Case Studies of Hospital Play in Japan No.1

Hospital Play Programs in the Case of a 4-year-old Female with Neuroblastoma- A Case Study throughout 9 months’ Hospitalization Mika Oyamada M.D.
(Pediatrics Department, Akita University Hospital)【Introduction】
A Hospital Play Specialist (hereinafter referred to as HPS) is a professional to support
children in hospital through play programs, in order for children to undergo medical
treatments smoothly. There are, however, very few medical facilities in Japan that
understand the work of HPS. As it stands now, there are few places for HPS to exercise theirfull potential. In our hospital, we organized a developmental support group in 2010
consisting of a pediatrician (the author of this article, who later obtained a certificate topractice play programs as HPS), a clinical psychologist and children’s nurses. It wasconcerned as a pediatric project to promote the awareness of healthcare professionals
regarding the areas of shortage of physicians set by the Ministry of Education, Culture,
Sports, Science and Technology. In the project, we have provided support for children
through play programs based on the understanding of the importance of play in hospital.
Even after the end of the three-year project, the activities have been continuously practiced
in our hospital. Surprisingly enough, even this environment where playing in hospital seems
well accepted, the concept of HPS is still not acknowledged enough and it seems a long way
to go. With our efforts, however, it is slowly but surely that healthcare staffs who
understand the work of HPS are increasing and a few request HPS to practice playprograms for their patients.
In this article, a case is reported where HPS was involved with a patient from the start ofher hospitalization upon request from the patient’s attending doctor. This case is a good
example of introducing hospital play programs, since it was a case where HPS had provided
consistent support throughout one’s hospitalization, including private support duringchemotherapy, group playing in a playroom, distractions during treatments, and preparation
for an operation and radiation therapy.
【The case】
Ａ-chan, Female, 4 years and a month at admission.
Name of disease：Infantile neuroblastoma
Current medical history: In February XX (day), A-chan was hospitalized due to her left thighpain and a fever. She was diagnosed as having purulent hip arthritis in her left thigh andunderwent an incisional drainage under general anesthesia. Since her condition relapsed
repeatedly under the course of antibiotics, a bone marrow puncture was performed and theresult indicated that she was likely to have acute lymphatic leukemia. She was thentransferred to a hospital where her condition was suspected to be Infantile neuroblastoma,and she was finally transferred to our hospital.
Current medical status: 36.7C. Swollen left superior tarsal plate associated with bleeding.
Having pain in her left hip and joint pain in her right leg.

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Pathological condition: Primary tumor is seen in right adrenal gland. Tumor-masses are seenintermittently within the vertebral canal of thoracolumbar spine. Images showing
accumulation considered as metastases are in her skull, thoracic spine, and lumbar spine.
Stage 4. Restriction on movement (walking is not allowed at the moment).
Development：Though a precise developmental test was not given due to the restriction on
movement at her admission to the hospital, she indicated development appropriate to her age.
When K's developmental test was given at the age of 4 years and 9 months, the result indicatedthat the girl’s developmental level was appropriate to her age: DQ 100 (4 years and 9 months)
on cognition and adaptation, DQ 96 (4 years and 7 months) on language and social ability, DQ
98 (4 years and 8 months) on general abilities.
Family：Parents and an older sister (8 y/o). A-chan was going to a kindergarten from X(month). Both parents were working full time. During the first half of her hospitalization,
parents and mother’s parents visited hospital to take care of the girl in rotation. 4 months
after the hospitalization, however, the girl’s mother took leave and stayed primarily with Achan. Father visited her once a week.
【A-chan’s status in hospital and the work of HPS】
1. The first day of the hospital
When a doctor informed us “A 4-year old girl with infantile neuroblastoma is going to betransferred from another hospital now”, we requested to provide her our support at arrival.
Our request was approved.
The girl was lying on a stretcher when she arrived at the hospital. Doctors and nurses left
the treatment room to gather information from the previous attending doctor, who came alongwith the girl. Her parents were not with her, since they were busy with administration
procedures. The girl, obviously nervous at arrival, was now almost crying when paramedics
moved her to a medical table. When we greeted her, however, she looked at us without startingto cry. We introduced ourselves as “play people”and asked her some questions about the rabbit
doll in her arms and about her favorite play. At measurement of her body temperature andblood pressure, and while a doctor examined her, we practiced a distraction using a whirling
luminous pen (Fig. 1). The girl was playing with the pen and smiled while approaching it to
HPS. Her parents visited her when they finished the administrative procedures, but left again
with her attending doctor. When HPS showed her a children’s book “I Spy (by Walter Wick)”,
she said “I’ve done this before” and read it together with HPS. She was initially talking quietly,
but her voice grew gradually stronger while playing “I Spy”, and another sign of getting used
to HPS was by touching her arm. We spent 50 minutes together, until her parents came backto the room.

