Case Study of Hospital Play in Japan No.2

The work of an HSP with a child (grade 7) with a blood disorder―The study of HPS support that encourages children to overcome their challenges―
Kayo Oya*・Hiroe Kojima*・Ikuko Hatai*(Seirei Hamamastu General Hospital)
Ⅰ. Introduction
In our pediatric ward, patients of pediatrics, pediatric surgery and the pediatric cardiovasculardepartment are treated all together. Currently the number of beds in the ward is 32. Six (6) beds
out of 32 are private rooms for those who suffer from leukemia, aplastic anemia, or malignant
lymphoma.
Since 2010, there have been three HPS working in the wards and they have provided private
support for children with blood disorders by rotation.
Because the ages of children vary from 1 to 15 years, the type of play preparation also varies
depending on the child’s interest. Children can select their favorite play before play preparation.
The contents of play and its schedule are planned based on the treatment status and test
schedules of a child. As age goes up, however, it is evident that as well as play, psychologicalsupport and counseling may also be required.
As shown below, the work of the HPS was recorded in order to clarify the roles and the tasks of
HPS through the interaction with patient K for a month right after he was to the hospital.
II. Case summary
1. K (12 years and 10 months old)
2. Name of disease：Aplastic anemia, the most severe case
※Aplastic anemia;

Aplastic anemia is a disease in which a type of blood cell (hematopoietic stem cell) residing in the bonemarrow decreases for some reason that causes a deficiency of all three blood cell types: red blood cells, white blood
cells, and platelets. The diagnosis are determined by the low density of bone marrow cells but at the same time there
shall be no sign of symptoms caused by abnormal cells such as leukemia cells.
[…]
A course of treatment and prognosis vary widely depending on the degree of severity of the disease. The degree
is determined by the amount of blood cell deficiency. Stage 1 and 2, considered to be the most severe stage, indicate
two out of three of the following conditions: less than 500/1 in neutrophil count, less than 2／μl in blood platelet
count, and less than 20,000／μl in reticulocyte count. Stage 3 and stage 4, the moderate and mild
stage respectively, show none of those three.
※Major symptoms；
Anemic conditions including pallor, shortness of breath, palpitations and dizziness, and bleeding
tendency including subcutaneous bleeding, gingival bleeding, and nasal bleeding are evident. A
patient may develop a fever due to inflammation led by severe neutron depletion. There are cases ofpatients who do not have an apparent symptom even though he/she may be severely anemic if it
progresses slowly. In such a case, a patient often unexpectedly finds the disease by a regular healthcheck at a medical clinic.

P※Treatment；
Two major treatments for aplastic anemia are immunosuppressive therapy and allogeneic marrow transplant from
HLA (human leukocytic antigen-matched donor).
(Abstracted from http://health.goo.ne.jp/medical/search/10N10400.html)
3. Hospitalization：From (month)(day), 2011 to (month)(day), 2011 (for a month)(currently still in
hospital)
4. Family: Father, Mother, Older sister (14 y/o)
5. Development: Appropriate for his age
6. Background:
Due to subcutaneous bleeding K was taken to a dermatologist where he was given a referral form
to K city-run hospital (hereinafter referred to as K-hospital). Soon after K visited K-hospital, he
was transferred to our hospital. The only apparent symptom was subcutaneous bleeding andnothing else. He was playing rubber-ball tennis even on the day when he visited K-hospital and did
not show any sign of the disease. Because of no subjective symptom, both his family and himself
were stunned by the rapid development of the situation.
1) Previous health status and characteristics
 Seldom had any illness and rarely had an episode of fever No history of hospitalization. Had rarely visited hospital.
 The result of a health examination taken in May showed “ no problem”
 Loves sports and enjoyed his school life very much
 Likes talking about his family, school and friends
2) Impression of K for HPS
 Friendly and talkative. Cheerful habit of mind. Shows no hesitation to greet strangers.
 Not shy about asking questions
 Not afraid of expressing what he feels: “I had no idea that there were people who would play withme. I am really lucky to be here”. No fear of accepting strangers.
3) Therapeutic strategy/procedure For this case, immunosuppressive therapy, bone marrow transplantation from a HLA (humanleukocyte antigen) -matched donor (his older sister, 14 y/o), regular blood testing, bone marrow
punctures, MRI examinations are scheduled.
If everything goes well, K may be able to leave hospital in the middle of XX (month), in threemonths from now.
* Bone marrow transplantation (BMT); A procedure to replace damaged bone marrow with healthy bone marrow stem
cells. It is performed for patients with serious hematological diseases, such as leukemia or aplastic anemia. The recipient’s
immune system is usually ablated with radiation or chemotherapy before the transplantation, this is called the conditioning
regimen. Since the conditioning regimen completely destroys the recipient’s hematopoietic function, transplantation must
be conducted; otherwise the recipient would die. The hematopoietic stem cells from a donor are injected into therecipient’s veins. There is no surgical operation.
When the procedure goes smoothly, the hematopoietic stem cells transplanted into the recipient’s body start producing
healthy blood in two weeks. Though it can be fatal if a recipient develops severe GVHD **, appropriate
immunosuppressive treatment is important since mild GVHD helps to eliminate remaining neoplastic cells and lower therisk for recurrence. When there is no complication after transplantation, a recipient can go home within three months.
(Abstracted from ja.wikipedia.org/wiki)

