Case Studies of Hospital Play in Japan No.2

Preparation based on the individualities of children who undergo orthopaedic surgery― With cooperation from families ―Kazue Goto*(National Rehabilitation Center for Children with Disabilities)
I. Introduction
Recently, there have been a number of researches and reports on preparation in apaediatric medical field. It is however, important to understand that preparation is carefully
practiced with a good understanding of children’s medical status, age and cognitive
development. Our rehabilitation centre operates surgeries on muscles, tendons and bones,and levels of cognitive development of children who undergo such surgeries vary, dependingon the severity of their diseases and developmental disorders. Consequently with thecooperation from parents, different preparation tools based on a childs cognitive level andneeds have been developed and been practiced. In this report, the effectiveness ofpreparation was evaluated from the responses of children and their families.
II. Subject
36 (17 boys and 19 girls) in total out of 180 children, aged between 3 and 17, who underwent
orthopaedic surgery in our centre during July 2010 to June 2011.
Medical condition：15 with cerebral palsy, 5 with spina bifida, 16 with otherconditions/symptoms
Method of treatment：muscle release operation - 14 cases; osteotomy - 8 cases ; tendon
elongation -5 cases; knee disarticulation - 2 cases; other: 7 cases
Intellectual impairment (IQ)：Borderline 3, Mild 5, Moderate 3, Severe 1
Speech difficulty：4 children – able to make sounds but no comprehensive utterance、2children – two-word sentence, 2 children – speech difficulty
III. Method
１. Preparation (Figure1.)•To explain about preparation to family members and obtain their consent•

To give the family a handout “Until the day when I-kun can walk 「いっくん足をなおす日」” and a survey sheet•

To collect subject’s information from family members(regarding how anxious their child appears, the previous medical history, treatments,etc. )•Before implementing preparations, let a child select his/her favourite toy/play, andplay together( not only to ease the tension of the child but also to get to know the child’s levels ofdevelopment and his/her characteristics)•To plan and consult with the family about the preparation based on information
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Case Studies of Hospital Play in Japan No.2•

To prepare the followings:
Ａ: A handout “Until the day when I-kun can walk”
Ｂ: Medical play (toys are used)
Ｃ: Real medical apparatuses are shown and used.
Preparation is practiced carefully by considering the child’s previous history•

Evaluate the child after the paly preparation.

Figure 1. Preparation tools
２. Evaluation• Observation：During preparation and when entering the operating room (OR), theManifest Upset Scale was used which indicates the level of child’s anxiety by a score of1~5, with a score 1 representing the least amount of anxiety, When the child was leaving
OR, the Cooperation Scale which indicates cooperative behaviours by a score of 1~5, witha score 5 representing the least cooperative behaviour was used.
• Survey: 4 days after the operation (OP), questionnaires to the child and his/her family
were given.
Children were asked about: how much “fun” and/or “tense” they felt about preparation;
how much they “understood” and were “motivated”; whether they were satisfied with“contents”; its “necessity”.
Parents were asked about: responses of their child towards preparation; ”meaning” ofpreparation; its “contents”; its “necessity”.
３. Case examples (Figure 2 & 3)
１）Case 1：3 y/o male (Mild Intellectual impairment, delay in language development (twoword sentence), in a wheel chair)
We were told from his parents that the child’s language and behaviours were difficult tounderstand. The handout was used to explain to his mother about operation/treatment
procedures, then medical play was practiced to the child in order for him to get used to medical

