Establishing consensus on principles and competencies for the use of play in clinical practice in hospitals: An international Delphi study

Play is increasingly seen as a valuable approach to help children and adolescents cope with the challenges of hospitalization [1]. The European Association for Children in Hospital includes play among the ten principles to promote children’s rights in hospitals [2]. Moreover, the World Health Organization (WHO) recommends that all doctors and nurses regularly use play in treatment and care [3]. In a previous review of 297 studies, we identified four clinical contexts where play interventions had a specific role in hospitals: procedures and diagnostic tests, patient education, treatment and recovery and adaptation (diversional or coping activities) [4].

A wide variety of healthcare professionals conduct play interventions. Some countries have play or child life specialists who use play in the clinic but typically only in specific situations (e.g. preparing paediatric patients for procedures like injections) or hours of the day. Thus, doctors, nurses, physiotherapists and other staff often use play in clinical practice [4] but generally without formal training. This lack of training is a barrier to using play effectively [5] and suggests a need to equip paediatric healthcare professionals with the competencies to integrate play into clinical practice.

A recent review highlighted a general lack of structured approaches for integrating play into healthcare education, with only few educational programmes available [6]. Moreover, a knowledge gap exists regarding how and why healthcare professionals integrate play into clinical practice [1, 4]. This amplifies the need for a shared interprofessional understanding of the use of play in hospitals to guide educational initiatives and operationalize local play interventions and practices. Therefore, this Delphi study aims to reach consensus among healthcare professionals on the principles and competencies for play interventions and practices in hospitals internationally.

A three-round Delphi technique enabled an international group of healthcare professionals to reach consensus regarding principles, competencies and learning objectives for using play in hospitals. Healthcare professionals with nine different backgrounds participated, revealing that play was similarly employed and valued across professions and nationalities. There was consensus among the participants that play helps healthcare professionals communicate with paediatric patients, although playful activities for adolescents are often overlooked. The participants agreed that play can be used to build trusting relationships, deliver information and increase understanding, promote cooperation and participation, reduce procedure-related anxiety and pain and support coping and development. Knowledge about patient background and preferences was deemed the most important facilitator for integrating play in clinical practice, while the most important barrier was time constraints.

Many of the identified principles about play in hospitals are closely linked to patient-centred care, which generally advocates planning healthcare around the patient and acknowledging the patients’ right to be fully involved in treatment and care [22, 23]. According to the WHO, developing good communication skills and the ability to form partnerships with patients are essential competencies for providing patient-centred care [24]. However, communication with paediatric patients is particularly complex due to large developmental variations, combined with triadic relationships with parents [25]. In our study, the participants agreed that play was used intuitively to facilitate age-appropriate communication, simplify medical terminology to make information more understandable for paediatric patients and parents, educate about disease management and prepare for various clinical situations. The use of play is well-established to prepare paediatric patients for clinical procedures (e.g. venepuncture or MRI scans) in some paediatric hospitals, along with distraction, which can reduce anxiety and feelings of pain [26‐28].

The identified learning objectives align with Gerteis et al.’s [23] seven core elements of patient-centred care, which the Picker Institute also adopted [29]. They include healthcare professionals’ ability to give patients the information they need to understand their illness and treatment, establishing trusting relationships, involving patients and their families in decisions and providing a supportive environment through physical and emotional comfort. Our findings indicate that playful approaches can be an integral part of clinical staff training on patient-centred healthcare in paediatric environments.

Our finding that play promotes paediatric patients’ participation in their own treatment and care also strongly aligns with the promotion of children’s rights in hospitals. The right to participation is a fundamental principle in the UN Convention on the Rights of the Child [30]. Healthcare professionals can promote this right by bringing patients into conversations and decisions in a child friendly manner [31‐33]. The recently published rights-based standards for paediatric tests, treatments, examinations and interventions also emphasize this, asserting that healthcare professionals should always communicate directly and ensure that paediatric patients understand, supporting their involvement in choices and acting accordingly [34]. By engaging in play activities, healthcare professionals signal to patients that they are approachable and willing to understand their perspectives and relate on a personal level. This provides a safe space for paediatric patients to express themselves and thereby increase participation in their own care. The participants also agreed that play interventions offer opportunity for increased family participation and noted that play should ideally be conducted in close collaboration with families to ensure engagement and mutually beneficial relationships. Partnerships with family members are also often emphasized in paediatric patient-centred care [35, 36].

