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A study investigating the themes of children’s play after major heart surgery Ralston, Marjory 1979

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A STUDY INVESTIGATING THE THEMES OF CHILDREN'S PLAY AFTER MAJOR HEART SURGERY by MARJORY RALSTON B .Sc .N . , The U n i v e r s i t y o f B r i t i s h Co lumbia , 1973 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES SCHOOL OF NURSING We accept t h i s t h e s i s as conforming to the r e q u i r e d s t anda rd THE UNIVERSITY OF BRITISH COLUMBIA October 1979 © Marjory Ralston, 1979 In presenting t h i s thesis in p a r t i a l f u l f ilment of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of thi s thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of The University of B r i t i s h Columbia Vancouver 8, Canada Date l*f • 10 - 7°\ i i ABSTRACT This study was designed to gather information about the nature and content of post-surgicalpplay behaviour displayed by hospitalized pre-school children. Four questions were explored: Are common themes expressed in the play behaviour of hospitalized pre-school children after major surgery? Does the quality and intensity of the play behaviour demonstrated by pre-school children follow a similar pattern? W i l l pre-school children use play therapy as a medium through which to express fears and concerns about their hospital experience? Do children tend to act out their perceptions of what has happened to them in hospital? The population selected for the study were four g i r l s and one boy between the ages of three and five years, who were admitted for major surgery on the heart or great vessels. During the recovery period after surgery each c h i l d had the opportunity to take part i n at least f i v e play therapy sessions l a s t i n g approximately one hour each. . Play therapy took the form of s i t u a t i o n a l play using r e a l or simulated hospital equipment and various d o l l s representing children and adults. Each c h i l d chose the direction and content of play. The investigator took part in play as directed by the c h i l d . Parents could j o i n in i f they wished. The verbal and non-verbal behaviour displayed by each c h i l d during play therapy was recorded by audio tape and by process recordings. Flour out of fi v e children in the study participated actively in play therapy. In the course of play they expressed f i v e common i i i themes: intrusive procedures; re-enactment of procedures? testing r e a l i t y ; autonomy: regaining control; separation from home and family; and nurturing a c t i v i t i e s . The quality and intensity of the children's play behaviour followed a pattern from intense to more relaxed and from aggressive to more gentle play. During play each c h i l d expressed some indiv i d u a l fears and concerns about his h o s p i t a l i z a t i o n . In-trusive procedures were the most frequent topic of play for a l l the children. F i n a l l y , each c h i l d tended to act through s p e c i f i c pro-cedures so that play behaviour became a factual account of the child's hospital experience. One c h i l d , the only boy in the study, did not want to participate i n play therapy. The reasons for th i s were not investigated. It was concluded that play therapy i s a useful technique which can a s s i s t nurses understand the pre-school child's perception of his hospital experience. Play therapy also has potential as a therapeutic intervention to help a c h i l d come to terms with the traumatic events of his h o s p i t a l i z a t i o n . i v TABLE OF CONTENTS CHAPTER PAGE I INTRODUCTION 1 The Problem 5 Purpose of the Study 9 Assumptions 10 Def i n i t i o n of Terms 10 Limitations 11 II REVIEW OF LITERATURE 13 Introduction 13 The St r e s s f u l Effects of Hospitalization on the Pre-School Child 13 Review of Selected Research Studies Investigating Hospitalization of the Pre-Schooler 24 Selected Theories of Play 29 Therapeutic Application of Play 32 The Child with Congenital Heart Disease . . . 43 Summary of Literature 48 III METHODOLOGY 49 Overview 49 Sample Selection 51 Collection of Data 51 Implementation 52 IV DISCUSSION AND INTERPRETATION OF THE DATA . . . . 53 Introduction 53 The Children i n the Study 53 Overview of Play Therapy Sessions 55 Intrusive Procedures . 57 Re-enactment of Procedures: Testing Reality 60 Autonomy: Gaining Control 62 Separation from Home and Family 64 Nurturing A c t i v i t i e s 65 The Child Who Didn't Want to Play Hospitals . . 65 Post-Hospital Behaviour 69 Discussion of Findings 70 Limitations of Study 75 CHAPTER PAGE V CONCLUSION AND IMPLICATIONS FOR NURSING PRACTICE AND RESEARCH 78 C o n c l u s i o n 78 I m p l i c a t i o n s f o r Nurs ing P r a c t i c e 80 I n d i c a t i o n s f o r F u r t h e r Research 82 BIBLIOGRAPHY APPENDIXES: Appendix A 89 Appendix B 91 Appendix C 92 Appendix D 93 ACKNOWLEDGEMENTS I wish to express my a p p r e c i a t i o n to my committee, Mrs . Ruth E l l i o t t and Miss Be t t y Bregg, f o r t h e i r gu idance and s u p p o r t , and f o r a l l the many hours o f t ime and e f f o r t on my b e h a l f . I am p a r t i c u l a r l y g r a t e f u l to the m e d i c a l and n u r s i n g s t a f f o f Vancouver Genera l H o s p i t a l uho made t h i s s tudy p o s s i b l e . I am a l s o i ndeb ted to the pa ren t s uho took p a r t i n t h i s s tudy so e n t h u s i a s t i c a l l y , and to the c h i l d r e n uho were such a joy to p l ay " h o s p i t a l s " w i t h . CHAPTER I INTRODUCTION TO THE STUDY Every year approx imate ly two hundred thousand p r e - s c h o o l c h i l d r e n are admi t ted to h o s p i t a l i n Canada. Some o f these c h i l d r e n are i n h o s p i t a l f o r weeks and may have to endure p a i n f u l and f r i g h t e n i n g p r o c e d u r e s . ^ C h i l d r e n at t h i s deve lopmenta l l e v e l have many age-r e l a t e d c h a r a c t e r i s t i c s which makes the h o s p i t a l e x p e r i e n c e e s p e c i a l l y t r a u m a t i c f o r them. There i s s t i l l much to be done i n the h o s p i t a l s o f B r i t i s h Columbia to ensure t h a t e f f e c t i v e a g e - r e l a t e d i n t e r v e n t i o n s are c o n -s i s t e n t l y used to he lp the p r e - s c h o o l c h i l d unders tand and accept h i s h o s p i t a l i z a t i o n . Over the pas t 25 year s t he re has been a s t e a d i l y i n -c r e a s i n g body o f knowledge about the e m o t i o n a l care o f the c h i l d . Much o f t h i s theory can be t r a n s l a t e d i n t o n u r s i n g p r a c t i c e . U n r e s t r i c t e d parent v i s i t i n g i s one improvement i n the care o f the h o s p i t a l i z e d c h i l d t ha t i s accepted i n most a r e a s . Some h o s p i t a l s a l s o a l l ow s i b l i n g v i s i t i n g . A few areas p r o v i d e p r e - h o s p i t a l i z a t i o n t o u r s and b o o k l e t s e x p l a i n i n g h o s p i t a l r o u t i n e s . In some i n s t a n c e s p r e - o p e r a t i v e t e a c h i n g i s c a r r i e d o u t . However these i n t e r v e n t i o n s do not g e n e r a l l y occur c o n s i s t e n t l y i n a l l p e d i a t r i c u n i t s . Fu r thermore , not a l l o f these i n t e r v e n t i o n s are e v a l u a t e d to determine i f they do a l l e v i a t e the trauma o f h o s p i t a l i z a t i o n f o r the p r e - s c h o o l c h i l d . S t a t i s t i c s Canada, H o s p i t a l M o r b i d i t y 1975. Cata logue 82-206, Canada: 1975, p. 8. - 2 -The problem of providing consistent and e f f e c t i v e emotional care for the pre-school c h i l d i s not peculiar to B r i t i s h Columbia. Azarnoff states that: "The manner in which children's stress i s managed by families and hospital s t a f f , i f i t iB dealt with at a l l , varies."2 She also states that in C a l i f o r n i a the most common forms of preparation for h o s p i t a l i z a t i o n for the pre-school c h i l d are pre-admission tours and booklets about hospital routines.'' The res u l t s of the study carried out by Azarnoff et a l . indicate that' t h i s form of preparation would seem to have lim i t a t i o n s in helping the c h i l d understand what i s happening to him. Hardgrove also points out that materials such as booklets, tours and s l i d e tapes may be misunderstood by younger children. She suggests that they should be used with discretion and in the presence of an understanding adult who could provide guidance 5 and further explanation. Although there seems to be a lack of detailed preparation in many pedi a t r i c areas there are also some well documented accounts of in d i v i d u a l i z e d programs espe c i a l l y designed to teach the pre-school c h i l d about his h o s p i t a l i z a t i o n . In p a r t i c u l a r , P e t r i l l o describes Pat Azarnoff, et a l . The Preparation of Children for  Ho s p i t a l i z a t i o n . Department of Pediatrics, University of C a l i f o r n i a , Los Angeles, 1975, p. 1. 3 I b i d . , p. 2. ^Ibid., p. 57. 