2Case Studies of Hospital Play in Japan No.2

apparatuses. Since he was initially afraid of I-kun doll, his family demonstrated how to playwith it and made sure that it was safe to play with. Eventually he started playing with toys
and real medical apparatuses in a positive manner.
He used to refuse a blood-pressure measurement, but after playing with a real apparatus
and a toy applying it to a doll, to his family and to himself, he started accepting themeasurement. Because his family understood the preparation well, we worked together tosupport his psychological needs.
２）Case 2：5 y/o male (No intellectual/speech impairment, in a wheel chair)
The handout was used for explaining the operation/treatment procedure to the child’sfamily. The child’s status during/after the previous hospitalization and how the family dealt
with the previous situation were discussed with his family. To the child, the handout was
shown and he was asked to find certain things in photos of the handout. To make him
understand his situation, his family emphasized things that he would understand in the story
such “oh, it was on TV, too” and “he is just like you” while reading the handout. After that, a
medical play was practiced to the child using I-kun doll.
３）Case 3：10 y/o fem (No intellectual/speech difficulty, in a wheel chair)
We came to know that this 10 year-old girl was talking with her friends about her
forthcoming operation rather than with her family. We suggested her, therefore, practicing
medical play with other children in order to reinforce the information and correct it whennecessary. During the medical play, questions addressed the girl such as “what do you do inthis situation?” were sometimes answered by other children and they were advising each other.
Her family said “we are encouraged to see children of similar ages of my daughter having such
positive attitudes toward operations”.
４）Case 4：10 y/o fem (No intellectual/speech difficulty, not able to run but can walk)
Both the girl and her family had severe anxiety and the girl was once hospitalized becauseof an anxiety attack. Since several anxiety behaviours were shown from her parents regarding
her operation, the procedure of the operation and how to manage certain situations after theoperation were discussed thoroughly. After a consultation with a psychologist, taboo words
and things that would happen to the girl during the operation were discussed and determinedwith her parents. Since her parents requested medical play, it was practiced based on thesurgical procedure. The parents said “It was great to experience the preparation because bothour daughter and we were really worried. Though we aren’t sure if every child shall read thehandout, we think it is necessary to discuss and consult regarding a surgical procedure”.
５）Case 5：7 y/o fem (moderately intellectually-impaired, speech difficulty (babbling), in awheel chair)
The parents told their daughter “you will sleep over to treat your legs” and couldn’t tell her
about the upcoming surgery. Using a doll and practicing a simulation of the surgery in frontof the operation room were suggested to the parents since they mentioned that they usuallyused a visual method when they explained to their daughter. The parents were also given3Case Studies of Hospital Play in Japan No.2information on possible pain and other difficulties that the girl would experience after thesurgery.
After the surgery, we received a comment from the parents; “Our daughter entered theoperation room with no panic and we were able to wait until she came out without unnecessary
anxiety. We were well prepared by knowing what would happen after the surgery”.
６）Case 6：6 y/o fem (No intellectual/speech difficulty, not able to run but walk due to motor
weakness in limbs)
4 days after an operation, the girl was hospitalized where no parent was allowed to sleepover. She had severe separation anxiety and seldom smiled and was often sobbing. Sensory
plays were used to reduce her stress. Since the girl had great pain during her treatment, a
medical play was practiced for several times. She was repeatedly playing with bandages anddisinfectant. She was saying to a doll “you don’t like it” “Don’t cry, well, it’s OK to cry but staystill” by which she expressed her feelings and released her stresses.
Her parents were informed their daughter’s behaviours during the play. It was suggested
that they observe what the girl said during her play at home. They were also encouraged topraise her efforts towards the treatment. In addition, parents were encouraged to tell us
anything that they did not understand.

Figure 2. During preparation

Figure 3. Playing

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Case Studies of Hospital Play in Japan No.2

IV.Result
Information on children who were going to undergo an operation was collected regarding
the following: the level of anxiety, the level of understanding, the way they normally receive
information, his/her medical history. The method of preparation, including detailed contents
and taboo wording, was carefully planned with children’s families. Information was gathered
through behaviour, observation and interviews, and then considered, Consequently
appropriate preparation that matched a child’s need was more likely to be practiced, with itcame a deepened understanding of preparation in the families. As a result, psychologicalsupport for children was properly provided with their families.
As for the evaluation of behaviour observation regarding the said 36 subjects, 80% of them
participated in a positive manner. 89% indicated a cooperative attitude when he/she wasentering the operation room (OR). When a child was leaving the operation room, 67%
were“Not crying” and had a “Serene look” (Figure 4). None of children answered “thepreparation was boring”. While 72% answered “I was nervous before the operation”, 85% said
“I was glad to receive the information through preparation”, 76% said “Encouraging”, and 75%
answered “It was easy to understand” (Figure 5). 67% and 91% of parents at an explanatory
session and during play preparation respectively felt positive about their children’s behaviours(Figure 6). All parents felt the preparation was necessary. 97% of them said “It was easilycomprehensible”, 92% indicated “It helped to reduce anxiety”, and 69% indicated “it is goodthe way it is” (Figure 7).

