静岡県立大学短期大学部

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研究紀要 36 号（2022 年）−6

Education of Hospital (Health) Play Specialists in Japan and theUnited Kingdom

Norma Jun-Tai＊1, Chika Matsudaira＊2, Kei Matsumoto＊3

Introduction
Commissioned by the Japanese Ministry of Education, Culture, Sports, Scienceand Technology, the University of Shizuoka Junior College introduced the first
hospital play specialist (HPS) training programme for working adults in 2006. In
the subsequent 15 years, 213 HPSs have completed the programme.
In Japan, an HPS is a professional who supports sick and disabled children bymeans of play so that those who are receiving medical care can be treated in a
way that does not deprive them of their sense of self-control and that makes
their experiences of such care positive. It is believed that the functioning ofthese professionals will help not only the children and their families but also the
medical staff, enabling better communication with the children, facilitating
treatment, and enhancing recovery.
This section will briefly summarise what kind of theoretical research has been
conducted on play to date and present issues in play research. It will thendiscuss the evolution of health play in Japan and its educational challenges,
citing specific examples.
Programme Leader for FdA Healthcare Play Specialism, Nescot College; Trustee,
Healthcare Play Specialist Education Trust (HPSET); Vice Chair, National Association of HealthPlay Specialists (NAHPS)＊1

University of Shizuoka Junior College, Department of Social Work: Manager of the HealthPlay Specialist Education Course＊2＊3Specially Appointed Researcher, Hospital Play Association

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Part 1 – Education for the Specialised Provision of Hospital Play in UK‘Deprived of play, the child is a prisoner, shut off from all that makes life real
and meaningful . . . .[Play] acts too as a safety valve, allowing [the child] to reliveand come to terms with fears and anxieties which have become overwhelming.’—Organisation Mondiale pour L’Éducation Préscolaire 1966
Over time, the shift from a medical model of paediatric healthcare to a more
holistic approach now incorporates the provision of play and recreation, whichenables children and young people to navigate complex and challenging
healthcare systems. When observing children and young people in a healthcare
environment today, one is likely to witness their engagement in a variety ofimaginative, familiar, and reassuring play and recreational opportunities.
Anecdotally, this scenario was succinctly captured by a child who, when visiting
the outpatient's department, was overheard to say, ‘I come to hospital to play;oh, and when I’m here, I see the doctor as well.’ However, play in hospital does
not happen by chance; it is the skilled intervention of the trained HPS who
facilitates these meaningful and creative interactions. Employed in a variety of
paediatric departments and clinical areas, the HPS is specifically trained toenable the sick child, young person, and family to assimilate and accommodate
healthcare procedures into a more manageable and positive experience (JunTai 2007).
The report to the Care Quality Commission (CQC) by Dr Sheila Shribman,
recommended that specific children and young people’s services should be
inspected by the CQC, including hospital play services, and that play specialists
may be part of the inspection team (Shribman 2014). The training programme
for the HPS is responsive to inspection frameworks and reflects the skillset
required to address the patient’s treatment plan. However, this must begin withthe fundamentals of building trusting relationships through advocacy,communication, and normalising play and recreation opportunities. Over a twoyear training course, student play specialists will learn how to apply nonpharmacological approaches to prepare and distract patients during invasive
procedures; these skills are transferrable to more specialised areas such as
burns units, oncology, feeding programmes, diabetes, loss and bereavement