5 Carol Hardgrove, "Emotional Innoculation: The 3 R's of Preparation", Journal of the Association for the Care of Children in Hospitals, \l (#k Spring 1977) p. 17. the g u i d e l i n e s used at C o r n e l l M e d i c a l Cent re to p repare c h i l d r e n f o r h o s p i t a l i z a t i o n . In t h i s program d o l l s and h o s p i t a l equipment are u t i l i z e d as t e a c h i n g a i d s to a s s i s t the p r e - s c h o o l c h i l d unders tand the reasons f o r h i s h o s p i t a l i z a t i o n , and to prepare him f o r what i s go ing to happen to h im.^ However, such p r e p a r a t i o n programs may a l s o have some l i m i t -a t i o n s . They must be s k i l l f u l l y geared to each c h i l d ' s l e v e l o f under -s t a n d i n g . T e s l e r and Hardgrove p o i n t out t h a t , i n p r e p a r i n g the young c h i l d f o r p r o c e d u r e s , the danger l i e s i n o v e r e s t i m a t i n g t h e i r i n t e l -l e c t u a l and emot i ona l growth and consequent l y g i v i n g them too much i n -f o r m a t i o n . Fur thermore , the p r e - s c h o o l c h i l d ' s t r a n s d u c t i v e mode o f t h i n k i n g can l e a d to m i s concep t i on s about what i s go ing to happen to 7 him. They a l s o p o i n t out t h a t , no matter how e f f e c t i v e a p r e p a r a t i o n program may be, not a l l c h i l d r e n w i l l be exposed to i t . For example, p r e p a r a t i o n i s not p o s s i b l e f o r c h i l d r e n who are admi t ted i n emergency s i t u a t i o n s . P r e p a r a t i o n programs a lone may not be t o t a l l y e f f e c t i v e i n e n s u r i n g t h a t each c h i l d unders tands and comes to terms w i th h i s h o s p i t a l i z a t i o n . P lay therapy has been suggested by s e v e r a l w r i t e r s as an a p p r o p r i a t e i n t e r v e n t i o n which may f a c i l i t a t e the c h i l d ' s under s t and ing Made l ine P e t r i l l o , " P r e p a r i n g C h i l d r e n and Pa rent s f o r H o s p i t a l i z a t i o n and T r e a t m e n t " , P e d i a t r i c Annals (December 1972) pp. Zk-kl. 7 Mary T e s l e r and C a r o l Hardgrove, " C a r d i a c C a t h e t e r i z a t i o n : P r e p a r i n g the C h i l d " , American J o u r n a l o f N u r s i n g , (January 1973) p. 82. - 4 -8 9 ID of his h o s p i t a l i z a t i o n . ' ' Play therapy usually occurs after a major procedure such as surgery, has already taken place. Using d o l l s and hospital equipment the c h i l d i s encouraged to express his feelings about h o s p i t a l i z a t i o n . It i s believed that through the medium of play a c h i l d may gain insight into the reasons for his h o s p i t a l i z a t i o n . As play therapy i s considered to be an e f f e c t i v e way for the pre-school c h i l d to communicate his feelings and b e l i e f s , areas of misunderstanding may also be revealed. Erik Erikson considers t h i s type of play to be cathartic i n nature, allowing the c h i l d to act out his problems in the same way that an adult may talk out his problems."'""'" Play therapy appears to be a promising intervention which could be u t i l i z e d by nurses to help reduce the traumatic e f f e c t s of h o s p i t a l -i z a t i o n for the pre-school c h i l d . Unlike most i n d i v i d u a l l y designed preparation programs i t i s r e l a t i v e l y simple to conduct and does not require a large c a p i t a l outlay. It also appears to be an intervention that could be b e n e f i c i a l to a c h i l d , even when a hospital does not also have a f u l l y developed preparation program. Although play therapy should never replace preparation programs, preparation programs which are not followed by play therapy may r e s u l t in a c h i l d returning home Madeline P e t r i l l o , "Preventing Hospital Trauma in Pediatric Patients", American Journal of Nursing, (July 1968) pp..1469-1473. g Hardgrove, op. c i t . , pp. 17-19. 1 DNaida Hyde, "Play Therapy: The Troubled Child's S e l f -Encounter", American Journal of Nursing, (July 1971) pp. 1366-1370. 1 J"Erik Erikson, Childhood and Society. Revised Edition, 0 (New York: Id. W. Norton Co., 1950) p. 475. - 5 -12 ha rbou r i n g dangerous f a n t a s i e s . Because o f the p o s s i b l e b e n e f i t s o f p l ay therapy f o r the p r e -s c h o o l c h i l d , the w r i t e r became i n t e r e s t e d i n s t u d y i n g the p o s t -s u r g i c a l p l ay behav iour o f t h i s age group i n an acute c l i n i c a l a rea o f the h o s p i t a l . A number o f g e n e r a l q u e s t i o n s r e l a t e d to p l ay therapy were i d e n t i f i e d : When g i ven the o p p o r t u n i t y do a l l p r e - s c h o o l c h i l d r e n engage i n p l ay r e l a t e d to t h e i r h o s p i t a l e x p e r i e n c e s ? Do c h i l d r e n d i s p l a y s i m i l a r themes i n p l a y ? I f t h i s i s so what are these themes? Would the p l ay behav iour o f h o s p i t a l i z e d c h i l d r e n be s i m i l a r to t ha t d e s c r i b e d i n the l i t e r a t u r e ? From these g e n e r a l q u e s t i o n s s p e c i f i c q u e s t i o n s were f o r m u l a t e d and a d e s c r i p t i v e s tudy was des i gned to gather f u r t h e r i n f o r m a t i o n about the na ture and content o f p o s t -s u r g i c a l p l a y b e h a v i o u r . THE PROBLEM P r e - s c h o o l c h i l d r e n have many a g e - r e l a t e d c h a r a c t e r i s t i c s t h a t compound the t r a u m a t i c e f f e c t s o f h o s p i t a l i z a t i o n . At t h i s d e v e l o p -menta l s tage the c h i l d i s s t i l l very dependent on h i s pa ren t s and p e r c e i v e s them as p r o t e c t o r s a g a i n s t h u r t . In the h o s p i t a l s i t u a t i o n pa ren t s can no l onger p r o t e c t t h e i r c h i l d from neces sa ry m e d i c a l and n u r s i n g i n t e r v e n t i o n s . When pa ren t s are p e r c e i v e d by the c h i l d to f a i l i n the r o l e o f p r o t e c t o r s the c h i l d may s u f f e r from c o n f l i c t i n g emotions of g u i l t , f e a r , and anger . These s t r o n g emotions may confuse the c h i l d and can l e a d to p s y c h o l o g i c a l upset which c o u l d con t inue a f t e r Hardgrove, op. c i t . , p. 19. he returns h ome.'^' ' ^ ' ^ In some cases such psychological upset can int e r f e r e with the child's emotional and s o c i a l g r o w t h . 1 8 ' 1 9 ' 2 0 ' 2 1 ' 2 2 ' 2 3 ' 2 ^ An important contributing factor to the hospitalized pre-school child's stress i s his limited a b i l i t y to understand the reasons for his h o s p i t a l i z a t i o n , surgery or treatments. At th i s 1 3R. B. Aisenberg and P. H. Wolff, "Psychological Impact of Cardiac Catheterization". Pediatrics, (June 1973) pp. 1051-1059. Ik John Bouilby, Attachment and Loss: Separation. II (London: Hogarth Press, 1973). 15 Barbara M. Korch, "Experiences with Children and Their Families During Extended Hemodialysis and Kidney Transplantation". Pediatric  C l i n i c s of North America, (May 1971) pp. 625-637. "^L. M. Linde, et a l . " A t t i t u d i n a l Factors i n Congenital Heart Disease." Pediatrics, (July 1966) pp. 92-101. 1 7G. H. Vaughan, "Children i n Hospital". Lancet, (June 1957) pp. 1117-1120. IB John Bouilby, "Separation Anxiety." International Journal of  Psychoanalysis, (May 1960) pp. 89-113. 19 Bouilby, op. c i t . , 1973. 20 Anna Freud, "The Role of Bodily I l l n e s s in the Mental L i f e of Children." Psychoanalytic Study of Children, (July 1952) pp. 69-81. 21 D. M. Levy, "Psychic Trauma of Operations i n Children." American Journal of Disease i n Children, (January 1945) pp. 7-25. 22 A. Mattsson, "Long Term Ill n e s s in Childhood: A Challenge to Psychosocial Adaptation". Pediatrics, (November 1972) pp. 801-809. 23 " P. Orsten and A. Mattsson, "Hospitalization Symptoms in Children." Acta Paediactrica, (August 1955) pp. 79-92. 2**J. Robertson, Young Children in Hospitals. (London: Tavistock Publications Ltd., 1958. - 7 -deve lopmenta l s tage the c h i l d may deve lop m i s concep t i on s and u n -25 26 27 23 r e a l i s t i c f e a r s about what i s happening to h im. ' ' ' Many common m e d i c a l and n u r s i n g i n t e r v e n t i o n s such as s u r g e r y , i n j e c t i o n s and temperature t a k i n g , are o f an i n t r u s i v e n a t u r e . The p r e - s c h o o l e r i s p a r t i c u l a r l y f r i g h t e n e d o f t h r e a t s to h i s body i n t e g r i t y and 29 3D f r e q u e n t l y p e r c e i v e s such t rea tments as punishment. ' P i a ge t s t a t e s t ha t the p r e - s c h o o l c h i l d ' s language does not always se r ve the f u n c t i o n o f communicat ion. The c h i l d cannot assume the p o i n t o f view o f a l i s t e n e r who r e q u i r e s i n f o r m a t i o n . ^ ^ T h i s q u a l i t y o f language makes i t very d i f f i c u l t f o r the c h i l d to v e r b a l i z e h i s f e e l i n g s about h o s p i t a l i z a t i o n . Fur thermore , at t h i s s tage o f development the c h i l d ' s r ea son ing c a p a c i t y i s l i m i t e d , and h i s i n t e r -25 E r i k E r i k s o n , C h i l d h o o d and S o c i e t y . (Rev i sed E d i t i o n , New York: Id. W. Norton C o . , 1950) . 26 F l o r e n c e E r i c k s o n , " R e a c t i o n s o f C h i l d r e n to H o s p i t a l E x p e r i e n c e . " Nurs ing Out look , (September 1958) pp. 501-504. 