Playful strategies in the pediatric hospitalization scenario

Childhood is a phase of life that, for the most part, is symbolized by the act of playing. It is through this stage that the child has new skills, experiences, and discoveries. In addition, one can also notice the development of processes such as creativity, self-confidence, social-affective relationships, and cognition. However, some situations sometimes hinder the realization of processes that are essential for childhood, hospitalization being one of them. The study aims to know the playful strategies in the scenario of pediatric hospitalization, highlighting its benefits and importance in hospital humanization. This is an integrative review, carried out from articles collected from the Scielo, PubMed, Lilacs, Medline and BDENF databases. The descriptors applied were "Child Health" AND "Play Therapy". The findings showed that play strategies are extremely important in the humanization of care for hospitalized children, as they reduce suffering and make hospitalization less painful and traumatic. It was concluded that playful strategies when implemented in the pediatric hospital setting promote a less traumatic recovery, in addition to allowing for greater tranquility in the hospital environment. Moreover, the use of playful strategies was pointed out by the studies as a communication resource that benefits not only the physical, emotional, and immunological stimuli, but also the relationship between the child and the health professional, thus contributing to a greater trust in the therapy adopted and in the multiprofessional team.


Introduction
Childhood is a phase of life that, for the most part, is symbolized by the act of playing. It is through this stage that the child has new skills, experiences, and discoveries. In addition, it is also perceived the development of processes such as creativity, self-confidence, socio-affective relationships and cognition (Paixão, Damasceno & Silva, 2016).
However, some situations sometimes hinder the realization of these essential processes for childhood, hospitalization being one of them. It is understood that hospitalization is a remarkable process in any life cycle, especially for a child, who may be isolated depending on his clinical condition (de Oliveira . With this, in playful activities, understood as those that have the purpose of playing and psychosocial development, the child ends up experiencing new sensations, create new everyday situations, and discover a world different from the usual one. In addition, they can transform children's desires and minimize the discomforts arising from hospitalization, thus assisting in coping with the disease (Lima & Santos, 2015).
It is also noteworthy that one of the situations that can lead not only the isolation of children, but also social restrictions is childhood cancer, because it is a condition that requires several moments of hospitalization. Thus, the child needs to leave his home and the interaction with his loved ones to adapt to the hospital environment and everything around him (Bezerra et al., 2021).
From this perspective, it is of utmost importance that there is a team trained to deal with such processes in the pediatric hospitalization scenario. The team can implement actions that contribute to the adaptation of the child in this environment, in addition to inserting family members in daily care and decision-making, because studies show that the presence and participation of the family can assist in the care of the hospitalized child, as well as provide more interaction with the team (Dal'bosco et al., 2019). Therefore, this study aims to know the playful strategies in the scenario of pediatric hospitalization, highlighting its benefits and importance in hospital humanization.

Methodology
The study is an integrative literature review, qualitative in nature. This type of review is one of the analytical methods of relevant research, because it provides subsidies for decision making and improvement of clinical practice, enabling, in a systematic way, the synthesis of knowledge of a particular content, in addition, it aims to promote the deepening of the investigated subject (Mendes, Silveira, & Galvão, 2019).
Moreover, the integrative review (IR) follows important steps for its preparation, such as 1) Define the theme of the work and elaborate the guiding question; 2) Search and select the primary studies and delimit the inclusion and exclusion criteria; 3) Extract and organize the data from the primary studies; 4) Evaluate the primary studies with the use of tools; 5) Synthesize the results of the review and 6) Present the review (Mendes, Silveira & Galvão, 2019). And as for the qualitative Research, Society and Development, v. 10, n. 5, e6210514652, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i5.14652 4 nature, Pereira et al., (2018) points out it is important for the researcher to be able to interpret with their opinions the studied phenomenon.
From this, the theme of the study was defined, and then the guiding question was formulated: What are the playful strategies in the scenario of pediatric hospitalization, and what are the benefits and importance in hospital humanization? Data collection was made by searching the Virtual Health Library (VHL) and its respective databases: Scielo, PubMed, Lilacs, Medline and BDENF. The descriptors "Child Health" AND "Play Therapy" were used, selected through the Descriptors in Health Sciences (DECS).
Subsequently, the PICo strategy was used, where the following were defined Population (P): hospitalized children; Intervention (I): use of play strategies in the hospital setting; Comparison (C): humanization of care for hospitalized children through play strategies; Outcomes (O): to promote a less traumatic recovery and allow tranquility in the hospital environment.
We included original articles available electronically, published from 2015 to 2021 and with linguistic parameters in English and Portuguese. Papers that did not address the subject of interest or did not answer the guiding question, publications with duplicity, theses, dissertations, and editorials were excluded. Based on the cross-referencing "Child Health" AND "Play Therapy", the review resulted in an initial sample of 246 articles. After using the inclusion criteria, only 54 articles remained, which were read individually and, at the end of the analysis, 17 articles were included in the study.

