ABSTRACT

Objective:

to present and discuss actions and strategies used by professors who teach therapeutic play in the Undergraduate Courses in Nursing.

Method:

qualitative research, that used symbolic interactionism as its theoretical framework, and Grounded Theory as its methodological framework. The scenario was the courses involving the theoretical-practical teaching of pediatric nursing, included in the curriculums of the Undergraduate Courses in Nursing. A total of 18 lecturers and three nurses participated, all involved in the process of teaching therapeutic play in the theoretical-practical scenario. Data were collected through participant observation and semistructured interviews.

Results:

it was revealed that the mobilization of the professors to teach therapeutic play in the Undergraduate Courses is permeated by a constant concern with offering and promoting significant learning to the student. They seek to do this through teaching strategies that involve: dramatization of therapeutic play sessions, the recovery of infancy and of playing, the use of audiovisual resources that raise awareness of learning, realistic simulation as innovation, the extending of possibilities of using Therapeutic Play, the re-presenting of therapeutic play to the student at the start of the practical activity, the providing of material for this practice, and the inclusion of the issue in the assessment process.

Conclusion:

the results contribute to assisting the lecturers in the task of awakening and introducing the student to the universe of therapeutic play, promoting her learning and systematic incorporation into academic life and, in the future, as a nurse, when she shall promote the inclusion of therapeutic play in the care provided to the child - in order to preserve and protect the child’s right to receive qualified care.

DESCRIPTORS:
Teaching; Nursing education; Pediatric nursing; Play and playthings; Problem-based learning

RESUMEN

Objetivo:

presentar y discutir acciones y estrategias utilizadas por profesores que enseñan el juego terapéutico en los Cursos de Graduación en Enfermería.

Método:

investigación cualitativa, que utilizó el Interacionismo Simbólico como referencial teórico y metodológico la Teoría Fundamentada en los Datos. El escenario se constituyó de disciplinas que involucran la enseñanza teórico-práctica de la enfermería pediátrica, insertadas en los currículos del Curso de Graduación en Enfermería. Participaron 18 docentes y tres enfermeros, involucrados con el proceso de enseñanza del juguete terapéutico en el escenario teórico-práctico, siendo los datos recolectados por medio de observación participante y entrevista semiestructurada.

Resultados:

se reveló que la movilización del profesor para enseñar el juego terapéutico en el Curso de Graduación está impregnada por constante preocupación en ofrecer y promover al alumno un aprendizaje significativo, lo que busca hacer por medio de estrategias de enseñanza que involucran: dramatización de sesiones el uso de recursos audiovisuales sensibilizadores del aprendizaje, la simulación realista como innovación, la ampliación de posibilidades del uso del juego terapéutico, el reapresión del juego terapéutico al alumno al inicio de la actividad práctica, providenciar el juguete terapéutico, rescate de la infancia y del juego, utilización de recursos audiovisuales sensibilizadores del aprendizaje, la simulación realista como innovación, la ampliación de posibilidades del uso del juego terapéutico, material para esa práctica y la inserción de la temática en el proceso de evaluación.

Conclusión:

los resultados contribuyen a auxiliar a los docentes en la tarea de despertar e introducir al alumno en el universo del juego terapéutico, favoreciendo su aprendizaje y la incorporación sistemática en la vida académica y, en el futuro, como enfermero, cuando deberá promover la inserción del juguete terapéutico en la asistencia al niño, para preservar y proteger su derecho a recibir una atención cualificada.

DESCRIPTORES:
Enseñanza; Educación en enfermería; Enfermería pediátrica; Juego e implementos de juego; Aprendizaje basado en problemas

RESUMO

Objetivo:

apresentar e discutir ações e estratégias utilizadas por professores que ensinam o brinquedo terapêutico nos Cursos de Graduação em Enfermagem.

Método:

pesquisa qualitativa, que utilizou o Interacionismo Simbólico como referencial teórico e metodológico a Teoria Fundamentada nos Dados. O cenário constituiu-se de disciplinas que envolvem o ensino teórico-prático da enfermagem pediátrica, inseridas nos currículos do Curso de Graduação em Enfermagem. Participaram 18 docentes e três enfermeiros, envolvidos com o processo de ensino do brinquedo terapêutico no cenário teórico-prático, sendo os dados coletados por meio de observação participante e entrevista semiestruturada.

Resultados:

revelou-se que a mobilização do professor para ensinar o brinquedo terapêutico no Curso de Graduação é permeada por constante preocupação em oferecer e promover ao aluno uma aprendizagem significativa, o que busca fazer por meio de estratégias de ensino que envolvem: dramatização de sessões do brinquedo terapêutico, resgate da infância e do brincar, utilização de recursos audiovisuais sensibilizadores da aprendizagem, a simulação realística como inovação, a ampliação de possibilidades do uso do brinquedo terapêutico, o reapresentar do brinquedo terapêutico ao aluno no início da atividade prática, providenciar o material para essa prática e a inserção da temática no processo de avaliação.