Figure 1. A whirling luminous pen that the girl requested to use during distraction2

Case Studies of Hospital Play in Japan No.1

2. The beginning of hospitalization（A-chan’s choice, a plan for play）
1) Day 1（A day after admission）
When we entered her room in the morning, she was about to draw a picture. We told her
and her mother that we visited her for play and sat beside her with permission. We brought a
Kiwanis doll that HPS made (materials were provided by Kiwanis Club of Sendai) and showed
her. Since A-chan said she would like to have it herself, we brought three Kiwanis dolls andasked her to choose the one that looked most like her. She chose one with no hesitation. She
completed a doll with many colors. When we visited a day after, the doll had a face on its
backside as well and her name was written. She said she added those new features during thenight. She smiled with satisfaction when praised by HPS (Fig.2 and 3).
○Impression and characteristics of the girl
• She seemed shy around strangers, but she was an active child by nature (according to
her parents)• She was able to express clearly what she wanted. Ex. “I wasn't to do it myself”• If there was something which she couldn't do herself, she would ask for help (ex. to HPS)
• She was having continuous pain because of her disease• She was afraid of treatments. Her mother said that the girl was easy to scare○Goals, considering her characteristics and conditions• To let the girl do what she can do during play, so that she can feel a sense ofachievement• To provide fun events for her• To reduce her anxieties and distresses○Plans for play
• To play with her on a daily basis and to decide the kind of play, depending on her
conditions• When at rest, to visit her privately and to play with her beside her bed• Once her condition stabilized, to encourage her to play in a playroom and to increaseplay with a group• Upon treatments and examination, to practice preparations and distractions○Parents and support for them
• Her parents did not really show their feelings to anyone. They often treated theirdaughter in a matter-of-fact way• To reduce the parents’ burden of looking after their daughter for a long time, our attempt
was to get close to their daughter and to act as a daycare nurse when possible• From X (month), a clinical psychologist would practice counseling of her mother once amonth○Support for a sibling• When a sibling visited her sister, to play with the sister as well, in order to understandher feelings• During the early phase of hospitalization, to talk about her family with the sister,
especially her mother and her younger sister (A-chan)3

Case Studies of Hospital Play in Japan No.1

The girl’s mother was given psychological counseling 8 times during X + 8 months. We
encouraged the family to have a break (such as taking a shower or going for a grocery
shopping) while HPS was playing with their daughter. The girl’s sister seldom had a chance
to interact with HPS since she could visit her younger sister only after their parents finishedwork, or during weekends. During the initial phase of the girl’s hospitalization, however, HPS
played with the sister privately using “Sticker Art (provided by PLAZASTYLE COMPANY)”
and other toys. While playing, HPS told the sister that people were concerned about her justas much as her younger sister, and HPS were willing to support her too. HPS also told themother about possible issues ( is this within the boundaries of the HPS role ?) that could have
happened during their daughter’s hospitalization and discussed how to deal with suchsituations in a timely manner. We occasionally asked about family situations, but there
seemed to be no issue or concern newly raised during their daughter’s hospital stay.

Figure 2,3 Kiwanis doll that the girl made a day after admission2) Following days
When shown a strap made of paper, A-chan wanted to make it by herself. Soon she learnt
how to make it and enjoyed making her own handicraft. She was enjoying working with playdough and cutting it with a pallet (Fig. 4). HPS let out the play dough and the pallet for her
during weekends when HPS were absent.

