How to communicate with children,according to Health Play Specialists in the United Kingdom: A qualitative study

Abstract

Child-focused anthropologists have described how sick-children utilise ‘Play’ and ‘imagination’ as a tool to cope and make-meaning of their illness-experiences. Health Play Specialists (HPS) are professional healthcare-workers who advocate for children and use ‘playful’ methods to improve communication with, and the lived-experience of, children in hospital. The research aim of this study was to identify strategies and methods employed by HPS to effectively communicate with children. The research methodology comprises interviews conducted with HPS and utilises a qualitative data-analysis model. The main findings include: the importance of ‘Play’ for chronically ill children; how HPS utilise material-resources to explain illnesses and procedures to children; structural challenges HPS face as a profession; and applicable advice for paediatric-healthcare-workers. This research highlights the importance of introducing a ‘pro-play’ mindset to healthcare-workers, in order to facilitate children’s basic human-rights in hospital. It seeks to advocate for the potential of ‘Play’ and the value of HPS within paediatric-healthcare-settings, as well as the need for further recognition and multidisciplinary research in this area.

Introduction

This research was triggered by one specific patient I, as a medical doctor, cared for: a twelve-year-old male admitted to the Intensive Care Burns Unit with a serious electrical burn, which compromised the integrity of his right-arm and left-leg. Both required amputation in order to preserve life. My shift began when the plastic surgeon took the patient to the operating room. I asked the nurses and family members: ‘Did someone explain to the patient that he is going to have a double-amputation?’ A long and disturbing silence followed. The patient had already been sedated; I asked again, this time directly to the surgeon: ‘Doctor, did you tell the child you were going to amputate two of his limbs?’ He replied: ‘That is not my job, nor my responsibility’. I have wondered ever since: who has the ‘job’ or ‘responsibility’ to explain procedures and chronic-illnesses to children? As a result, I continued my professional journey as a paediatrician searching for answers to what I believe is a significant gap in our overall medical knowledge: ‘How to explain illnesses to children?’.

Chronically ill children are confronted and challenged, on many levels, by illness and hospitalisation. Children in hospital are bound by strict rules; they are not allowed to play or engage in the decision-making process, and are rarely addressed directly by medical-staff. (Bluebond-Langner, 1978; Hubbuck, 2009; McKinty, 2013). Globally, children’s opportunities and overall-participation may differ according to each country, culture and healthcare-system. Furthermore, hospitalised-children can potentially have Paediatric Medical Traumatic Stress (PMTS): a combination of psychological and physiological responses to painful and invasive medical experiences resulting from single or multiple medical-events (NCTSN, 2017). Additionally, children are often subject to stigmatisation which has a profound effect on their psychosocial development and overall clinical evolution (Clark, 2012a; Kohn, 2000).

Children positively modify their behaviour and respond better to medical-treatment when acknowledged, encouraged and empowered to actively participate in their own healthcare, which has the potential to lead toward a ‘healthier’ life (Clark, 2003). Perrin and Garrity (1981), suggest that children who learn, in-detail, about their long-term illnesses and treatment have improved levels of agency, control and coping mechanisms. Coyne and Gallagher (2011) explored hospitalised-children and young-people’s experiences of participation in decision-making processes and communication. Their key finding exposed that some children wanted to be included in decisions that directly affected their lives, whilst others preferred to share the responsibility or avoided participating in ‘serious’ decisions (Coyne and Gallagher, 2011).

Child-focused medical anthropologists have described how sick-children utilise ‘Play’ and ‘imagination’ as a tool to cope and make-meaning of their illness-experiences (Bluebond-Langner, 1978; Clark, 2003; Hunleth, 2019; Rindstedt, 2014). Children construct their illness-narratives through ‘Play’, however, knowledge alone without the provision of play-like activities has little or no impact on how children understand their illness (Bluebond-Langner et al., 1990; Clark, 2003; Hunleth, 2019; Mattingly, 2006). Since abstract biomedical explanations carry ‘too little relevance in the face of children’s direct, lived-experience’ (Clark, 2003: 59), their illness-narrative and meaning-making process focuses on felt symptoms and their everyday experiences (Clark, 1998; Pérez-Duarte, 2020).