100
9080

8980

67

7060
50
40
30
20
10020

1980
プレパレーション時

143

入室時

帰室時

1点(積極的参加や協力 ;帰室時-穏やかな表情・泣かない)
3点(参加するが協力的でない ;帰室時-時折すすり泣く・穏やかに抵抗する)5点(最大限の抵抗や拒否 ;帰室時-泣き叫ぶ・思い切り抵抗する)

Figure 4. 行動観察評価(N=36)

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分かりやすかった(n=15)
説明通り(n=32)
頑張ろうと思えた(n=33)

75

2576

210
3
高い
1585

聞いて良かった(n=34)
術前132072

緊張した(n=32)

1681

楽しかった(n=16)020

126080

どちらでもない低い

19040

0100

Figure 5. Survey result (Children)0100

必要性(n=36)
分かりやすさ(n=30)
不安軽減出来る(n=26)
5

内容の改善(n=19)
095

590

1025

0070

2040608091

メディカルプレイ中の子どもの反応(n=32)

どちらでもない100967

説明中の子どもの反応(n=30)

はい楽しい・積極的33

不安・興味なし
020

40

60

80

100

Figure 6. Survey result (Mothers)
V. Discussion
The European Association for Children in Hospital (EACH) set out the 10 principles (EACH Charter1))
for the rights of the children before, during or after stay in hospital. In Article 2 and in Article 4, it states that
“Children in hospital shall have the right to have their parents or parent substitute with themat all times”, “Children and parents shall have the right to be informed in a manner
appropriate to age and understanding, and steps should be taken to mitigate physical andemotional stress” respectively.
Further, preparation shall be practiced to encourage children’s coping ability when he/she
receives medical care by providing a thorough explanation given from a child’s perspective,
and to reduce a child’s anxiety, fear and confusion as much as possible 2). The effectiveness ofpreparation seems to vary depending on how much children’s individualities are taken into
account in the practice, such as one’s development age, understanding, previous medicalhistory and one’s characteristics.
In our rehabilitation centre, preparation is usually practiced on the second day ofhospitalization. We encourage a child’s family, the closest entity for the child, to be involvedin the planning of preparation, In this way preparation seems to become more fun andencouraging for the child. Since we also encouraged the family to express their anxiety, anddiscussed with them how they could cope with a child’s pain and discomfort after the operation,
the anxiety of the family seemed to have been reduced and they could support their child in arelaxed state.
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According to the result of the survey in which all children and parents expressed thenecessity of preparation and many of them found its importance, we believe that theeffectiveness of preparation was well acknowledged. Our method is definitely based on“EACH Charter” mentioned previously in this report and it can be one of the ideal ways topractice it.
Since playing is absolutely imperative for a child’s growth and development, Matsudaira
２）states the power of play and its purpose as 1) A child learn through playing, 2) A childheals through playing, and 3) A child gains the sense of individuality through playing.
It is therefore, that our future task is to establish an environment where an “everydayplay” based on a child’s individuality is more focused on rather than where a play is just atool of a preparation and/or a distraction. Since the result of the survey indicated that thelevel of nervousness of a child before the operation was still considerably high, we see thatthe explanation before the operation merely is not enough and that to establish a systemor/and an environment that is/are able to alleviate such emotional distresses throughappropriate interaction with a child during and after a treatment is required.
References
1) EACH CHARTER：Hospital Environment for Children & Play Therapy Network NPHC
HQ. 2009.
2) Chika Mastudaira (2010). Introductory of Hospital-Play, Kenpakusha Press, 2010.

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