1. Methods

This is a qualitative research that analyzes several faces of the same phenomenon that allow knowing the human experience and support the most right interventions together with individuals (^{Brandão, Ribeiro, & Costa, 2018}). Lawrence Bardin’s theoretical and methodological framework was used from a set of procedures applied to discourses of every order for descriptive analysis when using the inference that seeks the cause of communication or its consequences (Bardin, 2011).

1.1 Sample

The study was conducted by 15 parents or guardians of hospitalized children at the João Paulo II Children’s Hospital, located in Belo Horizonte-MG, Brazil, belonging to a state hospital foundation. The pediatric care performed there involves several nosological frameworks because it is a reference children’s unit for health care in the state of Minas Gerais.

During the study, children aged between six months and 12 years were hospitalized in the health service and with hospitalization time ranging from four to 30 days.

1.2 Inclusion and exclusion criteria

Inclusion criteria were parents or guardians, aged over 18 years who accompanied minors. For each child, only one parent or guardian could participate. Those eligible should also have attended the playroom for at least five opportunities on different days. As exclusion criteria were considered parents or guardians of children in critical condition or under various interventions and procedures that prevented access to the playroom, boys and girls requiring contact precautions, respiratory or droplets, instituted by the Hospital Infection Control Commission and who received toys and activities in their own room. Adults absent from the unit were also excluded in the period defined for data collection.

Therefore, the participants were five grandparents, three fathers, six mothers and one aunt.

1.3 Data collection instruments

The collection of statements was carried out between June and July/2018. The research protocol was submitted and approved by the Research Ethics Committees of the Medical Sciences College of Minas Gerais and the João Paulo II Children’s Hospital, under opinions numbers 2.440.198 and 2.538.248, respectively registered in Plataforma Brasil. The study followed guidelines from Resolution MS 466/2012, which deals with research with human beings.

1.4 Procedures

Initially, the researchers presented themselves to the hospital managers, when they presented the objectives of the study and the general procedures to be adopted to ensure the ethics and privacy of those involved and then to the managers of the pediatric unit to know the physical space and professionals. After explaining the reasons, the team assisted in the identification of adults who could make up the sample of participants, according to the pre-established criteria. Subsequently, the parents or guardians pre-selected were approached by the researchers at an appropriate time and were invited to participate, after the explanations about the study, its objectives and propositions. The moments called appropriate refer to those destined for dialogue between researchers and participants, far from performing medical or nursing procedures and when guardians and children were more relaxed in the corridors, rooms or in the playroom itself. All those who agreed to participate signed an Informed Consent Form, a document required by the Ethics Committees involved. This document detailed the study, its objective, the steps to be followed for the collection of information, the guarantee of privacy of all involved and the interruption in the foreseen situations. The reading was carried out aloud, individually and the parents and guardians could remain with this document for as long as necessary until their decision to participate. Only two of the guardians asked to return the authorization the next day and all the others heard the reading, read the text, asked questions and signed the consent form.

The meetings were scheduled and held in a physical space reserved by the nursing team of the pediatric unit. The room was comfortable, with table, chair and armchair, as well as bright and pleasant. The statements were collected in recordings authorized by each participant, from a semi-structured guide and each interview lasted, on average, 30 minutes. The guide contained questions that were proposed to hear from adults about the process of play offered to children during hospitalization and the perceived influence of the playroom on the treatment and recovery of children. There was validation of the questions inserted in the respective guide at the time of the meeting with the first three interviewees to evaluate the need for adaptations that would allow greater understanding of what was sought and to verify the possible achievement of the objective. As there was no need to change the questions, the first statements of the validation test were considered part of the study.

Only two people were present in the place reserved for data collection: one of the researchers and the parent or guardian. There were no interruptions of any kind during the interviews. Each participant received the identification of the letter “G” of guardian, followed by a number, to differentiate them.

The researchers were three students from the last year of the Nursing Course, female, trained and guided by three professors, two MSc and one PhD, at the time of completion of the Nursing Course Completion Work. All interviews were conducted by one of the three student researchers and there was no return to the respondents during the research, either to redo or clarify questions or even to inform partial results.