The introduction of ‘Play’ into paediatric hospitals challenges our perception of this phenomenon, since ‘Play’ cannot be easily defined or attributed to a specific science (Clark, 2013b). As such, it ‘playfully’ jumps around disciplines and has been explored from multiple perspectives. Scholars have identified ‘Play’ as the means through which children make sense of the world (Clark, 2013b); it enables them to process and comprehend reality through their own language and on their own terms (Margolin, 2020).

The therapeutic benefits of ‘Play’ have been investigated by health professionals worldwide (Chilamakuri et al., 2014; Goymour et al., 2000; Graber et al., 2021; Nabors et al., 2013). Starlight Children’s Foundation conducted a literature review, including 139 studies, on the impact of ‘Play’ within hospital-settings (Gulyurtlu et al., 2020). They conclude that ‘Play’ enables children to have a more positive hospital-experience; reduces anxiety, fear and stress of hospitalisation (Bray et al., 2019; He et al., 2015; Hubbuck, 2009; Moore et al., 2015); can sometimes reduce pain and the need for sedation during medical-procedures (Scott et al., 2016; Törnqvist et al., 2015) and allows children to have a sense of control (Gulyurtlu et al., 2020). Contrarily, da Silva et al. (2017) conducted a systematic review regarding the efficacy of using therapeutic ‘Play’ to treat anxiety in children undergoing invasive procedures. The research concluded that using therapeutic ‘Play’ is still questionable and expressed a need for further studies with greater methodological rigour (da Silva et al., 2017).

Whilst ‘Play’ has been widely recognised as a valuable resource for improving the wellbeing of children with serious illness, implementation in hospital-environments has been challenging. Stenman et al. (2019) analysed the perspectives of thirty-multidisciplinary paediatric-healthcare-professionals from five diverse specialities. Although most participants acknowledged the benefits of ‘Play’, they highlighted their lack of training regarding ‘Specialised Play’ and the scarcity of time available to apply it (Stenman et al., 2019). Hence the need for specialised professionals in this area, a role whose effectiveness has been supported by extensive literature in the USA, where they are known as Certified Child-Life Specialists (CCLS) (Burns-Nader and Hernandez-Reif, 2016; Romito et al., 2021).

Within the United Kingdom, Health Play Specialists (HPS) are professional healthcare-workers who advocate for children and apply ‘Specialised Play’ to improve communication with, and the lived-experience of, children in hospital (Carter, 2019). Fundamentally, HPS aim to (1) normalise ‘Play’; (2) provide emotional support; and (3) impart information (Hubbuck, 2009). During the early 1990s, the ‘Department of Health’ recommended ‘Play’ be provided to all children within hospital-settings to promote emotional wellbeing and, therefore, recognised HPS as official members of ‘Health Service Staff’ (Baines, 2012). Gradually, this profession has garnered greater recognition and become more readily acknowledged within the wider healthcare-community, primarily due to the immense value they bring into paediatric-healthcare-settings (Baines, 2012; Carter, 2019; Gulyurtlu et al., 2020; Przybylska et al., 2019; Williams et al., 2019).

‘Play’ and ‘Clowning’, within hospital-settings, was identified as a phenomenon able to minimise gaps between age-groups, cultures and hospital-hierarchies (Adams, 2002; Clark, 2013a; McKinty, 2013; Zhang et al., 2017). During Hospital Specialised Play Interventions (HSPI), HPS intervene by kneeling or getting physically down to the child’s eye-level and facilitate the introduction of ‘Play’ to collapse hierarchies, fears and misunderstandings, which will then have a positive impact on self-image and improve their ability to adjust (Bluebond-Langner, 1978; Hubbuck, 2009). During an interview, Clark (2012b) stated that implementing ‘Play’ ‘requires time and a kind of mindset that is pro-play’. When children are afforded time and space ‘play will emerge naturally’. By stepping-back and witnessing their playtime, we may see them become their own-self. Nevertheless, within a strict biomedical environment, controlled by adults, playtime is noticeably limited. As such, it is vital to surround chronically ill children with professionals who have this ‘pro-play mindset’ (Clark, 2012b).