Figure 4. Figures made by play dough3) The Second Week
A-chan underwent surgery for central intravenous catheters (BROVIACR) and for biopsy.
HPS was not allowed to accompany her during the surgery since coordination with thepediatric department was not ready yet at the time. HPS had a private playtime with her
before and after the surgery. The morning after the surgery, HPS obtained permission fromthe mother and a pediatrician to accompany A-chan while she received a treatment in atreatment room. When HPS entered the room as her mother left, A-chan was screaming on
the medical table. When HPS held her hand and told her “I’m with you”, the girl looked at
HPS and nodded. HPS tried to distract her attention from the treatment by using the4Case Studies of Hospital Play in Japan No.1

luminous pen that was used on the first day of admission. It was not easy for her to look awayfrom her chest, but eventually she listened to HPS who encouraged her and said “let’s playwith this pen and you will get power”. She completed the treatment. While the pediatrician
was preparing for blood sampling, HPS was showing A-chan a children’s book. Penguin Race
(Fig. 5) was shown to her when a syringe needle was inserted to her arm. Though she wascrying, she did not refuse it. Unfortunately, the first attempt at blood sampling failed, and it
was tried using her other arm. She cried again, but was able to ask to the pediatrician “Onlyone more time?” by herself. The luminous pen and the Penguin Race were used as distractions.
The girl cried when punctured, but she soon stopped. The luminous pen had become anecessary item for her to encourage herself. After this treatment, her attending doctor had
started requesting HPS to practice distractions during treatments.
At her bedside, we made little toys from a plastic bottle (Fig. 6), with play dough, slime andbeads (Fig. 7). The toy using a plastic bottle was filled with polyvinyl alcohol (PVA), beads andspangles. When it was shaken, it was fun to see the particles in the bottle slowly falling to thebottom. The bottle toy was also useful for distractions.

Figure 5 Penguin Race

Figure 6. A toy made from a plastic bottle

Figure 7. The first bead craft4) The Third Week
During this period, she was having severe pain in her pelvis. Though she very much disliked
a suppository as a sedative, she did it with (coped with it through) distractions, including
relaxation breathing. It was sometimes seen that her father was trying to divert her attention
from the treatment by using the plastic bottle toy that the girl made the previous week.
The first chemotherapy was given. The pain was almost completely gone on the following day.
She was able to walk X + a month later and the restriction on movement was lifted.

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3. Periodic Chemotherapy
Chemotherapy was given once a month, 4 more times until X + 4 months. During the period,
A-chan frequently had to undergo blood sampling. Adverse effects, such as nausea andvomiting, were not prominent, but she had severe myelosuppression that had forced her tostay in bed with an air purifier for nearly two weeks. Though she had to play in her bed during
such times, she was encouraged to play in a playroom when possible. Though there were times
when HPS could not use the playroom, the HPS played in her room since the girl requested toplay with HPS at her bedside.
Though she always cried at blood sampling, A-chan tried to divert her attention by using
the luminous pen. After some trial and error with HPS, A-chan decided the way to take blood
sampling was as follows : 1) to have HPS, but not her parents, in the treatment room, 2) totake blood sampling while sitting and holding HPS’s hand, 3) to play with distraction tools
while waiting, and 4) to watch the whole procedure of blood sampling. Thereafter, A-chan wasable to take blood sampling calmly, without crying. HPS also tried to have playtime with her
before and after the treatment. X + 2 months later, she even smiled during blood sampling. X+ 3 months later, she said to HPS “ it doesn’t hurt at all”.
At the same time, A-chan underwent MRI and a bone marrow puncture. Since thesetreatments were done under general anesthesia, a distraction was not performed. A
preparation was given before MRI by a question-and-answer process. Though HPS prepared
figures and dolls for her, they were not used because A-chan said that she would feel scared
to see them. Later, her attending doctor reported to HPS that she had gone through CT scan
without anesthesia, at her request. A-chan said to HPS “ I was able to do it because I knew
the doctor and nurses were supporting me”.
Constipation occurred from X + 3 months and she started taking powdered laxative, which
she disliked very much. She made “I did it!” Cards (Fig. 8 and 9), where she would place seals(stickers) when she was able to take the medicine, and decorated it with stamps. She was
encouraged well and started taking laxative after she finished the card-making. Consequently,
her constipation was eased. Once the card was filled with seals (stickers), she made anothercard with HPS and continuously enjoyed the card.
During playtimes, she was using play dough, beads, sticker art, Origami, card, drawing,coloring, paper cutout, slime and so on. She enjoyed especially making fake food with playdough (Fig. 10 and 11) and she mentioned it in her letter to HPS when she was leaving hospital.
Because she was not allowed to have raw food, due to her immunocompromised state andother strict dietary requirements, she frequently enjoyed making fake food.
She drew a picture named “Me, HPS and Anpanman holding hands together (Fig. 12)”. She
started losing her hair at the time. While drawing herself with a fringe, she was showing herhair loss to HPS and said “But my fringe will be gone like this when I take a treatment”. “ I’ll
be like XX (a patient who lost all his/her hair). Look at me. Look here”. HPS then asked her“So you lose your hair when you take a treatment?” She replied “Yes”. When HPS said “ Butdo you know you will have it again?” she said to us “Yes, I know”. Later, A-chans motherconfirmed that the HPS had explained to her daughter that her hair would grow again”. It
was a good reminder for HPS to use similar terms and wording to the ones that family usuallyused when talked to A-chan.