3

support etc. Given that the Department of Health (2003: 14) recognised that‘there is evidence that play hastens recovery, as well as reducing the need forinterventions to be delivered under general anaesthesia’, it is apposite that the
profession is well trained in order to work with multi-professional colleagues in
the provision of a whole systems approach to healthcare.
Historic context relating to the justification of a specific group of professionals,
to be trained in delivering organised play in a hospital environment can be foundin the Platt Report, (Platt 1959), including the need for play to be organised
under skilled supervision. As with any profession it must evolve and adapt tomeet service needs, and this mirrors the profession’s journey. The first training
course in 1973 was delivered by Chiswick College as a post-qualification
course, with applicants typically from a professional background in art andmusic therapy, nursing, teaching, social work, and nursery nursing. The
establishment of the National Association of Hospital Play Staff (NAHPS) in
1975 identified a growth in the profession, and it became evident that aformalised curriculum should be aligned to an education body. NAHPS
consulted widely and the formation of the Hospital Play Staff Examination Board(HPSEB) saw the first examinations taking place in 1988 (Save the Children1989).
Further discourse with the profession, led to the change of title from HPSEB to
the Hospital Play Staff Education Trust (HPSET), as this corresponded with thewider remit of becoming a registered profession. Analysis of the HPS role
identifies an in-depth capacity to promote health and wellbeing in order tosupport healthcare interventions; therefore, the word ‘hospital’ in the title has
been replaced by ‘health’, which is fully reflected in the learning outcomes of the
training course. Today, qualified HPS are expected to re-register on an annual
basis in line with other health professionals; therefore, students are prepared forthis process through the reflective components of the summative assessments.
The current training programme is delivered as a Foundation Degree (FdA) in
Healthcare Play Specialism, and when first validated, a scoping exercise wasundertaken to identify how the FdA could be dovetailed into the existing NHS
careers pathway, enabling the profession to be positioned within the existing

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NHS Career Framework (Paulsen 2016). To achieve this, HPSET and NAHPS
collaborated on the development of a Code of Conduct (2019a) and Standardsof Proficiency Professional Standards (2019b). Both documents are integral tothe course curriculum.
The development and advancement of play in hospital is not unique to thelearning experiences of students in the United Kingdom. Early exchanges of
educational and professional practice in the 1980s were established when Child
Life Specialists from the USA began a tradition of visiting the UK in order toobserve HPSs in their work environments. This initiative is credited to Peg
Belson, as was her strong connection to the Klicek Foundation in the Czech
Republic, where a similar arrangement was made. In 2008, NAHPS joined the
University of Shizuoka in Japan to establish an affiliation to promote high-quality
play services for sick children and an alliance in sharing best practice inresearch and teaching.
Many HPSs have participated in the training programme since its inception in
1973, and today there are around 700 registered HPSs delivering differentiated,child-centred practice. The intervention of a trained HPS can increase the childand young person’s resilience in an environment where ‘children shall be cared
for by staff whose training and skills enable them to respond to the physical,
emotional and developmental needs of children and families’ (European
Association for Children in Hospital n.d.).
Education and training should evolve and be responsive to the needs of society,therefore NAHPS and HPSET consulted widely with NHS stakeholders in order
to align the current training provision to the UK Government’s drive forapprenticeships as organisations, including the NHS, with a salary bill of over
£1.5 million are now required to make a financial commitment to upskill theirstaff. Historically, many play workers or play assistants employed in paediatricdepartments self-funded or sought charitable support to train as HPSs;
therefore, the apprenticeship route has provided an opportunity to join thefoundation degree students in embracing a wonderful profession.
The Institute for Apprenticeships require all apprentices to demonstrate
knowledge, skills and behaviours at an academic and practice-based level, and5these have been mapped to the professions Code of Conduct (HPSET and
NAHPS 2019) and Professional Standards (HPSET and NAHPS 2019).
Following extensive engagement with NHS staff, education providers, parents,
and patients, the Higher Apprentice Health Play Specialist standard wasapproved in 2019 and is currently delivered in England.
Steph Fairbain provides a personal reflection on the changing face of HPS
training and the importance of professional mentoring for the HPS student,
which is an integral part of the FdA qualification:
Training and mentoring have been a privilege and passion for many
years; in performance arts (from 1981), in management andorganisational development (from 1994), play and youth work (from2003) and mentoring HPSs since 2008.
I have seen the development of play specialist training evolve from BTEC
qualification (Level 4) to a Foundation Degree (Level 5) and now towards
a new competencies-based assessment format (from September 2021).
The benefits of competency-based assessment ‘enables explicit
articulation of skills that successful graduates have’ (Bradley et al. 2008).
Furthermore, the grading of competencies gives the student a clear
understanding of their level of practice, with the top grading requiring thestudent to demonstrate both reflective and evidence-based practice. I
believe that the strengths of the Foundation Degree reside in theassessment of work-based practice and the understanding of theories
and evidence that underpin that practice carrying equal weight. I was
involved in the introduction of Playwork National Vocational
Qualifications when they were launched in the 1990’s to a largely
unqualified workforce, and I believe now as I did then that all children
deserve an appropriately qualified workforce.
My passion for training or coaching stems from the pleasure I get fromobserving the development of students, that light bulb moment when they
suddenly ‘get it’. For me, it is as satisfying as seeing an anxious childcope well with a procedure after receiving HPS preparation anddistraction, and the joy shared when they realise: ‘I did it!’.

