Ludicology

Play in Hospital: a Right and a Necessity

Tuesday March 2, 2021

In this post, Laura Walsh, Head of Play Services at Great Ormond Street Hospital for Children, provides a sensitive, often beautiful and thought-provoking account of play in hospital. Adopting the principle of play sufficiency requires adults to think about the various ways their actions influence children's access to opportunities to play and to develop their individual and collective response to children's right to play, protecting and improving opportunities for play wherever children are.

What or why is play in hospital

Often people react with surprise when they hear about play in hospital because they’ve never thought about it existing. I am told I must have the best job in the world to be paid to play all day. Whilst I don’t get paid to play all day, it really is a pretty amazing job, we’re privileged to be alongside children, and their families during some of the most unusual times in their lives. When the ordinary is disturbed there’s suddenly an open potential for the extraordinary to emerge and in this case, ordinary is whatever life looked like before hospital. The familiar and secure environment of home, family and playing is ordinary and through the ordinariness of play extraordinary coping can emerge.

We might be there to arrange a loved game while they have to be in for tests and go home the next day, making their brother furiously jealous that he didn’t get to be admitted to hospital (that is a real and true story). Or when a child’s condition worsens and they are receiving palliative care, play can be about a good quality of life, ways to express feelings, and meaningful memories, better enabling those involved to make sense of what’s happening. And everything in-between, every moment is a privilege.

  • Play in hospital supports children to access their right to play, through advocating for it, and removing obstructions to playing, and sourcing what is necessary.
  • Play in hospital helps children navigate productive ways to cope with change, anxiety, loss and spaces to express what previously was formless.
  • Play in hospital supports regulation of feelings as we can help to interpret complex information into morsels that are as digestible as possible.

Play can seem like a luxury when children are ill. Surely medicines, operations, school, recovery are all more important or most important. But when understood in the context of play as one of the most fundamental elements in a child’s life, linked to optimal development and human flourishing – it immediately seems obvious why it’s there and how important it is. And anyway, is the question of what’s top in a hierarchy of importance the right one to be asking?

Certainly, transplant consultants planning for potential heart, kidney or lung transplants know that with play to support their first meetings, the process of understanding and accepting what’s happening is eased. They know that anxiety is lessened and acceptance and compliance with treatment is better. Children who have procedures like injections or blood taken will cope better if they’re supported in a way that suits them and can take some control and be listened to.

Since the 1950’s it has been understood that if children have to come to hospital, they have a right to access a) their main carers and b) ‘play opportunities as they would at home’. Importantly this is written into care standards meaning that those planning services must consider this and address it if they are to be rated as a good service. It is true to say that services value what is measured, that play opportunities are an explicit requirement written into standards makes them one of the good things that can’t be cut when budgets are tight.

Example:

Denver, (not her real name) is admitted to Great Ormond Street Hospital and is isolated because she is infectious, and alone because Mum and Dad both have COVID so can’t be with her. She has to have invasive procedures and everyone is wearing bundles of PPE. Her Play Specialist takes time to connect, is sensitive enough to ‘get her’, they explore the things Denver loves and before she knows it, they’re having a lot of laughs. Denver is so delighted, feels so secure and happy that over a Zoom call to Mum says – “don’t worry mummy I’m having a brilliant time here”. That’s play in hospital. The experience of being supported to be in the flow state of play in that strange environment was stronger than the discomfort of being in a strange place alone.

WHO are the Play Team?

Great Ormond Street Hospital Play Team have over 40 posts with both Playworker and Play Specialist roles as well as supporting roles: Head of Service, Deputy Head of Service, Lead for Courses and our administrator. Playworkers in hospital have the same primary purpose as all playworkers – creating conditions for play and supporting children to extend their play, keeping an awareness of the children’s cues and subtle prompts.

Playworkers tune in to children helping them to remember what they like doing and helping them to do it. Having fun is not only allowed when you’re poorly but more important than ever. The role of the playworker is to understand what might restrict play and try to gently work to remove those barriers or work around them. A playworker understands developmental theories and with those and the Playwork Principles underpinning their practice, they facilitate opportunities for play. Always in response to younger and older children’s wants and needs in the knowledge that more play is likely to happen as a result. Playworkers trust children to be experts in their own play and are happy to let children and teenagers take the lead. Equally, that can mean listening to children when they say they need some inspiration and for the playworker to take a lead when energy levels are low, or a child’s Illness is a barrier to their play.

Play specialists can be understood as playworkers with an additional qualification that is both theoretical and applied – experiential practice-based learning. This gives them experience of being with ill children in a slightly different capacity. They have this playful foundation and also an understanding of ways of coping with illness and treatments and assimilating information about both. They walk alongside the child or young person and their families. Sometimes they are the most consistent person throughout and a vital part of treatment plans. They act as an advocate, ambassador, friend and ally.