Case Study of Hospital Play in Japan No.2**GVHD (Graft Versus Host Disease)；A condition in which lymphocyte cells of a donor attack recipient’s organs
as foreign. GVHD is less likely to occur when the HLA (human leukocyte antigen) types are matched with a recipient,or the donor is a relative.

III. Work of HPS
1. Friends who suffer from the same disease* Regarding bone-marrow puncture, K was already given preparation by a doctor and nurses. K
explained to us what he learnt – the procedure of the test.
The explanation that he was given was, “It is a disease by which cells producing blood decrease. The
most important treatment is to regain the energy of the affected cells. The treatments may involve
strong medication in order for him not to be infected by any possible germs and viruses including acold. Some tests may be given to find the best way to make affected cells get better and to see blood
status”. K understood that there would be possible side effects including hair loss and vomiting.
K was wondering if there was anyone who had been through the same treatments as he would beundergoing. A person who has been through the same process often feels familiar and can be a greatcompanion.
* In short, having a friend is very encouraging especially when they are of a similar age. K came toknow T who had things in common with K. He told HSP that he would like to know more about him.
T (12 y/o) under treatments for leukemia also became curious about K, and eventually HPS worked
as a bridge between K and T (See Appendix 1).
2. To become HPS whom children can talk about anything with
* Emotional change in K had been seen after the first examination along with a restricted life in
hospital (clean room, the limited amount of freedom). K seemed to speak out everything on his mind,
but still HPS reminded him “You can tell us anything, even when you are having a bad day” so that
we hoped he would be able to relax even when he did not feel well.
There are many physical changes while undergoing chemotherapy, and many patients tend to feelanxious by seeing such changes. We, as HPS, try to respond sincerely to their anxieties and fears ofpatients by visiting them every single day and to develop a relationship based on trust. Eventually
patients will gain confidence to overcome their hardships by themselves (See Appendix 1 – K was
expressing his feelings to HPS)
3. Planning and practicing of playChildren between grade 5 and grade 12 are likely to enjoy competitive games, especially Othello,tick-tack-toe, and Blokus (See Pic 1). Games in which players try to read other player’s strategies
and in which players feel accomplished when they win are popular. K liked playing “Blokus”, “Perler
Beads” and “Plastic plate creation”.
* In Blokus, each player choses a color from blue, yellow, red or green, then has 21 pieces (1~5 piece(s)per piece) as his/her own pieces. Players put their piece(s) on a twenty-twenty-square board startingfrom its corner and try to reach own piece(s) at the center but not on sides (your pieces may be at atangent to other player’s pieces). The winner is the one who put most pieces on the board.
* In our hospital, when three HPS staff are available all three visit a patient at the same time andoften with doctors and nurses. Children look forward to such a day very much by calling it “a specialday”.

*Hospital Play SpecialistP

Pic 1 (Blokus)

