CHILDS PLAY IN ACCIDENT AND EMERGENCY
In a document from the Royal College of Paediatrics and Child Health, it was estimated that 3.5 million children attend Accident and Emergency departments in the UK, every year. The Royal London Hospital developed a separate Paediatric Accident and Emergency department in 1998, and is seeing approximately 28.000 children per year.
The department employs a full time Hospital Play Specialist (HPS), one of the very few nation-wide. The HPS has a very unique role,
working in conjunction with the Nursing and Medical team.
She uses play to help the child and family whilst in the A&E department, making the child's visit less traumatic, and
therefore a more positive experience.
As you enter the Royal London Hospital Paediatric A&E department, through a set of double doors, you come directly to a
child-sized counter and assessment area. A Paediatric Nurse who assesses the child’s injury or illness greets children there.
This is where the HPS often meets the child and family for the first time. During the nursing assessment, the child may
experience a series of nursing procedures, for example he/she may have their temperature, oxygen levels,
or blood pressure taken. Medication may be given for pain relief. Distraction
therapy is often needed during these procedures, especially for younger
children, as their level of understanding is limited, and they can be fearful of these unfamiliar investigations.
The most popular item used for distraction, for the young age group, are bubbles. They have an amazing effect, turning tears to smiles. Bubbles are also a useful assessment tool, e.g. if medical staff are querying an arm injury, a child will only use the healthy arm to catch the bubbles, leaving the affected arm lying limp.
This is only one of the ways the HPS uses different toys to obtain play -based observations of the child to aid clinical judgements.
The HPS assesses each individual child's age, level of understanding, and likes and dislikes.
He/she then provides appropriate toys accordingly. Coping techniques are then
devised and discussed with the aim of distracting the child during hospital procedures, as these procedures can often be painful. Although distraction does not take the pain away, it serves to make it more bearable.
For the children and families, coming into the A&E department can, generally
be a frightening experience. A range of feelings have been documented. These
include anxiety, guilt, anger, fear, pain, and shock. Many children interpret
their admission as a punishment. Hence they respond poorly to the loss of
control and privacy that often accompanies a visit to A&E.
Take a second to think of the child who has had an accident in the school playground. Think of the parent called at home or work. We can all imagine how the child and parent may be feeling. Play provides safe outlets for the expression of these emotions. The HPS uses observations during play sessions to provide support for the family during their stay.
Case History
A female child, aged two, came to the department with a burn caused by boiling hot
water to her shoulder. Her skin was very red and had several large blisters. The child was assessed by the nursing and medical team, given pain relief,
and then taken to a cubicle. The cubicle provides a private area for the child/parent to play and relax while waiting for the pain relief to work.
Armed with lots of noisy toys and a pot of bubbles, the HPS went to see the child. Sitting on the floor, at the child's level, blowing bubbles,
the HPS started to get to know the child and mother. The child's mother felt very guilty and found it useful to talk to the HPS during the play session. As the three of them established a good relationship, the HPS learned a lot about the child's likes and
dislikes; information which would be needed during the cleaning and dressing of the child's burn.
When the time came for the dressing of the child's burn, she sat on her mother's lap for comfort and support. The HPS used toys to distract the child, and encouraged the mother to be a part of the child's treatment. The procedure is painful and uncomfortable. The child, on occasion, protested by crying; half
with discomfort, and half with frustration at being held still for too long. But the
dressing was completed without any delays, and a calm atmosphere was maintained throughout.
Case History 2
A male child aged nine years came to the department with a displacement fracture, needing surgery. He had
had an accident in the school playground.
The nursing staff informed the HPS that the child needed preparation for surgery. His father describe his son as a sensitive child and said that a previous hospital experience had been very
difficult. The father was unsure whether to tell his child about going to surgery. The HPS discussed
his concerns with him, and explained what would be said and how. His father gave permission, and the HPS went to see the child, who was sitting in the cubicle quietly with his mother and sister. Using play and real hospital kit, the HPS explained
the surgery procedure.
After concerns and questions were answered, the child asked the HPS to go with him to theatre. His father
also accompanied him to the anaesthetic room. The HPS talked and joked, distracting the child
whilst he was anaesthetised. The child felt nothing and, within seconds, was asleep.
The next day, the Play Specialist saw the child and family on the ward. The child, with his arm in a sling,
had just watched a magic show. His father was pleased that this admission had been
less distressing.
Children need preparation geared to their individual needs for all procedures. Research has shown that children are less frightened and more co-operative if they are informed, in an age appropriate way and able to communicate their concerns with someone who can acknowledge them and help them overcome problems. Preparation helps the child to be less traumatised by their visit and more willing to return to hospital in the future.
Distraction is one of the most important roles of the HPS in the A&E department, and it can change the experience into a positive one. The HPS also has a role in teaching other medical and nursing staff to use distraction.
Tracey Roe, Senior Play Specialist, Paediatric A&E Department, The Royal London Hospital
June 2000
READING LIST
Welfare of children and young people in Hospital - Department of Health
HMSO 1991.
Emergency Health services for Children and Young People - ASC 1998.
Accident & Emergency services for Children - Royal College for Paediatrics and Child Health 1999.