1.5 Analysis

After each interview, the researcher performed the literal transcription of the statements, that is, including interjections, pauses and manifestations of emotion. At each set of two or three transcriptions, all researchers, in addition to the advising professors, met to analyze the material until the joint decision to interrupt the inclusion of new participants, when all researchers agreed with the saturation of the collected data and achievement of the proposed objective, in view of concrete answers to the questions of the investigation and verification of repetition of the expressed content. It is noteworthy that defining the number of participants during the study design phase is always a question, when considering the interpretative character of qualitative research (^{Sim, Saunders, Waterfield, & Kingstone, 2018}). Despite the proposal submitted for ethical approval, due to the requirement, of 10 to 12 participants, in the end, 15 parents or guardians were needed.

The methodological framework (^{Bardin, 2011}) proposes three phases for follow-up, namely: pre-analysis, exploration of the material and treatment of the results, which allowed the clipping and approximation of the latent content of the statements that emerged about the object of the study. These are systematic and objective procedures that lead to inferences about the object of study. The similarity of contents was analyzed separately by each researcher and, subsequently, in a meeting, when all presented and argued about the clippings that resembled. The reference emphasizes, at this stage, obeying the rules of completeness, pertinence and exclusivity, among others. Knowing what is behind what is spoken allowed organizing the research corpus into three representative thematic categories or forms of thought that allowed reflecting reality, which would allow the deep reading of the object of study and greater understanding and discussion of the results.

Part of the study and its results were presented at the 9^th Congresso Ibero-Americano em Investigação Qualitativa (CIAIQ) (^{Cesário, et al., 2020}).

2. Results

After content analysis, three thematic categories were elaborated: “Occupation of the hospitalization time”, “Playing allows the bond between parents and children” and “Playing as a supporting therapy in child recovery”.

2.1 Occupation of the hospitalization time

The reports emphasized the importance of the place of play, because, according to adults, children yearn to be there and remain happy, for a long time that fills the gap generated by hospitalization:

“The day starts and my granddaughter already asks for the playroom. Otherwise, children would be trapped” (G1)

“After my son gets back from the playroom, he gets happy. He wants to stay there all day because he likes video games and puzzles.” (G6)

The idleness, distance from home and the climate of hospitals are mitigated, according to adults:

“In the hospital, playing is awesome, occupies and distracts. He is doing great! The playroom is a distraction.” (G3)

“Far from home, the child gets restless, there has to be a distraction. Television helps, but the playroom, I have never seen anywhere else. Very good.” (G8).

“Every day is different: crafts, storytelling and everything makes time go by faster.” (G5)

For parents and guardians, the hospital playroom is a space of joy and distraction, besides occupying the child’s time. Since adults are always together, it strengthens family ties.

2.2 Playing allows the bond between parents and children

When playing with the little ones, the approximation generated by the playroom was thus revealed:

“I like playing with him (referring to his grandson), because he gets happy, he becomes someone else.” (G12)

Playing allows greater interaction of parents and guardians and, according to the interviewees, helps in the development, by living with other children:

“I think it is important to participate, because I see his development.” (G4)

“After my daughter came to play she got more involved, smarter, lives with people. Thus, the child develops more when living with other children.” (G9)

The playroom allows, in addition to the interaction between parents and children, the memories of the adults’ own childhood:

“Any parent went through a childhood and seeing that space makes us a child again, it is important to play. Parents must participate, you teach, and the child also teaches us.” (G8)

In child hospitalization, play is essential to pass the time, distract the little ones and promote the approximation between adults and their children. The benefits arising are related to adaptation to the hospital environment, treatment adherence and health recovery.

2.3 Playing as a supporting therapy in child recovery

For adults, playing reduces the irritability of small ones and intolerance to the hospital environment:

“Even feeling pain, my granddaughter comes here and, short after, she feels better.” (G11)

“My son’s behavior was horrendous, he was violent, wanted to leave, screamed and woke people up at dawn. After he started playing, he got more relaxed.”