Perler Beads

Plastic plate creation

４. Support before examination, after treatment, and during chemotherapy* The more a patient undergoes examinations and treatments, the more he/she occasionally becomes
traumatized by his/her physical changes and feels anxious for the next treatments such as “I may
get sick after this” “what if I throw up again?” “ I may have a fever again” “I may throw up if I eat”
… etc. Please refer to Appendix 1 (a journal) to see the psychological support of HPS.
* Because HPS staff work the shift, reports like the journal indicating “when/how did a certain thing
happen, what did the patient feel” help us to offer support by sharing the patient’s information
among HPS staff.
５. Support for parents and a sibling* Since everything happened too quickly and unexpectedly for K and his family, it was obvious thatthe family were greatly upset at the first meeting (See Appendix 1: the underlined part A). Further,
they were even facing a bone-marrow transplant (from his sister to him). HPS, therefore, carefully
and consistently provided support toward the family until all the family’s questions had beenanswered regarding the situation.
6. Cooperative work with healthcare professionals in other departments*Before the bone marrow transplant, information exchange conferences across healthcare staff thatwere involved were held. Members of the conference consist of medical practitioners, nurses, dentists,
dental hygienists, pharmacists, nutritionists and HPS. Expected future events and support plans
were discussed together. There were two conferences: one was with the patient’s mother and anotherwas just with the healthcare team. In the conference with the mother, her emotional change andanxiety level but also what she was looking forward to and how family tried to deal with the situation
were also discussed and it provided a good opportunity to know specific requests from the family.
Though the work of HPS has been slowly recognized in our hospital, there are still some tasks to
improve in a cooperative system among other healthcare personnel. We have also seen that HPS
need to improve their approach toward staff in other medical fields. The future challenge is how toestablish a firm position of the HPS in hospital in order to carry out the mission that provides
support for patients’ (children’s and their families’) perspectives.
According to the report shown above, the indications of HPS work are as follows:
1) Through the everyday communication with HPS, K came to be able to freely express his feelings
including happiness, anxiety and unpleasant emotions. It had also been seen that K received
treatments by clearly expressing what he wished.

P2) As for playing, competitive games were repeatedly played at K’s request. To have experienced thejoy of winning and the frustration of losing must have encouraged K to fight against his situation.
3) Under the situation of limited personal freedom, K felt greatly encouraged to have known a friend
having a similar situation as K.
4) Even though HPS was trying to provide psychological support for K’s parents and to encouragethem to express their feelings, it was difficult for parents to talk openly in K’s room.
IV. Discussion
1. Children around K’s age are sensitive to any change in a given situation and how they perceive
such change varies depending on their previous experiences and their surroundings (ex. the waythat parents see the situation). Whatever the situation or health status that the child was facing,however, the continuous interaction of HPS seemed to have improved K’s mental health and to haveencouraged him to take treatments in a positive manner.
2. In this case, the longer the hospitalization, the more frustration and stresses toward hospital
meals, changes in his physical status, and isolation emerged. Though HPS tried to understand hisanxiety and to convey his message to healthcare practitioners in order to make the situation better,it was far from our satisfactory level, indicating that our approach should be improved.
3. In previous cases of children similar to K’s age, some children could not really express their true
feelings because of the atmosphere of the surroundings, having been too considerate to others, or
having lost interests in situations. In such cases, children may even lose their motivation to getbetter. To avoid it, working with children by considering their personal needs and by providing
support from their perspectives are imperative for our work as HPS.
V. Conclusion
Fortunately, active information sharing and extensive planning are available in our hospital
since three people are regularly engaged with HPS activities.
In this report, the patient’s situation was followed u for a month following the child’s admission
to our hospital. A trust relationship between the child and HPS had established slowly througheveryday play and communications. This helped to overcome the challenge of the upcoming bonemarrow transplantation including a conditioning regimen. The work of HPS should include thechild’s mental health and should help the child overcome his hardship, with a good cooperationfrom healthcare staff in other departments.
References
Chika Matsudaira (2010). Introductory of Hospital-Play. Kenpakusha Press. 2010.
Ryota Hosoya & Atsushi Manabe (1973). Pediatric Cancer-Team Medicine and Total Care.
Chukoshinsho Press.
Total Care for Children with Leukemia I. Pediatric Nursing, Oct 2006.
Nursing Care for Children in Pain. Pediatric Nursing, Jul 2011
Medical literature
Kimitoshi Murakami (Deputy director of Iwate prefectural Nanko hospital), Adolescence Mental

HealthP

Appendix 1

Record No. 1

Date
Monday,
○/○
Day 3

Ａ

Patient Name: K

Condition/Symptoms《First Encounter with K》- K was walking down the hospital
corridor with a telephone card in his
hand. We meet, and he returns ourgreeting.
《Symptoms》- Purpura was seen on hands and legs, but
no other symptoms. He looks fine.
《In the Bedroom》- He was lying on his bed alone. He tells
us how he ended up in the hospital andabout his school. We enjoy a good
conversation.
《K’s Mother》- She is surprised by the sudden
hospitalization of her son, and seems tohave many questions. However, learningthat HPS will be of support throughout
K’s stay at the hospital, she becomes verymuch relieved.

Tests/Treatments-Bone-marrow
puncture test (from2:00pm)- Explanation of thedisease is given by thedoctor.

