Which nursing intervention is most developmentally appropriate for a hospitalized 10 year old?

Mater Sociomed. 2015 Dec; 27(6): 438–441.

Abstract

Introduction:

Play constitutes an essential parameter of the normal psychosomatic development of children, as well as their statutory right. It is also an important means of communication in childhood.

Objective:

To review, detect and highlight all data cited regarding the role of play during the hospitalization of children.

Methodology:

Literature review was achieved by searching the databases Scopus, PubMed, Cinhal in English, using the following key words: therapeutic play, play therapy, hospitalized child, therapist.

Results:

During hospitalization, play either in the form of therapeutic play, or as in the form of play therapy, is proven to be of high therapeutic value for ill children, thus contributing to both their physical and emotional well-being and to their recovery. It helps to investigate issues related to the child’s experiences in the hospital and reduce the intensity of negative feelings accompanying a child’s admission to hospital and hospitalization. Play is widely used in pre-operative preparation and invasive procedures, while its use among children hospitalized for cancer is beneficial.

Conclusion:

The use of play in hospital may become a tool in the hands of healthcare professionals, in order to provide substantial assistance to hospitalized children, as long as they have appropriate training, patience, and will to apply it during hospitalization.

Keywords: Therapeutic play, play therapy, hospitalized child, therapist

1. INTRODUCTION

Hospitalization constitutes an unpleasant experience both for adults and mostly for children, who suddenly have to leave the familiar place of their home and the persons who are important for them, and stop their favorite activities, including play (1).

Removal from one’s home and entry to the intimidating environment of a hospital cause acute anxiety and stress both to the child and to the child’s family (2, 3). These negative feelings are intensified whenever there is a chronic or severe and life-threatening disease. The main causes of such feelings seem to include fear of medical examinations, pain, death, fear of separation from the parents, and fear of diagnosis, uncertainty, loss of control and safety (4, 5).

Upon hospital admission, particular attention is paid to the improvement of the clinical symptoms of the disease and to a reduction in the psychological burden. As a result, play is often disregarded, or considered of minor importance. However, the role and value of play increases when the child is repeatedly hospitalized, mostly due to a chronic disease or disability, since it decisively contributes to emotional, mental well-being, self-confidence and self-esteem (6, 7).

Therapeutic play is defined as a framework of activities taking the psychosocial and cognitive development of children into account, in order to facilitate the emotional and physical well-being of hospitalized children (8). Another definition refers to play as a structured form of play activities designed based on the age, development of cognitive functions, and health condition of a child (9).

A child’s ability to play while being in the hospital constitutes a sign of health in a particularly difficult environment, which shows that the child may continue his/her usual activities, or that there is some progress in the course of the disease (10). Certainly, there are also other activities which may be helpful to achieve this goal, e.g. dancing, provided that the appropriate conditions are ensured and the child may cope with them (11).

Play is a form of communication and self-expression, which gives them the possibility of communicating with both the family and the medical and nursing staff, while helping them process a series of emotions (7, 12).

In addition, play helps children become familiar with the unknown – until then – environment of the hospital, express their feelings and their concerns, feel more comfortable, or familiarize themselves with the medical procedures required (e.g., venipuncture), and make choices so as to feel that they maintain control. Many children use a toy (e.g. a stuffed animal) in order to cope with different medical procedures. Teddy bears often accompany children to the hospital and stuffed animals are in the arms of young children whenever there is a blood test or, for example, when they are vaccinated (7).

Nurses may use play as healthcare strategy for hospitalized children in three main fields: in everyday practice, during the preparation of children for surgery and invasive procedures, and also during painful and unpleasant procedures (13, 14).

The therapeutic use of play presupposes theoretical training, patience, and willingness to occupy oneself with children. Therefore, it constitutes a main component of healthcare of ill children and helps them better understand the needs of the children and help them prepare themselves as much as possible for therapeutic procedures (15).