Results and Discussion
After reading all the full articles, a data collection tool was applied, containing the topics described in Table 1 (Souza, Silva & Carvalho, 2010). Playful activities help promote the recovery process and make the hospital environment lighter so that children can progress in treatment; the junction between care and play makes it more humanized and induces better quality care. Playful activities are essential for both child development and the therapeutic process, so it is considered by health professionals as an important tool to promote humanized care for hospitalized children.
Dal'bosco et al., To report the experience of a horizontal and multidisciplinary teaching strategy and multidisciplinary teaching strategy in the Extension During the activities, the importance of the institutionalization of the toy room by the hospital management was evidenced, as well as the need to establish in the institution a nucleus for the implementation of research and extension projects that enable greater institutional autonomy to establish new projects.
dos Santos et al., Play therapy as a tool for humanized nursing care Integrative review The objective was to describe the treatment as part of the treatment and recovery of hospitalized people.
Treatment through play contributes to the the well-being of hospitalized patients, corroborating for a humanized care.
Ducca (2020) The benefits of ludotherapy and the use of therapeutic toy in pediatric intensive therapy units

Bibliographic review
To identify the importance of playfulness and therapeutic play in assisting children in the UTI environment The use of playful activities as an auxiliary therapeutic method in the care of children in Pediatric Intensive Care Units (UTIP) contributes to the multidisciplinary team professionals' ability to establish stress and tension reduction, both for patients and family members. patients and family members Lima & Santos (2015) Play as a care strategy for children with cancer Exploratory descriptive study To understand the infl uence of play in the care process as perceived by children with cancer There are several activities at the hospital that are considered play-related and, for the children, they all benefi t their care process.
Morais (2020) The importance of play therapy in the nursing care of hospitalized children

Integrative review
Bringing out the importance of play therapy in better quality nursing care It was noticed that the practice of play is easy to use and is indispensable for the suffering of this pediatric patient is alleviated or even eliminated.

Bibliographic review
To discuss the importance of play therapy in the care of children hospitalized with cancer, to identify the types of play activities developed during the hospitalization process and the benefits of play therapy for children with cancer.
It is essential to use play therapy resources in the care environments of children with cancer, because it favors, besides fun, the expression of feelings and emotions that the child goes through, making it possible to personalize the intervention.
Paula et al., Playful strategies in the nursing care of hospitalized children

Descriptive study
To analyze the use of play strategies in hospitalized child care from the perspective of the Nursing team It was evaluated that the limiting factors need to be overcome in order to guarantee integral care to hospitalized children, considering that playing is a legally guaranteed right, besides contributing to a more pleasant recovery and to full child development.  Humanization in the treatment of children with cancer through playful activities

Integrative review
To evaluate the positive impacts of playful activities playful activities in the treatment of children with cancer It has been proven that playful activity is effective during treatment, as it results in good prognosis for the children who have access to it. Silva et al., (2018) The importance of play in the context of children's hospitalization

Integrative review
To analyze the importance of play in the context of child hospitalization.
Playfulness is important in the context of children's hospitalization, since it brings benefits not only for the hospitalized child, but also for the family and the health team, besides enabling a more humanized care. Silva et al., (2017) Angels of nursing: the ludic as an instrument of citizenship and humanization in health Exploratory study To identify the perception of companions and/or tutors regarding the importance of Nursing Angels in the treatment of children/adolescents with cancer.
At the end of the study, the companions demonstrated the positive impacts that the playful activities developed by the Nursing Angels bring to the pediatric cancer treatment, which completely changes the family and hospital dynamics.
From the thorough analysis of the selected articles, three categories were elaborated, being them: the strategies and resources that help with playfulness, the benefits of playful activities in the pediatric hospitalization scenario, and the importance of playful strategies in hospital humanization.

Strategies and resources that aid ludicity
Play therapy is an important tool to be used in the hospital environment, as it provides improvements in coping with diseases and treatments. According to the literature, there are several playful activities that help care for hospitalized children, such as puppets, clow theater, story reading, role-playing, clowns, paintings, toy library, and the therapeutic doll, which are the most commonly used by health professionals (da Silva, de Souza, & Teixeira, 2019;Paula et al., 2019).
Regarding the hospital toy room, it consists of a specific place to use toys properly, therefore, the more toys there are in this space, the more distracted the child will be and the better their adaptation during hospitalization will be. Paixão, Damasceno and Silva (2016) mention some examples of toys that can be found in this environment, including dolls, assembly games and/or board games, balls, among other possibilities.
In the study by Melo Silva et al. (2018), a field research was conducted with ten caregivers about the use of the therapeutic toy (BT). The use of this instrument during the performance of procedures proved to be effective, and the companions reported a satisfaction and improvement in the emotional state of the children, where it was noticeable a greater willingness, better acceptance of the diet and there was improvement in communication and interaction between the child and the team. Corroborating the above study, Duca (2020) emphasizes that with the use of the BT it was noticed that children can come to understand the need for hospitalization and be able to experience this moment in a more peaceful way.
In addition to these playful activities, Lima and Santos (2015) emphasize the presence of the clown in this scenario of pediatric hospitalization, being an important participation for the reduction of traumas characteristic of hospitalization. It is noteworthy that this interaction between the child and the clown promotes stimuli, such as laughter and distraction, bringing benefits to the body, besides promoting relaxation, facilitating the interaction with other people, and establishing bonds and well-being to all those involved in the care process.
It is also observed some playful strategies that the team can use in the care of hospitalized children, such as the use of hospital materials, because children carefully observe the instruments used during procedures that are typical of the hospital environment, such as syringes and adhesive tape. In addition, another form of strategy are the group meetings that facilitate socialization, where it is possible to address issues such as healthy eating, personal hygiene, accident prevention, among others. Thus, it is important that professionals use this strategy to promote a playful scenario for hospitalized children (dos Santos et al., 2017;Paula et al., 2019).

