BRINQUEDO TERAPÊUTICO EM SERVIÇO DE URGÊNCIA E EMERGÊNCIA PEDIÁTRICA: REVISÃO INTEGRATIVA DE LITERATURA

The aim was to evidence and discuss the impact of the use of therapeutic play in the pediatric urgent and emergency service, as well as the nurse’s perspective regarding this technique. An integrative review of the literature was undertaken in databases in the area of health between December 2014 – January 2015. The descriptors used were: playthings, play and playthings, emergency medical services, urgent and pediatrics. A total of seven articles was selected and analyzed; these indicate a positive impact resulting from the use of therapeutic play during the nursing care, as this promotes the child’s recreation and comfort, prepares her for invasive procedures, and strengthens the bond between the nurse, child, and family. The nurse identifies that this technique is an alternative for constructing humanized care which embraces the child. It is concluded that there are few publications related to this issue, with further studies being necessary which contribute to the evidence on the subject studied. DESCRIPTORS: Play and playthings; Emergency Medical Services; Pediatrics; Nursing. Autor Correspondente: Recebido: 06/04/2015 Bruna Hinnah Borges Martins de Freitas Finalizado: 07/01/2016 Universidade Federal de Mato Grosso Av. Fernando Corrêa da Costa, 236778060-900 Cuiabá, MT, Brasil E-mail: bruhinnah@gmail.com http://ojs.c3sl.ufpr.br/ojs2/index.php/cogitare/ Revisão 1Enfermeira. Mestre em Enfermagem. Docente da Faculdade de Enfermagem da Universidade Federal de Mato Grosso. Cuiabá, MT, Brasil. 2Enfermeira. Hospital Regional de Sorriso. Sorriso, MT, Brasil. Cogitare Enferm. 2016 Jan/mar; 21(1): 01-08 JUGUETES TERAPÉUTICO AL SERVICIO DE URGENCIA Y EMERGENCIA PEDIÁTRICA: REVISIÓN INTEGRATIVA DE LITERATURA RESUMEN: Fue objetivo del estudio evidenciar y discutir acerca del impacto del uso de los juguetes terapéuticos en el servicio de urgencia y emergencia pediátrica, así como analizar la perspectiva del enfermero delante de esa técnica. Revisión integrativa de literatura realizada en bases de datos en el área da salud entre diciembre de 2014 y enero de 2015. Los descriptores utilizados fueron: juguetes y juegos; juguetes, servicios médicos de emergencia, urgencias y pediatría. Fueron seleccionados y analizados siete artículos que apuntan el impacto positivo del uso de juguetes terapéuticos durante la asistencia de enfermería, ya que ellos promueven recreación y bienestar al niño, preparándolo para procedimientos invasivos y fortalece el vínculo entre el enfermero, el niño y la familia. El enfermero identifica esa técnica como una alternativa para la construcción de un cuidado humanizado y acogedor al niño. Se concluye que todavía hay pocas publicaciones acerca de esa temática, siendo necesarias nuevas investigaciones para contribuir con las evidencias del asunto estudiado. DESCRIPTORES: Juegos y juguetes; Servicios Médicos de Emergencia; Pediatría; Enfermería.


INTRODUCTION
Urgent and emergency care for the child requires special attention on the part of the health professionals, due to the biopsychosocial and other characteristics which are specific to this population, requiring specialized material and human resources for emergency treatment (1) .
The causes which require care in the pediatric units are: diseases of the respiratory system, infectious and parasitic diseases, external causes, and diseases of the digestive system (2) .
The urgent and emergency pediatric services receive high demand from patients, causing the health team to work with great speed and efficacy in order to minimize the situations of risk to life, above all due to these patients being children, which culminates in subjective reactions of these professionals, geared towards the sensitivity of the human being (1) .
In this scenario, the principles defended by the National Humanization Policy (NHP), which focuses on the need of the patient, are suppressed at the time of undertaking the procedures for diagnosis and treatment.Among these, those feared most by the children are the invasive procedures, principally those using needles, whether for collection of blood or for venipuncture for the administration of medications (3) , besides the possibility of hospitalization, which generates a situation of stress for the children.
Studies indicate that these experiences, on most occasions, are unpleasant for the children, and are expressed through fear, anxiety, crying, rage, aggression and distress (4)(5) .One of the ways which is able to mitigate the suffering, to help the children to perceive what is happening, to verbalize what they are feeling, and to understand the therapeutic procedures to be undertaken is the use of Therapeutic Play (TP), which functions as a liberator of creativity and recreation, reducing the children's fears, tensions and anxiety.Its use is recommended whenever the child has difficulty in understanding or dealing with a difficult experience, or needs to be prepared for procedures (6)(7) .
Studies on the use of play in preparing the child for procedures in the hospital environment are considered positive, as this becomes more pleasant and similar to the everyday environment.It allows tranquility, courage and calmness for the children, facilitating communication, participation, acceptance of procedures and allowing the implementation of atraumatic care for the child and her family (8)(9) .
Play is used as a language of which the child has mastery, which she understands; it is, therefore, the easiest way to inform the child regarding the routine of procedures to which she will be subjected, as well as to mitigate her suffering.This experience comes to have meaning, and TP allows the recovery of the context which is familiar to the child, and her own condition as such (10)(11) .
In this way, the professional nurse being a provider of care, it falls to her to offer this resource, in which a common object, when it promotes well-being to the child, is transformed into therapy.This can contribute to coping and to the child's positive response when faced with a painful procedure, promoting the nurse-child bond through user embracement (5) .
It is appropriate to emphasize that the use of the technique of TP in pediatric care by the nurse is recommended and regulated by the Federal Council of Nursing through Resolution N. 295/2004, and that the majority of teaching institutions address this issue in the Undergraduate Nursing Courses (12)(13) .
The results of the study (14) demonstrate there to be difficulties in implementing humanizing practices, as many services do not offer conditions for undertaking this.The practices referent to professional training must allow the acquisition of skills of user embracement for urgent and emergency care, as the nurse must have critical and reflexive thinking in order to be able to take immediate decisions, without however failing to consider NHP.Inadequate physical structure and insufficient human and material resources have also been indicated as hindering these practices.
In the light of this context, the object of the present work was to evidence and to discuss the impact of the use of therapeutic play in the pediatric urgent and emergency service, as well as the nurse's perspective in relation to this technique, based on the analysis of scientific productions.It is hoped that

