Barriers and Facilitators Related to Play Among Children in the Hospital Setting of a Tertiary Care Centre, North India

https://doi.org/10.33698/NRF0292-Vartika Singh, Geetanjli Kalyan, Sushma Kumari Saini, Bhavneet Bharti, Prahbhjot Malhi

ABSTRACT:

Introduction: Play is a vital component of child’s physical, emotional, social and mental health. All children have right to be included in recreational activities including play. It is the responsibility of the nurses and the physicians to ensure that the child right to care is protected. It includes the child’s need to grow, play and learn during their hospitalization. Objective– 1) To identify the barriers and facilitators related to play among children in the hospital setting of a Tertiary Care Centre, North India. 2) To seek the remedial measures suggested by health care personnel to increase opportunities of play. Methodology: After obtaining consent from in charge of the units included in study, overt participatory observations were made and focused group discussion were conducted with HCPs (nurses and doctors) and caregivers. Result: thematic analysis was done, themes and subthemes were generated. Observations related to opportunities of play in paediatric wards/OPD include no policy, no resources and no xed duration of play. Playrooms and toys were available at certain places but they were underutilized due to poor attitude of health care personnel towards play. Major barriers were less efforts and motivation from staff, faculty, administration and government. Hospital are totally dependent on NGO for play; inappropriate staff- patient ratio and HCP were more focussed towards right to survival rather than right to play. The facilitator includes active participation to inculcate play in units by only few (one/two) physicians/nurses. Suggestions provided included increase accessibility of play materials, need to motivate the staff, reduce fear of white apron, reduce screen time, and need of protocol to conduct xed play sessions in wards. Conclusion: There are concrete barriers and limited facilitators. There is a need to incorporate the suggested measures to tackle barriers in order to make the hospital setup play friendly.

Keywords: focussed group discussions (FGD), overt participatory observations, health care personnel (HCP), barriers, facilitators and suggested remedial measure, play, hospitalized child.

Address for correspondence

Mrs. Geetanjli Kalyan Tutor, NINE PGIMER, Chandigarh

Email: geetss2@gmail.com

Introduction:

Play is the spontaneous or voluntary universal recreational activities pursued for enjoyment. It is essential for child’s normal growth and development. By supporting the child to improve emotionally, socially, physically and intellectually play is very important.1 Play has been reported to have positive impact on the child during their hospitalization. Hospitalization constitutes an unpleasant experience for children, as suddenly they have to leave their home, the persons who are important for them, and stop their favourite activities, including play.2 It is estimated that 50-75 % of children develop signicant fear and anxiety before surgery. Play prepares the children for hospitalization, c l i n i c a l v i s i t s , s u r g e r i e s a n d including both nurses and physician working in paediatric department of a tertiary care centre, North India. Purposive sampling technique was done. Ethical approval for the study was taken from the Institute’s Ethics Committee (No. INT/IEC/2018/000567) and permission was also taken from the head of diagnostic/therapeutic procedures.3,4 The department. Written informed consent was play interventions is effective in reducing perioperative anxiety, negative behaviours, and postoperative pain in children.5,6,7

In hospital setup right to play is compromised due to lack of sensitization of Health Care Providers (HCP) towards introduction of play in day to day practice, high patient overload and inappropriate staff patient ratio. Similarly, in our setup it has been observed that the children attending OPD/admitted remain deprived of play. It is the responsibility of the nurses and the physicians to ensure that this right of child is met in hospital setup. Keeping in view the importance of play in child life and its therapeutic effects of play we found it to be important to assess the barriers and facilitators related to play among children in the hospital setting.

Objectives:

To identify the barriers and facilitators related to play among children in the hospital setting of a Tertiary Care Centre, North
To seek the remedial measures suggested by health care personnel to increase opportunities of

Material and methods:

Qualitative approach has been used. Research setting was paediatric surgery and medicine wards and Children OPD of a Tertiary Care Centre, North India. Target population was caregivers of the children admitted in wards and health care personnel obtained from the participant. Tool used was FGD guide with open ended questions. In addition to these overt participatory observations were made. FGDs were conducted to get the maximum response till the data or information gets saturated. The focus was to explore major problems and issues related to less opportunities of play. Total 15 Focussed group discussion of 15-20 min duration were conducted with the physicians and nurses in the group of 3-4 members and with caregivers in the group of 5-6 members. Along with it, four one-to one interviews were conducted in OPD as it was difcult to organize group discussion. D i s c u s s i o n s w e r e a u d i o r e c o r d e d , transcribed, inferences was drawn and thematic analysis was done.