Benefits of playful activities in the pediatric hospitalization setting
According to the studies, there are numerous playful activities that professionals can use in order to improve the child's interaction with the environment in which he/she is, in this case, the hospital. Therefore, it is important to highlight the benefits that playful strategies have in the care process, such as reducing pain, reducing depressive behavior, anxiety, and fear, and facilitating better communication between the child and the professional (Paixão, Damasceno, & Silva, 2016).
In addition, the articles emphasize that the main feelings seen in children during playful activities were joy and contentment. From this, it is noted that this process minimizes tension and makes the hospital environment more pleasant, being a necessary and effective measure in the care of hospitalized children (Bezerra, Lima & Cavalcante, 2021;Lima & Santos, 2015).
It also emphasizes that playfulness influences not only children's emotions, but also the child's immunity (de Lima et al., 2020). According to the article by Silva et al., (2018), this resource contributes to the increase of the body's defense cells and, consequently, the child's well-being. For Dal'bosco et al., (2019) there is also distraction as a factor that helps in this process of care, since it allows the child to forget for a few moments the suffering and pain inherent to the disease and hospitalization.
Moreover, Paixão, Damasceno and Silva (2016) corroborate with the two authors cited above, they explain that laughter promoted by play has an analgesic effect, since it favors mood, increases immunity and decreases muscle tension and exhaustion, all through the limbic system and the release of neurotransmitters such as endorphin and serotonin. They also affirm that laughter promotes the exercise of breathing, considering that it acts as a myorelaxant, being essential to reduce tension, especially in moments of pain.

Importance of ludic strategies in hospital humanization
When hospitalized, patients have rights established by the National Humanization Policy (PNH), which promotes a closer relationship between health professionals and patients and between the hospital and society, aiming to improve the quality of services provided in the health unit. Thus, the use of playful activities in the hospital context emerges as a possibility to promote humanized care to hospitalized children, enabling proximity between the subjects and the formation of bonds between children, professionals, and family, and consequently, greater adherence to treatment (de Oliveira Soares et al., 2018; Morais, 2020).
As already mentioned, play helps to cope with hospitalization and provides humanization in the child's health care, through fun and relaxation, making them safer in the hospital environment, reducing stress and exposing their feelings with the purpose of the child making their choices and becoming more active .
In addition, according to Dal'bosco et al., (2019), health professionals need to strengthen bonds in order for the family to understand the process of hospitalization, the disease, and the necessary care for the child's recovery. Thus, it is believed that a well-informed family regarding the diagnosis and treatment enables more interaction with the team and easier adherence to treatment, thus providing humanization in child care.
Therefore, playful activities, when well employed in the pediatric hospitalization scenario, help in difficult moments for all those involved in the care process, in addition to playing an encouraging role, it also offers the child and family member the freedom to express their feelings (Paixão, Damasceno & Silva, 2016). Moreover, in the study by Oliveira Silva et al., (2019) they state that: Ludic is used mainly to reduce the suffering during the hospitalization process, both experienced by the children and their families. They arrive very weakened by the process of illness presented by the child, and this has repercussions on the entire family, not only on them. Play serves mainly as a way to make the hospital environment lighter (de Oliveira Silva et al., 2019, p. 3).
In this sense, it is evident that playful strategies are extremely important in the humanization of care for hospitalized children, because they reduce suffering and allow hospitalization to be less painful and traumatic. In addition, play therapy influences the ideal and humanized care, reducing the sequelae of the disease, awakening learning and social interaction (da Silva & de Oliveira Lima, 2018;Bezerra, Lima & Cavalcante, 2021).

Conclusion
It was concluded that playful strategies when implemented in the setting of pediatric hospitalization promote a less traumatic recovery, besides allowing for greater tranquility in the hospital environment. This junction between care and play therapy makes assistance more humanized; therefore, this resource must be implemented by the multiprofessional team so that hospitalized children can develop their abilities, such as self-confidence, cognition, psychomotor development, and socialaffective relationships.
Moreover, the use of playful strategies was pointed out by the studies as a communication resource that benefits not only the physical, emotional, and immunological aspects, but also the relationship between the child and the health professional, thus contributing to a greater trust in the therapy adopted and in the team. However, research on the application of play therapy in hospital settings is still limited. Thus, future studies are necessary to adapt the instruments to the characteristics of the hospital context, but it is noteworthy that the concepts and general lines of this methodological reference are perfectly applicable to the care of pediatric patients assisted in this space.