Ho spit al Pl ay Speci ali st C a se Stu dy No.2

The Effectiveness of Playing in Busy Pediatric Wards for Patients with Acute
Symptoms―The two-year work of HPS in pediatric wards at the regional center hospital―
Saeko Shimazaki*(N University Hospital)
Abstract: The attempt of this article is to introduce a two-year study to identify roles of HPS through“everyday play” with sick children and to find out optimal interaction with other healthcare
professionals in busy pediatric wards where most patients suffer from acute symptoms.
Keyword：Short-term hospitalization, surgery, play, support for treatment, HPS

I. Introduction
It has been five years (7th school term) since the Hospital Play Specialist (HPS) training programin University of Shizuoka Junior College started. Even though the concept of HPS is well establishedin the UK , the training program was the very first attempt in Japan. With persistent efforts of HPS
who graduated from the college, the significance of hospital play and roles of specialists are gradually
being acknowledged within hospitals. As time has passed, it seems that more people in medical
practice than before have come to learn pragmatic techniques and knowledge of HPS that can apply
immediately in a medical setting. In 2009 when I just finished the HPS training program and waslooking for a position as HPS in a pediatric ward, the awareness of HPS was still low and varied
depending on the region. Even though I made a handout introducing and promoting the role of the
HSP, I found that most hospitals, including one I came to work for, had never come across the concept
before. The hospital where I have been working is the regional center hospital where types ofpatients largely vary: children having acute conditions, required hospitalization/operations, somewere suspected of being abused, others were suffering from chronic conditions with a ventilator, andeven mothers having child-rearing anxiety. During times flu is epidemic, and many rooms in theward are occupied with affected patients.
In such a busy environment with countless complicated issues, everything seems “time-critical”
and the process of spending a great deal of time in a patient and his/her family is really difficult toachieve.
This article is to report on my efforts as an HPS in a busy pediatric ward where most patients
suffer from acute conditions. Through introducing HPS support including play preparation andwhat/how HPS have changed certain situations in a medical setting, I hope the roles andeffectiveness of HPS, even in a ward of patients requiring acute attentions, are properly
acknowledged.
II. Establishment of environment that can easily access to “play” (Playroom and bedside)
1. Before the intervention of HPS – how did other healthcare professionals consider “play”?
1) A daycare nurse was monitoring a playroom. The necessity of how a child actively participates inplay, however, was considered unimportant and tidiness of the room seemed prioritized.
2) Play at a patient’s bedside was practiced by a daycare nurse/a volunteer. It was however,considered just a time killer for a child.
2. Method
1) Playroom: Resources other than a playing board that would be used only for a short time, but also
*Shizuoka Children’s Hospital／Hospital Play Specialisthandicraft materials and tools, including cardboards and newspapers, that a child would be able toactively and continuously engage with were prepared.
2) Other: For bedside play, things that a child was able to actively be involved with were introduced.
In addition, toys that would encourage a child to receive treatments were prepared. Through a playdemonstration, the effectiveness of play was also introduced to healthcare personnel.
3. Result1) Children became active in the playroom and people often heard their cheerful voice from the room.
Some children even cried and said “I don’t want to go home” when they were leaving hospital. It wasevident that healthcare personnel gradually came to understand the fun that children had throughactive playing that I introduced.

(Left；Pic 1. The playroom where children made their own territories and houses)(Right；Pic 2. A sign for an ice cream shop that children made together)
2) A girl who came to the playroom crying after she had an argument with her mother regarding atreatment made a huge drawing on a white board. She went back to the treatment in relief after
talking about her drawing with the HPS (Pic 3,4).

Pic 3

Pic 4

3) A 6-year old boy who felt depressed after blood sampling at his bedside refused to put on an oxygenmask and an oximeter. After having played with a magnet fishing game at his request, he started
talking about the game. Eventually he put on an oxygen mask by himself while playing. After thathe accepted other treatments in a positive manner (pic 5).