2. PLAY IN THE HOSPITAL

Play in the hospital has multiple objectives, while it is of such considerable importance that it is thought that it may be of assistance in the recovery of ill children (16, 17, 18, 19):

• Play in the hospital ensures a type of connection with the familiar, friendly environment of home.

• Helps to create a continuity of everyday life.

• Provides a way out of all negative feelings and disappointment that may possibly accompany a child upon hospital admission and hospitalization, while they may be ‘transformed’ through play.

• Reduces distress and anxiety, while developing respect for other people’s views and feelings.

• Helps children maintain their self-esteem and confidence, and, thus, feel that they may have control of the entire situation.

• Contributes in the development of new creative solutions in the problems observed.

• Teaches in an amusing way. Almost in all cases of hospitalization, children undergo invasive medical procedures, including catheterization, venipuncture, and blood tests. Play may help young patients become familiar with such procedures and learn exactly how they are carried out, so as to reduce their fear and help their adaptation.

• Encourages the participation of parents and brothers and sisters. Thus, children achieve a stronger feeling of normality and continuation of their past life, while alleviating parents’ anxiety.

• Facilitates communication among children. Play is an excellent means of communication and development of social relationships and mutual assistance.

• Reduces regression, i.e., return to previous stages of development. Such regression among children may be shown by various disorders, e.g., enuresis, or behaviors including continuous crying, continuous search for parental care, outbursts of anger, and aggression. Play gives a way out of repressed desires, anxiety, and fear, and allows children express themselves in a more creative and pleasant way.

• Offers joy and amusement.

Focused play techniques used among hospitalized children are used to prepare them for surgery or other unpleasant medical procedures. Sometimes, even before hospital admission, the children may be encouraged to play with masks, nursing uniforms, syringes, stethoscopes. Teddy bears or dolls may also be used for demonstrations, for example, a demonstration of how placing of a peripheral venous catheter is done (20). Painting and sketching may be used when other means are unavailable, for example, among children confined to bed, e.g., after a car accident (21).

Therapeutic play is effective in reducing children’s anxiety and fears from the time of hospital admission to the post-operative period or hospital discharge (22, 23, 24), achieving self-expression (25), cooperation during painful procedures, and willingness to return to the hospital to continue their treatment (24).

Apart from the alleviation of psychological distress, therapeutic play also seems to be effective in reducing the physical symptoms of anxiety (24). The hospital area makes spontaneous play very difficult, since family and known objects are absent, daily routines have been interrupted, and, at the same time, there are real or suspected risks of infections, medication, and invasive medical procedures (26, 27).

Assistance provided by therapists is of great importance, since young children usually find it hard to play spontaneously, especially in an environment like hospital environment. However, even when they manage to play spontaneously, their play is usually not so productive as if it had been organized by a specialist (28). To maximize the benefit resulting from playing, its use as a part of a well-designed healthcare plan must be systematically promoted (26).

A therapist may make a list of the things that the child does not like, which are related to hospitalization. The therapist may write a letter, together with the child, addressed to the parents, to friends, to the doctors or nurses, even to a stuffed animal. They may even write and paint a book about disease and hospitalization (28).

It must always be taken into account that there are certain factors determining how effective play therapy may be in the hospital. Certain limits are necessary too, but there must be a balance (many limits prevent children’s play, very few allow bad behavior) and one must always consider a child’s level of development. Limits in play therapy are helpful in (29):

• Providing physical and emotional safety for therapists and children;

• Adopting a positive attitude towards children;

• Strengthening reality;

• Safely expressing any negative feelings;

• Promoting a child’s sense of responsibility and control, so as to enhance the development of consistency and stability in relationships;

• Providing a cleansing experience for children;

• Protecting the play area.

In research, there are papers documenting the efficacy of play therapy. In one of them, 30 minutes of play therapy every day seemed to help children hospitalized in a pediatric department to avoid an increase in anxiety levels during their hospitalization, unlike the children of the control group (30), while another paper has found a considerable decrease in the children’s fear, according to their reports, with just two half-hourly sessions of play therapy (23).

