Nurses have a key role in facilitating play for children and young people in their care. Both play therapy and distraction techniques are skills required as part of the Future Nurse proficiencies (Nursing and Midwifery Council (NMC), 2018).
Distraction is commonly used by both health professionals and family members to support a child experiencing pain or distress (Koller and Goldman, 2012). Distraction as a non-pharmacological strategy can be seen as a cost-effective approach to reducing adverse childhood experiences and increasing the opportunity for a family-centred approach.
It is important for nurses to be knowledgeable about developmentally appropriate ways to encourage play in a safe and supportive environment for children and young people.
Play is an essential part of childhood that supports the development of motor and verbal skills (Stonehouse et al, 2018). There is variety in the frequency and type of play children take part in; however, it can be argued that play is motivating, involves the child's attention in the ‘play journey’, is often symbolic, free of external rules and actively engaging (Jones, 2018).
Play therapy
Play therapy is a communication tool used to alleviate chronic, mild and moderate psychological and emotional conditions in children (Play Therapy UK, 2017). The focus for this article is the role that play therapy techniques can have in a healthcare setting. Many hospitals employ play therapists who work with children to help them understand what procedures doctors and nurses and allied health professionals will perform, relieve anxiety, and help to make their time in hospital more enjoyable. Both play and distraction techniques are skills required as part of Annexe A in the Future Nurse proficiencies (NMC, 2018). The use of play can allow for positive distraction from painful or anxiety-provoking procedures or interventions (see Box 1).
Distraction
Distraction is one of the psychological strategies commonly used by both health professionals and family members to support a child or a young person experiencing pain or distress (Koller and Goldman, 2012). The concept is based on the idea that by shifting a child's focus to something engaging and attractive, their capacity to manage painful stimuli or an anxiety-provoking experience is improved. When nursing children it can be used to engage the child's attention with something positive or a coping mechanism that can be passive or active (Koller and Goldman, 2012). In addition, the inclusion of parents in play distraction provides opportunities to be involved in their child's care (Al-Yateem et al, 2016). Ensuring parents are actively involved encourages family-centred care.
Play as a distraction technique
Gold et al (2014) suggested that play can help children cope with stress, overcome their fears and develop self-esteem. Play may be used to introduce nursing or medical procedures to children, and then used as a supportive mechanism during the procedure. In fact, at a molecular level, it has been found that significant amounts of play are associated with low levels of cortisol and high levels of norepinephrine (Jones, 2018). This may indirectly affect brain functioning by protecting against adversity and reducing harmful stress. Not only does pain have a negative impact on brain development, but, in one study, children whose pain had not been managed in early childhood reported lower pain thresholds as they age (Koller and Goldman, 2012). Through the experience of medical procedures associated with pain, distress and anxiety, children can develop negative emotional outcomes, particularly children with chronic conditions where ongoing interventions are required (Al-Yateem et al, 2016).
Using play as a distraction technique is an effective method in reducing negative behavioural responses (Koller and Goldman, 2012). Distraction though play is also considered to be more economical when compared with using medication, in terms of cost and safety aspects (Singh, 2012). Play has been found to have a positive impact on children receiving interventions, as well as on the pain scores. Singh's (2012) randomised control trial found that the use of toys was the most effective strategy in reducing negative behaviour responses in infants receiving immunisations.
There are thought to be two forms of play-based distraction—active and passive (Koller and Goldman, 2012). Active distraction promotes involvement in an activity during a procedure. This tends to involve several sensory elements, and includes the use of interactive toys, guided imagery and relaxation and virtual reality. Passive forms of distraction are more quiet and calm activities, such as listening to music or watching TV, achieved through observation rather than participation. Research comparing active and passive forms of distraction have led to mixed and inconclusive findings (Koller and Goldman, 2012). It could be argued that passive distraction requires little from the child aside from attention, whereas active distraction relies on a willingness and ability to engage in the activity as well as effective cognitive and motor skills. Active methods are often considered superior because they require multisensory engagement, which in turn interrupts pain stimuli.
Procedural distraction through play can be accomplished through the use of videos, engagement with toys or books, tactile stimulation or through other visual or auditory distraction. It may also involve a further embrace of technology through immersive rooms or virtual reality (Koushali et al, 2017). It is important to be creative and offer a wide variety of age and developmentally appropriate toys and techniques for distraction during healthcare procedures (Jones, 2018). Something as simple as blowing bubbles with a young toddler can be effective in distracting them during a procedure. In one study, children with long-term conditions have said they find play a helpful distraction (Lima and Santos, 2015). From the authors' personal clinical experience of working with children with long-term conditions, play has been an opportunity to build on relationships with the children being cared for and gives them an opportunity to express how they feel about their condition.
There are numerous types of play that might be helpful in distraction, which can make selection challenging for nurses. It is important to keep up to date when choosing methods to support children through procedures. Interactive technology is one of the most recent innovations (see Box 2).
It could be argued that the key to defining best practice can be found in identifying individual preferences and temperament (Koller and Goldman, 2012). This is supported by research that found that children who experienced distress in their lack of control over their medical treatment, felt a sense of control when given the safe choice of distraction method (Koller and Goldman, 2012).
In one randomised controlled trial, Al-Yateem et al (2016) found that the play-based distraction technique used could be considered as an efficient alternative to traditional pharmacological premedication for children undergoing day surgery. However, there is evidence to suggest that, in some circumstances, pharmacological medication and non-pharmacological distraction techniques can be used alongside each other to produce the best effects and outcomes for children and young people (Tanabe et al, 2002). Nurses need to be aware that different children will require different approaches. Research has shown that the presence of a supportive parent during invasive procedures can be more important than toy distraction in decreasing children's pain, stress and negative behaviours (Matziou et al, 2013).
Conclusion
The purpose and value of play increases dramatically when children are more vulnerable as a result of life-threatening illness, disease, or disability (Koukourikos et al, 2015). It is thought this is because play buffers against the adverse impacts of stress (Jones, 2018). The evidence available shows that children recover sooner, become compliant with interventions such as blood tests, and are less likely to be traumatised if play is incorporated into their care (Koukourikos et al, 2015). It is important that nurses are knowledgeable about developmentally appropriate ways to encourage play in a safe and supportive environment for children and young people requiring nursing care.