27 Jean P i a g e t , The C h i l d ' s C o n s t r u c t i o n o f R e a l i t y . (London; Rout ledge and Kegan L t d . , 1955) . 28 Mary T e s l e r and C a r o l Hardgrove, " C a r d i a c C a t h e t e r i z a t i o n : P r e p a r i n g the C h i l d . " American J o u r n a l o f N u r s i n g , (January 1973) pp. 80 -82 . 29 M i l t o n F u j i t a , "The Impact o f I l l n e s s or Surgery on the Body Image o f the C h i l d . " Nur s ing C l i n i c s o f North Amer i ca , VII (December 1972) pp. 641-649. ^ I r e n e R i d d l e , "Nur s ing I n t e r v e n t i o n s to Promote Body Image I n t e g r i t y i n C h i l d r e n " . Nurs ing C l i n i c s o f North Amer i ca , VII (December 1972) pp. 651-661. ^ J e a n P i a g e t , The Language and the Thought o f the C h i l d . (London: Rout ledge and Kegan L t d . , 1926) . - 8 -p r e t a t i o n o f the su r round ing environment i s f r e q u e n t l y i l l o g i c a l and 32 u n r e a l i s t i c . Both o f these a g e - r e l a t e d c h a r a c t e r i s t i c s make i t d i f f i c u l t f o r pa ren t s and f o r the h e a l t h ca re team to unders tand which a spec t s o f h o s p i t a l i z a t i o n c o n t r i b u t e most to an i n d i v i d u a l c h i l d ' s p s y c h o l o g i c a l u p s e t . As the p r e - s c h o o l e r cannot l o g i c a l l y v e r b a l i z e h i s f e a r s an a l t e r n a t e method o f communication a p p r o p r i a t e f o r the c h i l d ' s d e v e l o p -menta l l e v e l s h o u l d be u t i l i z e d . Sigmund F r e u d , E r i k E r i k s o n and P i age t a l l i n t e r p r e t p l a y behav iour o f p r e - s c h o o l c h i l d r e n as the c h i l d ' s way o f g a i n i n g b e t t e r under s tand ing o f h i s wor ld . - '3 ,34,35 The c h i l d communicates h i s f e e l i n g s and emotions through the medium o f p l a y . A x l i n e and Moustakas b e l i e v e t h a t a c h i l d " p l a y s o u t " h i s f e e l i n g s and problems j u s t as an a d u l t " t a l k s o u t " h i s d i f f i -36 37 c u l t i e s . ' A x l i n e , E r i k E r i k s o n and Moustakas a l l b e l i e v e t h a t s o l i t a r y p l a y therapy wi th t o y s , i n the presence o f a sympathet i c a d u l t i s the bes t way to unders tand a c h i l d ' s problems and to he lp him 32 Jean P i a g e t , P l a y s , Dreams and I m i t a t i o n i n C h i l d h o o d . (New York: W. W. Norton C o . , 1951 ) . "^Sigmund F r e u d , Beyond the P l e a s u r e P r i n c i p l e . XVII I (London: Hogarth P r e s s , 1955) . 34 E r i k E r i k s o n , Ch i l dhood and S o c i e t y . (Rev i sed E d i t i o n , New York: W. U. Norton C o . , 1950) . 35 P i a g e t , op . c i t . , 1951. " ^ V i r g i n i a A x l i n e , P lay Therapy . (Cambridge, Mas sachuse t t s : The R i v e r s i d e P r e s s , 1947). 37 C l a r k Moustakas, C h i l d r e n i n P l a y Therapy . (New York: B a l l a n t i n e Books, 1953). adjust to new and overwhelming situations.^B»39,40 In conclusion, a problem exists i n understanding the pre-school child's perception of his h o s p i t a l i z a t i o n . Play i s the pre-schooler's natural medium for s e l f expression. In play the c h i l d can act out his feelings and in doing so can communicate his perceptions of his experiences to a sympathetic and knowledgable adult. It there-fare seems to follow l o g i c a l l y that the hospitalized c h i l d could be assisted to express his feelings and to gain understanding of his h o s p i t a l i z a t i o n through the medium of play therapy. PURPOSE OF THE STUDY A study was designed to explore various aspects of play behaviour displayed by hospitalized pre-schoolers after major surgery. The study posed four questions: 1. Are common themes expressed in the play behaviour of hospitalized pre-school children after major surgery? 2. Does the quality and intensity of the play behaviour demonstrated by pre-school children follow a s i m i l a r pattern? 3. W i l l pre-school children use play therapy as a medium through which to express fears and concerns about th e i r hospital ex-perience? 4. Do children tend to act out t h e i r perceptions of what has happened to them in hospital? 38 Axline, op. c i t . , 1947. 39 Erikson, op. c i t . , 1950. ^Moustakas, op. c i t . , 1953, - 10 -ASSUMPTIONS P r e - s c h o o l e r s , because o f a g e - r e l a t e d c h a r a c t e r i s t i c s , are p a r t i c u l a r l y prone to p s y c h o l o g i c a l upset as a r e s u l t o f h o s p i t a l -i z a t i o n . The l onge r the h o s p i t a l s t ay and the more t r a u m a t i c the i n t e r v e n t i o n s the g r e a t e r the p s y c h o l o g i c a l u p s e t . P l ay i s one impor tant may t h a t p r e - s c h o o l e r s no rma l l y l e a r n to unders tand and master the c o m p l e x i t i e s o f t h e i r env i ronment . As p a r t o f t h e i r normal growth and development c h i l d r e n use p l ay to e x -p re s s f e e l i n g s and a n x i e t i e s t h a t they cannot v e r b a l i z e . DEFINITION OF TERMS P s y c h o l o g i c a l upset and p s y c h o l o g i c a l trauma r e f e r to adverse r e a c t i o n s e x h i b i t e d by a c h i l d i n response to the s t r e s s f u l e x p e r i e n c e o f h o s p i t a l i z a t i o n , s u r g i c a l , m e d i c a l and n u r s i n g i n t e r v e n t i o n s . In h o s p i t a l these adverse r e a c t i o n s are c o n s i d e r e d to be behav iour s such a s : c r y i n g , s c reaming , c o n t i n u e d r e s i s t a n c e to p r o c e d u r e s , extreme shyness , apathy or w i t h d r a w a l . F o l l o w i n g h o s p i t a l i z a t i o n p s y c h o l o g i c a l upset i s i n d i c a t e d by a comparat ive i n c r e a s e from b e f o r e h o s p i t a l i z a t i o n i n b e h a v i o u r a l responses such a s : f e a r o f s e p a r a t i o n from p a r e n t s , d i s t u r b e d s l e e p p a t t e r n s , a g g re s s i on towards a u t h o r i t y , r e g r e s s i o n to more i n f a n t i l e b e h a v i o u r s , or apathy and w i t h d r a w a l . S t r e s s i s d e f i n e d as a s t a t e o f p h y s i o l o g i c a l and/or p sycho -l o g i c a l imbalance which occu r s when an e x t e r n a l s t i m u l u s or s t r e s s o r i s p e r c e i v e d as t h r e a t e n i n g . The t o t a l impact o f a l l a spec t s o f h o s p i t a l -i z a t i o n i s c o n s i d e r e d to be the major s t r e s s o r . P lay therapy r e f e r s to i n d i v i d u a l p l a y c a r r i e d out by the c h i l d i n the presence o f the r e s e a r c h e r . The equipment i s e i t h e r r e a l or - 11 -simulated hospital equipment, for example: stethoscopes, blood pressure apparatus, syringes, instruments, bandages, catheters, intra-venous sets, and oxygen masks. There is also a collection of male and female dolls. The child is presented with the equipment and in-vited to play hospitals. The child chooses the direction of the play and is allowed to express himself freely. The researcher establishes rapport with the child, recognizes and accepts a l l feelings expressed by the child and reflects them back. It is expected that each child wi l l act out his hospital experiences and express in play personal feelings and perceptions about his total hospitalization. The researcher may make use of opportunities during play to correct misconceptions expressed by the child about his hospitalization and to clarify reasons for medical and nursing interventions. The researcher w i l l Use doll demonstrations in conjunction with verbal explanations to assist the child to understand his hospitalization. The child is considered to have taken part in play therapy when: a) he acts out at least three events that have occurred in hospital; b) he verbalizes by words, exclamations or sounds as he acts through events; c) he expresses emotions as he plays either by words or body language or by both, i.e. aggression, fear, anger; d) he plays the part of an "authority figure" on one occasion, i.e. a doctor, nurse or parent. LIMITATIONS The study w i l l describe the themes and patterns of play carried out by English speaking children only from similar cultural backgrounds whD have undergone major surgery Dn the heart or great vessels. - 12 -Play behaviour w i l l be observed only while the c h i l d i s in h o s p i t a l . The sample i s small therefore not a l l common themes of post-s u r g i c a l play may be expressed. The implications for children who may not express themselves through play w i l l not be studied. - 13 -CHAPTER II REVIEW OF THE LITERATURE INTRODUCTION T h i s chap te r p r e s e n t s a rev iew o f the l i t e r a t u r e r e l a t e d to f a c t o r s which a f f e c t the emot iona l ca re o f the p r e - s c h o o l c h i l d . F i r s t , those a spec t s Df h o s p i t a l i z a t i o n which are p a r t i c u l a r l y s t r e s s -f u l to the p r e - s c h o o l c h i l d are r e v i e w e d . As the c h i l d r e n i n t h i s s tudy undergo c o r r e c t i v e h e a r t s u r g e r y , the s p e c i a l i m p l i c a t i o n s o f c o n g e n i t a l h e a r t d i s ea se f o r the c h i l d and h i s f a m i