SYMPOSIUM: SOCIAL PAEDIATRICS

PAEDIATRICS AND CHILD HEALTH 18:5 233 2008 Elsevier Ltd. All rights reserved.
Play in hospital
Norma Jun-Tai
Abstract
Observing children during play nds them practising and mastering skills
in planning, investigation, discovery, construction, imitation and imagi-
nation; there is no less need for the continuation of these skills during
illness and hospitalization. Play produces comfort and reassurance at a
time of unfamiliar and potentially frightening experiences. Play helps to
coordinate developmental and learning strategies to help children un-
derstand their environment. The multifaceted nature of play contributes
to the non-pharmacological approaches to hospital procedures; play is
not just for passing time pleasurably or relieving boredom (though both
are crucial for a positive experience within this setting). The inuence
of normal play in hospital, alongside distraction therapy, preparation for
procedures, referrals and home visits, are explored using therapeutic,
cognitive and behavioural interventions.
Keywords behavioural intervention; cognitive intervention; distraction
therapy; non-pharmacological; play; referrals

Basic concepts
History: play in UK hospitals has taken many forms since the
Platt report, which highlighted its benets by advocating that
play should be organized 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.
1
Save the Children
helped the rapid expansion of hospital play schemes throughout
England in the 1960s and1970s,
2
with this practice subsequently
embedded in several leading UK Department of Health reports
on the efcacy of play provision as part of the treatment process
of sick children.
3
Play in hospital carries a wider remit because
there is evidence that play hastens recovery and reduces the
need for interventions to be delivered under general anesthesia
4
;
hospital play is a recognized and valued element of child health
services at every level.
5
Recommendations: the Department of Health recommends that
play in hospital should be organized and delivered by qualied
hospital play specialists.
3,6
Despite the generic term, play applies
from birth to 19 years of age. Safeguarding children (including
those with disabilities) is integral to play services. It should be
Norma Jun-Tai HPS MA is a Hospital Play Specialist Co-ordinator at
Kingston Hospital, and Chairperson of the National Association of
Hospital Play Staff, London, UK.
assumed that siblings are routinely included in most hospital
play services and, in some cases, programmes will be developed
specically for siblings if a sick brother or sister is chronically ill
or dying.
Normal play
Reducing fear: play forms the basis of a trusting relationship
between staff and children because it is probably one of the few
familiar and reassuring sights in an unfamiliar environment. If
children are enabled to play despite physical limitations or medi-
cal conditions, they receive the message that they are welcome,
particularly when they are most vulnerable. A vital function of
normal play is the reduction of fear; this is particularly noticeable
in A&E or outpatient departments, which are often the childs
rst experience of hospital. This type of play encourages the
rebuilding of skills lost through injury or illness, and can be used
to achieve treatment plans and goals.
Structured play: normal play occurs naturally through toys and
equipment in a relaxed atmosphere; its function is to reduce
fear and anxiety by introducing familiar activities in an unfa-
miliar setting. This approach can be structured and diverted
into directed play, where the adult requires specic outcomes
which may be part of the care plan.
7
Valuable information can be
gained by observing directed play and may contribute to clinical
decisions. For example, the level of pain may be observed during
a therapeutic play activity; conversely, the child may not exhibit
limitations in his play despite reporting pain. Such observations
offer a broader perspective on condition, and are of particular
relevance for children who are pre-verbal or have limited ver-
bal skills. They may communicate specic information through
painting, clay sculpting or doll play which identies their present
level of understanding of their condition and treatment. Carefully
structured therapeutic and directed play may help to inform the
child of the procedure and increase cooperation with treatment,
choice and consent.
Preparing children for procedures
Active participation: the UK Healthcare Commission recom-
mends that children should be active participants in decisions
about treatment. Findings indicate that children had a poorer
experience of hospital than they should because of a lack of
training among staff with highly variable access to staff who spe-
cialize in play.
8
The link between play and communication is integral to effec-
tive preparation for procedures; play specialists use various play
techniques and resources to deliver meaningful information to
children and young people. Children understand at a develop-
mentally appropriate level the procedures they are about to expe-
rience, resulting in adaptive coping strategies and participation
in the consent process.
5
Common fears: children can be successfully prepared for a range
of invasive procedures, including surgery, venepuncture, cannu-
lation, injections and lumbar punctures; despite pharmacologi-
cal advances, children and young people fear these procedures.
9