Conclusão:

os resultados contribuem para auxiliar os docentes na tarefa de despertar e introduzir o aluno no universo do brinquedo terapêutico, favorecendo seu aprendizado e a incorporação sistemática na vida acadêmica e, futuramente, como enfermeiro, quando deverá promover a inserção do brinquedo terapêutico na assistência à criança, para preservar e proteger o seu direito de receber um atendimento qualificado.

DESCRITORES:
Ensino; Educação em enfermagem; Enfermagem pediátrica; Jogos e brinquedos; Aprendizagem baseada em problemas

INTRODUCTION

In recent years, the area of education in Nursing has advanced and significant changes have occurred since the incorporation of the National Curricular Guidelines (DCNs) in the Undergraduate Courses in Nursing. The structural axes of the process of professional training should be fundamentally based in the adoption of a theoretical-pedagogical framework that supports significant learning that is transformative and suited to the social and professional needs presented at the current time.1Fernandes JD, Rebouças LC. A decade of National Curriculum Guidelines for Graduation in Nursing: advances and challenges. Rev Bras Enferm [Internet]. 2013[cited 2017 Mar 02];66(spe):95-101. Available from: Available from: http://dx.doi.org/10.1590/S0034-71672013000700013 .
http://dx.doi.org/10.1590/S0034-71672013...

The DCNs guide the curricular organization for the training of nurses who are generalist, humane, critical and reflexive, with the knowledge necessary for exercising general competencies and skills, such as attention to health, decision-making, leadership, administration, management, ongoing education and communication.2Fernandes JD, Silva RMO, Teixeira GA, Florencio RMS, Silva LS, Rebouças LCC. Aderência de Cursos de Graduação em Enfermagem às Diretrizes Curriculares Nacionais na perspectiva do Sistema Único de Saúde. Esc Anna Nery [Internet]. 2013 [cited2017 Mar 17];17(1):82-89. Available from: Available from: https://doi.org/10.1590/S1414-81452013000100012 .
https://doi.org/10.1590/S1414-8145201300...

In this regard, the courses directed towards care for the child must also form part of the curriculums of the Undergraduate Courses in Nursing, with theoretical and practical content developed over the course of the training - and must be obligatorily included in the supervised curricular placement, in an integrated and interdisciplinary way.3Ministério da Educação (Brasil). Conselho Nacional de Educação. Câmara de Educação Superior. Resolução CNE/CES 3/2001: Institui as diretrizes curriculares nacionais do curso de Graduação em Enfermagem. Diário Oficial da República Federativa da União. Brasília [Internet], 09 nov. 2001, Seção 1, p 37 [cited2017 Mar 25]. Available from: Available from: http://portal.mec.gov.br/cne/arquivos/pdf/CES03.pdf
http://portal.mec.gov.br/cne/arquivos/pd...

As a result, the teaching must be conducted based in respect for the child’s rights and legal representatives, in the exercising of autonomy, freedom to take decisions, appropriate information understood by all, and with the gradual participation of the child, respecting her cognitive development and capacity for understanding.4Coelho LP, Rodrigues BMRD. O cuidar da criança na perspectiva da bioética. Rev Enferm UERJ[Internet]. 2009 [cited 2017 Mar 08];17(2):188-93. Available from: Available from: http://www.facenf.uerj.br/v17n2/v17n2a08.pdf
http://www.facenf.uerj.br/v17n2/v17n2a08...

Furthermore, it must defend the comprehensiveness of the care for the newborn, child, adolescent and family, promoting the teaching of effective communication strategies with all these actors, as an expression of the humanized care, and must enable the students to develop concepts including the valuing of playing as a basic need of the child, and the promotion of this in all the scenarios of care.5Sociedade Brasileira de Enfermeiros Pediatras. Carta de Gramado [Internet].2013 [cited2017 Mar 25]. Available from: Available from: http://sobep.org.br/v-congresso/
http://sobep.org.br/v-congresso/... In this regard, the child’s right to play must be protected, preserved and promoted by all professionals involved in her care.6International Play Association. Declaration on the importance of play Internet. 2014. [cited 2017 Fev 20] Available from: Available from: http://www.IPAworld.org
http://www.IPAworld.org...

In attending these principles, we emphasise the teaching of therapeutic play (TP), the technology of care that facilitates communication between the nurse, child and family, with the potential to favor the bond and the promotion of the emotional well-being of all those involved.7Ribeiro CA, Borba RIH, Maia EBS. O preparo da criança e da família para procedimentos terapêuticos. In: Associação Brasileira de Enfermagem, org. PROENF Programa de Atualização em Enfermagem: Saúde da Criança e do Adolescente: Ciclo 8. Porto Alegre, RS: Artmed/Panamericana; 2013:9-50.