l y are e x p l o r e d . S t u d i e s examining the e f f e c t o f v a r i o u s s t r e s s r e d u c i n g i n t e r v e n t i o n s are d i s c u s s e d . As p l ay therapy i s the i n t e r v e n t i o n used i n t h i s s tudy , s e l e c t e d t h e o r i e s o f p l ay are rev iewed and the t h e r a p e u t i c a p p l i c a t i o n o f p l a y i s examined. D i s c u s s i o n o f these a spec t s o f the emot i ona l care o f the h o s p i t a l i z e d c h i l d f u r t h e r d e f i n e the problem o f s t r e s s due to h o s p i t a l i z a t i o n and s u r g e r y . T h i s rev iew o f the l i t e r a t u r e a l s o p r o v i d e s a t h e o r e t i c a l framework and an e m p i r i c a l b a s i s f o r the use o f p l a y therapy as a v i a b l e s t r e s s r e d u c i n g i n t e r v e n t i o n f o r the h o s p i t a l -i z e d p r e - s c h o o l c h i l d . THE STRESSFUL EFFECTS OF HOSPITALIZATION ON THE PRE-SCHOOL CHILD Because o f h i s deve lopmenta l l e v e l , the p r e - s c h o o l c h i l d i s p a r t i c u l a r l y prone to the t r a u m a t i c e f f e c t s o f h o s p i t a l i z a t i o n . H i s growth towards independence i s j u s t b e g i n n i n g and he i s unable to d e a l - 14 -w i th a new and f e a r f u l environment w i thout the cons tan t suppor t o f h i s s i g n i f i c a n t o t h e r s . H i s growing i n t e l l e c t u a l a b i l i t i e s are not yet s u f f i c i e n t f o r him to f u l l y unders tand why h o s p i t a l i z a t i o n must take p l a c e ; h i s s o c i a l competency i s not ye t s o p h i s t i c a t e d enough to d e a l w i th u n f a m i l i a r peop le and new s t r ange r o u t i n e s . E d e l s t o n was one o f the f i r s t to w r i t e about the adverse e f f e c t s o f s e p a r a t i o n from paren t s f o r the young c h i l d . E d e l s t o n s t a t e s t ha t p r o t e c t i o n and a f f e c t i o n from the pa ren t s g i ve young c h i l d r e n a f e e l i n g o f c o n f i d e n c e and s e c u r i t y . Loss o f p a r e n t a l p r o t e c t i o n r e s u l t s i n f e e l i n g s o f r e j e c t i o n or f e a r o f l o s s o f h i s mother.^" Robertson and 2 3 Bowlby e l a b o r a t e on E d e l s t o n ' s i d e a s . ' Both proposed th ree phases o f b e h a v i o u r a l r e sponse s , " p r o t e s t " , " d e s p a i r " , and "detachment " , which are expres sed by the young c h i l d du r ing s e p a r a t i o n . Bowlby h y p o t h e s i z e d tha t a l l t h ree phases are an e x p r e s s i o n o f mourning f o r the l o s t mother. The " p r o t e s t " phase o f weeping and a g g r e s s i o n demonstrates behav iour t h a t may r e s u l t i n mother ' s r e t u r n . The sad behav iou r o f the " d e s p a i r " phase i n d i c a t e s l o s s o f hope f o r a r e u n i o n , and the "detachment" phase w i th seeming ly calm and a c c e p t i n g behav iour i n d i c a t e s an unconsc ious rep roach f o r the mothe r ' s d e s e r t i o n . Bowlby c o n s i d e r s t ha t the s e r i o u s n e s s o f the c h i l d ' s r e a c t i o n ^"H. E d e l s t o n , " S e p a r a t i o n Anx ie t y i n Young C h i l d r e n " . G e n e t i c  P s y c h o l o g i c a l Monograms, XXVI I I : 1943, pp . 3 -95. J . Rober t son , Young C h i l d r e n i n H o s p i t a l s , (London: T a v i s t o c k P u b l i c a t i o n s , 1958) . 3 J o h n Bowlby, " S e p a r a t i o n A n x i e t y . " I n t e r n a t i o n a l J o u r n a l o f  P s y c h o a n a l y s i s , XL I : 1960, pp . 89 -113. 4 b i d . , p. 92. - 15 -depends upon which phase i s r e a c h e d . The f i r s t two phases are r e -v e r s i b l e , but the "detachment" phase may l e a d to l o s s o f emot i ona l c a p a c i t y and have l ong - te rm adverse e f f e c t s on the a b i l i t y to form c l o s e r e l a t i o n s h i p s . Bowlby c o n s i d e r s t h a t "detachment" does not deve lop 5 f o r s e v e r a l months. However, Robertson s t a t e s t ha t even s h o r t - t e r m s e p a r a t i o n s can have long l a s t i n g e f f e c t s . He suggest s t h a t a c h i l d ' s sense o f s e c u r i t y may be s e v e r e l y shaken by a b r i e f l o s s o f ma te rna l care and may r e s u l t i n l ong - te rm d i f f i c u l t b e h a v i o u r . ^ Anna Freud c o n s i d e r s t ha t the s e p a r a t i o n o f a c h i l d from h i s mother i s e s p e c i a l l y s e r i o u s du r ing i l l n e s s . However, her proposed reason f o r the adverse e f f e c t d i f f e r s from those o f Bowlby and R o b e r t -son . She suggest s t ha t a c h i l d c o n s i d e r s h i s mother as the r i g h t f u l owner and p r o t e c t o r o f h i s body, and tha t h i s need f o r e x t r a l o v e , a f f e c t i o n and p h y s i c a l comfort from her i s he i gh tened at t h i s t i m e . She a l s o suggests t ha t i t i s d i f f i c u l t to d i f f e r e n t i a t e the adverse 7 " p s y c h o l o g i c a l e f f e c t s o f the i l l n e s s from those o f s e p a r a t i o n . Or s ten and Mattsson l i k e Anna F reud , propose tha t i l l n e s s and s e p a r a t i o n may i n t e r a c t and tha t the combined upset i s g r e a t e r than e i t h e r i l l n e s s or . . , 8 s e p a r a t i o n a l o n e . A few a u t h o r s , f o r example, Smi th , s t a t e t ha t most c h i l d r e n f a r e very w e l l when sepa ra ted from t h e i r p a r e n t s as long as they have Ib l 'd . , p. 102. ^Rober t son, op . c i t . 7 Anna F r e u d , "The Role o f B o d i l y I l l n e s s i n the Menta l L i f e o f C h i l d r e n . " P s y c h o a n a l y t i c Study o f C h i l d r e n , VI I : 1952, pp. 6 9 - 8 1 . 8 " P. Or s ten and A. Mat t s son, " H o s p i t a l i z a t i o n Symptoms i n C h i l d r e n . " Ac ta P a e d i a c t r i c a , XLIV (August 1955), 79 -92 . - 16 -the companionship o f o ther c h i l d r e n and a d i v e r s i o n such as t e l e v i s i o n . However, Smith does not d i s t i n g u i s h between age, s o c i a l background, g l e n g t h o f h o s p i t a l s tay or s e r i o u s n e s s o f i l l n e s s . Rothman d i s c o u n t s s e p a r a t i o n as the cause o f t rauma. He c o n s i d e r s t h a t the major cause o f upset i s the l i m i t e d and imper sona l c o n t a c t the h o s p i t a l s t a f f has w i th the c h i l d r e n . 1 0 M o n c r i e f f s t a t e s t ha t i f a c h i l d " s e t t l e s down" and does not appear to be unhappy, p s y c h o l o g i s t s c l a i m wi thout p r o o f t ha t the c h i l d i s b r o o d i n g . 1 1 However, the b e h a v i o u r a l c h a r a c t e r i s t i c s o f the c h i l d who has s e t t l e d i n , which are d e s c r i b e d by M o n c r i e f f , are i n d i s t i n g u i s h a b l e from the behav iour o f a c h i l d who i s i n the "detachment" phase d e s c r i b e d by Robertson and Bowlby. M o n c r i e f f , u n l i k e Robertson and Bowlby, does not d e s c r i b e the post h o s p i t a l behav iour i n these c h i l d r e n so h i s s tatement c o u l d be open to doubt . O v e r a l l , i n the l i t e r a t u r e the re i s a w idespread acceptance o f the i dea tha t s e p a r a t i o n c o n t r i b u t e s to p s y c h o l o g i c a l upset both i n h o s p i t a l and a f t e r d i s c h a r g e . However, t he re i s a l a ck o f agreement about whether the upset l a s t s a few weeks or a few months. I t i s a l s o u n c l e a r which v a r i a b l e s are most s i g n i f i c a n t . Age does seem to be im -p o r t a n t and the re may be a c u r v i l i n e a r r e l a t i o n s h i p o f age to p sycho -l o g i c a l u p s e t . In an e a r l y s tudy by Levy the data p o i n t s to more upset R. M. Smi th , " P r e p a r i n g C h i l d r e n f o r A n e s t h e s i a and S u r g e r y . " American J o u r n a l o f D i sease i n C h i l d r e n , C I : (May 1961) pp. 650-653. 1 Q P . E. Rothman, "A Note on H o s p i t a l i s m . " P e d i a t r i c s , X: 0.962), pp. 995-999. 1 : L A . L. M o n c r i e f f , "New Aspect s o f C h i l d C a r e . " South A f r i c a n  M e d i c a l J o u r n a l , XXXI: (1957), pp. 978-981. - 1 7 — 12 i n the young c h i l d . In a s tudy by Prugh, e t a l . the data shows a q u a n t i t a t i v e d i f f e r e n c e i n the upset behav iour d i s p l a y e d by v a r i o u s age groups w i th most upset d i s p l a y e d by c h i l d r e n under 4 year s o f age. The data a l s o i n d i c a t e s an i n c r e a s e i n r e g r e s s i v e behav iou r s i n 13 " t h i s age group on r e t u r n from h o s p i t a l . Anna Freud and Or s ten and Mattsson both c o n s i d e r s e v e r i t y o f i l l n e s s to be an impor tant c o n t r i b -14 15 u t i n g f a c t o r . ' In c o n c l u s i o n the l i t e r a t u r e s t r o n g l y suggests t h a t age, s e p a r a t i o n and s e v e r i t y o f i l l n e s s a l l c o n t r i b u t e to i n c r e a s e the s t r e s s o f h o s p i t a l i z a t i o n . There are however, o the r a g e - r e l a t e d c h a r a c t e r i s t i c s tha t compound the t r a u m a t i c e f f e c t s o f h o s p i t a l i z a t i o n f o r the p r e - s c h o o l c h i l d . The p r e - s c h o o l c h i l d has a poor concept o f t ime and t h i s f a c t o r may c o n t r i b u t e to the upset o f h o s p i t a l i z a t i o n . In e a r l y speech p a t t e r n s , c h i l d r e n r e f e r a lmost e x c l u s i v e l y to t h e i r e x i s t e n c e i n the p re sen t t e n s e . The c h i l d beg ins to use the f u t u r e tense at about 30 months. Y e s t e r d a y , as a r e f e r e n c e to any t ime i n the p a s t , i s a concept tha t seems to appear from about 36 m o n t h s . ^ Spayde s t a t e s t ha t the p r e - s c h o o l e r has d i f f i c u l t y i n d i s t i n g u i s h i n g morning from a f t e r n o o n 12 D. M. Levy, " P s y c h i c Trauma Df Opera t i on s i n C h i l d r e n . " American J o u r n a l o f D i sease i n C h i l d r e n , LXIX: (January 1945) pp . 