Global research resulted in World Health Organisation (WHO) publishing ‘Child and Adolescent Health Strategy for Europe 2015-2020’, which advocates for children to actively participate in their own healthcare decisions and that doctors and nurses implement ‘Play’ and ‘Learning’ in hospital-settings to fulfil children’s basic needs (WHO Europe, 2017), thereby attempting to standardise paediatric-healthcare through a human-rights based approach. The American Academy of Paediatrics (AAP) has aligned their Child-Life Policy Statement to match the WHO agenda, regarding the importance of the therapeutic value of ‘Play’ (Romito et al., 2021). Additionally, Gjærde et al. (2021) provided a novel comprehensive overview of 297 original articles relating to ‘Play Interventions for paediatric-patients in hospital’ and concluded that ‘additional high-quality research is needed to guide when, where, and what play to integrate into hospitals’ (Gjærde et al., 2021: 9). Therefore, this research supports their call for professional and academic research regarding ‘play in hospital’.

Aim

To produce qualitative evidence to support the use of ‘Play’ by HPS within healthcare-settings. As such, this research has the following objectives: (1) use a qualitative approach to gather methods and strategies of HPS, specifically relating to how they effectively communicate with children and make-meaning of their illness-experiences; (2) raise awareness of the benefits of ‘Play’ and highlight the value of HPS and (3) respond to the identified gap in medical training and provide child-healthcare-workers with tools to provide child-friendly paediatric care, especially in situations where HPS are unavailable.

Methods

Recruitment and inclusion criteria

Research methodology comprises interviews conducted with HPS and utilises a qualitative data-analysis model. The adopted sampling method was ‘chain referral’, employing both of its variants. Initially, ‘respondent-driven’ sampling was utilised; contacting potential participants via email and direct messaging UK-based HPS on official webpages or through social-media (Facebook®). Following the completion of the first interviews, the ‘snow-ball’ technique became more prevalent (Bernard, 2011). Healthcare Play Specialists Education Trust (HPSET) staff-members sent an invitation to all registered HPS through their official website.

In terms of inclusion and exclusion criteria, participants were required to be certified and registered HPS, actively working in either hospital or community settings. Level of experience or being certified outside the UK did not exclude certain participants, as long as they were currently employed within the UK healthcare-system. Participants who failed to meet the criteria were excluded from this research.

Data collection and positionality

Semi-structured interviews were employed to direct the information gathered toward the main research question, allowing interviewees to talk freely and at length. The interview design was based on years of professional paediatric experience and thoroughly supported by available academic literature. The interview guide was flexibly used, adapting to each participant’s response and areas of expertise, which resulted in an organic ‘progressive focus’ (Sinkovics and Alfoldi, 2012). Example questions included (1) ‘In your role as a HPS, what methods do you employ to explain chronic-illnesses to children?’; (2) Physicians may not consider utilising ‘Play’, whilst providing explanations to sick-children. What advice or strategies would you recommend to general-practitioners, or paediatricians, that could be incorporated into their daily clinical practice? Data collection was conducted via phone-call or video-conference. They were recorded in three different ways, in order to guarantee accuracy: (1) manually jotting-down notes, ideas and observations during interviews; (2) writing-down further notes immediately following interview, aiming to describe general ideas behind answers received and (3) manually transcribing recorded audios to conduct an accurate, in-depth analysis. Data were collected by the author between 15^th June and 28^th July 2020.

My background as a paediatrician impacted this research in interesting ways. All participants expressed excitement at having a doctor listen to them; made comments in relation to having their role highlighted by someone outside their profession; and were enthused by the prospect of raising awareness of its benefits for paediatric-healthcare. This general enthusiasm was channelled in two ways: (1) to inspire them to encourage other HPS to participate; and (2) to encourage them to actively share their knowledge, experience, advice, as well as send materials to broaden our understanding of their profession and illustrate their work.

Ethical considerations

All participants were clearly informed regarding ethical considerations and data-protection measures. Prior to each interview, participants received an information sheet and informed consent form. Aligned with the Association of Social Anthropologists recommendations, confidentiality was respected and data constantly anonymised and pseudonymised. Data storage was securely encrypted and is being carefully managed, in accordance with the Data-Protection-Act (GOV.UK, 2018). Ethical approval for this research was granted by the Anthropology Departmental Ethics Committee, University College London (Number associated: PEREZ/MED/2020/04/01).