Adapting for play

There are a variety of restrictions to play in hospital. Risks that are acceptable in other settings have more serious consequences in a hospital. Understanding those risks well means we can do the important work of pushing against those boundaries wherever we can, disrupting the order as much as we bring order to the disruption. Children’s conditions can be restricting. We can be required to use other forms of communication, like Makaton for example, to really hear what someone wants if they can’t use words that we can hear with our ears.

The restriction which has dominated the last year is infection risk. With no possibility of children playing physically together, more bedside play is happening than ever. This can feel like you’re ‘a delivery service’, as one of the play team put it the other day. Work can be more tiring as you’re expressing so much through your eyes. Add into the mix the visor and plastic apron and it can be like you’re in a steamer all day. We’re used to wearing PPE when seeing children with infections, but we’ve adjusted so that masks are for all situations within the hospital and from that base precaution we increase protection for ourselves and for the children, young people and their families.

We mourn the loss of playrooms. They have had to close to free play as we can’t encourage mixing of families, and so can’t have social areas where that can happen. Also, some play spaces became testing rooms and are shared with staff to take tea breaks in to avoid staff infecting each other with COVID if they are asymptomatic. This happened many times, and in May 2020 a large outbreak resulted in a death within the Nursing team. Such a sad and scary time. So, my usual instinct to push back against the encroaching of other agendas on play space is dampened. I have no argument against the temporary use of the playroom for breaks for staff when an outbreak of COVID can wipe out a whole team if one asymptomatic person has been eating in the break room with another six people.

It has been incredibly hard over the last year to witness children separated from their important people due to restrictions on visitors, and parent’s illnesses. Brothers, sisters, uncles, aunts, friends all kept out and only one consistent adult allowed to be with them in hospital. Fortunately for our patients, play provision at our children’s hospital has been constantly seen as an essential service meaning we have been able to continue to provide play support to children and in the hospital. This was a year in which many paediatric centres were converted to adult-only care or increased intensive care provision, and lots of play specialist teams weren’t able to operate. Every moment is a privilege.

Play Sufficiency

A hospital environment filled with highly qualified expert adults affords tensions between the paradigms of pathology and experience. It is easy to see how a setting like this might misunderstand or undervalue a play service, reducing the service to bringers of iPads (I have nothing against iPads by the way) or finders of remote controls, blowers of bubbles etc. Having a clear vision is helpful, our vision is one in which children’s right to play is advocated for and supported at every level. Also, the commitment to adapting information to afford understanding of treatments, and emotional processing at every level of the organisation. We advocate for play as a dominant narrative throughout paediatric care.

Using the Play Sufficiency framework as a lens we can see that the team approach this using both direct and indirect methods.

Direct

  • Normalising playing and ensuring it is part of people’s everyday routines
  • Being a consistent presence, a friendly face, on the wards and around the hospital
  • Helping people to become familiar with play by facilitating events celebrating play
  • Talking to adults about the importance of play and encouraging them to re-think any fears or concern they may have for or about children
  • Identifying and providing additional support to individual children who are experiencing extraordinary barriers to accessing their right to play (such as very limited communication or movement or infectious status)
  • Advocating for children’s right to play at a local (ward) level
  • Arranging with our sustainability partners a Play Street on the street. This was amazing and will happen again after COVID is no longer the Boss Of Us! https://vimeo.com/348195177

Indirect

  • Improving policies and procedures so that they support rather than constrain play
  • Influencing the development planning of new services and spaces to ensure a focus on play as the dominant narrative
  • Securing funding, evidencing the impact of play interventions against other funding outcomes
  • Identifying and building relationships with influential people (infection control and built environment or senior leadership), encouraging them to take action in support of play
  • Providing professional development opportunities to improve adult responses and support for play (for example we have been developing learning modules for clinical and non-clinical staff)
  • Advocating for children’s right to play at a strategic level within the hospital and externally
  • Periodic review of service spread to identify and address any groups who may be missing out

A large part of my job is creating the conditions in which play can be a dominant narrative within the Trust – something that is accepted as a given for children of any age. That requires adults to believe in the power of play, and accept that it is accessible, desirable, realistic, and a shared responsibility. The play team accept the heaviness of the themes they work with and still access the lightness of play that is only possible when we’re open to trying and failing and willing to navigate the edge of chaos. We know what we do works, and so do the children.  Our focus for the next three years is to establish an evidence base through research so that this amazing work becomes ever more sustainable, respected and understood.

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