TP was developed by nurses, and since the 1990s has been classified into three types: dramatic or cathartic, a modality in which the child can express herself through play and dramatize new, difficult-to-articulate experiences - and, through this, become emotionally secure; instructional, that allows the professional to explain procedures and/or other events which are unknown to the child; and physiologically enhancing, when the child participates in activities in order to improve her physical status through play.8Vessey JA, Mahon MM. Therapeutic play and the hospitalized child. J Pediatr Nurs. 1990;5(5):328-333.

All this potential for humanized care, promoting the child’s rights, evidences the need and importance for TP to be taught in the Undergraduate Courses in Nursing.

Although studies have evidenced that the majority of nurses come to know of this during their undergraduate studies, many continue to feel unable to apply it, or leave it to one side when providing care to children - prioritizing the managerial demands of the unit, associated with the predominance of the understanding that this action is superfluous in comparison with others. They indicate lack of knowledge and training, and failure to understand or be aware of TP as an advanced nursing practice, as hindrances to its application in clinical practice.9Oliveira CS, Maia EBS, Borba, RIH, Ribeiro CA. Brinquedo Terapêutico na assistência à criança: percepção de enfermeiros das unidades pediátricas de um hospital universitário. Rev Soc Bras Enferm Ped [Internet]. 2015 [cited 2017 Mar 15];15(1):21-30. Available from: Available from: http://sobep.org.br/revista/images/stories/pdf...n1/vol_15_n_2-artigo-de-pesquisa-3.pdf
http://sobep.org.br/revista/images/stori... ^-11Baldan JM, Santos CP, Matos APK, Wernet M. Adoption of play/toys in the assistence practice to hospitalized children: nurse’s trajectory. Cienc Cuid Saude[Internet]. 2014 [cited 2017 Apr 05];13(2):228-35. Available from: 329. Available from: 329. http://www.periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/viewFile/15500/pdf_197
http://www.periodicos.uem.br/ojs/index.p...

Such evidence led to certain questions: if the nurse interacts with the content of TP during her Undergraduate Course, and does not feel secure in applying it, what happened during her training? How is the teaching taking place? Are the teaching methodologies used appropriate, and capable of involving the student and promoting her learning?

A review of the literature on this topic in national and international databases indicated a scarcity of studies focusing on the teaching of TP in Undergraduate Courses in Nursing, evidencing a vast field of investigation to be explored.

Reflecting on the role of the professors who teach TP on Undergraduate Courses in Nursing throws light on their responsibility to transmit values and ethical principles to the students, involving respect for the child’s personal integrity and autonomy - including to take decisions7Ribeiro CA, Borba RIH, Maia EBS. O preparo da criança e da família para procedimentos terapêuticos. In: Associação Brasileira de Enfermagem, org. PROENF Programa de Atualização em Enfermagem: Saúde da Criança e do Adolescente: Ciclo 8. Porto Alegre, RS: Artmed/Panamericana; 2013:9-50.^,12Cunha MLR, Costa JB, Almeida FA, Maia MM. Crenças do enfermeiro na promoção da autonomia do escolar com câncer frente aos procedimentos de enfermagem. Investigação Qualitativa em Saúde. Atas CIAIQ. 2016;2:1214-1223.which, in situations involving young ages, can be encouraged and valued through dialogue based on TP sessions, giving the child the opportunity to act through play, exercising her role in decision-making and recovering her autonomy and self-control as she plays.12Cunha MLR, Costa JB, Almeida FA, Maia MM. Crenças do enfermeiro na promoção da autonomia do escolar com câncer frente aos procedimentos de enfermagem. Investigação Qualitativa em Saúde. Atas CIAIQ. 2016;2:1214-1223.^-13Manav G, Ocakci AF. Play Model for evaluation of self-concept of children with cancer. Iran J Nurs Midwifery Res Internet. 2016 [cited 2017 Apr 05];21(2):124-130. Available from: Available from: https://doi.org/10.4103/1735-9066.178227
https://doi.org/10.4103/1735-9066.178227...

Hence, this article aims to present and discuss actions and strategies used by professors who teach TP in the Undergraduate Courses in Nursing. It forms part of a study which sought to investigate the experience of the professor in the process of teaching TP in the academic scenario, and to construct a theoretical model that is representative of this experience.14Maia EBS. Empenhando-se em promover um ensino significativo do Brinquedo Terapêutico, almejando a qualidade do cuidado à criança: vivência do docente de graduação em enfermagem [tese]. [São Paulo, SP]: Universidade Federal de São Paulo, Programa de Pós-Graduação em Enfermagem; 2016. 290 p.

METHOD

A qualitative study that used Symbolic Interactionism as its theoretical framework, intending to analyze the human experiences, focusing on the nature of the interaction - that is, the activities of social dynamics that take place between people, emphasizing the meanings that they attribute to the events as determinants of the actions that they perform.15Charon JM. Symbolic interactionism: as introduction, an interpretation, an integration. 10th ed. Englewood Cliffs: Prentice-Hall; 2010.