Participants relate the playroom to the child’s treatment and faster recovery. They mention a reduction in the use of medications, stabilization of clinical markers and improvement in mood:

“He was nervous and agitated. Now he is quieter. He has diabetes, his glucose was high and playing has stabilized his blood glucose.” (G2)

“Do you think my agitated grandson would stop at the hospital? He used to take three tranquilizers, now decreased.” (G12)

In some way, the playroom reduces the tensions caused by hospitalization and promotes children’s treatment adherence:

“Yesterday my son improved and interacted with the children. Now he expends his energies in the playroom and sleeps well at night.” (G7)

“It is an interesting stimulus. My little girl has forgotten the pain. I see it as a reaction to the treatment.” (G14)

According to parents and companions, the hospitalization of their children is a painful process for them and for the little ones. They state that the playroom is a cheerful space that distracts and favors the approximation between them. Moreover, the statements highlighted the perception of the therapeutic view of the play, in the improvement of relationships, acceptance of treatment and favorable evolution.

3. Discussion

Parents or guardians referred to the playroom as an appropriate space to distract from the hospital environment, usually perceived as heavy and loaded. It is a differentiated environment for hospitalized children because it is colorful and fun and where they can experience the world of imagination and creativity, because it represents welcoming and humanization by bringing them closer to their home environment and their needs (^{Oliveira, Silva, & Fantacini, 2016}; ^{Faria, et al., 2017}). The play reduces anxiety and fear, besides changing the focus from the disease and hospitalization, before the stressful condition (^{Rockembach, Espinosa, Cecagno, Thumé, & Soares, 2017}; ^{Nijhof, et al., 2018}; ^{Godino-Iáñez, et al., 2020}), as evidenced in the statements.

The parents and guardians and their little ones feel that part of their needs is the concern of the hospital team, which allows reducing the experience of negative feelings (^{Faria, et al., 2017}). In fact, most parents or guardians realized the benefits and praised the joy and happiness of children when attending the playroom. The literature reinforces the finding that the playful in hospitals enhances the process of adaptation by smile, joy, relaxedness and emotional and behavioral well-being in a more pleasant environment (^{Paula Marques, et al., 2016}; ^{Jiang, 2020}; ^{Ribeiro, et al., 2020}; ^{Franco da Silva, et al., 2020}).

In addition to embracement, anxiety, anguish, pain, fear and recurrent stress decrease. Behavior and attitudes change, because, from play, the little ones can elaborate their feelings while hospitalized (^{Silva, et al., 2016}; ^{Nurwulansari, et al., 2019}; Godino-Yáñez, et al., 2020; ^{Kapkin, Manav, & Muslu, 2020}), what was perceived by parents and guardians as treatment adherence, tranquility during hospitalization and more joy. Importantly, from the child’s perspective, satisfaction is associated with the guarantee of having a place to play and be distracted (^{Franco da Silva, et al., 2020}).

The “magic” aspect of the playroom, so evidenced in the statements, was translated into the desire of the children to stay longer in the place. A study on play in pediatric cancer care, from the perspective of the nursing team, states that playing with other children promotes interaction and approximation between them (^{Paula Marques, et al., 2016}). It is also a protective space that improves mood and alleviates suffering for a greater understanding of the process of illness by information and elaboration of meanings (^{Silva, et al., 2016}; ^{Lucietto, et al., 2018}; ^{Gillard, 2019}). However, health professionals should be prepared to use and incorporate play in their daily activities, which requires time, structure and continuing education (^{Ribeiro, et al., 2020}). There are still obstacles to the full use of entertainment strategies in the hospital environment associated, mostly, with the profile and competence of the professionals involved (^{Faria, et al., 2017}).

Furthermore, child hospitalization is a challenge for adults and children due to the change in the routine of those responsible for accompanying their children during the hospitalization process. Adults also need shelter and the playroom becomes a pleasurable space, which allows strengthening established bonds. Moreover, the relationship between the little ones and the care team is deepened upon perceiving that they transfer scenes from hospital routine to games, as a way of coping (^{Nascimento, et al., 2016}).