7 -25 . •^D. G. Prugh, e t . a l . , "A Study of the Emot iona l Reac t i on s o f C h i l d r e n and F a m i l i e s to H o s p i t a l i z a t i o n and I l l n e s s , " American  J o u r n a l o f O r t h o p s y c h i a t r y , XXII I (January 1953), pp . 70-106. 14 Anna F r e u d , Dp. c i t . 15 " P. Or s ten and A. Mat t s son , op . c i t . L. B. Ames, "The Development o f the Sense o f Time i n the Young C h i l d . " J o u r n a l o f G e n e t i c P sycho logy , LXV/III: (1946) pp. 97 -125. - 18 -17 and i n knowing the days o f the week. G e l l e r t expres ses t h i s b e l i e f and c o n s i d e r s t ha t f o r the young c h i l d i n h o s p i t a l , unab le to c o n -c e p t u a l i z e f u t u r e or pas t t ime c l e a r l y , hours and days drag on i n -t e r m i n a b l y . The p r e - s c h o o l c h i l d ' s r ea son ing c a p a c i t y i s s t i l l ve ry l i m i t e d and h i s i n t e r p r e t a t i o n o f the su r round ing environment i s f r e q u e n t l y i l l o g i c a l and u n r e a l i s t i c . P i a ge t c o n s i d e r s t ha t between the ages o f two and f o u r , the c h i l d e n t e r s a p e r i o d o f c o g n i t i v e development known as p r e - c o n c e p t u a l thought . Dur ing t h i s s t a ge , the c h i l d l e a r n s to d i f f e r e n t i a t e words and images from o b j e c t s or events to which the words or images r e f e r . T h i s development o f s ymbo l i c f u n c t i o n i n g i s seen most c l e a r l y i n c h i l d r e n ' s p l ay behav iour when the c h i l d can c r e a t e menta l images of o b j e c t s which are not p h y s i c a l l y p r e s e n t . A l though symbo l i c f u n c t i o n i n g i n c r e a s e s the c h i l d ' s i n t e l l e c t u a l a b i l i t y h i s mode o f 19 thought i s s t i l l immature. In the p e r i o d o f p r e - c o n c e p t u a l thought , P i a g e t c o n s i d e r s r e a s o n i n g to be " t r a n s d u c t i v e " r a t h e r than deduc t i ve or i n d u c t i v e . In t h i s type o f r e a s o n i n g , the c h i l d moves from the p a r t i c u l a r to the p a r t i c u l a r w i thout t ouch ing on the g e n e r a l . T r a n s d u c t i v e r ea son ing f i n d s a r e l a t i o n s h i p between two c o n c r e t e i tems where there i s none. P i a ge t quotes from h i s daughter L u c i e n n e : "I h a v e n ' t had my nap so i t i s n ' t a f t e r n o o n . " As Luc ienne u s u a l l y had a 17 P. E. Spayde, " K i n d e r g a r t e n C h i l d r e n ' s F a m i l i a r i t y w i th Measurement." E d u c a t i o n a l Research B u l l e t i n , XXXII: 1953), pp. 234-238. 18 E l i z a b e t h G e l l e r t , "Reduc ing the Emot iona l S t r e s s o f H o s p i t a l -i z a t i o n f o r C h i l d r e n . " American J o u r n a l o f O c c u p a t i o n a l T h e r a p y y XI I : (May-June 1958) pp . 125-129. 19 Jean P i a g e t , P l a y , Dreams and I m i t a t i o n i n C h i l d h o o d . (New York: U. Ul. Norton C o . , 1951) . - 19 -nap i n the a f t e r n o o n she saw a d i r e c t r e l a t i o n s h i p between the two 20 event s and conc luded tha t one event depended on the o t h e r . The p r e -s c h o o l e r and even the e a r l y s choo l - a ge c h i l d w i l l r e l a t e two events on ly because they occur at the same t i m e . T h i s can g r e a t l y i n c r e a s e the l i k e l i h o o d o f m i s concep t i on s and u n r e a l i s t i c f e a r s i n the h o s p i t a l i z e d c h i l d o f t h i s age. T e s l e r and Hardgrove emphasize the importance o f under s t and ing t r a n s d u c t i v e thought when p r e p a r i n g the c h i l d f o r p r o -c e d u r e s . They s t a t e : "We make cause and e f f e c t c o n n e c t i o n s f o r the c h i l d knowing tha t h i s i n e x p e r i e n c e might o therw i se l e a d him to f a u l t y and f r i g h t e n i n g c o n c l u s i o n s . " 2 1 P i age t c o n s i d e r s another c h a r a c t e r i s t i c o f the p r e - c o n c e p t u a l p e r i o d to be "egocentr ism!!? The c h i l d sees the wor ld from h i s own p o i n t o f view and i s unable to put h i m s e l f i n another p e r s o n ' s s i t u -22 a t i o n . T h i s " e g o c e n t r i c " q u a l i t y i s p a r t o f the c h i l d ' s l anguage. P i age t b e l i e v e s t ha t the c h i l d ' s language, e s p e c i a l l y i n the years from k to 6, does not always se rve the f u n c t i o n o f communicat ion. F r e q u e n t l y , the c h i l d does not assume the p o i n t o f view o f the l i s t e n e r who r e q u i r e s 23 i n f o r m a t i o n , but t a l k s o f h i m s e l f , to h i m s e l f , and by h i m s e l f . T h i s q u a l i t y o f language makes i t very d i f f i c u l t f o r the p r e - s c h o o l c h i l d to a c c u r a t e l y v e r b a l i z e h i s f e e l i n g s about h o s p i t a l i z a t i o n . 20 P i a g e t , op . c i t . , p. 232. 21 Mary T e s l e r and C a r o l Hardgrove, " C a r d i a c C a t h e t e r i z a t i o n : P r e p a r i n g the C h i l d . " American J o u r n a l o f Nurs ing LXXI I I : (January 1973) p. 82. 22 Jean P i a g e t , The C h i l d ' s C o n s t r u c t i o n o f R e a l i t y , (London: Rout ledge and Kegan L t d . , 1955) . 23 Jean P i a g e t , The Language and the Thought of the C h i l d , (London: Rout ledge and Kegan L t d . , 1926) . - 2 0 - -The e n t i r e theme o f t h r e a t s to body i n t e g r i t y and i n t r u s i v e t rea tments seems to generate f e a r i n the p r e - s c h o o l c h i l d . F l o r e n c e E r i c k s o n s t a t e s : In a d d i t i o n to s e p a r a t i o n a n x i e t y , p r e - s c h o o l c h i l d r e n have i n t e n s e f e a r s o f body m u t i l a t i o n . . . Very l i t t l e i s known about c h i l d r e n ' s i n t e r p r e t a t i o n s o f i n t r u s i v e p r o c e d u r e s , and tha t has been g leaned i n r e t r o s p e c t by a n a l y s t s or through the sympathy o f doc to r s and nurses who have observed h o s p i t a l i z e d c h i l d r e n ' s p l a y and emot iona l r e a c t i o n s . * k E r i k E r i k s o n d e s c r i b e s the moda l i t y o f behav iour i n the p r e - s c h o o l c h i l d as " i n t r u s i v e " . He s t a t e s : They are dominated by the i n t r u s i v e mode. They i n t r u d e i n t o o t h e r bod ie s by p h y s i c a l a t t a c k : i n t o o the r p e o p l e s ' ea r s and minds by a g g r e s s i v e t a l k i n g ; i n t o space by v i go rous l o c o m o t i o n ; i n t o the unknown by consuming c u r i o s i t y . 2 5 F u j i t a b e l i e v e s t h a t : C h i l d r e n are i n t e n s e l y i n t e r e s t e d i n min ima l d i f f e r e n c e s between themselves and o t h e r s . C h i l d r e n ^5 are most p e r c e p t i v e o f body i n t e g r i t y and i t s s u r f a c e s . A c t u a l a s s a u l t s to body i n t e g r i t y such as s c a r s and even bandages and c a s t s , may i n s p i r e f e a r s o f m u t i l a t i o n and punishment i n the p r e - s c h o o l c h i l d . As these c h i l d r e n are i n the phase o f " e g o c e n t r i s m " d e s c r i b e d by P i a g e t , they tend to see o the r p e o p l e s ' a t t i t u d e s and a c t i o n s as r e f l e c t i o n s o f t h e i r own f e e l i n g s and, t h e r e f o r e , may p e r c e i v e any 24 F l o r e n c e E r i c k s o n , " Reac t i on s o f C h i l d r e n to H o s p i t a l E x p e r i -e n c e " . Nur s ing Out look , VI : (September 1958) p. 501. 25 E r i k E r i k s o n , Ch i l dhood and S o c i e t y (Rev i sed E d i t i o n , New York : Id. Id. Norton C o . , 1950) pp. 194-195. 26 M i l t o n F u j i t a , "The Impact o f I l l n e s s o r Surgery on the Body Image o f the C h i l d . " Nurs ing C l i n i c s o f North Amer i ca , V I I : (December 1972) p. 641. - 21 -h o s p i t a l p rocedure or t reatment as a h o s t i l e a c t . R i d d l e says t ha t when the c h i l d ' s t a c t i l e , k i n e s t h e t i c , and v i s u a l p e r c e p t i o n s are decreased he may be unable to d e f i n e h i s body boundary and h i s l o c a t i o n i n s p a c e . She s t a t e s : In many i n s t a n c e s , the on l y ev idence a c h i l d may have t h a t something has happened to him i s the presence o f a bandage a f t e r he wakes from the p e r p l e x i n g s l e e p o f a n e s t h e s i a and the expe r i ence o f u n u s u a l , o f t e n p a i n f u l , p e r c e p t i o n s o f a s p e c i f i c body p a r t . . . In a l l i n s t a n c e s , body image d i s t o r t i o n i s most c e r t a i n l y m a g n i f i e d by the c h i l d ' s f a n t a s y o f what he does not comprehend.27 For the p r e - s c h o o l e r , i m a g i n a t i o n , f a n t a s y , and g u i l t are i n t e r t w i n e d . E r i k E r i k s o n b e l i e v e s : Because o f f a n t a s i e s and imag in ings Df an D e d i p a l nature tha t the c h i l d may engage i n , he may i n c u r a deep sense o f g u i l t . He beg in s a u t o m a t i c a l l y to f e e l g u i l t y even f o r mere thoughts and deeds nobody has m a t c h e d . 