Despite the potential benefits of using play in paediatric care, the participants agreed that activities for adolescents are often lacking and overlooked. Interruptions to school life and friendships can have a real impact on the hospitalized youths’ mental health [37, 38], necessitating patient-centred interventions to help them cope. Other studies have found that age-appropriate activities like music are commonly used by adolescents to cope with hospitalization [39], and music therapy supports adolescents with mental disorders and potentially reduces depressive symptoms [40, 41]. However, more research is needed involving adolescents to provide insights into meaningful opportunities for play and recreation in hospital settings for this age group.

For healthcare professionals to integrate play into clinical practice, we found that the most important factors to consider are the patient’s mental and physical state, age, interests and hobbies. The participants also cited knowledge about the patient (interests, hobbies, social background) as the most essential facilitator for integrating play. This suggests a need to incorporate such knowledge in patient records. The most important barriers to using play are generally related to organizational resources, including insufficient time, lack of toys and activities and staff shortages. Time pressure has previously been found to be the most important barrier for the use of play, as reported by nurses [42].

Another identified barrier was healthcare professionals’ lack of education and formal training. A previous study also found that a lack of training made healthcare professionals unsure of how to effectively integrate play [5]. Although some of the participants came from hospitals employing trained staff (e.g. child life or health play specialists), they noted that these professionals were not available in every relevant clinical situation. To provide more healthcare professionals with skills in using play, consensus was reached that all healthcare professionals should have access to formal education on integrating play into paediatric practice. Our findings demonstrate that using play in clinical practice is engaged by all paediatric healthcare professions, rather than being limited to a few specialities. By expanding the description of why and how play can be integrated into paediatric hospitals, this study may support initiatives in generating goals for healthcare professionals’ training on how to use play in clinical practice. Such training can support healthcare professionals working in paediatric departments to provide care using a patient-centred approach to promote children’s rights in hospitals. To help break down barriers identified in this study, providing paediatric healthcare professionals with opportunities to learn more systematically about the value and benefits of play might be a fundamental future step (Table 4).

We used an electronic Delphi technique and translated the invitation letters and initial surveys into eight different languages, which allowed us to include the views of participants with limited English proficiency who are often excluded in international research. Although the participants’ views may not be representative of all healthcare professionals and practice settings, the inclusion of multiple nationalities and professions supported a broad range of opinions and perspectives on play in hospitals. A limitation of the Delphi panel was that it only represented high-income countries, which may limit the generalizability of our findings. However, these high-income countries are frontrunners in certain healthcare areas and may serve as inspiration for the innovative delivery of care. Three hospitals in the USA were invited to participate in our Delphi study but did not respond. The mean consensus threshold of ≥ 3 meant that consensus was reached regarding all statements in rounds 2 and 3. Using a higher threshold might not have yielded different results since only five statements had a mean rating < 4. One of the potential pitfalls of conducting multiple survey rounds is the probability of false consensus, which can arise due to fatigue, in which participants agree with statements just to end the process [12]. To mitigate the risk of false consensus, we predefined the number of survey rounds and informed participants before the study began. Another common bias in Delphi studies is the potential of low response rates and attrition between rounds [43]. By providing weekly reminders in the participants’ native language and conducting the survey rounds shortly after each other, we maintained a consistent response rate across all rounds (62–68%). A limitation is that the study’s design did not include the perspectives of families and patients, which should be included in future research.

Using the Delphi method allowed us to identify common international principles and competencies for the use of play in paediatric clinical practice. We found that play can be used to communicate and build relationships with paediatric patients. Reaching consensus on principles and competencies for using play in hospitals is an important first step in developing a formal curriculum for an interprofessional education programme on how to use play in paediatric clinical practice. The insights from this study can help inform future patient-centred initiatives for healthcare professionals as play may be a way to communicate and involve paediatric patients appropriate for their age, stage of development and preferences for communication and engagement. It is essential to ensure that healthcare professionals can provide a patient-centred approach to protect the rights of paediatric patients in hospitals to potentially improve hospital experiences for paediatric patients and their families.