Data analysis

Data analysis and coding participant’s responses was conducted following the Standards for Reporting Qualitative Research (SRQR) guidelines. In reading and analysing manual notes, recurring topics were identified across all participants. A list of the most notable codes was created, which included HPS profile, use of concrete materials, recommended advice for child-healthcare-professionals, amongst others. All transcripts were entered into ‘NVivo’ software (‘NVivio for MAC’ version 12, developed by QSR International), which procured an in-depth analysis and coding of all data collected. During this process, a log containing new thoughts and ideas was completed. It was continually updated, aiming to keep a record of the evolution of initial ideas, which were later either confirmed, modified or discarded. To verify these findings, such data was discussed in-depth with the remaining six-participants, with the aim of searching for accurate explanations behind initial findings or additional information, until the point of data saturation was reached (Patton, 2014).

Research participants

The National Association of Health Play Specialists currently has 650 registered members in the UK, from whom twelve (n = 12) were interviewed. Most of the research-participants possessed backgrounds in a variety of child-related professions. The training required to become an HPS has been dramatically modified during the last two-decades, evolving to a 2-year foundation degree accredited by HPSET (HPSET, 2020). Most participants (11) worked in hospital-settings, whilst one (1) worked in the community. Eight (8) possessed 10 years’ experience or more, with the maximum being 25. The other four participants have been working as HPS for two-to-six years. Participants were spread across the UK: England (8), Wales (1), Scotland (2) and Northern Ireland (1).

Findings

The main findings include (1) The importance of ‘Play’ for chronically ill children; (2) How HPS utilise material-resources to explain illnesses and procedures to children; (3) Structural challenges HPS face as a profession and (4) Applicable advice for paediatric-healthcare-workers.

(1) The importance of ‘Play’ for chronically ill children:

With the aim of understanding and highlighting the importance of ‘Play’, the following categories were identified: Definitions of ‘Play’, Benefits of ‘Play’, Normalising ‘Play’ and Developmental ‘Play’.

It is challenging to encapsulate the innumerable components of ‘Play’ into one worldly definition (Karpatschof, 2013; Malaby, 2009). Regardless of age, neurodevelopment, emotional status, verbal or non-verbal communication capacity or physical limitation, ‘Play’ is the time and space for little, and not so little, young-people to simply exist, or can be referred to as ‘a child’s universal language’ (Jennifer/04:13).

The participants routinely outlined the comprehensive benefits of ‘Play.’ Some examples include:

“Play gives a language and a shared experience that then can open-up into much more depth, exploring, understanding, asking questions, expressful things, it’s so rich” (Miranda/16:10).

It can also provide children with opportunities to take an active role in their own healthcare. One of the participants confidently summarised the powerfulness of ‘Play’:

“…empowerment is definitely the thing that's always in the forefront of my mind” (Marian/14:19).

The presence of a lifelong affliction introduces multiple changes in the family dynamic where the sense of ‘normality’ is hard to achieve:

“… helps with a feeling of normality. It's something that children do, if you keep encouraging that, even when a child has chronic-illness, it's kind of normalising their lives a bit” (Christopher/03:22)

Normalising ‘Play’ allows them to understand they ‘are still a child, (who) actually still has other stuff going-on’ (Valerie/03:35), thus, their identity will not be defined by their illness.

Normalisation improves rapport and communication between adults and paediatric-patients, allowing sick-children to know ‘you will be honest with them’ (Carrie/29:15), strengthening trust with hospital-staff. Childhood development can be impaired by repetitive hospital visits or long-term admissions, where access to nurseries and school are constantly interrupted. HPS provide ‘Developmental Play’ to mitigate this. Methods include:

“…sensory play, tactile play… placing objects on their skin… messy play, arts and crafts, board-games” (Clara/09:04).

Some new-borns, infants and toddlers spend months or even years in hospital, which can hamper their development:

“… think about the amount of development that goes on with a very small baby. Just walking-down the street … you've got wind … sound … other people … conversation … a lot of facial expressions … A lot of that is taken-away when they’re stuck in hospital, so we find a different way of doing things … we’re looking at maintaining or building development as well” (Clara/10:20).

• (2) Material resources to explain illnesses and procedures to children:

During interviews, HPS-participants drew my attention to the lack of material-resources in hospitals to effectively communicate with children. They shared examples of how they operate, achieving as much as possible, with limited supplies or their own materials. Tangible objects were employed by HPS as teaching tools, emotional support mechanisms and vehicles to enable communication with children (see Table 1 supplementary material).

One of the participants clearly summarised their benefit:

“…you need to have fun, so if you can find some sort of physical activity that helps to explain what’s going on, then the children will understand that more” (Clara/26:36).

