POWER TO THE PATIENTS!POWER TO THE PATIENTS!Play in Healthcare Settings: Challenges and OpportunitiesPlay in Healthcare Settings: Challenges and Opportunities

Presented byPresented byRosemary Bolig, Ph.D.Rosemary Bolig, Ph.D.

The Association for the Study of PlayThe Association for the Study of Play

May 2006May 2006

PLAYPLAY

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Playing in Healthcare Playing in Healthcare SettingsSettings

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Overview and PurposeOverview and Purpose

Discuss changes in healthcare Discuss changes in healthcare Outline changes in play provisionOutline changes in play provision Summarize research and societal Summarize research and societal

issuesissues Highlight need for studyHighlight need for study Invite dialogInvite dialog

History & Current Status History & Current Status of Play in Healthcare of Play in Healthcare SettingsSettings

Early recognition of children’s Early recognition of children’s psychosocial needs and play as the basic psychosocial needs and play as the basic process:process:

Through play a child grows, Through play a child grows, develops,expresses his emotions, develops,expresses his emotions, and adjusts to his environment. and adjusts to his environment. Play becomes a safety valve for his Play becomes a safety valve for his hidden wishes andfears and a hidden wishes andfears and a balance for the tensions that are a balance for the tensions that are a part of every growing child’s life. Ill part of every growing child’s life. Ill or well, the child needs play. or well, the child needs play. (Richards & Wolff, 1940,p. 229)(Richards & Wolff, 1940,p. 229)

Changes in the Changes in the 1940s/1950s/1960s1940s/1950s/1960s

Move from disease-oriented to Move from disease-oriented to patient/child-oriented carepatient/child-oriented care

Long-hospitalizations, hospitals as center Long-hospitalizations, hospitals as center for carefor care

Establishment of play activities programsEstablishment of play activities programs Changes in parental involvementChanges in parental involvement Emerging research on deprivation of play Emerging research on deprivation of play

and relationshipsand relationships Founding of the Association for the Care Founding of the Association for the Care

of Children’s Healthof Children’s Health

Changes in the Changes in the 1970s/1980s1970s/1980s

New children’s hospitals built, pediatric services New children’s hospitals built, pediatric services expanded into outpatient and related facilitiesexpanded into outpatient and related facilities

New treatments in various contexts, shorter hospital New treatments in various contexts, shorter hospital staysstays

Expanding play programs, now generally termed “Child Expanding play programs, now generally termed “Child Life”Life”

Play focused in playrooms, now available on most unitsPlay focused in playrooms, now available on most units Multiple disciplines use play as one of several modalitiesMultiple disciplines use play as one of several modalities Expanding body of research on effects of hospitalization Expanding body of research on effects of hospitalization

interventions – mostly on preparation and parent interventions – mostly on preparation and parent involvement, few on play or play program participationinvolvement, few on play or play program participation

Changes in the Changes in the 1990s/2000s1990s/2000s

Specialization of play provisions – medical play Specialization of play provisions – medical play and specific therapies (e.g., art, music)and specific therapies (e.g., art, music)

Training/roles of Child Life specialists changeTraining/roles of Child Life specialists change Greater use of technology in interaction with Greater use of technology in interaction with

childrenchildren Slowing of new Child Life programs and Slowing of new Child Life programs and

expansion of existing onesexpansion of existing ones Increased emphasis on a continuum of Increased emphasis on a continuum of

healthcare, greater emphasis on homecare healthcare, greater emphasis on homecare and outpatient careand outpatient care

Limited research on effects of hospitalization Limited research on effects of hospitalization or interventionsor interventions

Current Status of Play in Current Status of Play in Healthcare SettingsHealthcare Settings

Although there are play facilities and sometimes play Although there are play facilities and sometimes play facilitators in outpatient areas and emergency rooms, facilitators in outpatient areas and emergency rooms, the majority of play services are focused in the acute, the majority of play services are focused in the acute, hospital settinghospital setting

Play is primarily focused on preparing children for Play is primarily focused on preparing children for procedures/experiences and or expression of feelings procedures/experiences and or expression of feelings about same (Medical Play)about same (Medical Play)

Group play, focused in play rooms is less prevalent, and Group play, focused in play rooms is less prevalent, and often conducted by the less trained, less credentialed often conducted by the less trained, less credentialed Child Life specialists.Child Life specialists.

Specialized therapies (e.g., pet, music, art) and Specialized therapies (e.g., pet, music, art) and entertainment are increasing.entertainment are increasing.