Pic. 5

As described above, play based interventions helped to encourage a child to take treatments byreorganizing their feelings and emotions through playing. Consequently, I found other healthcare
staff members were trying to bring in plays when they were applying a treatment and they often
brought a child’s favorite books and toys when they entered the child’s room.
4. Discussion
Even children understand the importance of their treatments and although they want to get well,they sometimes refuse to cooperate for some reason. In such cases, children feel calmer when theyregain the initiative through playing actively and are eventually able to reflect on own behaviors.
Through play-based interventions, therefore, children seem to come out of their shells and toencourage themselves to move forward to treatments. The approach of active play has madehealthcare staff aware of the great potential of play and consequently they are also now actively
involved in creating a better play environment.
III. Support for treatment through playing for children having a short-term hospitalization
１. Issues on comparatively common children’s diseases and support for treatment
Asthma, allergic purpura, and Kawasaki disease were most common diseases that caused
hospitalization in our ward. Though all three require rather short periods of hospitalization, from1week to 3weeks, it could be far from a pleasant experience because patients were forced to stay in
bed and/or to repeatedly undergo blood sampling. It was, therefore, discussed that play based
interventions relative to a patient’s age could be useful for medical procedures including medication
taking, blood sampling, examinations and other treatments. Some patients who suffered from
diseases that had often relapsed had little awareness of the importance of treatments because
treatments had become part of their life against their will. It was, therefore, necessary to apply some
support and care for such patients so that they would be able to relate to the treatments actively,
once again.
2. Subject and Method
1) Children (2~5 y/o) with asthma /Kawasaki disease: Children were told that playing was always
available no matter when they were in a hospital or at rest. Through playing, they were informedthat medication and blood sampling were necessary for them to get better. Stickers were used toindicate to other children that the child was doing well.
2) Children (5y/o~ primary-school children) with allergic purpura: Many were very appreciative andthere was no problem in proceeding with treatments. The concern was that children were likely tofeel helplessness as their treatments were often associated with pain. Through the use of plenty ofactive playing including handicraft, the likelihood of depression and lack of motivation was to be
avoided.
3) Result1) A child (2 y/o, female) had relapsed asthma since she was 1 year old. When she started showing
her own will and refused to take medication, the message “you are now in hospital but you can gohome when you get well” was shown to her by an illustration and a seal game where the child collects
seals by tracing a route from start to goal (Figure 1: You did it! Card). Eventually she started looking
forward to her treatments. Likewise, a child with Kawasaki disease was encouraged with collecting
seals of his favorite TV character.

2) Children with allergic purpura were restricted walking. Some of them just shut their mind andothers showed their irritation to adults when scolded too often. Since many were full of energy bynature and they were good at doing crafts, HPS showed handicraft materials and waited quietly
until they showed their interests. Eventually a child came up to HPS when he felt better and soon
became busy making a house with cardboards. Once he had completed the house, he asked HPS
whether he could make the house fly. He attached balloons to a small house and make it fly. Whenhe was satisfied with the play, the relationship with healthcare staff became normal again. After hewent back home, he recalled memories in hospital positively “I did it. It was fun” (Pic 6 and 7).

← The handiwork ofanother child withallergic purpura

Figure1. “You did it!” Card

Pic 6, Pic 7

4. Discussion
For patients with allergic purpura and asthma, their distress has not received enough attention
since they were rather common diseases and required rather short-term hospitalization. It has beena challenge for healthcare professionals to provide concrete advice to a mother having difficulties
with medication and inhalation to her breast-fed infant. Through our observation, however, it wasevident that even a 2 year-old child understood through illustrations, dolls and explanation that
there was a meaningful connection between medication, inhalation and examination in order to treat
her illness. Consequently, treatments proceeded more smoothly.
When children become school age, it is not difficult to proceed with treatment. Because of therepeated passive experiences however, many of them become unnecessarily passive unconsciously.
In our observation, they regained their sense of control and started expressing their feelings once
again through practicing enough active play. In addition, they seemed to maintain the trust
relationship with their healthcare professionals.
IV. Preparation for a child who will undergo a major examination/operation
1. Subject
A girl (5 y/o): Hospitalized due to encephalopathy, but later diagnosed as Moyamoya syndrome (alsocalled cerebrovascular). She underwent bypass surgery twice to prevent any aggravation.
Her mother indicated good understanding of the HPS role since a play-based intervention by HPS
was already practiced while her daughter was recovering from the first surgery.