Another participant shared a powerful example of how a simple teddy-bear improved the hospital-experience of all stakeholders. A three-year-old oncology patient, under general anaesthesia, required a Central-Venous-Catheter (line) placement, however, prior to the foreign and invasive procedure:

“…nobody spoke to him about it… he had the line put-in and then when he woke up, the line was just on his body” (Marian/5:01).

The patient was terrified of anybody looking at or touching it. This included medical-staff, who were confronted by screaming when they needed to access his line to provide medical-treatment. As a result, nursing-staff called-upon the ‘Play Team’ to intervene. Having built rapport and gained the patient’s trust, the HPS then used a teddy-bear as a pretend-patient. With the assistance of the patient, the HPS placed a similar line into the teddy-bear. This HSPI uncovered the child’s fear of someone pulling-out his own line. Gradually, the patient learned how to clean the line and normalised its presence by:

“…becoming more comfortable with it being on his body… So actually, it ended-up being very powerful, his parents were very grateful because… it did become quite traumatic, whenever his line needed to be accessed” (Marian/06:13).

• (3) Structural challenges HPS face as a profession:

Interviews with HPS identified various structural challenges that impede their ability to function, as well as effectively communicate with children, in hospital-settings. These include timing of intervention, medical knowledge, parental consent and hospital-hierarchies.

Health Play Specialists-participants reported that healthcare-professionals usually summon the ‘Play Team’ when a patient is kicking, screaming and/or resisting, during a medical-procedure:

“We are often used only at the point that the child is facing a procedure and probably had become distressed, resistant or anxious… the best practice would actually be to involve Play Specialists right from the very start” (Miranda/34:18).

Health Play Specialists are often dependent on doctors and nurses, when available, to provide medical explanations, or must research, in their spare-time, specific and technical aspects of a particular condition:

“…if we had more of a sort of medical knowledge, instead of having to just wing it and find out your own information. I think… it would make a huge difference” (Samantha/17:19)

Parental consent is another structural challenge faced by HPS when trying to explain chronic-illness and lived-experiences to children. Parents are bound by their own beliefs, emotions and fears, thus don’t want their children to know what is truly happening:

“…a lot of parents are so frightened themselves they don't want to have their child told anything. So, I would always… advocate, that it's better the child is told something, rather than telling them nothing” (Miranda/44:58).

Health Play Specialists are constantly having to establish and justify their own position within the strict hierarchical-structure of the hospital-environment and healthcare-system. During the COVID-19 pandemic, it was debated whether HPS were, indeed, ‘essential-workers’ or not.

“… people aren’t aware of the play specialists’ role” (Emma/19:17).

• (4) Applicable advice for paediatric-healthcare-workers:

To challenge hospital-hierarchy, improve patient outcomes and provide professional development for healthcare-professionals with limited access to ‘Play Teams’, interviewed-HPS provided advice and recommendations.

A key piece of advice related to breaking-down the subliminal hierarchy between adults, more specifically healthcare-professionals, and children. HPS were adamant about getting physically down to the child’s level to build rapport and reduce vulnerability:

“…is the clinician sitting on their level? Are they sitting on a little chair? Are they sitting on the floor? … how far down will you go?”(Emma/15:22).

‘Information dosage’ and the ‘type of language’ used are important considerations when providing explanations.

“…explaining the illness at the start is too much, I’ve learned that quite a long time ago. I think you just have to do it, a very slow process, and some children straight away will say: ‘Well, what is a brain tumour?’ or ‘What does cancer mean?’, and that’s okay” (Marian/18:51).“… if you’re going to focus on anything, it would just be ‘use developmentally appropriate language’” (Jennifer/19:55).

Health Play Specialists highlight the importance of having a preparation session with the child and their family, which provides a time for communication and asking questions:

“…let’s think of a list of presents that we really want at Christmas and let’s think of a list of questions that we might ask the nurse or doctor” (Emma/11:56).

Children tend to be rarely addressed directly by medical-staff (Hubbuck, 2009), and this was confirmed by a selection of research-participants:

“… everyone is talking to my Mum and Dad, but they’re not talking to me” (Carrie/14:12).

Empowering children, giving them a voice and involving their families were readily discussed by HPS-participants:

“The last session of the preparation (before surgery), the young-person or child is delivering the session to their family… in that way I can then correct any misunderstandings or gaps … (this) offers them control and ownership over the procedure and that develops their confidence and resilience” (Clara/18:56).