Results:

The themes/subthemes about existing opportunities of play in paediatric wards/OPD, barriers, facilitators and suggested remedial measures related to play were generated from the FGDs conducted with HCPs and caregivers.

Observations related to opportunities of play in paediatric wards/OPD

Observations related to opportunities of play in paediatric wards/OPD include no policy, no resources and no xed duration of play. Playrooms and toys were available in certain places but less utilized due to poor attitude of health care personnel towards play. No play activity was performed in wards and OPD. About the playful environment The walls outside the unit in the main corridors were colourful and designed with cartoons whereas, the walls of the units were plain except surgery ward, where the framed pictures of famous cartoons were hanged. These nding are depicted in table 1.

Table 1 : Observations related to opportunities of play in paediatric wards/OPD

Sl. No.	Observations
1.	No policy and xed duration of play.
2.	No resources/play material available in the unit/ with parents
3.	Very few HCP were encouraging play in the units. They were not even interacting with the child during procedures.
4.	The existing playrooms were less utilized very few children were going to the play rooms. None of HCPs encouraged parents to take their child to play room.
5.	No play activity was performed in wards and OPD. Only the playrooms run by the NGO were used for play. Hospital was totally dependent on NGOs for play.
6.	Toys were locked in vaccination clinic and were not directly used for preparing the child for vaccination
7.	The walls were colourful and designed with cartoons outside the unit in the main corridors whereas, the walls of the units were plain except surgery ward, where the framed pictures of famous cartoons were hanged.
8.	There was no efforts from residents/doctors and nurses to inculcate play in day to day routein of different units.

Barriers related to play in hospital as per FGD /In-depth interviews with HCP

Major barriers were lack of government and administrative support,, hospital totally dependent on NGO for play, inappropriate staff- patient ratio, HCP are overburdened with work and were more focussed towards right to survival rather than right to play. No play therapist and no supply of play material. No protocol or policy and xed duration of play in APC. Parents are usually from low income status and less educated and even uneducated. The ndings are shown in table 2.

Facilitators related to Play in hospital as per HCP

There were no to minimal facilitators. The only facilitator was encouragement and promotion of play by two physicians and one nurse. There was limited participation from faculty, nurses and residents. The themes and subthemes are presented in table 3.

Remedial Measure/ Suggestions as per HCP

Remedial Measures/ suggestions provided include ensuring increase administrative as well as government support, increase accessibility to play material, motivate the staff, reduce the fear of white aprons, reduce screen time, and a need to develop and implement play protocol to conduct xed play sessions in wards. There is need to have play therapist in every ward. The ndings are depicted in table 4.

Thematic analysis of Focussed Group Discussion with caregivers

The caregivers also found that lack of play protocol and physical health of children were the major barriers, and encouragement by few staff is the only facilitator. Related to remedial measures they also suggested that there should be xed duration of play, the staff should encourage the child and family for play, and the interaction between the child and staff should be increased. The ndings are shown in table 5.

Table 2: Barriers related to play in hospital as per FGD /In-depth interviews with HCP

SL. No.	Themes /Sub-Themes	Verbatim
1.	Lack of government and administrative support* No funding from government or administration No supply of play materials Lack of play therapist	V: there is no funding from the administration as well as government for arranging resources V: there are no resources of play in APC V: there is no separate personnel who could look over these activities apart from nurses and doctors.
2.	Dependent on NGOs for play*	V: there are some NGOs who are organising competition for games and provide eatables. Sometime they organise one or two programs.
3.	No protocol and ﬁxed duration of play in APC*	V: there is no policy and ﬁxed duration of play. I’m posted here from last 8 month but I haven’t seen any.
4.	Less involvement/encourage ment from HCP*	V-P: residents are really overburdened and they are having very less time to involve the child in play. We sometime advise the child to colour, and nothing more than that. When we are going for the sampling, we use some chocolates for the children who are annoyed/not cooperating. Actually we want this to happen but we are not able to do it in reality. We won’t be able to do this, but there should be a separate team to basically indulge the child in this type of activities. V-N: It is very rare that the child carry a toy with him. If child has toy we can play with the child, moreover few nurses interacts with the child due to their busy schedule.
5.	Health issues of the child* Sick and unconscious child	V: There are only sick children, so they can’t go for play. Children who are stable can play. Still i instruct the parents of our respective beds to indulge the child in play. Apart from this there is nothing related to play in wards.
6.	Family factor* Low socio-economic status Uneducated parents	V: Majority of the children admitted here are below poverty line so they are not be able to afford even medicines and food, so how can we expect them to buy toys. V: Major fraction of children belongs to the low socio-economic status having less knowledge regarding importance of play
7.	Inappropriate staff- child ratio*	V-P: Residents are overburdened here due to high work load due to more number of patients. We really don’t interact with the children as such because we didn’t get time to interact with the child, we have lots of work like sampling, writing summary, taking new cases and many more. If the child is having something to play then I just only interact with child two to three minutes. V-N: Due to heavy work load of the patients and poor staff-patient ratio, nurses are not able to even provide basic care, so it is difﬁcult to pay attention to these kind of activities.