2 8 T h i s sense o f g u i l t may a l l ow the c h i l d to i n t e r p r e t any u n e x p l a i n e d or mi sunders tood s e p a r a t i o n s as punishment. Woodward and Jackson p o i n t out t h a t the young c h i l d tends to f e e l t ha t h o s p i t a l i z a t i o n r e p r e s e n t s l o s s o f l ove because o f d i s o b e d i e n c e , and t h a t any unp leasant 29 e x p e r i e n c e s are a punishment f o r h i s w i ckednes s . A l though the p r e - s c h o o l e r i s a c t i v e l y s t r i v i n g f o r independence 27 I rene R i d d l e , "Nur s i ng I n t e r v e n t i o n s to Promote Body Image I n t e g r i t y i n C h i l d r e n " . Nur s ing C l i n i c s o f North Amer i ca , V I I : (December 1972) pp . 665-656. 2fl E r i k s o n , op. c i t . p. 195. 29 Woodward and D. Jack son , "Emotion Reac t i on s i n Burned C h i l d r e n a n d t t h e i r M o t h e r s " . B r i t i s h J o u r n a l o f P l a s t i c Su rgery , X I I I : 1961, pp . 316-324. - 22 -and s o c i a l s k i l l s , he has on l y r e c e n t l y ga ined c o n t r o l o f v a r i o u s b o d i l y f u n c t i o n s . He takes p r i d e i n the s k i l l s he has mastered and i n h i s growing independence. In h o s p i t a l , h i s a b i l i t y to c o n t r o l h i s l i f e i s taken from him and he i s t h r u s t back i n t o a dependent r o l e . Woodward and Jackson note tha t a young c h i l d i n h o s p i t a l g e n e r a l l y f e e l s he has l i t t l e c o n t r o l over h i s environment and h i m s e l f . They suggest tha t the c h i l d t r i e s to cope w i th t h i s l o s s o f c o n t r o l by such behav iou r s as tant rums, r e f u s a l to e a t , r e f u s a l to t a l k , or by r e -g r e s s i o n to more i n f a n t i l e b e h a v i o u r s . " 5 0 Parent s are s t i l l v iewed by the p r e - s c h o o l e r as p r e s t i g i o u s , power fu l and the u l t i m a t e a u t h o r i t y i n h i s w o r l d . In the h o s p i t a l s i t u a t i o n the parent can no l onger p r o t e c t the c h i l d from harm. S t r a n g e r s i n f l i c t s t range t r e a t m e n t s , and the parent s tands by h e l p -l e s s l y . O ' C o n n e l l and Brandt i n d i c a t e t ha t the c h i l d may be upset when h i s pa rent i s p re sen t because o f the d i s i l l u s i o n m e n t and h o s t i l i t y a r i s i n g when he d i s c o v e r s t ha t the p a r e n t , whom he f e l t was a l l power-f u l , cannot p r o t e c t h i m . 3 1 Woodward and Jackson a l s o p o i n t out t h a t the young c h i l d cannot unders tand why pa ren t s can not c o n t r o l c e r t a i n s i t u a t i o n s . The c h i l d may b e l i e v e tha t because pa ren t s a l l ow u n -32 p l e a s a n t t h i n g s to happen to him they no l onger l o v e h im. The normal p r e - s c h o o l e r i s an e n e r g e t i c p h y s i c a l l y v i go rous b e i n g . The day i s taken up w i th r u n n i n g , jumping, and o ther k i n e t i c Woodward, Jack son , dp . c i t . , p. 323. 3 1 E . O ' C o n n e l l and P. B rand t , " L i b e r a l V i s i t i n g Hours f o r P a r e n t s " , American J o u r n a l o f N u r s i n g , LX: (June 1960) pp. 812-815. 32 Woodward, Jackson , op . c i t . , p. 323. - 23 -a c t i v i t i e s . Even p r e - s c h o o l c h i l d r e n who are p h y s i c a l l y handicapped m i l l engage i n t h i s type o f a c t i v i t y as long as t h e i r p h y s i c a l c a p a c i t y a l l o w s . When a c h i l d i s h o s p i t a l i z e d h i s p h y s i c a l a c t i v i t y i s u s u a l l y c u r t a i l e d . Vernon s t a t e s t ha t these l i m i t a t i o n s on g e n e r a l motor a c t i v i t y are f r u s t r a t i n g f o r the p r e - s c h o o l e r and deny him a n a t u r a l o u t l e t f o r aggress ions . " 3 " 3 In summary, t he re are a number o f t h e o r i e s and s t u d i e s which s u b s t a n t i a t e the i d e a t h a t h o s p i t a l i z a t i o n i s p s y c h o l o g i c a l l y up -s e t t i n g f o r the p r e - s c h o o l e r . There are a l s o s e v e r a l w e l l documented c h a r a c t e r i s t i c s r e l a t e d to deve lopmenta l l e v e l which c o n t r i b u t e to t h i s u p s e t . These a r e : s e p a r a t i o n , s e r i o u s n e s s o f i l l n e s s , a poor concept o f t i m e , l i m i t e d r e a s o n i n g c a p a c i t y , l i m i t e d communicat ion s k i l l s , f e a r o f i n t r u s i v e t rea tment and t h r e a t s to body i n t e g r i t y , a l i v e l y i m a g i n a t i o n and a sense o f g u i l t , l o s s o f r e c e n t l y ga ined i n -dependence, l o s s o f p a r e n t a l p r o t e c t i o n and l i m i t a t i o n s i n g e n e r a l motor a c t i v i t y . The degree to which s p e c i f i c c h a r a c t e r i s t i c s c o n -t r i b u t e to upset i s u n c l e a r , a l though s e p a r a t i o n and s e r i o u s n e s s o f i l l n e s s seem to be impor tant v a r i a n t s . The q u e s t i o n has been r a i s e d by Vernon and Shulman tha t h o s p i t a l i z a t i o n may be b e n e f i c i a l to some c h i l d r e n ; t ha t mas ter ing the s t r e s s o f h o s p i t a l i z a t i o n may promote 34 m a t u r i t y . There i s no c l e a r ev idence on t h i s i s s u e and i n a l a t e r D. Vernon and A. F o l e y , The P s y c h o l o g i c a l Responses o f  C h i l d r e n to H o s p i t a l i z a t i o n and I l l n e s s , ( S p r i n g f i e l d , I l l i n o i s , C h a r l e s C. Thomas, 1965) p. 70 . D. Vernon and J . Shulman, " H o s p i t a l i z a t i o n as a Source o f P s y c h o l o g i c a l B e n e f i t to C h i l d r e n . " P e d i a t r i c s , XXXIV: 1964, pp. 694-696. - 2k -35 study by Vernon et a l . t h i s i d e a i s not s u b s t a n t i a t e d . T h i s does not negate the b e l i e f t ha t h o s p i t a l i z a t i o n can be b e n e f i c i a l , on l y t ha t the c h a r a c t e r i s t i c s o f the expe r i ence which l e a d to b e n e f i t have not been f u l l y i d e n t i f i e d . Some r e s e a r c h has been c a r r i e d out i n v e s t i g a t i n g v a r i o u s ways i n which s p e c i f i c adverse e f f e c t s o f h o s p i t a l i z a t i o n can be i n s t i g a t e d . T h i s i s d i s c u s s e d i n the f o l l o w i n g s e c t i o n . REVIEW OF SELECTED RESEARCH STUDIES INVESTIGATING THE HOSPITALIZATION OF PRE-SCHOOLERS In t h i s s e c t i o n s e l e c t e d s t u d i e s i n v e s t i g a t i n g some adverse e f f e c t s o f h o s p i t a l i z a t i o n f o r the p r e - s c h o o l c h i l d w i l l be d i s c u s s e d . Some i n t e r v e n t i o n s which may a l l e v i a t e the p s y c h o l o g i c a l trauma o f h o s p i t a l i z a t i o n are a l s o d i s c u s s e d . An e a r l y s tudy conducted by Mahaffy i d e n t i f i e d the problem tha t c h i l d r e n i n h o s p i t a l become anxious and f r i g h t e n e d and t h a t t h e i r a n x i e t y i n c r e a s e s as t h e i r mother ' s care i s wi thdrawn. He a l s o i d e n t i -f i e d the problem tha t p a r e n t s ' a n x i e t y i n c r e a s e s when they leave t h e i r c h i l d a lone i n h o s p i t a l and when they are unable or u n c e r t a i n hDw to c a r r y out normal p a r e n t a l f u n c t i o n s i n the h o s p i t a l s e t t i n g . Mahaffy p o s t u l a t e d tha t i f p a r e n t a l a n x i e t y c o u l d be reduced , then the c h i l d ' s a n x i e t y would a l s o d e c r e a s e . In t h i s s tudy the method used to decrease p a r e n t a l a n x i e t y was termed " e x p e r i m e n t a l n u r s i n g " , t ha t i s a s i n c e r e warm acqua in tance between the pa ren t s and the nurse which p e r m i t t e d them D. Vernon e t a l . , "Changes i n C h i l d r e n ' s Behav iour a f t e r H o s p i t a l i z a t i o n . " American J o u r n a l o f D i sease i n C h i l d r e n , I I I : (June 1966) pp . 