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Non-invasive procedures such as mask preparation for radio-
therapy, removal of plaster, and nebulizer masks can evoke dis-
tress. Play in this situation offers coping strategies for managing
pain and invasive procedures, and prepares the child and family
for medical and surgical interventions using an understandable
medium.
Exploratory play: expressions of fear and fantasy are given a
safe outlet through well-planned activities such as exploratory
play; the child is given opportunities to assimilate new experi-
ences. For example, having a blood test supported by appropri-
ate resources (e.g. anatomical dolls and puppets) can facilitate
inquiry into why blood taken does not need to be replaced. The
non-threatening use of play to explain procedures helps children
to reveal specic fears or misunderstandings that are conveyed
to the healthcare team. Preparing children for procedures is good
practice and an acknowledgement of childrens right to be kept
informed of their treatment.
10,11
Distraction therapy
The play specialist creates a safer clinical environment through
distraction and alternative focus activities
5
because children are
less likely to exhibit fear and distress if their attention is diverted,
and are more likely to be compliant during the procedure; this
technique should, if possible, accompany preparation for pro-
cedures. Successful distraction therapy offers children choice,
which can create a sense of empowerment when they may feel
most vulnerable. By constructing a plan about which chair the
child wants to sit on and the choice of distraction techniques (e.g.
talking, counting, blowing bubbles, visualization or guided imag-
ery), the child experiences an increase in control and a reduc-
tion in the feelings of helplessness and uncertainty. Introducing
distraction techniques and coping strategies requires planning
and the skilful use of play to avoid the build-up of anticipatory
distress; shifting attention from the distressing aspect of the pro-
cedure towards more interesting and pleasant experiences.
12
Dis-
traction therapy can signicantly increase the successful outcome
of a procedure, so clinicians should minimize disturbances in the
treatment room by switching off bleeps and not walking in and
out during procedures; interruptions can cause a child to lose
focus, increasing the risk of failure or repeating the procedure.
Referrals
Hospital play specialists receive referrals from nurses, physi-
cians, physiotherapists, dieticians, speech therapists and lan-
guage therapists.
Exploring play as a method of working with children who
experience difculty in coping with ongoing treatment (short-
and long-term) and who are referred for specialized therapeutic
play is discussed below.
Chronic encopresis and soiling
Toileting regimens must be established. Instruction in techniques
to raise awareness of the sensation and muscle tone involved
in emptying the bowel properly, as well as games that explore
supportive nutrition and strategies to build condence and self-
esteem (which may be lacking in children with this condition).
This basic description should not distract from the joint plan-
ning involved in the construction of play programmes for these
patients.
Headaches and abdominal pain
Children presenting with headaches and abdominal pain without
clinical evidence of a physiological cause may be referred by cli-
nicians who suspect an underlying emotional problem. Success-
ful outcomes may be experienced if art and craft are introduced
alongside relaxation techniques. These methods of management
of chronic pain may allow the child to express his pain through
art (possibly highlighting the primary cause); relaxation tech-
niques provide a practical response which the child can control
and implement. Most evidence-based data on pain management
support the recognition and assessment of acute pain in chil-
dren; less information is available on pain management for non-
organic causation. The Healthcare Commission found that many
children are not as able as adults to communicate their pain,
which leads to it being underestimated.
8
Anecdotally, interven-
tions that show children that their pain is being taken seriously
can produce positive outcomes.
Radiotherapy
Play programmes involving simulation of the process of radio-
therapy treatment can help children requiring mask moulding
and compliance during radiotherapy. The aim of these sessions
is to enable children, some as young as three years of age, to lie
completely still without the need for anaesthesia during radio-
therapy. There is a reduced health risk to the child, and a reduc-
tion in cost and clinician time.
Needles
Fear of needle-related pain is the commonest fear in healthy and
chronically ill children,
13
and often manifests as anxiety and mal-
adaptive behaviours. The term needle phobia is frequently used
and may be inappropriate, but a child who is so distressed that
sedation is required or the procedure abandoned needs further
input to restore condence and self-control.
Fear has been described as a normal response to threatening
stimuli and involves three responses:

physiological arousal

covert feelings and thoughts

overt behaviour reactions.

Phobias are described as unreasonable responses to a benign
stimulus, which result in one of the three elements of fear being
excessively and persistently activated.
14
Regardless of the terminology, this is likely to be the com-
monest referral by clinicians, and play specialists will see these
children (often on a weekly basis) as outpatients or in ambula-
tory care units.
Non-pharmacological treatments depend on the:

age of the child

cognitive development of the child

nature of the procedure

history of the child.

The choice of techniques often falls into cognitive and behavioural
therapy (CBT; see below) or a combination of both. A recent
Cochrane review assessed the efcacy of cognitivebehavioural
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PAEDIATRICS AND CHILD HEALTH 18:5 235 2008 Elsevier Ltd. All rights reserved.
interventions for needle-related procedural pain and distress in
children and adolescents; it concluded that some aspects of CBT
were more effective than others. Distraction, combined CBT and
hypnosis can help by reducing the pain and distress that accom-
pany needle-related procedures.
15
CBT
Denition
Barlow
16
describes cognitive interventions that involve identify-
ing and altering negative thinking styles related to anxiety about
the medical procedure and replacing them with more positive
beliefs and attitudes, leading to more adaptive behaviour and
coping styles. Behavioural interventions are dened as interven-
tions based on principles of behavioural science as well as learn-
ing principles by targeting specic behaviours.
15,16
Intervention types
The types of interventions used by play specialists are not
divided into mutually exclusive categories and often comprise a
combined cognitive and behavioural approach (see Case study).
Adapting Barlows denition
15
the interventions discussed below
have merit across age ranges and work well in the hospital and
community setting for children referred with needle-related fear
and for many procedures that cause distress in children.
Cognitive interventions
Cognitive distraction shifts attention from the procedure using
agreed or spontaneous activities (e.g. non-procedure related talk,
bubbles, counting, music).
Imagery child-led guided imagery empowers the child to
construe an image that is pleasant and one he can control (e.g.
walking along a beach). Visualization allows the adult to use
suggestive prompts and to join in (e.g. can you tell me about
your favourite holiday/party/day out?).
Preparation for procedures gives information about a proce-
dure through visual and sensory prompts. For example, show-
ing photographs of the process involved in surgery (including
the theatre gown the child will wear), theatre trolley, uniform of
theatre staff, recovery room, alongside the sensory experience of
touching and trying on an anaesthesia mask.
Parent training decreases parent distress through engage-
ment in cognitive strategies, which in turn benets the child.
Behavioural interventions
Behavioural distraction shifts attention from the procedure
using agreed or spontaneous activities (e.g. interactive books,
specic toys and games).
Progressive muscle relaxation training progressive tensing
and relaxing of muscle groups one at a time.
Breathing exercises include deep breathing, which can con-
centrate on the breathing technique or be combined with a
related activity (e.g. blowing bubbles).
Modelling includes demonstration of positive coping behav-
iours during a mock procedure by another child or adult (e.g.
watching a DVD of a child having a plaster cast removed, or a
child going into theatre).
Desensitization can be gradual systematic exposure to the
feared stimuli. This may be graded exposure to each part of the
procedure which leads to the rehearsal of the event, including
the childs choice of cognitive/behavioural intervention.
Positive reinforcement can include providing positive state-
ments and/or tangible rewards as the child achieves agreed goals
for the procedure (e.g. star chart, stickers, toys, certicates).
Home visits
Home visits undertaken by play specialists are usually requested
by child community teams. Recognition by those who deliver
community paediatric services that play for the sick child is
benecial to the community maximizes skill mix and improves
continuity between primary health care, hospital and community
settings. Community nursing services take account of the need
to prevent hospital admission, and facilitate early discharge and
care for children with complex needs.
17
A play-based approach
enables children to reconcile the dichotomy of invasive proce-
dures being carried out in what was the secure environment of
their home.
Therapeutic programmes: play specialists link into community
services by providing therapeutic programmes such as develop-
mental play for children and young people who are at home on
traction, in immobilizing plaster, or are oxygen-dependent. Play
offering an intellectual, social and emotional dimension alongside
activities that compensate for physical limitation is particularly
benecial for children who have been discharged as in-patients
but are unable to leave home until treatment is complete. Home
visits can be instrumental in supporting the transition back to
school because all aspects of development are addressed and
reinforced through play.
Long-term conditions: clinical goals set by the multidisciplinary
team can be achieved for those with long-term conditions, par-
ticularly children requiring needle interventions (e.g. diabetes,
juvenile arthritis). It is imperative to begin with a positive experi-
ence of venepuncture, given the lifelong nature of the condition
and the need for full compliance from the child. Play specialists
use the techniques discussed above to help the patient under-
stand the condition but, through systematic graded exposure, the
child and parent can rehearse the treatment process, resulting in
a positive adjustment and adaptation to changed circumstances.
The UK government advocate that children, young people and
their parents become expert patients by accessing services
that give them skills in self-management of their condition
17