The methodological framework was Grounded Theory (GT), a method that uses a set of systematized procedures for guiding the collection and analysis of data and developing a theory on a specified phenomenon.16Corbin J, Strauss A. Basics of qualitative reseach. techniques and procedures for developing Grounded Theory. 4th ed. Thousand Oaks, US: SAGE Publications; 2015.^-17Charmaz K. Constructing Grounded Theory. 2nd ed. Thousand Oaks, US: SAGE Publications; 2014.

The study scenario was courses involving the theoretical and practical teaching of pediatric nursing, in the curriculums of the Undergraduate Courses in Nursing of public and private institutions from different regions of Brazil.

A total of 18 lecturers and three nurses participated. These met the following inclusion criteria: to be a professor on the undergraduate course in nursing involved with the process of teaching TP in the theoretical-practical scenario; or to be a nurse, working in the process of teaching TP in the clinical field and/or in assisting in lecturing activities, irrespective of the length of experience in teaching, in both cases.

The number of participants was specified by the process of theoretical sampling, and was configured as the data was analyzed. The concepts that emerged based on the same led to reflections which led to the seeking of other participants for the collection of further data.16Corbin J, Strauss A. Basics of qualitative reseach. techniques and procedures for developing Grounded Theory. 4th ed. Thousand Oaks, US: SAGE Publications; 2015.^-17Charmaz K. Constructing Grounded Theory. 2nd ed. Thousand Oaks, US: SAGE Publications; 2014.As a result, four sample groups were made up: professors who worked in the theoretical and practical teaching of TP; those who worked only in the teaching of theory; those who worked only in practical teaching; and those who presented resistance to and/or apparent unawareness of the issue, who were indicated by colleagues who participated in one of the other sample groups.

The data were collected between April 2014 and March 2016. To access the participants, the Snowball sampling method was used, indicated when the population studied is wider. Based on the indication of one or more individuals, it begins with a certain number of people selected, in some way, by the researcher, and who form part of the target-population.18Vinuto J. A amostragem em bola de neve na pesquisa qualitativa: um debate em aberto. Temáticas. 2014;22(44):203-220.

The strategies for accessing the lecturers’ experience were: participant observation and semistructured interviews. The first took place in two locales: in the classrooms, and in the environments of academic practice, with interactions being observed between the professor and the students and the content of the TP, in theoretical classes on the topic; in the use of TP by the students, during clinical practice, and also in discussions with the professor. These observations were noted in the field diary, elsewhere, soon after the interactions took place.

The interviews were individual and were recorded, taking between 50 to 100 minutes. These took place in previously agreed locales, and began with the guiding question: “How do you see the teaching of therapeutic play in the Undergraduate Courses in Nursing?”. These were transcribed in full and conducted simultaneously with the analysis of the data, which led to further questions, such as: how is the topic addressed in the course that you teach? How do you see the development of the topic of TP in the classroom and in the academic practices?

In order to analyze the data, the steps stipulated by GT were followed. The first stage of the analysis was open codification: the text of each interview was fragmented into small excerpts and examined line by line, allowing the identification of the codes. Based on this, the data were compared in search of similarities and differences, and were grouped in categories.17Charmaz K. Constructing Grounded Theory. 2nd ed. Thousand Oaks, US: SAGE Publications; 2014.

In the second stage of the analysis, the selective codification, the categories were related to the subcategories, until theoretical saturation was achieved and the central category was identified, permitting the construction of the theoretical model.16Corbin J, Strauss A. Basics of qualitative reseach. techniques and procedures for developing Grounded Theory. 4th ed. Thousand Oaks, US: SAGE Publications; 2015.^-17Charmaz K. Constructing Grounded Theory. 2nd ed. Thousand Oaks, US: SAGE Publications; 2014.

It is emphasized that data collection began following approval from the Research Ethics Committee. In order to ensure anonymity, the participants were identified with the letter D and the number corresponding to the interview. The observation notes were identified using the letters NO followed by the same identification of the lecturer.

RESULTS

The analysis of the data revealed categories which were representative of the professor’s mobilization for teaching TP in the Undergraduate Courses in Nursing, which is permeated by a constant concern with offering and promoting to the student significant learning, with a view to improving the quality of the care for the child. For example: “Seeking to maintain a stimulating climate for learning in the classroom”, “Integrating strategies that favor the learning in the environment of academic practice”, and “Including the topic in the evaluation process”. These integrated one of the phenomenon which make up the experience of the professors teaching TP: “Concerning themselves with offering significant learning to the student”.14Maia EBS. Empenhando-se em promover um ensino significativo do Brinquedo Terapêutico, almejando a qualidade do cuidado à criança: vivência do docente de graduação em enfermagem [tese]. [São Paulo, SP]: Universidade Federal de São Paulo, Programa de Pós-Graduação em Enfermagem; 2016. 290 p.