The one key piece of advice or recommendation that emerged the most throughout the interviews was establishing rapport and connecting to the way children experience:

“…OBSERVE… if they’re wearing a Spider-Man t-shirt for example, that’s a good opener, isn’t? Because you can say: ‘Hi, how are you? Oh Wow! You like Spider-man?‘… and already you’ve connected with that child, …that’s a really good way of kind of breaking-the-ice and building that rapport in a playful way” (Nora/20:21)

“Actually, sometimes you have to take five-minutes of not talking, and just playing, finding-out about the child: How are they today? What do they like doing? … What did they bring with them on the bus? Just a general talk” (Miranda/42:22).

Despite this, the same participant pointed-out one of the major obstacles in achieving this:

“Nobody has five spare minutes in health, ever!” (Miranda/43:05).

Discussion

This research aimed to respond to an ongoing call for greater research surrounding the use of ‘Play’ in healthcare-settings (Gjærde et al., 2021; Gulyurtlu et al., 2020; da Silva et al., 2017; WHO Europe, 2017) by interviewing HPS to utilise their expertise in this area and apply their methods and strategies into clinical practice. The findings of which seek to contribute to the significant need for evidentiary proof of the efficacy of ‘Play’ in improving child health outcomes, as well as advocate for ‘Play’ and the profession of HPS, which is often overlooked or undervalued within the hospital-hierarchy and healthcare-system (Hubbuck, 2009; Perasso et al., 2021). These findings have significant implications for practice within the healthcare-industry. The invaluable experience, as well as the tailored advice and recommendations, of HPS, have the potential to influence current and future generations of healthcare-professionals. Implementing these strategies into medical training and daily practice can have a considerable impact on health outcomes and healthcare.

The findings did not yield the anticipated outcome in relation to the main research question. When asked about ‘explaining chronic illnesses’ to children, HPS often shared examples related to explanations of medical-procedures associated with these illnesses. When pushed further, HPS repeatedly established that their priority, as professionals, is to help children understand their ‘everyday’ experience with their disease. General knowledge about their condition will gradually build-up over time; guided individually and ‘step-by-step’. Explaining the finer biomedical details of, for example, diabetes is not as important as the ‘lived experience’, such as needles and dietary restrictions (Clark 1998, 2003).

Whilst detailed biomedical explanations were not deemed entirely necessary or developmentally appropriate, one should also consider other contributing factors. Structural challenges such as the positionality of HPS within the healthcare-system mean that they are often called in too late which may diminish their ability to gradually, through sustained sessions, provide more information and detailed explanations to children regarding their conditions (Hubbuck, 2009).

Whilst detailed and biomedically accurate explanations may not be a priority for HPS, their shared strategies and methods have the potential to enable such explanations to be provided. The approaches they employ to explain procedures and prepare children for the lived-experiences of their conditions are valuable tools for all child-healthcare-professionals. These findings resonate with services provided by CCLS, which are primarily aimed to minimise the anxiety associated with medical attention (Burns-Nader and Hernandez-Reif, 2016; Romito et al., 2021; Scott et al., 2016).

The interviewed-HPS echo the research, objectives and sentiments of WHO, Starlight Children’s Foundation and AAP. HPS confirm, in this research, the benefits and overall importance of ‘Play’ for chronically ill children, ranging from therapeutic, empowerment, normalisation and alleviating developmental concerns (Gulyurtlu et al., 2020; Romito et al., 2021). HPS utilise material-resources, such as teddy-bears, Play-Doh® and Lego®, to provide explanations to children; enable avenues for communication, teaching and emotional support (Bagge-Petersen et al., 2020; Rindstedt, 2014); promote understanding, engagement and fun; and combat stigmatisation, anxiety and fear (Bray et al., 2019; He et al., 2015; Moore et al., 2015). Whilst this research study aims to contribute to the evidence needed to highlight the value of ‘Play’ and use of material-resources, it supports the recognised conclusion that further research is required.

Implications for practice

Despite these findings, not every child diagnosed with a chronic-illness will have the ‘time and space’ they deserve, or access to the ‘imaginative’, ‘playful’ and ‘valuable’ service provided by HPS, nor the material-resources they utilise to effectively communicate and engage with children. This could be linked to the (1) limited quantity of job-placements for HPS within the UK National Health Service; (2) lack of awareness of the value and benefits this role brings to child-healthcare-settings and (3) scarce funds allocated yearly to their professional development. In other countries and diverse healthcare-scenarios, children have no access to anything resembling a ‘Play Team’.