Actions/Approach by HPS《Listening to K》- We listened to him about his
school, family, club activities,
and friends.
《Answering Questions》- About the Bone-marrow
puncture《Planning of Play》- We showed K cards that
introduce the types of games
and play available in thehospital ward.
- We decided on what K wants
to do daily and before thebone-marrow puncturet.
《Play》- 11:00am-11:30am
Plastic plate creation- 1:15pm-2:00pm
Othello- before anesthesia
picture book Mikke

Response to HPSOthers- K likes to talk very much, 《Attending HPS》:
and answers to any questions Oya, Hatai
we ask him.
- “What kind of places are
there in this ward?” “Where
will I have the bone-marrow
test?” “How many nurses are
there?”-We decided to play Othello
and make plastic plates- He was much satisfied withthe plastic plate he made. “Iwant to make one for mysister tomorrow.”- He won Othello after a close
game before the anesthesia,
and was in a good mood. We
stayed until the induction ofanesthesia.

P

1 《 About T (another - K learns about the existence○

Tuesday,
Day 4

○/○

Wednesday, ○/○Day 5

patient in the ward)》- We learned by coincidence
that T has a similar
background as K including
age, gender, family members,club activities, and sister’sclub activity. We talked abouthim.
- K is in the clean room 《Psychological Support》《Blood Collection》- 11:00am We stay by his side,starting today.
- K walks to the blood collection room.
- Conference with K’s talk to him, and share his《In the Bedroom》
feelings.
- After the blood collection, he has parents and doctors
stomach pain, nausea, and dizziness. He
shows some tears.

- blood collection《Symptoms》- morning temperature : 37.8 C《In the Bedroom》- K says. “I want to do Othello.” His
mother is surprised. “What? You looked
so weary just a while ago.”《Play》- 2:00pm-3:00pm
Othello, playing cards- plays cards including K’s
motherof T, who by chance hadmany things in common. K
seems excited. He says, “Iwish we could play together.”
He cheers up.

- After vomiting he says “Ifeel better now.” His
expression brightens.
- He says “I want to makeplastic plates again”, and falls
asleep.

《 From HPS 》(Oya and Hatai)- K says “I didn’t feel
well last night andcould not sleep.” K’s
mother guesses that
he may have become
anxious after learning
the name of his
disease.
- K enjoys playing Othello, 《Attending HPS》:
saying “I feel better than Oya, Hatai
yesterday.”P

Appendix 2

K.Y. Pre-Transplant Expanded Conference

Date: Tuesday,○/○/ 2011 3:00 pm-《Conference with the Healthcare Team》
Schedule towards the transplant:
Conditioning regimen: from ○/○/ 2011
Transplant Day: ○/○/ 2011
Comments

From the doctor

From the nurse- The donor is K’s biological elder sister (14 yrs.) Leukocyte blood type (HLA) is completely compatible. From this,
we believe the transplant will be performed under good condition. We have informed K and his parents of thetreatment plan, outlook, side effects of the medications, and possible risks which may result from the transplant.
- K has fever at present, but if it can be controlled to a certain level, the transplant will be performed as scheduled.
- As a preparative regimen is necessary, the sister’s health condition must be ensured and close attention needs to be
payed to before the transplant.
- We expect a very difficult time during the conditioning regimen. We plan to ask for support to stay by his side.
- He has not eaten well for the past few days. Is there any good idea to help change the situation?
- Explanation on the medicines which will be used, and their side effects

From the pharmacist

From the dentist

From HPS- On oral care: As the room is dry, lips tend to become dry. K has a clean mouth with no cavities. I would like to ask
for continued care to maintain this.
From the nutritionist- On Clean food: There are foods which patients can eat besides hospital meals. I would like to ask K’s preferencesand give suggestions.
- On play until today, during the conditioning regimen, and after the transplant: K is much concerned about his fever
and the changes of his body. We would like to be whom he feels comfortable to talk to, including sharing fun through
play.

P

Conference Including K’s Mother 3:40 pm-

From the mother

The doctors have explained to us about the conditioning and the transplant, so we fully understand. We are justworried if the sterile condition can be maintained.
- K’s sister (donor) is not nervous at present, and I am told she is acting as usual at school. She seems to be
thinking “Let’s get it over with soon.
I work, but I can adjust my schedule, so I hope to take time off and be with K as much as possible during thetransplant treatment.
- My child looks forward to meeting and playing with HPS every day. Can you be with him during thetransplant treatment even under sterile condition?