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Though it was a rare occasion when she was not severely immunocompromised, one day (X+ 3 months) we suggested playing with sand. Since the playroom was not available, we useda conference room. The conference room looked barren and we heard footsteps andconstruction noise outside. She seemed a little uncomfortable in the conference room and she
did not request sand play until the very end of her hospital stay. It was anyway the first sandexperience for her so she seemed to enjoy its texture and she poured water and moulded
vigorously.

Figure 8, 9 “I did it!” Cards

Figure 10 Sushi made with play doughFigure 11 Noodles made with play doughFigure 12 Drawing
4. Tumorectomy
In X + 5 months, an abdominal operation was performed to remove the primary tumor,
which had become smaller after chemotherapy. Her mother received an explanation about theoperation from her attending doctor, 5 days prior to the operation. HPS had a talk with Achan’s attending doctor and her mother. Her mother said “My daughter has been given a lotof information and she understands things in her own way. My concern is that she could havemisunderstood and misinterpreted certain things. She is very easy to scare and I don’t thinkthat telling her everything is always the right thing for her”. When it was explained aboutplay preparation to the mother,, she requested us to practice for her daughter. We discussed
how we should practice it together. Since the mother told us “I don’t think I am strong enoughto tell her about the operation”, it was agreed, after discussion with her attending doctor, that
HPS would be the ones to do so. The operation was to be held on Monday. A preparation was
initially planned to be on Sunday, the day HPS were usually absent. Since the mother wasconcerned that it would be too unusual for A-chan to see HPS during a weekend, we changed
the date to Thursday (4 days prior to the operation) and practiced the preparation in that