On the other hand, the influence of play for adults emerged, given the memories of the time when they were also children. Everyone has fun, while facing and adapting to the experience, being the playroom also a place of citizenship training (^{Nascimento, et al., 2016}; ^{Paula Marques, et al., 2016}). It allows the companion greater proximity and sharing of the process with the child. A connection of certainty is built between adults and small ones that contributes to making coping lighter (^{Nascimento, et al., 2016}; ^{Lucietto, et al., 2018}). By providing greater interaction, from play, adults became more attentive to child development and the acquisition of skills such as living in society, respecting others and dealing with feelings.

In fact, research on the pedagogical aspects of playrooms in hospitals, in addition to a tool that assists in care, reinforces other findings, from learning and teaching simultaneously to allowing the performance of procedures considered to generate suffering, in a more peaceful way. Playing facilitates adaptive processes and allows their understanding to become a co-author of their own history (^{Lucietto, et al., 2018}). The playroom, on the other hand, allows children to move between pain and pleasure, in a more subtle way, because sometimes they forget the reason for being hospitalized (^{Oliveira, et al., 2016}). More specifically, each phase of the child’s development and growth in this environment needs to be considered, consolidating the prominent role of hospital pedagogy, when considering the distance from the formal educational environment. The teacher is also an important character in playrooms and must act together to ensure the objective of effective and efficient recovery of the small ones (^{Souza, & Rolim, 2019}).

The formulated hypothesis of therapeutic benefits perceived by adults in relation to their children can be proven in the discourses, with meaning in reducing the impact of hospitalization (^{Nurwulansari, et al., 2019}, ^{Islaeli, et al., 2020}). Thus, parents and children feel good because the environment becomes favorable to health care (^{Faria, et al., 2017}). In the literature, the findings praise the therapeutic toy in the presence of chronic diseases, in pediatric hospitalization or, specifically, before and during the most painful hospital procedures and concluded that playful activities provide well-being and help in recovery (^{Nijhof, et al., 2018}; ^{Jiang, 2020}; ^{Kapkin, et al., 2020}). Health professionals, on the other hand, corroborate the perception that playing favors less traumatic care, representing benefits for both the professional and the child (^{Faria, et al., 2017}; ^{Karbandi, et al., 2020}; ^{Ribeiro, et al., 2020}). Likewise, children yearn for affectionate and careful communication when performing procedures (^{Franco da Silva, et al., 2020}).

Children with fear, silent and non-cooperative changed their behaviors, which suggests spontaneity to understand, cooperate and better accept treatment. Thus, the playroom favors social interactions, reduces pain and contributes to greater adaptability and clinical improvement, which should be a concern of managers for their implementation and training of workers (^{Oliveira, et al., 2016}; ^{Silva, et al., 2016}; ^{Rockembach, et al., 2017}; ^{Nijhof, et al., 2018}; ^{Gillard, 2019}; ^{Godino-Yáñez, et al., 2020}).

This said, the study allowed understanding the perception of parents and guardians about the role of the playroom in the recovery of their hospitalized child. The playroom and the use of play are basic institutional strategies in childcare (^{Faria, et al., 2017}; ^{Franco da Silva, et al., 2020}).

The in-depth analysis of the statements, by the methodological framework, based on the current literature on the subject were fundamental to problematize and point out paths that, according to ^{Brandão, et al. (2018}), allow knowing, perceiving and intervening on identified issues. In this sense, only the qualitative approach is able to give voice to the subjective and enhance the exercise of this citizenship.

The limitations of the study include its development in a single hospital setting, despite being a reference in pediatric care, which may represent only local results. However, the qualitative approach does not seek to generalize results, but to envision new paths that qualify childcare and can be evaluated and reflected in similar scenarios. Other dimensions need to be considered, such as the view of hospitalized children, managers who have already implanted the playroom and professionals in relation to the need for training for playful performance as therapy in children’s hospitalizations.