In this regard, the professor seeks to include various teaching strategies, both theoretical and practical, constantly evaluated and reevaluated, which she believes will have a positive effect on the learning of the topic, as will be described below.

Promoting the dramatization of therapeutic play sessions

With the intention of making the theoretical content of TP in the classroom closer to the reality of care for the child, and promoting to the student a more concrete knowledge of what a TP session is, the lecturer, as well as offering the theoretical content, proposes dynamics - such as the dramatization of the TP sessions, undertaken by herself or by groups of students.

Reflecting on this strategy, the professor assesses that this activity has an impact on the student’s learning, offering greater security at the start of the academic practice, as its undertaking in the classroom allows prior knowledge of what is expected for the development of the TP session to be undertaken by each student.

Recovering childhood and playing

The lecturer believes that the TP class, on its own, is motivating for the topic of “playing”. Encouraged by this belief, during the theoretical class the professor uses the strategy of remembering childhood, sharing events, feelings and sensations experienced by the students, when they played in that period, seeking to bring them closer again with this universe.

Another strategy used by the professor in the classroom is to propose games with the use of balloons, so as to mobilize in the student pleasurable feelings as they remember playing, relaxing with the games and promoting reflection on this activity in the life of the children who they will be caring for.

Seeking to keep the playful atmosphere in the classroom, the lecturer brings along toys used in the TP sessions and costumes, for the undergraduate students to handle, enter into the spirit and accept the invitation to play. The presence of the toys functions as a lure, helping the student to establish fun interactions, with the toy, with classmates and with the professor. The lecturer defines this play activity as something that excites the students, causing them to interact from the beginning to the end of the class.

Seeking dialogue with the students

During the class, the lecturer dialogues with the students, sharing experiences related to the use of TP and to the experiments that he or she has undertaken on the topic. They are careful to leave the students at ease to share their ideas in small groups, formed with the task of - together - planning recreational gaming strategies involving TP, in order to include these in their academic practice with the children.

In a meeting on the planning of activities in academic practice with a small number of students, the lecturer - with the objective of dialoguing and planning the care for the hospitalized child, offers the students the possibility to share and consolidate their knowledge on TP.

Another teaching strategy mentioned by the lecturer of the TP class is the use of the Maguerez’s Arch method, which he believes promotes dialogue and the more active participation of the student, exposing what the latter knows about the topic and promoting the construction of knowledge in a shared way. This is a methodological path which can be used by the lecturer as a pedagogical practice that allows the student intellectual development and critical thinking, based on prior knowledge actioned in the discussion, stimulating curiosity and maintaining interest.19Prado LM, Velho MB, Espindola DS, Sobrinho SH, Backes VMS. Arco de Charles Maguerez: refletindo estratégias de metodologia ativa na formação de profissionais de saúde. Esc Anna Nery Internet. 2012;16(1):172-177. Available from: https://doi.org/10.1590/S1414-81452012000100023
https://doi.org/10.1590/S1414-8145201200...

Another strategy used as a basis for dialogue is to propose prior reading of articles by the students, making time and a reading list available so that the topic will be familiar to them, and they will be able to extend and consolidate their knowledge, generating stimulus for discussion in the classroom and supporting the construction of directed study and the resolving of clinical cases in groups of students.

The strategy is assessed by the professor as accepted well by the students. Equally, the professor observes the positive impact on their learning, as she can see that the students who comply as they are asked arrive at the class already much more familiarized with the topic of TP than the students who did not comply with the proposal.

Using audiovisual resources to raise awareness of the learning

The lecturer adds audiovisual resources to the play strategies, through presenting images of children playing freely, and videos with content raising awareness on care for the child, with the aim of contextualizing and promoting the discussion of the topic.

Seeing realistic simulation as a possibility for teaching therapeutic play

On reflecting about new possibilities for teaching the topic, the lecturer sees realistic simulation as a strategy with potential for impacting on raising the student’s awareness for TP, when compared to the expositive theoretical class, as it allows the student to visualize, question and validate information prior to experiencing it in practice with a child.

Re-presenting therapeutic play to the student at the start of the practical activity

By extending the teaching of TP to outside the classroom, the professor is concerned with having a second look at the theory on this topic, seeking not only to reinforce the content, but also to plan the care for the child with the student. He also requests the handing-in of the directed study indicated in the theoretical part, discussing it and using it as a basis so that the student is able to establish the relationship between theory and the practical activity of preparation for venipuncture proposed at that point.

On beginning the activities in the practice fields, the professor carefully organizes the scenario so that the practice of TP may take place, explaining respect to the mother and to the child, choosing first to undertake a session so that, later, the students will take responsibility for applying it individually or in pairs, under the professor’s supervision.