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afternoon. There was not enough time to get preparation materials ready. We then decided tomodify a preparation booklet used for pediatric surgery for other patients and used the book,after receiving permission from the attending doctor. The book was about a bear doll going
through a surgery. For a surgery scene, an image of a bear closing its eyes was used – insteadof a bear doll with eyes open.
There was no meeting room in the pediatric ward, so we asked A-chan to meet us at theplayroom, and we showed her the preparation book. We told her that we made the book forher. During this period, there were not many users of the playroom, as HPS did not use it for
their activities. HPS carefully chose the time, so that no-one would enter the room during the
preparation. Her parents had explained to her “You are in the hospital because you have pain
in your legs”. HPS then told her about the operation “You have been given medical treatment
for your legs. Now we found in the pictures (she underwent MRI in the previous week) thatsomething in your stomach is making signals of “It hurts! It hurts!” and we can take that awayby ‘an operation’. This ‘operation’ is not practiced in your room, but in the special room called‘operation room’. We have made a book explaining about this operation room, so that you won’t
be surprised when you are taken there”. After having received an agreement from A-chan, we
read the preparation book together with her mother. We read slowly to make sure sheunderstood. Though she initially said that she did not recall anything about the first operationthat she had at the beginning of her hospital stay, she said to us “I think I remember thisroom” when she saw the picture of the operation room. HPS told her that HPS in hospitalgown would come along to the operation room with her and would be waiting for her in therecovery room. When we finished reading the book, she asked us “While I’m sleeping during
the operation, does my mom come in and try to wake me up? If I then become awake, I think
I will get confused”. HPS replied that her mother would be waiting in her room and no one
would try to wake her up until the operation finished. As for the preparation book, she said “I
get scared if I read it again, so I don’t want to have it in my room”, and she only grabbed abear doll, a main character in the story book. She also chose three children’s books that she
would bring into the operation room.
On the day of the operation, A-chan was dancing when HPS entered her room. Once HPS
put on a hospital gown, HPS went to the recovery room, waiting for the girl. The girl, on astretcher with children’s books and the bear doll that she borrowed from HPS on the day of
preparation, came to the recovery room with her mother and her attending nurse. As
explained in the book, she gave her name to a nurse and made sure she had her name band.
She said good-bye to her parents while HPS came along with her to the operation room. She
said “ I think I have been here before”. She fell asleep when she was given an inhalation
anesthetic, after talking and singing to the nurses around her. The operation took about 7
hours and her attending doctor called HPS to come to the operation room when she awoke.
She responded by nodding when HPS spoke to her. She was already planning to play. She said
to HPS “I want to make a heart-shaped figure with beads” as she was detached from theendotracheal tube. While waiting for her parents in the recovery room, we were reading thechildren’s books that she brought along. From the following day, play support was provided toher. She was able to get up and walk 4 days after the operation, and visited the playroom andstarted actively playing again.

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2 days after the operation, she said she wanted to return the books that she had borrowed
from HPS. HPS suggested reading the preparation book together. Initially she refused because
it would scare her, however, she agreed when HPS asked if she could tell the book and thereal operation room were the same. Instead of reading sentences, we made sure what she
experienced through the operation. She was smiling when she told us “It (the operation room)
was a bit different from the book”. “I fell asleep in the middle of music..”. We said together“Everything is done now” while closing the book. She returned the bear doll after she playedwith it a little. She said “I played with it a lot. We sleep together every day and I made him
dance for me”.
5. Radiation therapy
From X + 6months, radiation therapy started. The internal radiation therapy was
performed to (given to her) her 11 times over a total. 5 days before a radiotherapy localization,
her attending doctor requested HPS to practice distractions during the therapy, since thedoctor was hoping to provide it without any anesthesia. After a discussion with the doctor, we
decided to practice preparation as well. Her mother also asked us to provide a preparation forher daughter. Since there was not enough time to create a preparation book, we suggested
having a tour of the therapy room. The tour was held 4 days before the radiotherapy
localization (as the therapy room was closed for the following 3 days). Since we received arequest from her mother who said to us “Please tell my daughter that she will go to takepictures. I don’t think she will understand any detail of the procedure”, HPS and other
healthcare staffs ensured the request and would reply to A-chan only when she asked aquestion. HPS told A-chan “You will go to have photos taken every day from next week. So
why don’t we have a look at the photo-taking place together?” With her mother, three of us
went down to the basement floor by an elevator and went to the therapy room along a corridor
that was being refurbished. She enjoyed talking to us and looking at dolls and paintings placedalong the way to the room. Because a CT room and the therapy room that we were supposed
to be visiting were occupied at the time, we went to another therapy room. She went close toa therapy machine and said “ I wonder if it comes this close to my face?” HPS told her and hermother that it was a good thing for A-chan to see the actual place even the doctor would go forusing anesthesia during the therapy, and her attending doctor anyway would choose the best
way for A-chan. Then A-chan said to HPS “It’s better to see than to be worried”. After we went
back to her room, we were wondering how we could perform distractions while she was having
the therapy. Finally, we decided to provide her with quizzes and riddles from outside thetherapy room. Three riddle books (Fig. 13, 14, and 15) that HPS made with A-chan were given
to her and she was asked to prepare the books by coloring them and practicing the riddles.
On the day of the radiotherapy localization, HPS went along to the therapy room at her
request. Both an attending radiologist and her attending doctor decided to perform theexamination without anesthesia. During the procedure, however, everyone except A-chan was
asked to leave the room and HPS could not even talk to her through a microphone. HPS thenreceived permission from the radiologist to accompany her during the actual radiation therapy
for distractions. A-chan went back to her room with a smile on her face after she had a little
tour of the therapy room that would be used for her. The actual therapy started 2 days later.

