the child lives to its contact with reality (Porto, 2016).

The second case is the report of a child hospitalized with an infection and signs of depression, presenting aggressiveness and several other symptoms that pointed towards this diagnoses. However, the staff observed during treatment that it used drawing to report a case of violence, which led to the child’s diagnose and received support from the agencies responsible for childcare. This discovery was enabled by drawing, which is highly used by psychologists during sessions with children (Camon, 2005).

In the third case, the child, who was mute, was very resistant to hospital interventions. However, the medical staff discovered that it liked magic and, once again, used it as a ludic technique, thus approaching the child’s symbolic world. In parallel, the drawing technique was employed, and the child was treated.

It is the responsibility of the medical staff to know its patient, as is the teacher’s at school to know as much as it can about its students. The fact that they remember such exciting reports demonstrates that these health care workers worry with a wider concept of health, which also involves humanization. The ideal of humanizing for better caring is one of the hospital’s flags, which despite the eventual setbacks, still exist, and playing creates the path for it (Kishimoto & Friedmann, 1998).

The fourth case was of a child that did not communicate in the moment of playing at the toy room with hospital staff, but only with its mother. However, in the following days, playing led it to start socializing with the other children and medical staff.

In this sense, playing is a socializing agent. Cunha (2008) states that children explore worlds, meet people, and tighten bonds through ludic activities, which consequently contributes to its personal and humane development.

The fifth case is of a child with visceral leishmaniosis, who was not very cooperative. Few people could examine it. As the days passed by, the medical team discovered that the only way to approach this child was through ludic activities. Therefore, they started using videos from their own phones and slowly gained its trust.

It becomes evident through this report how widely ludic interventions can be employed: in the toy room, in the hospital beds and hallways, as well as the materials used can easily transform a child. It is all a matter of exercising imagination and the power of creativity. Through that a cell phone may become a toy, as the materials used by the multidisciplinary team can also become whatever the child dares to. In the ludic world, anything is possible (Velasco, 1996).

The sixth case brings the report of a child with a serious kidney condition and who was rejected by its father. The medical staff used free drawing to identify its sadness and overcome that reality. From this situation, one can infer that the child only got to socialize the feelings that bothered it through ludic activities. Thus, the adults that promote ludic activities had to be sensible and perceptive to understand the specific situation of each child and employ all available techniques to better approximate the sick child to the games. Through this strategy, they can promote the benefits from ludic activities to hospitalized children.

The seventh case regards a child from inland Maranhão state suspected of being a victim of sexual violence. She arrived at the hospital completely debilitated. The medical staff’s intervention with ludic activities aided in the child’s recovery and made it share the feelings the imprisoned her, which culminated on its full recovery and the release from the hospital. This case demonstrates that, regardless of the situation that brings a child to the hospital, the ludic is unlimited. It does not matter if it is employed in the ICU, in isolation, in the hallway or the pediatric corner. Ludic activities can and should be practiced with children (Vasconcelos, 2006).

The eighth and last case reveals the story of a child hospitalized due to mistreatments, which caused it not to play, even at home. It simply isolated itself, escaping from any kind of approximation attempt from the medical team. However, it started becoming close to its peers by playing outside and to better accept treatment: first the medical, and then the psychological. The staff reported another case of a child that, after a prolonged hospitalization, had a surprising reaction when it heard that it would be released. It started crying and saying that it wanted to stay at the hospital, because it did not have the same toys to play at home.

In all these cases, we observe how relevant ludic activities are in pediatric hospitals given the mechanisms of approximation between children, health care workers, parents, and companions (Mitre, 2000). By playing, they create bonds, friendships are strengthened, people socialize their experiences, share the same environment, and this mix of good feelings undoubtedly influences the health condition of the sick child.

 

4. Conclusion

The hospital environment is, a priori, a place marked by disease, which leads to continuous stress and harmful impacts to children. The damage caused to the child’s health are exteriorized through words and uncommon emotional reactions, when compared to other non-stressful moments. These feelings can evolve into severe anxiety and symptoms of depression, such as lack of interest and pleasure in activities, weight loss or gain, sleep alterations, guilty feeling, difficult to concentrate, among others.

Hospitalization itself constitutes a moment of discomfort for the child due to conflicting interests. For the multidisciplinary team it matters to treat the disease, and for the child it matters to return home. In this context, conflicts are inevitable. However, ludic activities can mediate relationships and have emotional and physical benefits for both the child and the medical staff to gain the child’s trust.

Additionally, hospitalization compromises the child’s development because it often separates the child from its family, distances it from its friends and school. Therefore, its entire routine is replaced by painful and embarrassing situations, with the worst fears including being at the hospital and the fear of death, which afflicts both the child and its family/companions daily.

However, if the child is treated with ludic activities at the hospital, the hospitalization period can become a continuity rather than a discontinuity moment in its life. In this sense, playing at the hospital may provide a way for fun, learning, and therapy, or even a form of prevention and rehabilitation from diseases. Finally, ludic activities aim to promote playing, the physical and emotional well-being, and health recovery. Through them the child finds a way to turn the hospital into a less traumatizing place, thus reducing the anxiety caused by sickness.