Play interventions may promote the self-condence required to
become autonomous patients.
Seriously ill children: play techniques incorporating coping
strategies can produce a participatory framework that help the
child react positively to the condition and assume ownership
and control over treatment plans. The need for play should be
assumed if patients are receiving palliative care at home or in a
hospice, and appropriate and adapted activities can enable par-
ents and siblings to share the pleasure of doing a familiar activity
together, even in the most tragic circumstances. Some children
may wish to leave messages for family and friends but are unable
to articulate their thoughts and feelings; play is used as a channel
for communication and a means of processing difcult issues,
5

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PAEDIATRICS AND CHILD HEALTH 18:5 236 2008 Elsevier Ltd. All rights reserved.
and can be achieved using painting, decorating pebbles, making
picture frames or producing video diaries.
Summary
Even if their parents are in hospital, children are separated from
the familiar and comforting sights, sounds and smells of home
life. Intrusive and painful hospital routines can exacerbate fear
and anxiety, rendering them less able to understand and coop-
erate with hospital procedures. Children who suffer least stress
from a hospital stay are those who retain some control over what
is happening, and this in part is achieved by maintaining auton-
omy through play.
18
Susan Harvey, former adviser to Save the Children, discussed
the mechanisms of delivering play services in hospital and warned
against play that takes the initiative from the child and gives him
a passive role. Play that becomes a diversion and a denial of
what is happening does not help him come to terms with cur-
rent experience.
19
Today, registered hospital play specialists use
a child-led approach to play as a means of informing and sup-
porting children through hospital routines and procedures, thus
ensuring that patients are active participants in their healthcare.
The collaboration between play specialists and multidisciplinary
colleagues supports an integrated and coordinated service that
promotes the best interests of the child and family.
Case study
Jo is 8 years old and has had eczema since birth. She lives with
her mother (who has a history of eczema) and her two younger
sisters, who do not have eczema. The condition ranges from mild
to severe, and presents on the back and front area of both legs,
feet, inside the elbow area, hands and neck. Treatment had con-
sisted of a range of emollients, topical corticosteroids and anti-
histamines (p.o). Occasionally, antibiotics had been prescribed
to counteract skin infection. The treatment regimen included
creams (q.d.s.) and wet wraps. Jo was seen by the paediatric
community nursing team, but was referred to the hospital play
specialist due to increased non-compliance with treatment. She
attended six weekly sessions at her local hospital with a good
outcome in physical and emotional terms.
Jo expressed an interest in art and craft during the rst ses-
sion and a suitable activity was set up. Though initially shy, she
responded appropriately when the play specialist asked her if
she understood why she had come to the hospital. She said she
hated her eczema, especially the wet wraps because they hurt
when you take them off but wanted to get better. Jo expressed
anger at the number of times a day the cream had to be applied.
The play specialist reiterated the nursing plan, which empha-
sized the importance of the wet wrap procedure in relation to
the effectiveness of the cream. Further discussions during this
play session revealed feelings of ugliness and wanting to keep
covered.
From this initial assessment, the play specialist used language
that presupposed positive change to help Jo consider her life
when her eczema improved; together they drew up agreed short-
and long-term aims and strategies:

having clear skin so that she could wear a pretty dress for a
special occasion

keeping a diary to record positive and negative feelings using

the write and draw method

using a doll to practice dispensing the cream with a spoon, to

prevent reinfection and developing a technique of applying
the cream without causing skin friction

to remove the wet wrap in the bath to minimize discomfort

to achieve a daily target of four cream applications and one

wet wrap; a star chart would be introduced as a positive rein-
forcement to record compliance

to have weekly photographs taken of the most affected sites to

monitor progress
This session ended with Jo creating and decorating her diary and
the rst photograph was entered.
Jo appeared relaxed and enthusiastic during the next session.
She showed great pleasure in sharing her news of achieving a
complete set of stars and was excited about the buddy system
the school had instigated (a peer accompanied her to the school
ofce when it was time to apply her cream). The success of the
previous week had been a challenge because her diary revealed
several negative comments.

Hate my eczema and want to die.

My sock stuck to my feet and it really hurt.

Look at me, Im ugly.

My skin is badder than last time, help me!

Cant go to school because my skin is stinging so much.

Jo could articulate her feelings about these entries and said
that she felt much better now because the cream and the wet
wraps were working. The diary continued to be an important
outlet for Jo to record her feelings; one drawing revealed sev-
eral circles of squiggles that she had used as a diversion strategy
when her skin was intolerably itchy.
Jo continued to make progress over the next four weeks, but
removal of the wet wraps still caused some discomfort, so the
play specialist introduced relaxation exercises. The weekly pho-
tographs provided evidence that her compliance with the treat-
ment was emotionally and physically benecial. The paediatric
community team said that the wet wraps could be stopped, but
the application of cream would be increased to six times a day.
Jo was fully compliant because she now had a greater sense of
control over her eczema. On the nal session, Jo attended her
appointment wearing shorts and sandals, which she had never
previously had the condence to wear.
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Practice points

Frequent and/or long stay admissions can be detrimental to a

development; play sustains normal growth and development,
and minimizes the loss of skills associated with hospitalization

The UK National Service Framework for Children and Young

People recognizes play in hospital as a means of helping the
child to assimilate new information, adjust to and gain control
over a potentially frightening environment, and as a way of
coping with procedures and interventions. This framework is
included in the UK Healthcare Commission reviews

There is evidence that play hastens recovery, as well as

reducing the need for some interventions to be delivered
under general anaesthesia. The hospital play specialist
prepares structured play programmes to support care plans

Research has shown that preparation for procedures using

play techniques reduces anxiety, supports effective pain
management, and encourages cooperative behaviour

Post-procedural play gives the child the opportunity to reect

on and make sense of hospital experiences. Observations
made during post-procedural play can be incorporated into
the care plan

Play is a channel for communication and a means of processing

difcult issues. Play specialists can actively support children
with terminal illness or those experiencing other major loss