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Reflecting on the students I have supported over the years, I believe that
one of the strengths of a mentor that comes with experience is anunderstanding that students’ progress at different rates. There areplateaus in learning and practice where the student just does not seem to
be moving forward, and the struggle and loss of confidence that thenensues can be both difficult to watch and frustrating for the mentor. An
Open University (n.d.) session on Learning development, cites Atherton’s
learning curve model (Figure 2), which I believe more accurately depicts
a learning curve than the smooth curve usually described.

Figure 2: A typical learning curve (Atherton 2013, cited by the Open
University n.d.)Awareness that the learning curve is not steady and continuity is key,along with an understanding that progression is a ‘process that contains
growth, peaks, troughs and plateaus’ (ibid). Experience has shown methat there are few students who do not suddenly bloom with a ‘light bulb’
moment, and it is the calm confidence a mentor can bring that will
support the student through.
In developing my own mentoring skills, alongside the training provided by
HPSET, I found ‘The Nurse Mentor’s Handbook’ (Walsh 2014) to be a7

useful tool. Through reading this I now use the SWOT analysis(Strengths, Weaknesses, Opportunities, Threats) to help students
identify their transferable skills and learning objectives (applied slightly
differently than suggested in the book) and this has cemented myunderstanding of the need to provide students with different learning
approaches to meet different learning needs.
In researching the mentoring role, there seemed to be little emphasis on
the impact of a passionate mentor. I opened this reflection by stating
training and mentoring have been a privilege and passion and I believethat passion and the ability of the mentor to express this is the foundationof a great mentor, underpinned by knowledge and good practice. The
mentor/student relationship is stronger when viewed as a partnershipwhere both can learn from each other. Therefore, a mentor needs to beable to critically appraise their own work and to be open to change andnew ideas.
‘The greatest of mentors inspire their mentees and become a living
example to emulate. They do so by exuding a genuine passion for theirwork.’ (The One Thing n.d.)Part 2 – The Evolution of Hospital Play in Japan
Overview and Issues of Play Research
By reviewing previous studies on play, this section discusses the difficulties indefining play and what kind of theoretical exploration is needed in hospital playresearch in the future, and for what purpose theoretical research is required.
Until now, play has been examined from diverse perspectives not only in social
welfare studies, on which this paper is based, but also in anthropology,sociology, psychology, childcare studies, and many other fields, and there is avast body of research on the subject. When it comes to play research,
Huizinga’s Homo Ludens (1963) and Caillois’s (1967) work, which succeeded
Huizinga's research and revised it, are probably the first to be mentioned.