Use of technology for preparation, interaction, contact Use of technology for preparation, interaction, contact with schools, and emotional support are increasing.with schools, and emotional support are increasing.

Rationale for Play Rationale for Play ChangesChanges

The age distribution of hospitalized children has shifted to an The age distribution of hospitalized children has shifted to an increasing proportion of infantsincreasing proportion of infants

although fewer children are being hospitalized, the children although fewer children are being hospitalized, the children who are admitted are more seriously ill and often require who are admitted are more seriously ill and often require longer stays. longer stays.

Child life programs have had to adapt to less mobile patients Child life programs have had to adapt to less mobile patients who have more complex medical problems. As a result, who have more complex medical problems. As a result,

fewer group interactions are possible, and greater fewer group interactions are possible, and greater individualization of care is needed. individualization of care is needed.

Staff members are challenged to meet each child's Staff members are challenged to meet each child's developmental, emotional, and educational needs more developmental, emotional, and educational needs more quickly and efficiently than before and to provide as "normal" quickly and efficiently than before and to provide as "normal" a life experience as possible. a life experience as possible.

At the same time, the expansion of outpatient care has At the same time, the expansion of outpatient care has resulted in more demands for ambulatory child life activities resulted in more demands for ambulatory child life activities as their value and benefits have become recognized. American as their value and benefits have become recognized. American Academy of Pediatrics: Child Life Services. PEDIATRICS Vol. Academy of Pediatrics: Child Life Services. PEDIATRICS Vol. 106 No. 5 November 2000, pp. 1156-1159 106 No. 5 November 2000, pp. 1156-1159

Child LifeChild Life

Child life programs in health care settings Child life programs in health care settings promote optimum development of children and promote optimum development of children and their families, to maintain normal living patterns their families, to maintain normal living patterns and to minimize psychological trauma. and to minimize psychological trauma.

Typically, child life professionals (1) supervise Typically, child life professionals (1) supervise therapeutic and diversional play; (2) prepare therapeutic and diversional play; (2) prepare children for and assist children during medical children for and assist children during medical tests and procedures through education, tests and procedures through education, rehearsal, and coping skill development; and (3) rehearsal, and coping skill development; and (3) support families during hospitalization or support families during hospitalization or challenging events. challenging events.

Child life professionals support a philosophy of Child life professionals support a philosophy of "family centered care" in health care facilities. "family centered care" in health care facilities. (Child Life Council, retrieved on 5/15/06 from www.childlifecouncil.org)(Child Life Council, retrieved on 5/15/06 from www.childlifecouncil.org)

SPONTANEOUS/FREE SPONTANEOUS/FREE OR UNSTRUCTURED OR UNSTRUCTURED PLAYPLAY

Playroom-focused play and Playroom-focused play and activitiesactivities

Impact of Self-selected Impact of Self-selected PlayPlay

Play is expressive and facilitates release Play is expressive and facilitates release of feelings;of feelings;

Play allows children to select Play allows children to select object/themes to regulate their feelings;object/themes to regulate their feelings;

Play encourages children to be self-Play encourages children to be self-initiatorsinitiators

Play permits children to interact with Play permits children to interact with others in a manner that is comfortableothers in a manner that is comfortable

Play and playrooms encourage a sense Play and playrooms encourage a sense of normalacy, continuity, predictabilityof normalacy, continuity, predictability

Play settings and opportunities tell Play settings and opportunities tell children they are valued and empowerchildren they are valued and empower

Medical PlayMedical Play Structured dramatic medical play can offer Structured dramatic medical play can offer

opportunities to relieve children's emotional opportunities to relieve children's emotional distress (which often is not openly demonstrated) distress (which often is not openly demonstrated) through imaginative play situations. through imaginative play situations.

Properly structured medical play, which often Properly structured medical play, which often includes using pretend medical or nursing includes using pretend medical or nursing equipment, allows children to express thoughts equipment, allows children to express thoughts and feelings, assimilate reality, resolve internal and feelings, assimilate reality, resolve internal conflicts, achieve mastery, and cope effectively. conflicts, achieve mastery, and cope effectively.

Guided medical play allows the teacher to Guided medical play allows the teacher to scaffold the learning of the child to incorporate scaffold the learning of the child to incorporate higher levels of understanding (Vygotsky, 1976). higher levels of understanding (Vygotsky, 1976). It also provides a vehicle for a child's self-It also provides a vehicle for a child's self-expression and is a way for children and adults to expression and is a way for children and adults to communicate nonverbally. communicate nonverbally.