* -common theme from physicians and nurses #- themes from physician

$- themes from nurses

Table 3: Facilitators related to Play in hospital as per HCP

SL.

No.

Themes /Sub-Themes

Verbatim

Less facilitators for play

Only few HCP are facilitating play*

V-P: Dr. X and Dr. Y only promote play that I have seen in APC. They constantly give reminders whenever we are posted. They also ask us to get some age appropriate toys and they enhance to collect money to buy toys. Dr. Z also promote play. She promote the play which enhance learning and intelligence of the child . That is thing I learned from her only , that how to stimulate the baby. So just giving toy is not only important but giving age -appropriate toy and stimulate the child to use it as a tool to enhance knowledge is actually important.

V-N: There is a nurse, Miss X who is highly active in this direction and taking initiative to indulge the child in play.

-common theme from physicians and nurses #- themes from physician $- themes from nurses

Table 4: Remedial Measure/ Suggestions as per HCP

SL. No.	Themes- Sub-Themes	Verbatim
1.	Administrative as well as government support is needed*	V: Administration and government needs to work together in this direction to increase the existing opportunities of play because their role is really important.
2.	Increase accessibility of play materials_*	V: First of all we should have resources related to play in wards and the second thing is, some person needs to be appointed to take care of these resources.
3.	Play therapist must be appointed in every ward*	V: Play therapist is needed to be appointed in every wards. He/she could take care of all those resources and also educate the parents about how to use and maintain them.
4.	Motivation to HCP*	V: Constant m otivation not only for parents but equally for us is needed . In our busy schedule, we forg et these thinks so motivation for the health care personnel is very necessary to increase play in wards.
5.	Arrange money and resources from HCP by collection or donation#	V: What we can do is as mam already said that we can arrange money from the residents. If others are not willing, that’s ok, but at least we should do, because we are in constant touch with the child and parents . So we should be caring enough to provide some money to the patients.
6.	Use waiting time of APC for play specially in OPDs#	V: Apart from the management and ﬁnancial issue , I have another suggestion because in the huge patient load of APC t here is a patient waiting time of maximum 1-2 hours. We can utilize that time for the play and at that time HCP may involve the small child in rhymes, songs and hand games and for older children simple physical activity session are good choices.
7.	Reduce screen time #	V: I would like to say to decrease the screen attachment time from the children because I have seen that many parents feed their children by showing the movie or cartoons on mobile phone. It’s a very difﬁcult issue. Craving for cartoons are more among hospitalized children. So its imp to decrease screen time.
8.	A Play protocol is needed for ward*	V: there should be a play policy in the ward which include a daily ﬁxed play session in wards.
9.	Fixed duration of play*	V: Fixing the schedule of play is very imp. A routine is required in ward. According. to me every child should get involve in a ﬁxed duration of play either after breakfast or any time just like in psychiatric ward in Nehru hospital, where such activities are held among patients , such as prayer in morning and recreational activities after breakfast and lunch.
10.	Reduce fear of white apron#	V: sometimes we also wear different kind of clothes to divert the child, like as in foreign setup coloured, pre sterilized and autoclaved cloths are worn. . My suggestion is to create an environment that makes the child feel as a part of our family.
11.	Staff-patient ratio should be improved$	V: Nurse-patient ratio should be improved. It is actually the demand of time.
12.	Special preparation for invasive procedures$	V: After invasive procedures children should be awarded. Award should be l ike star stickers and cartoon stickers, which increase the acce ptance and preparation of child towards invasive procedures.