2. Method
An attending nurse had vigorously tried to make a good relationship with the girl including
practicing preparation, and play interventions from HPS were provided to support the nurse and tofulfill the girl’s psychological needs.
3. Result１）Examinations
Though the girl had undergone CT and MRI several times, HPS carefully observed her feelings
through playing with dolls imitating an angiographic procedure (Pic.8). Patients may find theprocedure disturbing as their body movement is restricted after the examination. Regarding theexamination, the girl was explained about its procedure by a book “Curious George” and was toldthat the examination was necessary for her to get well. Before a nurse came to explain to her indetail, the girl requested to play doctors and nurses with a George doll. She was happily talking
about the examination procedure during her play (Pic.9).
While a nurse explained the procedure, the girl was listening to him carefully with interest (Pic.
10). After the examination, she was a little agitated about the strange feeling after anesthesia andthe sense of suppression of her abdominal area that she had never experienced before. It was,however, evident that she understood the purpose of the examination as she was saying “I wonder if
Dr. H could see my veins clearly” even when she was still feeling dizzy. She also understood well thatshe should not move her body. She completed the examination smoothly and went back to sleep after
reading her favorite book.
(Pic. 8)
(pic.9)(pic.10)2) Blood Sampling
Though the first surgery went well with her cooperative behavior as shown above, there had beensome problems when she was about to undergo the second surgery that was held 2 weeks after the
first one. Three possible causes of her agitated behaviors would be: a) healthcare staff forcefully
restricted the girl’s body in ICU and she lost her trust toward staff, b) She went through a very
painful procedure of removing the stiches after the first surgery. Though the treatment proceededwith distractions to ease her breathing such as singing, deep-breathing and blowing soap bubbles,
the pain was enormous and she developed a great fear of the treatment room, c) Her mother was notcooperative enough toward preparing her daughter for another surgery. Her mother did not talkabout another surgery to her daughter (her mother told the reason later).
Eventually she even refused to have blood sampling with which she did not have much problems
before. A nurse tried to understand her feelings and took time until the girl calmed down without
forcing. When asked what the problem was, she answered that she was afraid of a syringe. Hearing
this, HPS played with her using a syringe and splashed water on toys at a sink for 15 minutes. Afterthe play, she sat on the lap of a nurse who was practicing distractions and eventually the girlaccepted blood sampling. After this incident, the girl frequently requested to play with a syringe tocalm herself down before a blood sampling (Pic. 11).

３）Surgical Preparation
For both surgeries, her attending nurse and nurses who were using preparation vigorously
searched for optimal preparation through creating books and picture-story shows. HPS and nurses
consulted each other and together created these books. Areas that needed improvement at the firstsurgery (ex. in ICU) were well improved for the second surgery. The girl attentively listened to theprocedure explanation since her favorite characters were in the book, and eventually she was able
to go to the surgery room without nervousness (Figure 2: One of scenes of a story book that her
attending nurse made).

Pic.11Figure 2

4. Discussion
Overall, it was the success of the coordination between HPS and nurses. HPS attended thesurgery procedure explanation with the girl provided by her nurse. After the explanation, HPS asked
the girl her feelings and reflected the explanatory session while playing together with her. HPS theninformed nurses about the girl’s psychological state and her understanding.
Since HPS were involved even before the girl’s hospitalization and played together, the girlalready had a strong sense of trust in the hospital. Nurses also understood well the idea of
preparation/distractions which was not to reduce crying of a patient, but to build trust relationshipbetween a patient and healthcare staff through open and honest communication. Even those times
when the girl could not help crying and faced difficulties, the good relationship with healthcare staff
remained until she went home and she expressed her sense of achievement “I did it, I went throughit, and I got well”.
Since preparation was practiced by nurses parallel to medical play practiced by HPS, it was easier
to assess the effectiveness of preparation than other cases, and it had been seen that the preparation
by nurses was done in a respectful manner.
V. Support for development and treatment for children with special needs
1. CASE 1 (Developmental support for children hospitalized for long periods)
1) Subject:
Two and a half year old boy with Spinal Muscular Atrophy (SMA), Type I. Hospitalized since twomonths old. While taking care of his two siblings (4 y/o and 0 y/o), his mother visited the hospitaland stayed for a half-day. The boy had been in and out of the hospital. As time passed, he became
able to vocalize and to express his feelings by the subtle movement of his face and his fingertips.
2) Method
Body massage and singing had been continuously practiced with him since birth. Around a year
old, when he started having his own will, his family, doctors and nurses decided to use the same sign
to communicate with him. When communication became possible, play which would make him
actively join in by using his body parts was introduced.