Broadening the possibilities of the use of therapeutic play

Seeking to ensure that the content goes beyond the barriers of the classroom, the lecturer is concerned that the student should experience the practice of TP in different environments: hospitals, emergency room, primary care centers and child education centers. In the hospital, the proposals for the use of TP are geared towards the preparation of the child for procedures, such as checking vital signs, venipuncture or dressings, as well as to give the child a voice where they are maltreated, allowing them to express themselves through play.

As well as preparation for painful procedures, such as venipuncture, the lecturer also emphasizes to the student the need to use TP with children in situations of trauma or urgency, even when it is not possible to prepare the child prior to the operation.

As a result, in the scenario of academic practice in the hospital, the lecturer takes advantage of the opportunities for the student to use TP, in the light of the child’s needs, planning actions with its use, as with any other technique undertaken and with the same importance.

In primary health care, the opportunities for teaching and using TP take place during the nursing consultation, physical examinations, preparation for using an inhaler, taking bloods and in the vaccination room, which, in the assessment of the lecturer, is something that the students really like doing.

In the child education center, on the other hand, the professor supervises the students, giving them the opportunity to interact with the children who present difficulties adapting to school and helping them to eat better through applying Dramatic TP.

Providing the material for the practice of therapeutic play

In order for the student to be able to experience the practice of TP, the professor builds a TP kit for the course and shares her own material with the students and with the other lecturers and, what is more, recommends the students to include a ragdoll as an item to be carried in their bag.

Including the topic in the process of the student’s assessment

Although throughout the teaching process one finds the sharing of ideas between students and professors, both in the classroom and in the practical activity environments, the lecturer reflects on the need for assessing the learning, also through formal strategies, such as a written test and the handing in of reports. In addition to this, the professor requires at least one TP session to be undertaken during the practice, in any one of its fields, which will influence the student’s final grade.

DISCUSSION

The concepts described in the categories presented made it possible to understand that the lecturer’s concern and responsibility in the construction of knowledge on TP permeate the entire teaching-learning process, mobilizing the professor to seek new ways of innovating the teaching and motivating the student’s interest in the topic. As a result, she comes to develop participative methodologies and adopts different pedagogical methodologies with the aim of promoting a listening space for the student.

These findings agree with what is being applauded in the literature, regarding the need to incorporate strategies which activate the students into the teaching process, involving them in the process of thinking, elaborating new meanings, learning and acting.20Barbosa EF, Moura DG. Metodologias ativas de aprendizagem na educação profissional e tecnológica. Bol Tec Senac. 2013;39(2):48-67.^-21Soares AN, Gazzinelli MF, Souza V, Araujo LHL. The Role Playing Game (RPG) as a pedagogical strategy in the training of the nurse: an experience report on the creation of a game. Texto Contexto Enferm [Internet]. 2015 [cited 2017 Apr 05];24(2):600-8. Available from: Available from: http://dx.doi.org/10.1590/0104-07072015001072014
http://dx.doi.org/10.1590/0104-070720150...

Meta-analysis undertaken with the aim of assessing the effectiveness of teaching strategies for developing critical thinking in undergraduate nursing students has revealed that problem-based learning (PBL) is one of the effective methods in increasing scores for critical thinking, confirming the hypothesis that active teaching strategies are more effective.22Oliveira LB, Diaz LJR, Carbogim FC, Rodrigues ARB, Puschel VAA. Effectiveness of teaching strategies on the development of critical thinking in undergraduate nursing students: a meta-analysis. Rev Esc Enferm USP [Internet]. 2016 [ cited 2017 Apr 05]; 50(2):355-364. Available from: Available from: https://doi.org/10.1590/S0080-623420160000200023
https://doi.org/10.1590/S0080-6234201600...

The use of these methodologies has the potential to develop autonomy and critical thinking in the student, and to wake her up to the fact that learning becomes significant to the student, emphasizing: case studies, videos, dramatizations, group discussions, integrated panels, Role-playing Game (RPG), teamwork, online programs, pedagogical workshops, participation and extension projects and the use of the laboratory.22Oliveira LB, Diaz LJR, Carbogim FC, Rodrigues ARB, Puschel VAA. Effectiveness of teaching strategies on the development of critical thinking in undergraduate nursing students: a meta-analysis. Rev Esc Enferm USP [Internet]. 2016 [ cited 2017 Apr 05]; 50(2):355-364. Available from: Available from: https://doi.org/10.1590/S0080-623420160000200023
https://doi.org/10.1590/S0080-6234201600... ^-23Sousa ATO, Formiga NS, Oliveira SHS, Costa MML, Soares MJGO. Using the theory of meaningful learning in nursing education. Rev Bras Enferm [Internet].2015 [cited 2017 Apr 05];68(4):713-22. Available from: Available from: http://dx.doi.org/10.1590/0034-7167.2015680420i
http://dx.doi.org/10.1590/0034-7167.2015... Many of them were used in the teaching of TP by the professors in this study, which, according to them, allowed the students to clarify doubts and gave them greater confidence for experiencing it in their academic practice.

