Recognition of the importance of play in hospital
Play in hospital is not a new concept. Several earlier reports highlighted the damaging effects of hospitalisation when children were removed from all that was familiar to them.
The Platt Report (1959) made 55 recommendations including the need for play to be organised under skilled supervision to reduce the negative effects of separation of mother and child, disturbance of routine and lack of training for doctors and nurses regarding the emotional and mental needs of children.
In 1966 an OMEP working party concluded that unrestricted visiting and generous arrangements for play must be organised in hospital. Susan Harvey, a Save the Children Fund adviser, stated that “Deprived of play, the child is a prisoner, shut off from all that makes life real and meaningful.’ In writing this, she (1972) was expressing a view held by many educationalists and psychologists over the years.
The DHSS Expert Group on Play, (1976) and Department of Health, (1991) made clear recommendations that play be provided in the hospital setting in order to maintain the emotional well being of the child.
The first hospital play schemes were established in 1957 at St Bartholomew’s and St Thomas’ Hospital, followed by the Brook Hospital in 1963. Since those early days, a child’s need for play has not changed; however, the way it is now used and delivered in hospital has. Play in hospital is no longer viewed as a useful way to relieve boredom and pass the time in a pleasurable way, although both points are key elements in relieving fear and anxiety in a strange and unfamiliar setting.
In fact the need for play is even greater in a hospital environment, where the child is exposed to strange sights, sounds and smells. This is now recognised by the National Service Framework for Children (2003), who advise that children visiting or staying in hospital have a basic need for play and recreation that should be met routinely in all hospital departments providing a service to children.
The value of play in a child’s development is recognised by experts and, for the child or adolescent in hospital, play has a very special significance. It is not a way of keeping them quiet or passing the time; it is part of the treatment they receive. Play is important, both in preparing children for what is going to happen and in providing ways for them to work through anxieties and fears and deal with their experiences in hospital.
The objectives of play
Therefore, a successful, well run play programme can:
– increase the child’s ability to cope with a hospital admission;
– facilitate appropriate channels of communication between the child, the family and relevant health care professionals;
– create an environment where stress and anxiety are reduced;
– provide the child with the means with which to cope with diagnosis, illness and treatment, which ultimately gives control back to the child or young person;
– reduce developmental regression and therefore promote confidence, self esteem and independence;
– assist in the assessment and diagnosis of illness;
– offer the child coping strategies for managing pain and invasive procedures;
– prepare the child and family for medical and surgical procedures using terms that can be understood by all.
The impact of play
The use of focused and therapeutic play interventions assists the child and family to understand the illness, treatment and management of pain and this is achieved in the following ways.
Normal play enables the child or young person to relax as s/he finds comfort in familiar toys and activities. This is essential, especially in the case of emergency admissions where a disturbance of normal routine and lack of preparation for the event can cause emotional distress both long and short term. The use of play enables the continuation of physical, emotional, social and intellectual development, and, as a result, the loss or regression of skills is minimised. Through the use of normal play, important observations can take place which contribute to assessment and diagnosis when communicated to the paediatric multi-disciplinary team.
Preparation for procedures offers the child and family a means of understanding, accepting and cooperating with treatment. This last point should not be underestimated as it is known that the cooperation of children undergoing blood tests, for example, enables the procedure to be carried out quickly and efficiently, whereas the first attempt may be unsuccessful with the child who fights and struggles through fear, and further attempts may be required. Whilst this is time consuming for the doctor, it is deeply traumatic for the child and parent. To truly assimilate something fearful or unknown, the child requires opportunities to come back to it in his/her own time.
When considering the efficacy of preparing children for procedures, a review on current perspectives would suggest that it is now more common practice as health professionals generally recognise that a child’s understanding can be enhanced by appropriate information. Eiser and Hanson (1989) point out that knowledge, and not cognitive development, is significant in determining children’s understanding of health and illness.
Rushforth (1999) suggests that for the hospitalised child enhanced information of their condition can reduce fear or their pain experience. In addition, this creates the potential for the child to become an active participant in the decision-making surrounding their care. To prepare children for procedures is not only good practice but an acknowledgement of their rights to be kept informed, as highlighted in the Children Act 1989 (Department of Health 1992), whilst Article 12 of the UN Convention on the Rights of the Child clearly advocates “the child’s right to express an opinion and to have that opinion taken into account in any matter or procedure affecting the child” (UNICEF 2002 ).
Distraction therapy involves a range of techniques, acknowledging that the child may be frightened during a procedure but offering a means of coping whilst the procedure is taking place. Successful distraction therapy enables the child to feel positive about their treatment and empowers them to take control.
Post-procedural play can be used to identify fears and misconceptions following a procedure. This form of play is pertinent for emergency admissions and a sensitive approach is required which involves returning the child to the point of admission and filling in any gaps s/he has. When children have major misconceptions about why they were admitted or what “things” were done to them, post-procedural play enables them to work through these events.
Individual referrals are requested by various members of the multi-disciplinary team and can include children and young people who are needle phobic, newly diagnosed diabetics, children with eating problems, headaches or pain with no obvious cause or children with chronic illness being cared for at home. Here, a range of therapeutic activities are used depending on the individual needs of the child. Referrals usually involve the child coming back to the hospital for specific play sessions with agreed aims and objectives set. The number of visits will depend on the nature of the problem.
Working with siblings should be established practice in any hospital play scheme, as it is understood that when a child is admitted, the whole family unit can be altered. Siblings, depending on their age, developmental level, emotional maturity and previous experience of hospital, may adapt to the hospitalisation of a brother or sister without any difficulty. However, for some children this may be traumatic. They may come to resent the sick child and the time their parents spend caring for him/her, particularly in the case of long term or chronic illness. They may show signs of jealousy or anxiety, sensing parental worries. Their behaviour may alter; they may regress or feel guilty that they have caused the illness (when they wished their brother/sister would go away); they may become fearful that they too will become ill and have to undergo painful procedures. They may also miss their sibling.
To help siblings make sense of the changed family circumstances and environment, they are encouraged to play in hospital with the ill child whenever possible or to have their own time in the play room where they can work through their feelings. Depending on the individual, play may be guided or a non-directive approach taken. Provision of play in hospital for siblings helps to reduce parental anxiety as many parents balance the needs of the sick child and those children left at home.
Hospital Play Specialist
Play in hospital does not happen by chance, it is the Hospital Play Specialist, employed in a variety of paediatric settings, who is specifically trained to enable the sick child to assimilate and absorb the hospital situation into a more manageable and positive experience. Play services can be found in acute paediatric wards, burns units, A&E departments, day surgery wards and specialist areas such as cancer. Today it is widely recognised that hospital play services run by qualified Play Specialists add value to the paediatric setting by enhancing the environment in which children are enabled to make choices and participate in their own health care.
Norma Jun-Tai is a member of the National Association of Hospital Play Specialists and the Hospital Play Specialist Education Trust.
This article was first published in OMEP UK Update No. 129 March 2008. OMEP is an international professional organisation which focuses on early years child care and education. For more information on OMEP go to: www.omepuk.org.uk.