581-593. - 25 -36 to communicate F r e e l y w i th each o t h e r . The r e s u l t s o f Maha f f y ' s s tudy suppor t s the h y p o t h e s i s t ha t a warm r e l a t i o n s h i p between the n u r s i n g s t a f f and the pa ren t s r e s u l t s i n a decrease i n the c h i l d ' s anx i e t y i n h o s p i t a l . However, a p o s t - h o s p i t a l q u e s t i o n n a i r e l i s t i n g v a r i o u s r e -g r e s s i v e behav iou r s common to p r e - s c h o o l e r s r e v e a l e d t h a t both the e x p e r i m e n t a l group and the c o n t r o l group demonstrated some r e g r e s s i v e behav iour s on r e t u r n home. I t would seem t h a t one i n t e r v e n t i o n which reduces the p a r e n t s ' and the c h i l d ' s a n x i e t y i n h o s p i t a l does not p r e -vent the o c c u r r e n c e o f p o s t - h o s p i t a l upset i n the c h i l d . Vernon e t a l . conducted a s tudy i n v e s t i g a t i n g and d e f i n i n g p o s t -37 h o s p i t a l b e h a v i o u r a l change. They deve loped a p o s t - h o s p i t a l i z a t i o n q u e s t i o n n a i r e . c o n s i s t i n g o f 27 i tems d e r i v e d from symptoms ment ioned i n s i x p r e v i o u s s t u d i e s . F a c t o r ana l y se s o f the 27 i tems r e v e a l e d 6 c a t e g o r i e s o f upset b e h a v i o u r : g e n e r a l a n x i e t y and r e g r e s s i o n ; s e p a r -a t i o n a n x i e t y ; a n x i e t y about s l e e p ; e a t i n g d i s t u r b a n c e s ; a g g r e s s i o n ; and a p a t h y - w i t h d r a w a l . The q u e s t i o n n a i r e has been used i n two o t h e r 38 39 s t u d i e s by C a s s e l l and A z a r n o f f . ' The data c o l l e c t e d du r ing the Per ry R. Mahaffy, J r . , "The E f f e c t s o f H o s p i t a l i z a t i o n on C h i l d r e n Admit ted f o r Tons i l e c tomy and Adeno idectomy. " Nurs ing Research XIV: (Winter 1965) pp . 12 -19 . 37 Dav id Vernon, e t a l . , "Changes i n C h i l d r e n ' s Behav iour a f t e r H o s p i t a l i z a t i o n . " American J o u r n a l o f D i sease i n C h i l d r e n , I I I : (June 1966) pp. 581-593. 38 S. E. C a s s e l , "The E f f e c t o f B r i e f Puppet Therapy upon the Emot iona l Responses o f C h i l d r e n Undergoing C a r d i a c C a t h e t e r i z a t i o n . " Unpub l i shed D o c t o r a l D i s s e r t a t i o n , Northwestern U n i v e r s i t y , Ch icago , 1963. 39 P. A z e r n o f f e t a l . , The P r e p a r a t i o n o f C h i l d r e n f o r H o s p i t a l -i z a t i o n . A N a t i o n a l I n s t i t u t e o f Menta l H e a l t h Gran t , #22856, D e p a r t -ment o f P e d i a t r i c s , U n i v e r s i t y o f C a l i f o r n i a , Los Ange le s , 1975. - 26 -Vernon s tudy con f i rmed the h y p o t h e s i s t h a t c h i l d r e n from 6 months to 4 year s are most l i k e l y to be upset f o l l o w i n g h o s p i t a l i z a t i o n . A r e l a t i o n -sh i p was demonstrated between l eng th of h o s p i t a l s t ay and degree o f upset s u f f e r e d . The data d i d not r e v e a l a s i g n i f i c a n t d i f f e r e n c e i n 40 response r e l a t e d to the sex o f the c h i l d . U o l f e r and V i s i n t a i n e r conducted two e x t e n s i v e s t u d i e s i n v e s t i g -a t i n g the p s y c h o l o g i c a l p r e p a r a t i o n Df c h i l d r e n f o r h o s p i t a l i z a t i o n and f o r minor s u r g e r y . The f i r s t s tudy con f i rmed the h y p o t h e s i s t ha t c h i l d r e n and pa ren t s who r e c e i v e s y s t e m a t i c p s y c h o l o g i c a l p r e p a r a t i o n f o r h o s p i t a l i z a t i o n and con t i nued s u p p o r t i v e c a r e , would show l e s s upset b e h a v i o u r , more c o o p e r a t i o n , and l e s s p o s t - h o s p i t a l upset than pa ren t s and c h i l d r e n who were not p r e p a r e d . T h i s s tudy i s i n agreement w i th the f i n d i n g s o f o the r s t u d i e s i n t ha t low p a r e n t a l a n x i e t y i s a f a c t o r i n d e c r e a s i n g the c h i l d ' s a n x i e t y , and tha t p r e p a r a t i o n f o r 41 su rgery reduces the c h i l d ' s a n x i e t y . The second study by V i s i n t a i n e r and Wo l fe r based on the r e s u l t s o f the f i r s t s t udy , proposed the h y p o t h e s i s t h a t i f the c h i l d and pa ren t s were g i ven p r e p a r a t i o n and i n f o r m a t i o n b e f o r e su rgery and a l s o b e f o r e o ther s t r e s s f u l p r o c e d u r e s , t he re would be a g r e a t e r decrease i n the c h i l d ' s a n x i e t y . The age range o f the c h i l d r e n i n the s tudy was from 3 to 12 y e a r s , and su rgery was m inor . P lay was used e x t e n s i v e l y i n p r e p a r i n g the p r e - s c h o o l c h i l d r e n f o r su r ge ry and p r o c e d u r e s . The data con f i rmed the h y p o t h e s i s tha t the combina t ion o f p r e p a r a t i o n f o r su rgery 40 Vernon, bp . b i t . , pp . 591-592. 41 John Wo l fer and Madelon V i s i n t a i n e r , " P e d i a t r i c S u r g i c a l P a t i e n t s ' and P a r e n t s ' S t r e s s Responses and Ad ju s tmen t . " Nurs ing  Research XXIV: ( J u l y - A u g u s t 1975) pp . 244-255. - 27 -and p rocedures p l u s c o n s i s t e n t s u p p o r t i v e ca re was s u p e r i o r i n r e d u c i n g 42 s t r e s s over c o n s i s t e n t s u p p o r t i v e care a l o n e . T h i s s tudy emphasizes the e f f e c t i v e n e s s o f i n f o r m a t i o n - g i v i n g i n r e d u c i n g a n x i e t y i n the c h i l d and the p a r e n t s . I t a l s o suppor t s the theory t ha t p l a y i s a u s e f u l t o o l i n t e a c h i n g young c h i l d r e n . Johnson et a l . used puppet therapy as a t e a c h i n g t o o l to p repare an e x p e r i m e n t a l group o f c h i l d r e n f o r h o s p i t a l i z a t i o n and minor s u r g e r y . The h y p o t h e s i s t h a t puppet therapy b e f o r e su rgery would reduce a n x i e t y 43 was c o n f i r m e d . T h i s s tudy suppor t s C a s s e l l ' s f i n d i n g s t h a t puppet 44 therapy b e f o r e s u r g i c a l e x p e r i e n c e s reduces a n x i e t y f o r c h i l d r e n . The age range o f the c h i l d r e n i n both s t u d i e s was 5 year s to 8 y e a r s . Aga in both s t u d i e s support o the r l i t e r a t u r e tha t suggest p r e - o p e r a t i v e p r e p a r a t i o n i s one way to reduce a c h i l d ' s a n x i e t y . Both s t u d i e s w i th 45 tha t o f V i s i n t a i n e r and Wo l fer , suppor t the concept t ha t p l ay i s a u s e f u l t o o l which can f a c i l i t a t e the t r a n s f e r o f i n f o r m a t i o n to the p r e -s c h o o l c h i l d . Vredevoe et a l . conducted a study i n v e s t i g a t i n g the degree o f a g g re s s i ve p o s t - h o s p i t a l p l ay responses i n h o s p i t a l i z e d p r e - s c h o o l e r s , 42 Madelon V i s i n t a i n e r and John W o l f e r , " P s y c h o l o g i c a l P r e p a r -a t i o n f o r S u r g i c a l P e d i a t r i c P a t i e n t s : The E f f e c t on C h i l d r e n ' s and P a r e n t s ' S t r e s s Responses and Ad ju s tmen t . " P e d i a t r i c s , LV I : (August 1975) pp. 187-202. 43 P a t r i c i a Johnson e t a l . , " E f f e c t s o f Puppet Therapy on Palmer Sweat ing o f H o s p i t a l i z e d C h i l d r e n . " John Hopkins M e d i c a l J o u r n a l , CXXXVII: ( J u l y 1975) pp. 1-5. 44 C a s s e l l , bp . c i t . , 1963. V i s i n t a i n e r and W o l f e r , bp . c i t . , pp . 187-202. - 28 -46 age 4 to 5 y e a r s , who had minor s u r g e r y . The p l ay responses o f these c h i l d r e n were compared wi th h o s p i t a l i z e d c h i l d r e n who d i d not have su rge ry and w i th n o n - h o s p i t a l i z e d c h i l d r e n . The data d i d not c o n f i r m the h y p o t h e s i s tha t p r e - s c h o o l e r s ' p l ay was more a g g r e s s i v e a f t e r s u r g e r y . The p l ay equipment used d i d not r e p r e s e n t h o s p i t a l equipment. wooden d o l l s r e p r e s e n t i n g a f a m i l y , a ca t and dog, wooden b l o c k s , a te lephone and a dump t r u c k were p r e s e n t e d to each c h i l d . Us ing t h i s p l ay m a t e r i a l the h o s p i t a l i z e d c h i l d r e n s ' p l a y was d e s c r i b e d as l e s s than f r e e and spontaneous. Moustakas has noted tha t p l a y immedia te ly 47 a f t e r a c r i s i s tends to be s e r i o u s and q u i e t e r . I t may be tha t the p l ay behav iour t h a t o c c u r s , u s i ng o r d i n a r y t o y s , t a k i n g p l a c e immediate ly a f t e r s u r g e r y , i n a new env i ronment , and w i t h new p e o p l e , would not r e -f l e c t s t r o n g emot ions . A more i n t e r e s t i n g q u e s t i o n about pos t s u r g i c a l p l ay would seem to be, not whether i t i s more a g g r e s s i v e than normal p l ay but what k i n d o f post s u r g i c a l p l ay i s d i s p l a y e d by p r e - s c h o o l c h i l d r e n . I t would a l s o be i n t e r e s t i n g to i n v e s t i g a t e the con ten t o f t h i s p l a y . O v e r a l l , the data from the s t u d i e s d i s c u s s e d suppor t s the b e l i e f t ha t c h i l d r e n do s u f f e r from p s y c h o l o g i c a l upset a f t e r h o s p i t a l i z a t i o n . The data a l s o s t r o n g l y suggests t ha t r e d u c i n g p a r e n t a l a n x i e t y i s a f a c t o r i n d e c r e a s i n g the c h i l d ' s a n x i e t y . The s t u d i e s support the i d e a t h a t both i n f o r m a t i o n g i v i n g and t e a c h i n g about p rocedures r e -duces a n x i e t y i n the pa ren t s and the c h i l d . The data a l s o suppor t s the i d e a t ha t toys and puppets seem to be u s e f u l t o o l s which can f a c i l i t a t e Donna L. Vredevoe