The professors also showed their wish to incorporate realistic simulation as a teaching methodology, which promotes the significant learning of TP. The literature emphasizes simulated practice as a positive strategy, as - when it is used prior to the student being placed in clinical practice - it ensures the development of the skills necessary to minimize errors when the students are in a real context.24Martins JCM, Mazzo A, Baptista RCN, Coutinho VRD, Godoy S, Mendes IAC, Trevizan MA. The simulated clinical experience in nursing education: a historical review. Acta Paul Enferm [Internet]. 2012 [cited 2017 Apr 05];25(4):619-25. Available from: Available from: http://dx.doi.org/10.1590/S0103-21002012000400022
http://dx.doi.org/10.1590/S0103-21002012...

The encouragement for its use is related to the fact that it facilitates the communication between professor and student, that it offers a more secure learning environment, and helps to develop clinical expertise and confidence for decision-making, with consequent greater safety for the patient who will be cared for in the clinical environments.25Quilici AP, Bicudo AM, Gianotto-Oliveira R, Timerman S, Gutierrez F, Abrão KC. Faculty perceptions of simulation programs in healthcare education. Inter J Med Educ [Internet]. 2015 [cited 2017 Apr 05];6:166-171. Available from: Available from: https://doi.org/10.5116/ijme.5641.0dc7
https://doi.org/10.5116/ijme.5641.0dc7...

Nevertheless, as the literature emphasizes, the student must be predisposed to learning and the professor has the role of selecting the potentially significant material - that is, what makes sense to her, in order to promote links with prior knowledge.23Sousa ATO, Formiga NS, Oliveira SHS, Costa MML, Soares MJGO. Using the theory of meaningful learning in nursing education. Rev Bras Enferm [Internet].2015 [cited 2017 Apr 05];68(4):713-22. Available from: Available from: http://dx.doi.org/10.1590/0034-7167.2015680420i
http://dx.doi.org/10.1590/0034-7167.2015...

For this, students who participated in a study on the teaching and practice of TP in the undergraduate nursing course suggested that the professor should address, in the theoretical teaching of the topic, reports on his or her professional experiences with the use of the intervention, that the professor should offer case studies and discussion of articles, and should use videos and dramatizations of TP sessions so as to encourage and stimulate the learning. In academic practice, the students recommended that a specific time period of sufficient length should be made available for them to experience the use of TP, with support and encouragement from the professor.26Barreto LMSC, Maia EBS, Depianti JRB, Melo LL, Ohara CVS, Ribeiro CA. Giving meaning to the teaching of Therapeutic Play: the experience of nursing students. Esc Anna Nery [Internet]. 2017 [cited 2017 Sep 05];21(2):e20170038. Available from: Available from: https://doi.org/10.5935/1414-8145.20170038
https://doi.org/10.5935/1414-8145.201700...

In this study, the professors who were moved by the belief that the topic of playing, per se is motivating, as well as providing in the classroom the toys that make up the material stipulated in the TP sessions for the students to handle, undertook play dynamics, with the intention of recording events, sentiments and feelings experienced in childhood while the students were interacting with playing. Concomitantly, they used videos to raise awareness of the topic, and songs related to play.

This movement undertaken by the professor links with studies that reveal the need for the lecturer to provide an educational atmosphere that favors meaning, so that the student may feel respected in her differences and her values and thus be able to be adventurous and open up to the experience brought by the professor.27Souza MVL, Lopes ES, Silva LL. Aprendizagem significativa na relação professor-aluno. Rev Cienc. Humanas. 2013;13(2):407-420.

We agree that in the teaching of nursing, teaching situations based in real situations, such as those described above, enrich the teaching-learning process, because they viabilize a situation which is closer to reality and clarify how the student should behave with the small patient, providing an appropriate time for the lecturer to intervene in the construction of the knowledge.23Sousa ATO, Formiga NS, Oliveira SHS, Costa MML, Soares MJGO. Using the theory of meaningful learning in nursing education. Rev Bras Enferm [Internet].2015 [cited 2017 Apr 05];68(4):713-22. Available from: Available from: http://dx.doi.org/10.1590/0034-7167.2015680420i
http://dx.doi.org/10.1590/0034-7167.2015...

This study also revealed that the lecturer seeks to promote dialogue with the students, recovering theoretical concepts, including analogies and examples that she has experienced in her routine with TP, allowing the student to share her doubts and anxieties and reflect on the relationship between the theoretical bases and the academic practice. In this regard, the use of Maguerez’s Arch19Prado LM, Velho MB, Espindola DS, Sobrinho SH, Backes VMS. Arco de Charles Maguerez: refletindo estratégias de metodologia ativa na formação de profissionais de saúde. Esc Anna Nery Internet. 2012;16(1):172-177. Available from: https://doi.org/10.1590/S1414-81452012000100023
https://doi.org/10.1590/S1414-8145201200... allowed dialogue and the exchanging of knowledge and experiences related to the topic.