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After she was lying safely on the medical table, she was left alone for 5-6 minutes, the HPS
was allowed to enter the control room and talk to her through a microphone. Since she was
not allowed to speak during the therapy, she was to give HPS the answers to riddles after thetherapy. It was, however, a little too long a time for her to remember her answers. From thesecond therapy to the eleventh therapy (the last one), therefore, it was decided that HPS would
sing her favourite songs during the first half of the therapy and HPS would give her riddles
during the second half.
On the day after the last radiation therapy, a seasonal event was held in the ward and Achan also attended. She did not want to leave HPS even after the event and kept on tagging
along after HPS. She requested HPS to read a children’s book called “ WAGAMAMA IMOTO(a story of a brother who scrambles ? for pleasing his sick sister) written by Shoichi Nejime.
When HPS started reading, she abruptly asked HPS “Why did I get sick?” HPS replied“Whydo you think you did?” She shook her head. HPS said to her “No one knows why, but the only
thing we know is that it was not because you did something wrong”. Then the girl said “Oh I
thought I ate something bad”. HPS replied “No. It wasn’t because you did something wrong or
you did something good. We just don’t know why it happened”. She then wanted to go back toreading, saying “Never mind. Let’s read the book now” so we continued reading the book. She
was looking into HPS’s face and smiling while listening to the story. HPS reported theconversation to her mother and her attending doctor where the girl was not present. We
decided to see if she would ask the same question later. Her mother subsequently reported
that her daughter asked the same question when she had a sleep-over at home right before
leaving the hospital.
Around this period, the playroom became available for HPS. Since the girl’s health status
was stabilized, HPS and she mostly used the playroom instead of her room. After HPS started
using the playroom, the number of playroom users was increased. Though there was not apatient around her age, A-chan started interacting with small children and their mothers who
visited the room. In the playroom, we were also using beads, slime, sticker art, play dough,and coloring play-dough figures (Fig. 16).

Figure 13・14・15

Riddle books

Figure 16 Colored handicraft

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6. Oral medication
From X + 7 months, the differentiation-inducing therapy started by taking 13-cis retinoic
acid orally. Though she disliked taking medication, she was doing well when she took laxativeby using an “I did it!" card beforehand. HPS then suggested making another card for this new
medication. The medicine was in tablet form and she said “The shape of this medicine isdifferent from the previous ones, so I’ll make a different type of card for this. I’ll make it bydrawing, not with stamps”. Then she drew a picture of her parents, her sister and herself,
holding hands together with a rainbow in the card (Fig. 17).
In the playroom, she was fond of physical activities, such as bandying? (tapping) a balloon,
playing a little soccer game, and playing a battle game. Sometimes mothers of other children
joined her sport festival and HPS was looking after infants while calling out “ready, go!” and“goal!” for them. After the sport festival, HPS honored them for their good work. Around thattime, a girl who was the same age as A-chan was hospitalized and by and by they were playing
together. A-chan played vigorously in imaginative ways, including making a house withnewspaper (Fig. 18), playing tag in a ball pit (Fig. 19), and making imaginary popcorn withballs (Fig. 20).