Preparation and Preparation and ExpressionExpression

Medical PlayMedical Play [Pictures deleted][Pictures deleted]

Impact of Medical PlayImpact of Medical Play

Encourages children to focus on Encourages children to focus on relevant hospital events/experiences;relevant hospital events/experiences;

Provides opportunity to for children to Provides opportunity to for children to reveal understanding/distress about reveal understanding/distress about impending or experienced events;impending or experienced events;

Allows adults to assess Allows adults to assess knowledge/feelings and scaffold their knowledge/feelings and scaffold their understanding.understanding.

Specialized Therapeutic Specialized Therapeutic Activities/TherapiesActivities/Therapies

Art therapyArt therapy Music therapyMusic therapy Pet therapyPet therapy

Specialized therapeutic Specialized therapeutic activity/therapies activity/therapies rationalerationale

Focused/increased empowermentFocused/increased empowerment Diverse interests/stimulation enhancedDiverse interests/stimulation enhanced Greater evidence of efficacyGreater evidence of efficacy Physiological evidence of impact (e.g., Physiological evidence of impact (e.g.,

endorphins, heart rate, oxygen intake)endorphins, heart rate, oxygen intake) Support to general play/activitiesSupport to general play/activities Third party payment (when certified Third party payment (when certified

therapists used)therapists used)

EntertainmentEntertainment

DiversionDiversion Laughter Laughter EmpowermentEmpowerment

ClowningClowning

Computer/InternetComputer/Internet

EmpowermentEmpowerment Continuation of normal activities Continuation of normal activities

(school), relationships(school), relationships Development/continuation of Development/continuation of

support systemssupport systems Access to information to assimilate Access to information to assimilate

at own initiation/needat own initiation/need Play with games/symbolsPlay with games/symbols

Foundations & Special Foundations & Special GroupsGroups

Starlight/Starbright FoundationStarlight/Starbright Foundation Life Skills 4 KidsLife Skills 4 Kids

Microsoft Club HouseMicrosoft Club House Microsoft Grant Supports Computer Center for Hospitalized ChildrenMicrosoft Grant Supports Computer Center for Hospitalized Children

The Clubhouse, funded by a grant from Microsoft, has computers equipped with The Clubhouse, funded by a grant from Microsoft, has computers equipped with state-of-the-art adaptive hardware and software -- such as touch screens, state-of-the-art adaptive hardware and software -- such as touch screens, keyboards with oversized keys, voice-activated switches and talking monitors -- keyboards with oversized keys, voice-activated switches and talking monitors -- to ensure that all children of all abilities will have full access to the Internet and to ensure that all children of all abilities will have full access to the Internet and be able to use the computers for communication, education and therapy to be able to use the computers for communication, education and therapy to enhance their recovery. Today's opening ceremonies were helped along by two enhance their recovery. Today's opening ceremonies were helped along by two professional athletes, Paul Pierce of the Boston Celtics and Tim Wakefield of the professional athletes, Paul Pierce of the Boston Celtics and Tim Wakefield of the Boston Red Sox, whose teammates have pledged to provide mentoring and Boston Red Sox, whose teammates have pledged to provide mentoring and support for children using the Microsoft Clubhouse. support for children using the Microsoft Clubhouse.

. . At the new Microsoft Clubhouse, children will be able to communicate with other At the new Microsoft Clubhouse, children will be able to communicate with other

children coping with similar health issues; keep in touch with friends and children coping with similar health issues; keep in touch with friends and relatives who may not live close enough to visit them in the hospital; and relatives who may not live close enough to visit them in the hospital; and maintain friendships with classmates. According to hospital officials, the maintain friendships with classmates. According to hospital officials, the Clubhouse will help facilitate the children's transition between home, hospital Clubhouse will help facilitate the children's transition between home, hospital and school by assisting with academic training and breaking down the barrier of and school by assisting with academic training and breaking down the barrier of isolation that often surrounds children who are hospitalized or recovering from isolation that often surrounds children who are hospitalized or recovering from serious injuries or illnesses. The Clubhouse also will be used as a therapeutic serious injuries or illnesses. The Clubhouse also will be used as a therapeutic tool to enhance recovery, allowing children to work on skills ranging from visual-tool to enhance recovery, allowing children to work on skills ranging from visual-motor and fine-motor skills to cognition and memory training. motor and fine-motor skills to cognition and memory training.