-common theme from physicians and nurses #- themes from physician $- themes from nurses

Table. 5 : Thematic analysis of Focussed Group Discussion with caregivers

A: Barriers related to play in hospital
SL. No.	Themes /Sub-Themes	Verbatim
1.	No play protocol No xed duration of play Less encouragement from health care providers No play enhancing environment	V: There is no ﬁxed time for play among hospitalized children but it is needed to be, so that he/she don’t feel suffocated in hospital. V: Only few staff are involved in play and send the child in playroom. V: There is nothing related to play are available in wards and today is the 4th day of my child’s admission but we didn’t see any activities related to play yet.
2.	Condition of child Physical condition of child Low socio-economic status	V: Due to illness, child is so sick that he isn’t be able to play. V: Majority of children belongs to the low socio ec-onomic status . We aren’t be able to afford the medications, So how you expect us to buy toys. We are only here to treat our child and we are more focused towards that only.
B: Facilitators Related to play
3.	Less facilitators for play Few staff facilitate play	V: Very few staff encourages the children to play and sometimes in evening very few of them encourage the parents to send their child in playroom.
C: Remedial Measure/ Suggestions
4.	Fixed duration of play	V: In ward we need to indulge the child daily in drawing activities just like home work.
5.	Need more encouragement from staff	V: Limited encouragement is there from staff ’s side. Only the few evening staff sometimes indulge the child in drawing. So more encouragement from staff is required.
6.	Increase staff interaction with the child	V: We need to increase the staff interaction with the child so that child feel happy and more familiar in hospital.
7.	Increase physical play activity	V: According to me, physical activities should be encouraged more than other play activities. That will be helpful in physical development of the child.

Discussion:

The play has known benet for all the children including the hospitalized children. The benets include decrease in compromised. In hospital it is the responsibility of the health care providers to ensure the child’s right to play. The hospital where the study was conducted was a pain, anxiety and negative emotions, 8,4 tertiary care centre catering to the needs of prepares the child for hospitalization, c l i n i c a l v i s i t s , s u r g e r i e s a n d the children with different systemic illnesses and the availability of the existing diagnostic/therapeutic procedures6 and play opportunities remains an explored improve child’s overall growth and development 1 , 3 , parent child bond, communication and problem solving ability..8 In hospital setup the play remains area. Moreover, the hospitalized children were not seen to be engaged in play during the observations. Keeping this into view the current study was undertaken to nd out the barriers, facilitators and suggested remedial measures related to play opportunities in the hospital.

In the present study qualitative approach has been used. This approach is very helpful in understanding the exact situation and nding out the barriers and facilitators related to the area under study as it explores the totality of the phenomenon.

order to generate key emergent themes from the discussions. On the same note a study conducted by David Carlton, Taylor- Robinson, et.al where they used the focus group discussions in order to explore barriers related to partnership in public health and also generate the themes to carry out an in-depth exploration of the emergent Similarly Gillard S, Edwards C, et.al also ndings of the discussions.14 Number of used the same approach in a study to introduce the barriers and facilitators related to the adoption of peer worker role in mental health services and also to seek their suggestions to nd out the new ways of working in mental health services.9

I n t h e c u r r e n t s t u d y c o v e r t participatory observation were made and focused group discussion were conducted to assess the current practices. The purpose of covert participatory observations was to prevent the participants from altering their behaviour that ultimately prevent the study discussions depend upon the point of saturation. This means conducting the discussion till the point no new information is gained.15

Data triangulation was done in the study to cross validate the ndings of FGDs between the physicians, nurses and caregivers in terms of the barriers, facilitators and suggested remedial measures. It not only help to validate the results but also help in deepening and widening the one’s understanding about the result. This method has also been used to bias.10 Focused group discussion were compare the information generated through conducted in wards and OPD with the health care personnel and the caregivers. FGD’s are the best ways to nd out the experience of the participants who work or deal in actual situation.11,12 It is a process to gather people of same background and experience with common objective to discuss specic topic of common interest. It can provide insight related to various issues, barriers, prospective and attitude of people, and generate hypothesis that cannot be made by observation. 13 Total 15 FGD were conducted with the HCP and the caregivers. In each FGD there were 3-4 HCPs and 5-6 caregivers. Discussions were audio recorded, transcribe, inferences were drawn and thematic analysis was done in the observations and the FGDs to determine corroboration between the ndings. This is how data triangulation was ensured in current study. Yu-Yung Wang conducted a s tudy in which he used the data triangulation method to explore the effects of kids-yoga-emotional-efcacy group intervention among children with ADHD and emotional disturbance.15 The common ndings were no policy, no resources and no xed duration of play in the hospital. Playrooms and toys were available in certain places but were less utilized and health care personnel had poor attitude towards play. It is recommended that there should be policy by the hospital administration to have play environment and play facilities in all childcare units. All the health setups must explore the existing barriers and facilitators related to play and start quality improvement initiative to improve the play among hospitalized children.

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