As a result, the following section outlines a series of recommendations or applicable advice regarding the methods and strategies employed by HPS. This advice, which responds to the main aims of this research, has the potential to be beneficial for nurses, doctors, medical students, psychologists, hospital clowns, family members or any other healthcare-provider that interacts with children, and may inspire them to modify their behaviour and increase their communication-skills with chronically ill children.

The first series of recommendations allow us to learn how HPS creatively employ ‘Play’ as the main source to build rapport, communicate with children and invite participation in conversations: (1) Build rapport with children: it is essential to get physically down to their level, make eye-contact and carefully observe what they are holding or wearing so it can be used as an ‘ice-breaker’ to spark conversation and gain trust; (2) Observe/listen to children’s questions and opinions: advise patients, and their families, to write-down questions before the next appointment or hospital-round. Allow children, if possible, to ask these questions; (3) Clarify misunderstandings: tailor explanations to children; utilise drawings, dolls or simple props. Once the child has received age-appropriate information, further conversations with parents could be conducted, in order to fill-in gaps; (4) Use developmentally appropriate language and doses of information: ask them ‘what they want to know’ and respond according to their neurodevelopment, providing ‘bite-size’ information and (5) Be continuously honest: facilitate orientation with parents, and all members of the family-unit, to promote honest communication.

The next series of recommendations specifically target interactions with two particular groups: (1) Patients with special needs: employ alternative methods to communicate with non-verbal patients. Invite brothers and sisters to participate in conversations, as they live in a family-unit where their sibling requires intensive and continuous care; and (2) Teenagers: it is important to empower teenagers to take control of their condition, giving them greater autonomy over treatment, keeping track of appointments, as it is important for them to acquire a sense of independence.

The third series of recommendations relate to clinical practice and training: (1) Involve all members of the team: an inclusive, team-based approach to the care of chronically ill children will improve results; leave behind hierarchical-structure and focus on helping each other; (2) Medical training: Permit a ‘kind of mindset that is pro-play’ within the biomedical world and incorporate this approach into medical/healthcare training of young professionals.

The final piece of advice would be: Do not underestimate or overlook children’s opinion:

“… children know themselves better than we give them credit for” (Marian/25:39).

Study limitations

Despite the positive response and active participation of HPS, this research has its own limitations. Due to time-constraints and COVID-19 restrictions, data was collected via phone-call or video-conference, impeding the researcher’s ability to observe HSPI. This study captures the perspectives of HPS, but it would be beneficial if further research included other methodologies, such as participant-observation, and capturing children’s perspectives regarding HSPI. Additionally, it could potentially increase its value if a larger sample of HPS were recruited.

This research did not include any HPS working outside the UK, reducing its capacity to portrait a wider perspective and/or cross-cultural comparisons. These research findings would be enriched if additional interviews were conducted with specialists working in other countries, where these play-workers are also known as: Child-Life Therapists/Specialists. Nevertheless, as a Medical Anthropology academic research project, it was intentionally limited to UK-HPS to avoid clashing into cultural variations. Further research, comparing similar professionals globally, might bring valuable finding that could potentially adapt to cultural variabilities regarding ‘Play in Hospital’.

Conclusion

This research presents professional examples of strategies and methods employed by HPS to effectively communicate with hospitalised-children and make-meaning of their illness-experiences. Whilst Health Play Specialists do not prioritise providing biomedical explanations to chronically ill children, their strategies, methods and pro-play mindset contain a high-degree of implication for current and future medical practice, thereby aiming to fill the identified gap in medical training. This research advocates for the use of ‘Play’, the value of HPS within the healthcare-system, and the crucial need to empower and listen to children. In addition, I invite paediatric-healthcare-workers to fight to find ‘five spare minutes’ in their overcomplicated shift and apply, into their clinical practice, the strategies and methods we can and need to learn from Health Play Specialists.

Supplemental Material

Supplemental Material – How to communicate with children, according to Health Play Specialists in the United Kingdom: A qualitative study

Supplemental Material for How to communicate with children, according to Health Play Specialists in the United Kingdom: A qualitative study by Paulina Pérez-Duarte Mendiola in Journal of Child Health Care