3) Result:
By collaborating with nurses and by observing him closely, a small development was found in his
subtle movement. It was also evident that he expressed his happiness when praised. We encouraged
him to repeat what he did in order to maintain the level of his development.
4) Discussion
Since the boy had spent almost his entire life in a hospital since birth, the level of his psychologicaldevelopment was also carefully observed and closely checked with nurses so that the necessary
emotional development relating to attachment for his age should not be disturbed. Eventually theboy’s development was well stimulated and he started responding to many of the healthcare staff
who were positively involved in the communication process.

Pic. 12：An example of active play：The paper-made butterfly moving its wings as he moves his
fingertips
2. CASE 2 (Support for treatment for children with developmental impairment)
1) Subject:
There were two similar cases (a boy and a girl, both were 10 y/o). Both were initially hospitalized
due to suspected vomiting disease and facial neuralgia, which was later diagnosed as Asperger’s
syndrome. In this article, the boy’s case is reported. Each period of hospitalization was from a month
to two months depending on his condition. Hospitalization continued until his condition calmed downor was calm enough to allow a normal school life. Some friction within his family had been seen as
they did not know how to deal with the situation.
2) Method:
The first priority was to build a trust relationship with the boy. Some visually structured
preparation for examinations that he had never had before were carefully undertaken by using dolls
and making the actual sounds of an examination so that he would understand what he should expect.
Since he tended to forget things easily, including rules in the hospital, visually structured
explanations were used.
3) Result:
In order not to result in any psychological damage being caused by an examination,
preparation using dolls was practiced. Though he had a great fear of blood sampling, HPS
encouraged him to use a syringe during his playing because he showed interest in the apparatus.
Rules and events were visually indicated in his daily schedule (Pic. 13) and HPS drew a line at aplace where he should not enter. He insisted on carrying on doing his favorite play, imaginary stories
using handicrafts, and HPS let him play as much as he wanted to (Pic. 14).
Frequent communication between HPS and his school continued so that he was informed of his
current status at school in a timely manner.

Pic.13

Pic.14

4) Discussion:
Information to the boy was delivered in a concrete manner rather than an abstract one. Since hisfamily also learnt how to communicate with him, the friction between the boy and his family was
reduced. Compared to before, he became calmer and his symptoms became better as he became
emotionally more stable through plenty of playing.
For many cases such as adolescent eating disorders, great stresses tend to build up inside patients
because of the discrepancy between their mental age and expectations of their families andsurroundings. They become calmer and often start pouring out their feelings through play based
strategies. It was effective to understand their psychology and how playing worked for them.
VI. “Worldwide” support and encouragement for preparation and distraction practice
1. Preparation
1) Previous issues
There had been a number of attempts where HPS practiced preparation directly with a child.
However, very little preparation was addressed directly to a child by HPS since HPS were occupied
with other everyday duties. At such times, nurses were mainly in charge of preparation practice.
Consequently, an explanation was given just to parents and enough explanation toward smallchildren was often not done. Moreover, nurses with little experience of working with children did notknow how to deal with children, and eventually a treatment was forcefully given.
Further, there was no opportunity for nurses to learn about preparation from, HPS and CLS.
2) Method:A study session for nurses of the pediatric ward was held where the author of this article was alecturer. The session was about not only the general procedure of preparation / distractions but also
human rights for children in hospital, the true purpose of preparation which was not just an
explanation/agreement but an opportunity to build trust with a child. It was also taught that theconcept of preparation originally started from making a good relationship with a child. Playing witha child before and after a treatment is equally important as providing a distraction during atreatment and this point was emphasized.
3) Result:
The session received a great response especially from young nurses who had difficulties withdoing blood sampling with small children. They poured out their feelings of their deep distress when
they had had to separate children from their mothers and to forcefully treat them in a supine position.
Nurses were willing to try blood sampling by asking for the cooperation of the child’s mother to holdtheir child during the treatment. As a result, more nurses were gradually asking mothers toparticipate in blood sampling for their children that led to the following cooperative effort.
2. Distractions at blood sampling
1) Previous issues
Since a great number of blood sampling was to be done in the morning, readiness was prioritized:
children were separated from their mothers and the treatment was often forcefully done on a medical