In this sense, ludic activities are used in the hospital for the child to externalize thoughts, fears, and concerns, as in the cases presented. Similarly, playing functions as a bridge for the child to overcome the hospitalization period, thus improving its resilience capacity, a crucial factor for adult life. Through the ludic the child will develop social skills, ease aggressiveness, integrate with its peers, and add this to its development process.

Regarding the conditions to perform ludic activities at the hospitals, studies point that playing becomes a strong ally to the child, its family, and the medical staff. For the child, it can maintain itself psychologically ready to withstand the challenges caused by the hospital environment. It could be used by the family to approximate family members when in contact with the child at the hospital. Furthermore, the medical staff can use it as a facilitating element to sensibilize the child about procedures that need to be done. 

According to the perception of the medical staff, ludic activities developed with hospitalized children are important because they contribute to their self-esteem and help integrate the child with the others also hospitalized. Furthermore, it can improve the acceptance of the medical treatment and even make the child forget that they are hospitalized, allowing them to better enjoy the hospital routine during treatment.

Indeed, hospitalization is not a synonym for sadness, since the ludic can make this moment be seized if means are created for the child to develop into multiple facets of its growth.

Therefore, data reveal that ludic activities developed with hospitalized children are important for socialization and integration processes. Nevertheless, the studied hospitals lack the adequate physical structure to offer these services efficiently. Among the main activities carried out with hospitalized children are expressive and rhythmic activities such as painting, drawing, music, theater, games, etc.

In the interviewees’ perception, playing at the hospital has at least four goals: fight or ease the stress caused by hospitalization; contribute to the recovery process by making the child accept medical procedures more easily; develop the child’s cognitive system; and promote social interactions between all those involved in the hospital community.

In this sense, ludic activities developed with hospitalized children consist in not letting these children solely in sickness, but bringing them towards health, since they create means to find support mechanisms to prevent them from falling at the scenario of pain and fear, so common in hospitals. Therefore, the health team sees the ludic not only as a recovery-potentializing agent but also as a faster therapeutic mechanism by psychologically comforting the child and its family during hospitalization.

The multidisciplinary health team emphasizes that the toys and materials used are cleaned daily to prevent possible harm and disease spreading foci for the hospitalized children. However, they acknowledge the risks involved in playing at the hospital, since toys must be adequate to children’s age to prevent potential accidents.

In this context, the challenges faced for ludic activities to be developed with hospitalized children include educating the multidisciplinary health staff that playing is a serious activity and that the ludic can be used as a therapy with the hospitalized child.

The main difficulties related to operationalizing ludic activities with hospitalized children are the physical and material resources. Our data reveal that the space destined to playing is small and the toys are scarce and insufficient. About this matter, the interviewees stated that the whole collection of toys comes from donations, which means that many toys come in broken, thus preventing its use for prolonged periods.

We observed that ludic activities developed with hospitalized children are relevant because they help them cheer up and gather strengths to continue the medical treatment, since there are children who are hospitalized for years. In fact, there are cases of children who were hospitalized for up to six years in one of the studied hospitals.

For the health staff, playing enables the child to have a better recovery process compared to the children who do not play. Thus, although it is hard to empirically measure how the ludic contributes to the child’s physiology, we observe that the children who play are happier, more engaging and soliciting.

We also observed that the health team believes that ludic activities must be fomented during the child’s entire stay at the hospital, embedded in a welcoming policy throughout the hospital treatment, regardless of its duration. Other aspects raised by the interviewees were that the ludic activities can be carried out in hospital toy rooms or beds. The main health care workers responsible for these activities are those that comprise the multidisciplinary team, such as doctors, nurses, psychologists, occupational therapists, nursing technicians, etc.

We also observed that participants in this study were unfamiliar with the history of ludic activities in the hospitals they worked at. However, they unanimously stated that such activities already occurred in the hospitals when they started working. We highlight that these employees have worked in these hospitals for six years on average.

However, ludic activities at these hospitals are performed daily in shifts. We reinforce that toy rooms only function in the morning, but the occupational therapist also develops ludic activities at night, which includes those at hospital beds.

We hypothesized that ludic activities were unsystematically carried out in these hospitals. Therefore, our hypothesis is partially confirmed since most ludic activities are carried out in these hospitals by external agents, including professionals tied to universities and religious institutions. Thus, few of these activities are planned and performed in a way to become Standard Operational Procedure (SOP). Likewise, the medical staff does not have a systematization encompassing all possible cases in which playing can be used as a ludic technique with the sick child.

Finally, we consider that ludic activities carried out in public pediatric hospitals of São Luís/MA are relevant to the socialization and integration processes of hospitalized children. Although the studied hospitals lack the physical space and the materials to develop such activities, the medical staff tries to treat the children in the most humanized and ludic possible way.

We hope that this study brings attention to the importance of ludic activities for hospitalized children and foment other researchers to deepen this subject.