Figure 17 “I did it!” card for tablet

Figure 18 Making a house

Figure 19 Playing tag
popcorns

Figure20 making

7. A month prior to discharge
The oral medication got on track and it was decided that A-chan would be treated on an
outpatient basis. She was informed at the end of X + 7 months that she would be leaving
hospital soon. A-chan told HPS “I’ll go back home soon”.“ If MRI shows that I’m better now, I
really can go home” and “I’m happy”. She showed her interest in a toy MRI when HPS asked
if she wanted to see it on the day when she was scheduled to take MRI. Since she was scaredof the toy in X + 2 months, HPS carefully asked the same question again in a different way.
She again said she was interested in seeing the toy, so HPS brought ”PREPARA WOODS(produced by HORIUCHI WOODCRAFT)”, woodcrafts modeling medical apparatus anddevices including an operation room, MRI, and CT scan. A-chan started playing with thewoodcrafts with another two children, who were also in the playroom at the time. When HPS
brought more models and Playmobil such as a hospital room, an ambulance, a living room anda children’s room, A-chan became deeply absorbed in the play. She was just playing by herself

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and did not interact with other children, who went to other toys to play (Fig. 21). In the middleof her play, HPS handed her a toy doctor set, as she wanted to have a syringe. She played
repeatedly with a doll that was going through CT, MRI, blood sampling, IV, and operations.
She made up a story that the doll had pain in its leg and she said “just like me”. In every single
setting that she played, she had a doll of HPS and asked the HPS doll to be with the patient
doll. She also clearly said to the HPS doll “Hold her (doll’s) hand”, “Read a book” and “Sing asong for the patient”. She played with the same woodcrafts and toys a day after MRI. The
story of the toy, however, was changed, so that the doll was going home after MRI. She kept
on playing the same thing in later days as well.
When A-chan went to have a developmental assessment from a psychologist in a counselingroom in X + 7 months, A-chan saw many toys and sand for sandplay therapy in the room. That
was when she wished to take a play therapy (“I want to play with sand”). She had taken playtherapy three times before she left the hospital and it was planned that she would
continuously take the therapy after discharge. When there was a two-week interval in theplay therapy, A-chan requested HPS to play with sand. For administrative reasons, thecounseling room was not available for HPS to use. When HPS told A-chan that she could playwith sand only in the conference room just like she did in X + 3 months, she said that she
would like to play anyway, even in the conference room. We decided to decorate the conference
room and put our drawings on the white board. She started playing with sand in a box bypouring water in it and cutting out a shape. Gradually she poured more and more water andplayed wildly ( excitedly). In the end of her play she turned over a bucket filled with sand, hida doll in sand and made fake mixed rice by mixing it with a shovel (Fig. 22). She insisted oncleaning up by herself after playing and told HPS “It was fun. I want to do it again”.

Figure 21

PREPARA WOODS & Playmobil

Figure 22 Playing sand

8. Right before discharge
The last concern that A-chan had was the removal of central intravenous catheters. The
operation was scheduled for 4 days before discharge. HPS responded to every single concern
and question that she poured out while playing. The operation was performed under generalanesthesia, but HPS was staying with her at her request. After she awakened, she was given
a suppository for pain relief while practicing relaxation breathing with HPS. She stated to hermother, who was waiting at her bedside, “I did both (the operation and the suppository)”.
The day before she left the hospital was the last day for HPS and A-chan to play together,because HPS was scheduled to be absent on the following day. A-chan was devoted to play allday, except when she had to attend an event held in the ward in the afternoon. She wanted toplay with Playmobil in the morning. She said “I always play doctors and nurses, but I think I
want to make a house today” and did not wish to use “PUREPARA WOODS” and the hospital

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set that she had always played with. She made a living room and children’s rooms and played
day-to-day life with dolls; father, mother, her sister, her cousin, and herself, repeatedly. She
was called for the removal of her IV while playing and went through it smoothly with the very
last distraction that HPS practiced for her. Though there was only an hour to play in theafternoon, she made a beads ring and played with three kinds of slime. (Fig. 23 and 24). We
played together even after the open-hour of the playroom for a little while. When she wasabout to leave the playroom, she smiled at HPS and said “It’s good-bye tomorrow”. She left thehospital the following day.