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According to Ellis (1973), the study of play is divided into three major stages
after the appearance of Huizinga. Although somewhat rough, Ellis’sclassification of the three phases is as follows: classical theories of play prior to
Huizinga’s appearance, modern theories of play by Huizinga and his
successors, and modern theories of play after Huizinga.
Prior to Huizinga, play studies discussed play as a by-product of some action.
Therefore, play itself was not discussed as a substantive act. Three points
deserve special mention in Huizinga’s study: first, he treated play itself as anentity that exists in an independent realm; second, he typified play by focusing
on its form and defined it as something that is located at the centre of culture;and third, while acknowledging the essence of play to be fun, he dismissed as
impossible any theoretical interpretation of fun.
Caillois, who took over Huizinga’s work, modified the unity of play as presented
by Huizinga and typified play into four types: agon (competition), mimicry(simulation), area (luck), and inkus (dizziness). Thus, Huizinga’s definition ofplay as the centre of culture was redefined as play as a domain of culture.
Kohara (2011) commented on Caillois’s revision, ‘Caillois tried to overcome theproblems of Huizinga’s theory by adding more elements to the theory and by
narrowing the scope of the theory, but many unclassifiable hobbyist activities
remained.’
What Huizinga and Caillois have in common in their definition of play is thatthey assume fun to be its essence, but they do not give any theoreticalinterpretation of or meaning to fun. In other words, they treat fun as an a prioriconcept wherein fun accompanies play or lies at its heart.
The above assumption of fun has been considered by later researchers,
especially Ellis and Csikzentmihalyi, who explain the fun of play in psychologicalterms as an equilibrium/transition of information content or psychic entropy
through their own concepts such as ‘optimal arousal’ (Ellis 1973) and ‘flow’(Csikzentmihalyi 1990). Csikzentmihalyi’s flow theory is often referred to in
today’s play research, especially in psychology and related fields. From this, it
can be regarded as an attempt to explain play from a psychological aspectusing some kind of index or theory.

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There also exist approaches from a completely different perspective than these
psychological ones. One of these is the research focusing on the interaction ofplay as seen in Goffman’s (1961) study. Here, using play as a model, a unique
way of constructing the world based on the nature of interaction is examined.
Goffman’s study of play is an extension of Bateson’s (1972) framing theory,
which concerns interpretive frameworks and which states that the meaning of agiven action depends on what kind of interpretive framework is used tounderstand the mutual actions of the players. To summarise Goffman’s
argument, what constitutes play is left to the player receiving the message. The
major difference from other studies is that Goffman tries to define what play israther than to categorise it.
There are various other studies of play, including an attempt to understand playfrom a phenomenological perspective (Henriot 1969) and a study that discusses
play from a sociological perspective (Inoue 1981), but all of them seem to be
struggling with the question of how to understand play.
It should be clear from the discussions in these previous studies that it is very
difficult to define play in general. However, it is crucial to seek a theoreticalstandpoint for what kind of play should be considered in hospital play research.
The question is what frames of reference are used by sick children, theirfamilies, and the HPS to interpret play, and what frames of reference can beshared and used to construct a world of meaning together. These issues are notlimited to the level of theoretical research. Yano (1996) once described play as
something that ‘brings radiance to life’; however, it is also a clinical challenge topractice play that imbues life with such radiance when dealing with sick children
and their families.
The next section will discuss the evolution of health play in Japan, thechallenges they currently face, and their achievements, with specific examples.
Health Play Specialism in JapanThe techniques used by an HPS can be broadly categorised into the following
areas:

10•

Normal Play•

Therapeutic Play•

Play Preparation•

Distraction Therapy•

Post Procedural Play•

Distraction•

Post Procedural Play•

Sibling Support•

Individual Referrals

All children are eligible to participate in HPS activities. Whether a child is mildly
or severely ill, the HPS realises an environment in which the child has access tosome form of play, and all the areas listed above come under the remit of the
HPS. Unfortunately, in Japan, preparation is the only recognised nursing
technique; however, the role of the HPS is not confined to preparation, and the
HPS knows that unless play-based support is incorporated into the entire
treatment programme from the time a child is admitted to hospital to the timethey are discharged, preparation will not be fully effective.
Challenges faced through HPS training education
We have been providing HPS training and education for 15 years, but the roadhas not been a smooth one. Japan adopted the United Nations Convention on
the Rights of the Child (UNCRC) in 1989, and it was ratified in 1994 (Runnels
Ranck et al. 2016). However, in the fourth and fifth periodic report of Japan on
measures taken to implement the UNCRC in January 2019, Committee Expertssuggested that Japan ‘did not seem to be as child-friendly as one would wish’
and that only three per cent of health establishments carried the ‘child-friendly’label (Office of the High Commissioner on Human Rights 2019).
This is reflected in our healthcare establishments, where even now, there aremany hospitals in which parents are not allowed to be present during
procedures such as drawing blood from their children. We are still using
restraint belts and other methods to restrain children during procedures. It is11unfortunate that the rights of the child are not being protected in Japan, adeveloped country, and HPSs have been making changes under the slogan of‘child-friendly medical care’ by strategising their approach and encouraging
each other.
This has a lot to do with the culture in Japan, where hospitals are veryhierarchical, and it is not easy to make people understand the importance ofincluding the HPS in the paediatric care team. Often, when I raised the issue
with a paediatrician, advocating that children had the right to play, I was
rebuffed, the paediatrician saying that play in the hospital sometimes had thepotential to deprive a child of their right to life. A particular point raised was thequestion of how to present the evidence for the effectiveness of HPS. It is clearthat the medical model leans towards numbers. On the other hand, there aremany physicians who believe that it is impossible to prove everything
numerically. We, as HPSs, decided to prove our value by accumulating casestudies and have been publishing such studies every year since 2009. As of thecurrent year (2022), which marks the 13th anniversary of beginning this project,more than 100 case studies have been published and undoubtedly represent
the birth of the HPS in Japan.
Japan is a country with universal pensions and universal health insurance, but
one aspect that differs slightly from the UK healthcare system is the concept of
medical fees. In Japan’s medical fee system, points are awarded to doctors,
nurses and pharmacists for their professional activities, and payment isdetermined on the basis of these points (Shinya 2017). For example, when adoctor explains a treatment to a patient, the doctor receives a correspondingscore, and the amount paid to the hospital is determined accordingly. In order
for an HPS to be eligible for reimbursement as an independent professional, it
will be necessary to award points for some of their professional activities. We
will be discussing this in the future, but we believe that preparation anddistraction will be the easiest activities to understand in order to be awarded
points.

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We do not deny the value of expressing efficacy in terms of numbers, but weare certain that the benefits an HPS brings to sick children can be seen only byobserving the interaction between the HPS and the children. We believe thatwhen truths that cannot be expressed numerically are ignored, medicine walks
alone, away from the child.
How paediatricians evaluate play for sick children
While preparation and distraction are a form of support that needs to be
standardised in Japanese paediatric medicine, the role that HPSs have come tobelieve they have a responsibility to develop goes beyond this. The reasons forthis are explained below.
In this 15th year of HPS training and education, we planned a study based oninterviews with physicians to identify factors that promote and inhibit retention in
health play specialism. Five paediatricians who work with a Japanese HPS
were selected for this qualitative study. Semi-structured interviews wereconducted according to four main themes:•

The changes that have occurred as a result of working with an HPS•What they want and do not want from an HPS•

The knowledge, skills, and attitudes required of an HPS•

The role an HPS plays in paediatric care

The results are very interesting: the physicians appreciated the preparation anddistraction that an HPS provides, thereby helping them do their jobs, and theytalked about the need to standardise preparation and distraction. However, they
expected the HPS to go further.
A paediatrician who treats children in medical care talked about the meaning ofplay for sick children as follows:‘Play is a way of life, isn’t it? You’re the one who can do your best to stay alivefor one more week, and for medical-care children, HPS is the way to go.’A second paediatrician said the following:

13‘I think it’s play that gives children the opportunity to have a transformative
experience in the hospital.’
A third paediatrician praised the activity as ‘bringing the true voice of the child tous’.
A fourth paediatrician said, ‘I think the wards have started to move in the same
direction since hospital play was introduced.’ He then stated that he would like
HPS to ‘develop support that goes beyond the boundaries of hospitals’ and to‘work within hospitals is a matter of course’. He added, ‘I would like HPS to
become a human resource that can deliver play support to children with chronic
diseases living in local communities.’
The background to these statements is the existence of children who have long
lives despite being ill, and the fact that the need to support children in thecommunity is emerging as genetic diagnostics develops and we can assume
our own life expectancy to some extent.
The value that HPS adds to healthcare
One of the doctors suggested in the interview that he thought Japanese
medicine was the same as Western medicine, but the way of thinking about andproviding medicine was different. I find this a very thought-provoking statement.
As we have explained, by incorporating play into the hospital environment andinto treatment, children can feel the kindness of medical care and remember it
as an experience. The HPS maximises the power of play and applies it to thehospital environment to provide concrete ways to support sick and disabledchildren. However, as I train and educate people in health play specialism, I
realise that the meaning of training for this profession in Japan goes beyond the
how to of teaching and spreading HPS techniques, and that we need to findanswers to the why? questions.