METHOD
Cogitare Enferm.2016 Jan/mar; 21(1): 01-08 this study may contribute to health professionals' knowledge regarding the impact and repercussions of the use of the technique of TP in pediatric urgent and emergency care.
An integrative review of the literature regarding the use of therapeutic play in the pediatric urgent and emergency service, through an electronic search on the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index to Nursing and Allied Health Literature(CINAHL), Scientific Electronic Library Online (SciELO), Latin American and Caribbean Health Science Literature (LILACS) and the Nursing Database (Base de Dados de Enfermagem) (BDENF).Data collection took place in December 2014 -January 2015.
In order to guide the study, the following guiding question was formulated: "What is the impact of the use of therapeutic play in the urgent and emergency service, and what is the nurse's perspective regarding this technique?".
A total of 733 articles were eligible, published in periodicals and indexed in the databases mentioned above, independent of the language or year of publication, which encompassed capture with the following descriptors: playthings, play and playthings, emergency medical services, urgent and pediatrics.The following were excluded: articles which did not address the issue studied, which were not available in full, which were duplicated, and those from secondary sources.For this type of research, one must rely mainly on primary sources, which are reports of studies written by the researchers who undertook the research (15) .Because of this, in this research, the decision was made to use primary sources.
Following reading of these in full, to achieve the objective proposed, seven articles were selected for analysis.These met the criteria previously established, as shown in Figure 1.
With the intention of systematizing, optimizing and presenting the findings, a table was elaborated with the information which supports the study, covering the following aspects: Title; Authors; Periodicals; Objective; Main results and Conclusion.

RESULTS
A total of seven articles was found regarding the use of therapeutic play in pediatric urgent and emergency care; five were published in Brazilian periodicals, and two in foreign periodicals.The period of publication of the articles is 2000 -2011.
In relation to the themes, three address the use of TP in preparing the child for venipuncture, one the collection of blood for laboratory tests, one its use as an instrument for supportive intervention in data collection, and two address aspects related to the nurse's experience with this practice, as well as to her perspective and awareness in relation to the issue.
In Table 1, one can check the article selected for this study, with the title, authors, periodicals, objective of the work, main results and conclusion presented.
The studies captured indicate that TP has a significant impact in reducing the child's anxiety during the undertaking of invasive procedures, as it provides her with the understanding of the purpose of this action, making her more collaborative.This helps the child in reducing fear and discomfort, contributing to the nurse's work process due to the child's greater receptivity.These studies evidence that the nurse experiences the recognition of her work during the undertaking of the technique of TP, and feels encouraged to continue to use it due to this intervention's benefits for the child and her family, and due to perceiving her action as revalidated.
For the critical analysis of the study selected, the categorization of the works by similarity of content was undertaken, with three categories for analysis being constructed: The use of therapeutic play and playthings in comforting the child in the urgent and emergency service; The use of the technique of therapeutic play in preparing the child for an invasive procedure, and; The nurse in relation to this technique.

The use of therapeutic play and playthings in comforting the child in the urgent and emergency service
The use of play in healthcare promotes benefits to the child, evidenced by the expression of her happiness in seeing the play materials or when she plays freely with them, forgetting the hospital environment (16) .This is because playthings and play are part of the child's development, being considered a basic need of childhood.
During the occurrence of this play process during the procedures necessary in the urgent and emergency service, there occurs a relaxation of the child's tension, observed both through the change in her facial expression and by her receptive behavior.She takes on a role of mastery, having liberty to express herself (5,16) .The use of TP leads the child to verbalize her feelings and wishes better, as it relieves anxiety, promoting well-being (6)(7) .
The use of play and playthings is also relevant for reducing the child's fear and shame, promoting an environment which is favorable for her to express her feelings and contribute in the process of taking the case history (17) .This is one of the stages of the Systematization of the Nursing Care (SAE) , a skill of the nurse in the pediatric emergency department, which contributes to the holistic care for the child.
The use of TP has a positive impact in distracting the children, and promotes skills for coping with difficult situations, eliminating fear and generating comfort (5,16,18) , as the experience in the urgent and emergency department is not always pleasant for the child, creating feelings of sadness, fear and aggression, mainly when one is dealing with invasive procedures (4) .