Apart from the aforementioned points, play therapy also seems to be an appropriate treatment for abused children who are admitted to a pediatric department. Many of these children better express themselves through activities rather than through words. Thus, play therapy in a safe environment may teach them to express themselves and be able to cope with their difficulties (31).

3. PRE-OPERATIVE PREPARATION AND PREPARATION FOR INVASIVE PROCEDURES

When a child is admitted to hospital for surgery, anxiety, both for the disease and for the imminent surgical procedure, may be the first component of the crisis the child is faced with. Thus, surgical anxiety is an answer to the fear of hospitalization, disease, anesthesia, and surgery (32).

Anxiety among children is a frequent phenomenon and has been associated with several negative behaviors, both pre-operatively (stimulation, enuresis, intense crying) and post-operatively (pain, sleep disorders, stress of separation) (33), while children are more vulnerable than adults (34). Post-operative anxiety is related to anxiety in the pre-operative period and in the beginning of anesthesia (35), while post-operative recovery presents more complications among children with high levels of pre-operative anxiety (36). Children often experience anxiety when they are separated from their parents for the operation (37, 38), while pediatric anxiety is associated with a high frequency of post-operative stress of separation, fear, eating and sleep disorders (39).

Personalization of play prior to surgery is an intervention effectively reducing anxiety, since it is based on the patient’s history, any previous negative experiences from hospitalization, and, mostly, age (40).

Ghabeli F., Moheb N., and Nasab SDH, (2014), have conducted a study among 60 children, aged 3-8 years, who were about to undergo ENT surgery, and have found, among other things, that play and participation in team games prior to surgery contributed to a considerable decrease in their anxiety (41). In other research has shown that, when the children were left to play with dolls or other toys before surgery, they were calmer and showed less negative behavior (42).

4. CHILDREN SUFFERING FROM CANCER

Apart from normal stress caused by hospitalization, children suffering from cancer have to face a disease which is accompanied by a long-term treatment with several difficult side effects, including frequent, probably long-term periods of hospitalization, a disease which may result in death (43).

Play therapy among children suffering from a terminal disease may create an atmosphere where young patients, even for a short period of time, will be able to develop a sense of control of the situation, they will have the chance to handle their lives in their own way, and will be able to externalize their frustrations, fears, and feelings (43).

In order to provide complete care to dying children, nurses working in the context of pediatric palliative care must realize that children need opportunities to talk about their lives and incorporate it into the way for death. Play is the most convenient way to help children have the chance to say whatever they want. For children suffering from a serious disease restricting their life expectancy, play is the most natural means to release their aggression and assume control of their world (6, 44).

All children receiving palliative care need play and, despite the fact that not all of them need play therapy, the need for this kind of therapeutic intervention is higher in this vulnerable group of children (6).

5. CONCLUSIONS

Play constitutes an important parameter of a child’s normal development. It is also an important means of communication in childhood, while the effects of the child’s physical or mental disease may affect the child’s ability to play.

In hospital, play can have a special therapeutic value for ill children, thus contributing to their physical and emotional well-being. It helps to investigate issues related to the experiences of children in the hospital and lead to a reduction in the intensity of negative feelings, which often accompany hospital admission and hospitalization. Play has multiple characteristics which, when used in the context of treatment, are of great assistance in the development and improvement of a child’s function.

Healthcare professionals can use play as treatment and care strategy for hospitalized children, and its role and value increase when children become more vulnerable due to a life-threatening disease or disability. A child’s ability to play in the hospital restores the discontinuity resulting in his/her life due to hospital admission and shows somehow that the child may continue his/her normal life even inside the hospital.

Through this understanding of play, healthcare professionals can accurately understand the effects of hospitalization and disease on children, on the one hand, and, on the other hand, enhance the emotional development of children. Though the use of play, they have the chance to gain control in many situations, thus changing hospitalization into a positive rather than a negative experience. They must choose the appropriate activities, which help the children grow, while encouraging the parent to bring the child’s favorite toys to the hospital and actively take part in the entire procedure.

Footnotes

CONFLICT OF INTEREST: NONE DECLARED.

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