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The following examples will show why health play specialism must challenge
the question of what is the value of its presence in hospitals and what is thesignificance of providing play for sick children and their families?
There was a child with whom an HPS was involved who was able to play veryrichly during his hospitalisation. When it was decided that the child would bedischarged from the hospital after his surgery, the child cried and got angry
saying, ‘No, I don't want to leave the hospital, I still want to stay in the hospital’.
We told the child that he could come back and play anytime he wanted, and wewere on our way. But one of the medical staff who was watching said, ‘That’s amistake; a child shouldn’t like hospitals. You have to make the child feel a little
scared of the hospital.’ The HPS was surprised to hear the child crying andsaying that he did not want to go home and, seeing he was still there, wondered
where this difference in perception came from. This case leads to the questionof what a hospital should be like for an adult or a child. It also raises thefundamental question of what kind of experience a child’s relationship withhealthcare should be.
In 2003, the UK Department of Health published The National Service
Framework for Children, Young People and Maternity Services. In a supporting
document, there is a passage that says, ‘Children will become adults; and there
is a growing understanding of the effects of childhood experiences, including
illness, on their adult life’ (Department of Health 2004: 10). In other words, theexperience of interacting with medical care as a child continues into adulthood,and recognition of this leads to the idea of including an HPS in the medical
team. I think it is important to create a system that allows children to grow up
healthily while trusting and utilising Japanese medical care rather than disliking
it or disliking medical staff because of their involvement with it.

15Conclusion
The next stage is to give the HPS a Japanese name. This will require athorough examination of the role of the HPS in paediatric care in Japan. Until
then, it will be important to continue training and education for HPSs.
During this process, we are currently facing the need to deepen clinicalresearch and increase awareness of the meaning of play for children and thevalue of integrating play with medical care. Anyone who is involved with children
knows that play is an essential activity for their development, but in order toincorporate play into paediatric medicine, discussing it must be limited tomatters related to development, and it is necessary to understand the depth ofplay. In fact, play has fascinated researchers in many fields since ancient times.
Plato said, ‘You learn more about a person by playing with him for an hour thanby talking with him for a year’, and the historian Johan Huizinga (1963) argued
that ‘all cultures have developed from play’. Clinical pedagogue Satoji Yano
(2006) said, ‘Children connect with the world through play’, and mathematician
Kiyoshi Oka (2008) explained the importance of emotion in scientific research:‘Academic discoveries are guided by the keen joy of discovery that children feel
when they see a beautiful butterfly.’
In particular, when we talk about play in the context of medical care, we would
like to focus on the fact that play has the power to create trust and empathy,
which are the foundations of human relationships. Play cannot develop without
such feelings towards others, and it is very important for these feelings to becreated and nurtured between the therapist and the child and to continue after
treatment. In addition, it is important that children who are at a remarkable stageof growth and development experience rich human relationships based on trustand empathy even though they are undergoing medical treatment, or evenbecause they are undergoing medical treatment, and that they return to generalsociety with the seeds of building relationships based on trust and empathy inthem. I believe that all adults, not just those involved in the care of children,
have a responsibility to create such a world and that play is not merely an16activity to pass the time for children undergoing medical care but a medium toconnect the medical care and the children. It is precisely because modern
medicine protects life by making full use of advanced modern science that weconclude that it is necessary to combine science with play, which inspires life inchildren and fosters the joy of interacting with others.

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（受理日 令和５年２月 21 日）