The use of the technique of therapeutic play in preparing the child for an invasive procedure
TP can be used in the various stressing times which the child experiences during medical care, in order to prepare her for invasive procedures such as venipuncture and the placing of catheters.The nurse undertakes work involving providing guidance for such procedures with the plaything, causing To understand how the awareness of the nurse takes place for the use of TP as a nursing intervention instrument In learning about TP and using it in the care, the nurse observes the benefits of this intervention, which increasingly re-validates her work *TP: Therapeutic Play; **TIT: Therapeutic Instructional Toy.
the response to be better when compared with those who do not receive the same preparation (16) .
One study undertaken in Australia assessed the impact of TP in guidance regarding venipuncture in the pediatric emergency service and identified that the children of the group in which this technique was employed were more prepared for the procedure and presented less feeling of distress before, during and after the same, in comparison with the children of the control group (18) .
A study undertaken in Brazil identified that therapeutic instructional toy(TIT) allowed the child to prepare herself and participate in venipuncture, as she understood its purpose and gained trust in the health professional (5) .
The children who participate in the play session become more cooperative during venipuncture, as they understand the need for, and the technique of, this procedure, exteriorize their feelings more, and relate better to the team, benefiting the nursing care (4) .TP, when used in preparing the child for the taking of blood for laboratory tests, a phase which is necessary for the medical diagnosis, is shown to be efficacious in the understanding, and in the control, of the negative reactions which arise from this situation (6) .
The recovery of children who experienced the use of TP is faster when compared with those who have not experienced this during urgent and emergency care (18) .This points to the need to use this with more frequency in the hospital environment, above all by the professional nurse who is responsible for the nursing care.

The nurse in relation to this technique
One can observe a change in the behavior of many nurses following the introduction of TP to their practice, as, prior to its use, they expressed disbelief in relation to the positive effects of this instrument; while after its use, they show themselves to be surprised with the benefits observed, and demonstrate great interest in using this resource (4) .
The professionals expressed that the use of TP leads the procedures undertaken to be faster and easier, due to the greater collaboration from the children (18) .This is because the environment is transformed and brought closer to the children's routine, causing them to feel at ease regarding the health professional.
The nurse perceives TP as a resource for preparing the child and her family for the procedures, promoting the child's well-being through minimizing fear and calming the child, who comes to understand the situation and accept this experience positively.The nurse learns that, in using play, she is promoting the child's development and socialization, through stimulating her imagination and her development, as the use of TP brings benefits for her too, through a relationship which is permeated by trust and security (16) .
The health professional identifies that this technique allows greater understanding in relation to the child and her feelings and behaviors, strengthening the nurse-patient-family bond.In this way, the health professional presents various feelings in using it, pleasurable feeling, gratified, and accomplished as a person and professional (16,19) .
One complicating factor nearly always reported by the health professionals is the question of the time which is necessary for undertaking TP, principally in preparing the child prior to invasive procedures.The reports, however, indicate that the time spent on initial preparation is approximately 15 minutes; therefore, time is not an obstacle to its use, bearing in mind the positive aspects demonstrated by the children, such as a reduction in physical and emotional strain (4) .
In addition to this, the nurses reported in one study that when they practice this intervention they feel valued, as they perceive the recognition of people involved in this trajectory.As a result, they feel motivated to continue using TP as they perceive their actions to be revalidated (19) .
The integration of TP into nursing care is a challenge which still needs to be overcome by the nurses, through understanding of the specific characteristics of the child, and of playing as a need of childhood.In allowing themselves to experience this, the professionals will certainly recognize TP as a positive instrument for intervention in their work process.

FINAL CONSIDERATIONS
This study ascertained that the use of TP in the urgent and emergency service promotes many benefits, contributing to the holistic character of the care and the acceptance of procedures necessary for the diagnosis and treatment, and in the maintenance of the child's rights.Its use allows the construction of humanized and quality care for the children, in an atmosphere of embracement and recognition of their needs.
It is emphasized that there are few publications related to the use of therapeutic play by nursing during pediatric care in the urgent and emergency department.The studies found are limited mainly to procedures of venipuncture and collecting blood for laboratory tests, as well as the collecting of data during the taking of the case history and regarding the nurse's experience in relation to this practice.It is understood, therefore, that it is necessary to undertake further studies which contribute to providing evidence on the topic studied.
It is hoped that the knowledge revealed by this study may encourage the use of TP by the multiprofessional team, above all the nursing team, in support of the provision of care in the urgent and emergency service, so that they may cause the care to transcend the biological context, and consider the emotional needs of the children involved in this process.

Figure 1 -
Figure 1 -Flowchart -selection of the scientific articles regarding the use of therapeutic play in the urgent and emergency service, according to the databases established.Cuiabá, MT, Brazil, 2015