table. Some children who repeatedly underwent such treatment developed negative feelings toward
the treatment room and some could not overcome their traumatized feelings until they grew up (ex.
they could not help but start crying at blood sampling). The common belief among nurses was “itshall not be that bad because they can go home once they get better.”.
2) Method
In the study session mentioned above, children’s rights that they shall have their parents
available at all times were discussed. Moreover, the fact that the threshold value of pain was lower
in children who stayed with their parents than those who did not. Some nurses wondered whether
this new practice, blood sampling with the child’s mother, could be applied to their wards eventhough they found it effective. Some wondered how to teach the practice to other healthcare staff. In
the end, it was decided by all participants that they would run some trials in their wards and see
the result.
(1) Subject: Children aged between 3 and 5 years, Trial period: One month(2) In the previous day of blood sampling, an explanation to a mother and preparation to achild were given (about the procedure of blood sampling and toys they would use) by HPS and nurses.
The day of the treatment, HPS performed distractions with toys to a child who was held by his/hermother while two nurses practiced blood sampling.
3) Result:
The total number of children was three. Since their mothers were with them, all managed wellduring the treatment without being forced to stay still, even though some were just about crying.
Another common result was that all children had a good relationship with healthcare staff after thetreatment.
One of the three children had taken a long time before he/she made up his/her mind to take thetreatment. It was because the preparation to the child was not sufficient. Some nurses pointed out
the above situation as a reason that they were concerned whether it was the right time to introduce
this new practice in their ward. It was decided however, that overall the trial received positive
responses from children and parents; “ It was good to do it together”, “ I appreciate the staff who
waited for my child to be ready”, and the common agreement among nurses was to apply the newpractice to the real setting.
A 5-year old girl who had an angioma was filled with a sense of uncertainty toward healthcare
staff. She eventually underwent blood sampling four times and HPS were involved each time.
Eventually, she put up her arm by herself and instructed a nurse where to puncture withconfidence. It indicated that when preparation/distraction was practiced properly, children weregreatly encouraged and motivated to overcome the situation.

Pic.15. Example of a distraction

Pic16. Look at me. This is how it goes4) Discussion
Although how and what the HPS can do during preparation and during medical treatment suchas blood sampling is still not yet fully applied in the real settings, to have had an opportunity tointroduce the concept and work of HPS in the study session was a major turning point for the longpracticed common belief in the ward. Through the trial in the real setting during blood sampling,
the practical work of HPS was conveyed in a concrete manner that led to the common acceptanceand the understanding among nurses regarding respectful treatments to children.
VII. Conclusion
In this report, a two-year overview of practice of HPS was divided into 5 sections. Time course of theevents was from 2009 to 2011. Sections 2, 3, and 5 were events that chronologically occurred from
August 2009, the time when the author started working for the ward. Sections 4 and Section 6 were
events from April 2011, a year and half after the first attempt.
Why was there a year and half interval between the two reports? It was because, as mentioned
in the beginning of this report, no one had any idea what HPS would do. It is undeniable that there
should have been a better way of disseminating information about HPS, having shown theeffectiveness of making a good relationship and having good communication with children in theearly phase of my attempt, and having demonstrated some positive consequences.
Currently, the term “preparation” is almost over-used among pediatric healthcare professionals
as if it were some sort of boom. It could be the case that some would consider preparation as“informed consent for children” and practice preparation without knowing its true purpose – to bewith children. On the other hand, nurses in the ward where I am working vigorously play withchildren and try to understand the families’ perspectives (Pic. 17: When I opened the door, a nurse
and a patient were laughing cheerfully as the nurse was making soap bubbles with a patient’s
respirator!).
Healthcare professionals who understand how to communicate with children by using play as atool have a great advantage. In my ward, every single healthcare professional takes advantage ofplay as a communication tool on a daily basis. It is closely related to what Matsudaira states (2010)“What makes HPS distinct from other healthcare professionals? That is, they introduce “play” in the
medical environment in order to support pediatric treatment, and they improve the medical
environment from children’s perspectives”.
Though this report may not enable an immediate change to the pediatric environment, it at least
clearly indicates specific roles of HPS, introducing “everyday play” into the medical field.
Overall, I am grateful for having had the opportunity to summarize my past two years ofexperiences as an HPS in the medical field, which was an unknown world for me initially. Eventually,
I have established a warm relationship with staff through playing with children. I hope this reportencourages our HPS colleagues across the country who are also making steady efforts to build up
our activities.

Pic. 17Reference
1) Chika Matsudaira (2010). Introductory of Hospital-Play. Kenpakusha Press. 201