Research has evidenced that although the students initially resist the proposal of Problematization through the use of Maguerez’s Arch in the teaching of TP, this methodology was shown to be significant in the teaching, as it allowed interlinking between theory and practice, and the exercising of the collective construction of knowledge and encouragement to the students’ creativity and critical thinking. 28Fujita JALM, Carmona EV, Shimo AKK, Mecena EH. Uso da metodologia da problematização com o Arco de Maguerez no ensino sobre o brinquedo terapêutico. Rev Port Educ [Internet]. 2016 [cited2016 Oct 23];29(1):229-58. Available from: Available from: http://dx.doi.org/10.21814/rpe.5966
http://dx.doi.org/10.21814/rpe.5966...

It should be emphasized that when the professor proposes discussions on TP in small groups in the classroom, as undertaken by the lecturers studied here, this contributes not only to consolidating concepts on the topic, but also to acquiring communication skills, ²⁹ although - from the student’s perspective - this collaborative learning strategy is questioned, as these do not perceive it as favoring the gaining of knowledge, causing them to lose time which could be spent studying.30Rodríguez-Borrego MA, Nitschke RG, Prado ML, Martini JG, Guerra-Martín MD, González-Galán C. Theoretical assumptions of Maffesoli's sensitivity and Problem-Based Learning in Nursing Education. Rev Latino-Am Enfermagem [Internet]. 2014[cited2017 Apr 05];22(3):504-510. Available from: Available from: https://doi.org/10.1590/0104-1169.3065.2444
https://doi.org/10.1590/0104-1169.3065.2...

The lecturer’s concern with extending the possibilities for the use of TP outside the classroom is shown to be of fundamental importance, as the student recognizes that, upon interacting with the child and TP during clinical practice, she is surprised and impressed by the benefits that emerge from this interaction and the difference that it promotes in the care, favoring not only the child and the family, but the student as well - who feels gratified.26Barreto LMSC, Maia EBS, Depianti JRB, Melo LL, Ohara CVS, Ribeiro CA. Giving meaning to the teaching of Therapeutic Play: the experience of nursing students. Esc Anna Nery [Internet]. 2017 [cited 2017 Sep 05];21(2):e20170038. Available from: Available from: https://doi.org/10.5935/1414-8145.20170038
https://doi.org/10.5935/1414-8145.201700...

Depending on how the student is during this practice, he may come to understand TP as a communication strategy that benefits the child, as it minimizes the stress resulting from a difficult situation, as well as demystifying the figure of the nurse as somebody who only causes pain. He also emphasizes that it is through the practical activity of TP that the student comes to give meaning to the theory addressed on the topic in the classroom26Barreto LMSC, Maia EBS, Depianti JRB, Melo LL, Ohara CVS, Ribeiro CA. Giving meaning to the teaching of Therapeutic Play: the experience of nursing students. Esc Anna Nery [Internet]. 2017 [cited 2017 Sep 05];21(2):e20170038. Available from: Available from: https://doi.org/10.5935/1414-8145.20170038
https://doi.org/10.5935/1414-8145.201700...

In the light of the above, we believe that it will be possible to keep the classroom as a teaching-learning atmosphere if the educational project is innovative and considers active methodologies. Although few studies mentioned the lecturers’ concern with using these, it is fundamental for the learning that they should be prepared to advise their students, causing these to feel that they are protagonists of a learning that is rich and stimulating. 23Sousa ATO, Formiga NS, Oliveira SHS, Costa MML, Soares MJGO. Using the theory of meaningful learning in nursing education. Rev Bras Enferm [Internet].2015 [cited 2017 Apr 05];68(4):713-22. Available from: Available from: http://dx.doi.org/10.1590/0034-7167.2015680420i
http://dx.doi.org/10.1590/0034-7167.2015...

This article limited itself to describing the professor’s search and perception regarding the use of teaching strategies, so as to promote significant learning of TP, with a view to improving the quality in the care provided to the child. As a result, other studies must be undertaken, related both to the experience of using the strategies mentioned in this article, and to others, such as referring to the effects of its use in the student’s learning, with the aim of promoting the extending of the state-of-the-art on the teaching of TP.

CONCLUSION

The study made it possible to investigate didactic strategies used by the professor in the teaching of TP, that the professor considers effective for motivating the student and giving her significant learning, both in the theoretical field and in clinical practice. In this way, the hope is to help the lecturers in the task of awakening and introducing the student to the universe of TP, promoting its learning and the systematic incorporation of this important technology of care in academic life and in the future as a nurse.

It is known that there is much space for improvement not only in how the content of TP is worked with, but also in how to evaluate whether the learning was indeed significant, and the effect that this will have on the student’s life, as a professional who is responsible for promoting the inclusion of TP in the care for the child, preserving and protecting the child’s right to receive the care which she deserves.

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