Figure 23・24

Plays before leaving hospital(beads and slime)【Result】
During her hospitalization (the actual length of hospital stay: 263 days), the amount of
support for everyday play was 130 times, preparations: 5 times, distractions: 60 times,
pre/post-playing at operations: 4 times, support for mother: 16 times, and support for a sibling:
twice. The provision of play materials and interactions was 30 times. Considering the fact that
HPS was absent during weekends and holidays, the statistics indicate that HPS provided theirsupport almost every single day during A-chan’s hospitalization.
During times when she suffered from severe pain caused by her primary disease and nausea/vomiting induced by chemotherapy, we, as HPS, continued offering our support through play.
Consequently, a trusting relationship was built between us. She started expressing her
feelings freely and enjoyed every single play with us. A-chan faced any treatment bravely andstarted feeling a sense of achievement once she went through a new treatment with supportof HPS. By seeing their daughter’s efforts, her family gradually came to express their feelingsto HPS too and tried to support their daughter together with HPS.
It was seen that the way of A-chan’s play often represented her own experiences in thehospital and about treatments. In every single scene of her play, there was HPS helping out apatient doll. She no longer played doctors and nurses on the day prior to her discharge. She
was just playing house on that day. A-chan enjoyed playing until the very end of her hospital
stay.

【Discussion】
To treat a disease is, of course, the first priority when you are in hospital. It is, however,that one’s hospitalization shall not disturb his/her development nor become a traumatic
experience. Considering children who are likely to be passive during their hospital stay, HPS
shall provide children as many opportunities to choose things themselves and to feel the senseof self-control as possible. Children shall not be treated with our typical preconception,
considering they are too small to understand, that would discourage children to face their

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Case Studies of Hospital Play in Japan No.1

hospital experiences. Children shall be given appropriate explanation in the similar mannerto that of informed consent (explanation and agreement) given to adult patients. To letchildren receive better medical treatments, it is important for children to face the reality andto gain the sense of achievement when they overcome the experience by themselves. The play
support that HPS offer is definitely helpful. HPS is a professional who offers support forchildren in hospital through playing and it is evident that HPS is one of imperative membersof a medical team in order to provide better medical care to children.
A-chan recreated her own experiences by playing dolls. During such doll play, she always
put the HPS in a story. She understood the work of the HPS precisely and it indicated thatthe HPS was imperative for her to imagine a place called “hospital”. HPS’s are not just aprovider of distractions and preparations because the work of HPS is based on everyday playwith a patient. Because we had built a trusting relationship with A-chan, distractions andpreparations worked effectively, so that her constructive manner toward situations was
induced even though she was severely ill. For A-chan and her family, playing in the hospitaland receiving distractions and preparations seemed to become a very natural thing.
Appropriate play interventions that we had provided made her hospital experiences positive
ones. It was a valuable example that indicated the importance of hospital play through alongitudinal study of A-chan whose anxieties and even pain had been alleviated in relation to
HPS.
A proper environment where HPS provides sufficient support for children is still on its way.
Our challenge is to provide the same quality of support to every single child who stays in thehospital. To achieve the goal, a playroom shall be the center of HPS’s activities. The reason
that no HPS initially was able to use the playroom is beyond the objective of this report.
During the first phase of A-chan’s hospital stay therefore, HPS’s support was provided mainly
at her bedside. After the playroom became available for HPS, the number of playroom users
was significantly increased and opportunities for HPS to support for other children were also
expanded. Though the number of private support provided by HPS was decreased, daycare
nurses working in the hospital provided support for children when HPS were not available. It
may be an issue of our ward in particular, but to obtain the understanding from daycare
nurses and clinical psychologists regarding the collaborative work is essential to make things
work. A developmental support group, including HPS, shall be developed and recognized as apart of medical team.
【Conclusion】
This report was about the work of HPS from the very start to the end of hospitalization of
a 4-year old female who suffered from infantile neuroblastoma. This is a valuable example ofhospital play consistently practiced throughout hospitalization, including support for everyday play, distractions during treatments, preparations for surgeries/radiotherapy, and postsurgery play.
The importance of play in hospital and the role of HPS in alleviating children’s anxieties and even pain - were evident in this report.

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