Summary Values of PlaySummary Values of Play

Play allows adults to enter their world Play allows adults to enter their world and to show that children are and to show that children are recognized and valued;recognized and valued;

When an adult plays with a child, there When an adult plays with a child, there is a temporary equalization of power.is a temporary equalization of power.

When children play on their own using When children play on their own using objects and relationships as symbols as objects and relationships as symbols as they transform them, they have power.they transform them, they have power.

(Hughes, F.P.{1999}.Play, children, development.(Hughes, F.P.{1999}.Play, children, development.

Boston: Allyn & Bacon)Boston: Allyn & Bacon)

Primary ReferencesPrimary References REFERENCESREFERENCES Bolig, R. (2006). Play in healthcare settings. In Rollins, J., Bolig, R. & Mahan, C. Bolig, R. (2006). Play in healthcare settings. In Rollins, J., Bolig, R. & Mahan, C.

Meeting children’s psychosocial needs across the healthcare continuumMeeting children’s psychosocial needs across the healthcare continuum . Austin, . Austin, TX: ProEd.TX: ProEd.

Bolig, R., Fernie, D.E., Klein, E.L. (1986). Unstructured play in hospital settings: An Bolig, R., Fernie, D.E., Klein, E.L. (1986). Unstructured play in hospital settings: An internal locus of control rationale. internal locus of control rationale. Child Health Care, 15Child Health Care, 15, 101-107., 101-107.

Bolig, R., Yolton, K.A., Nissen, H.I. (1991). Medical play and preparation: Questions Bolig, R., Yolton, K.A., Nissen, H.I. (1991). Medical play and preparation: Questions and issues. and issues. Child Health Care, 20Child Health Care, 20, 225-229., 225-229.

Frost, J. L., Wortham, S. C., & Reifel, S. (2005). Frost, J. L., Wortham, S. C., & Reifel, S. (2005). Play and child developmentPlay and child development. . Columbus, OH: Pearson.Columbus, OH: Pearson.

Kaminski, M., Pellino, T., & Wish, J. (2002). Play and pets: The physical and Kaminski, M., Pellino, T., & Wish, J. (2002). Play and pets: The physical and emotional impact of child-life and pet therapy on hospitalized children. emotional impact of child-life and pet therapy on hospitalized children. Children’s Children’s Health Care, 31Health Care, 31, 321-335., 321-335.

Nachmanovich, S. (1990). Nachmanovich, S. (1990). Free play: The power of improvisation in life and in the Free play: The power of improvisation in life and in the artsarts. New York: G.P. Putnam. . New York: G.P. Putnam.

Perry, B.D. (1999). Perry, B.D. (1999). Memories of fear: How the brain stores and retrieves Memories of fear: How the brain stores and retrieves physiologic states, feelings, behaviors, and thoughts from traumatic eventsphysiologic states, feelings, behaviors, and thoughts from traumatic events . Child . Child Trauma Academy. Retrieved on 5/12/06 from Trauma Academy. Retrieved on 5/12/06 from http://www.childtrauma.org/ctamaterials/memories.asp.http://www.childtrauma.org/ctamaterials/memories.asp.

Stallibrass, A. (1989). Stallibrass, A. (1989). The self-respecting child: Development through spontaneous The self-respecting child: Development through spontaneous playplay. New York: Addison-Wesley, Inc.. New York: Addison-Wesley, Inc.

Snow, C. W., Triebenbacher, S.L. (1996). Child life program employment trends Snow, C. W., Triebenbacher, S.L. (1996). Child life program employment trends and practices. and practices. Children’s Health Care, 25Children’s Health Care, 25, 211-220., 211-220.

Super Power Tour. Retrieved on 5/10/06 from Super Power Tour. Retrieved on 5/10/06 from http://www.lifeskills4kids.com/hospital_programs.html. http://www.lifeskills4kids.com/hospital_programs.html.

Lila: Play in SanskritLila: Play in Sanskrit

Richer than our term “play”, lila Richer than our term “play”, lila means divine play – the play of means divine play – the play of creation, destruction, and re-creation, destruction, and re-creation, the folding and unfolding of creation, the folding and unfolding of the cosmos; free and deep, it is both the cosmos; free and deep, it is both the delight and enjoyment of this the delight and enjoyment of this moment, and the play of God; it moment, and the play of God; it means love.means love.(Nachmnaovitch, S. {1990}. Free play: The power of (Nachmnaovitch, S. {1990}. Free play: The power of improvisation in life and the arts. New York: G.P. Putnam’s Sons, improvisation in life and the arts. New York: G.P. Putnam’s Sons, p. 1)p. 1)