et a l . , "Agg re s s i ve P o s t - O p e r a t i v e P lay Responses o f H o s p i t a l i z e d P r e - S c h o o l C h i l d r e n . " Nur s ing Research  Repor t , IV: No. 2, p. 1, pp. 4 - 5 . C l a r k Moustakas, C h i l d r e n i n P lay Therapy (New York: B a l l a n t i n e Books 1953) p. 7. - 29 -a c h i l d ' s under s t and ing o f su rgery and h o s p i t a l i z a t i o n . P l ay a l s o seems to enhance the communication p roces s w i th p r e - s c h o o l c h i l d r e n . SELECTED THEORIES OF PLAY In t h i s cen tu ry a number o f p s y c h o l o g i s t s have at tempted to e x p l a i n the u n d e r l y i n g dynamics o f c h i l d r e n ' s p l a y . The p sycho -a n a l y t i c i n t e r p r e t a t i o n o f p l a y b e h a v i o u r , p r i m a r i l y i n the w r i t i n g s o f Sigmund Freud and E r i k E r i k s o n , i s t h a t one purpose o f p l ay i s c a t h a r t i c . That i s , the c a t h a r t i c theory i n t e r p r e t s p l ay as r e f l e c t i n g the c h i l d ' s attempt to master s i t u a t i o n s t ha t at f i r s t , are too much f o r h im. From ,the deve lopmenta l s c h o o l o f p s y c h o l o g i c a l t h e o r y , P i a ge t b e l i e v e s t h a t p l a y i s c l o s e l y bound up w i t h growth o f i n t e l l i g e n c e . He a l s o b e l i e v e s t h a t r e p e t i t i v e p l a y , e s p e c i a l l y o f s t r e s s f u l e v e n t s , he lp s the c h i l d a s s i m i l a t e a s i t u a t i o n , thereby g a i n i n g a b e t t e r u n d e r -s t a n d i n g o f the e v e n t . Sigmund Freud suggests t h a t c h i l d r e n ' s p l a y behav iou r s dD not occur by chance bu t , l i k e a l l o ther human b e h a v i o u r s , are determined by the i n d i v i d u a l ' s f e e l i n g s and emot ions . O r i g i n a l l y Freud wrote tha t p l ay i s mot i va ted by the " p l e a s u r e p r i n c i p l e " . That i s , p l ay i s sought a f t e r because the behav iour b r i n g s p l e a s u r e . From o b s e r v a t i o n o f c h i l d r e n at p l a y , he determined tha t they use o b j e c t s and s i t u a t i o n s from t h e i r r e a l wor ld but t h a t i n p l ay c h i l d r e n a l t e r events so t ha t re -enactment i s more p l e a s i n g and g r a t i f y i n g than the r e a l e v e n t . With con t i nued o b s e r v a t i o n Freud observed t h a t t h i s assumption d i d not e x p l a i n why c h i l d r e n f r e q u e n t l y repea t unp leasan t e x p e r i e n c e s i n p l a y . He b e l i e v e d tha t a l l organisms t r y to keep l e v e l s o f nervous t e n s i o n as low as p o s s i b l e . He t h e r e f o r e p o s t u l a t e d t h a t c o n f l i c t s were r e - v peated i n p l ay because r e p e t i t i o n reduces the exc i tement which had been - 30 -a rou sed . He emphasized tha t by r e p e t i t i o n i n p l a y , the c h i l d can master d i s t u r b i n g events by a c t i v e l y t a k i n g pa r t i n the event i n s t e a d 48 o f be ing a p a s s i v e p a r t i c i p a n t . F r e u d ' s view o f c h i l d r e n s ' p l ay has d i r e c t l y i n f l u e n c e d v a r i o u s forms o f t h e r a p e u t i c i n t e r v e n t i o n s which u t i l i z e p l a y both as a form o f c a t h a r s i s and as a means o f i d e n t i f y i n g event s t ha t may t r o u b l e a c h i l d . E r i k E r i k s o n f o l l o w s the p s y c h o a n a l y t i c t r a i n o f thought . He s t a t e s tha t p l ay attempts to s y n c h r o n i z e b o d i l y and s o c i a l p roce s se s w i t h i n the s e l f . He b e l i e v e s t ha t p l ay h e l p s the c h i l d a d j u s t to the demands o f e x t e r n a l r e a l i t y . E r i k s o n d i s t i n g u i s h e s t h ree s tages o f p l ay development: " a u t o s p h e r e " p l ay which i s the i n f a n t ' s e x p l o r a t i o n of s e n s u a l p e r c e p t i o n s ; " m i c r o s p h e r e " p l ay which i n c l u d e s the c h i l d ' s i n t e r a c t i o n w i th manageable toy s and p r o v i d e s him w i th the o p p o r t u n i t y to p r o j e c t i n n e r c o n f l i c t s upon p l a y t h i n g s ; and f i n a l l y "macrosphere" p l ay which b r i n g s the c h i l d i n t o s o c i a l c o n t a c t w i th o ther c h i l d r e n or a d u l t s and i s t y p i c a l p l ay behav iour o f the p r e - s c h o o l c h i l d . T h i s p l ay i n v o l v e s r e - e n a c t i n g v a r i o u s s o c i a l r o l e s and seek ing out s o c i a l b e -49 h a v i o u r s a p p r o p r i a t e i n the r e a l w o r l d . E r i k s o n b e l i e v e s t h a t the c h i l d needs s o l i t a r y p l ay w i th toys i n the presence o f a sympathet i c a d u l t . He s t a t e s : S o l i t a r y p l a y remains an i n d i s p e n s i b l e harbour f o r the o v e r h a u l i n g o f s h a t t e r e d emotions a f t e r p e r i o d s o f rough go ing i n the s o c i a l seas . . .50 Sigmund F reud , Beyond the P l e a s u r e P r i n c i p l e , XVI I I : (London: Hogarth P r e s s , 1955) . E r i k E r i k s o n , Ch i l dhood and S o c i e t y , (Rev i sed E d i t i o n , New York: Id. Id. Norton C o . , 1950) . I b i d . , p. 194. - 31 -He a l s o b e l i e v e s t ha t the most f a v o u r a b l e c o n d i t i o n f o r p l ay therapy i s t h a t : . . . the c h i l d has the toys and the a d u l t f o r h i m s e l f , and tha t s i b l i n g r i v a l r y , p a r e n t a l nagg ing , or any k i n d o f sudden i n t e r r u p t i o n does not d i s t u r b the u n -f o l d i n g p l ay i n t e n t i o n s , whatever they may b e . For to " p l a y i t o u t " i s the most n a t u r a l s e l f - h e a l i n g measure c h i l d h o o d a f f o r d s . E r i k E r i k s o n emphasizes the s e l f - c u r a t i v e t r e n d i n spontaneous p l ay and c o n s i d e r s t h a t p l ay therapy can make use o f t h i s s e l f - c u r a t i v e p r o v e s s . P i a ge t d e s c r i b e s the p l ay behav iour o f c h i l d r e n 2 to 7 years o l d as s y m b o l i c , or make -be l i eve p l a y . He p o s t u l a t e s t h a t a s s i m i l a t i o n , the p roces s by which an organism i n t e r n a l i z e s i n f o r m a t i o n from the o u t s i d e w o r l d , and accommodation, the p roces s by which an organism a d j u s t s to the r e a l i t y o f the e x t e r n a l w o r l d , are both u t i l i z e d i n symbo l i c p l a y . He d i s t i n g u i s h e s s ymbo l i c p l a y from mere i m i t a t i o n : I f s ymbo l i c p l a y uses i m i t a t i o n , i t i s e x c l u s i v e l y as a s ymbo l i c i n s t r u m e n t . T h i s f o l l o w s because the re are on l y two ways tha t an absent s i t u a t i o n can be r e p r e s e n t e d ; i t can e i t h e r be d e s c r i b e d by language or evoked by i m i t a t i v e ge s tu re s or images. T h i s i n no way means, however, t ha t s ymbo l i c p l a y can be reduced to i m i t a t i o n s i n c e p l a y i s e x c l u s i v e l y an a s s i m i l a t i o n o f r e a l i t y tD the s e l f . - ^ 2 P i age t d i s t i n g u i s h e s between p l ay as r e p e t i t i o n o f an event a l r e a d y mastered and the r e p e t i t i o n o f an event i n o rder to unders tand i t . He w r i t e s : A l though p l a y sometimes takes the form o f r e p e t i t i o n o f p a i n f u l s t a t e s o f mind, i t does so not i n o rde r t h a t the p a i n s h a l l be p r e s e r v e d , but so ^ E r i k s o n , op . c i t . , p. 475. 52 Jean P i a g e t , "Response to B r i a n Sut ton S m i t h " . P sycho - l o g i c a l Review, LXXI I I : 1966, p. 112. - 32 -t ha t i t may become b e a r a b l e , even p l e a s u r a b l e , through a s s i m i l a t i o n to the whole a c t i v i t y o f the ego.53 In c o n c l u s i o n P i age t i n common w i th Sigmund Freud and E r i k E r i k s o n , b e l i e v e s tha t c h i l d r e n i n the p r e - s c h o o l p e r i o d u t i l i z e p l a y as a means o f under s t and ing and cop ing w i th the wor ld i n which they l i v e . THE THERAPEUTIC APPLICATION OF PLAY There are two c l a s s i c sources on the s u b j e c t o f p l a y t h e r a p y . A x l i n e p r o v i d e s a theory and methodology f o r " n o n - d i r e c t i v e 1 1 p l ay 54 t h e r a p y . Moustakas b e l i e v e s t ha t what the p l ay t h e r a p i s t says and does i s impor t an t , but t ha t how he f e e l s towards the c h i l d determines 55 to a g r e a t e r degree h i s t h e r a p e u t i c e f f e c t i v e n e s s . L i k e E r i k E r i k s o n , A x l i n e suggest s t ha t p l ay therapy i s a method o f h e l p i n g c h i l d r e n h e l p themse l ve s . She s t a t e s : P l ay therapy i s based on the f a c t t ha t p l a y i s the c h i l d ' s n a t u r a l medium o f s e l f e x p r e s s i o n . I t i s an o p p o r t u n i t y which i s g i ven to the c h i l d to " p l a y out h i s f e e l i n g s and problems j u s t as , i n c e r t a i n types o f a d u l t therapy an i n d i v i d u a l " t a l k s o u t " h i s d i f f i c u l t i e s . 5 6 A x l i n e b e l i e v e s t ha t the re i s a power fu l f o r c e w i t h i n each i n d i v i d u a l which s t r i v e s c o n t i n u o u s l y f o r complete s e l f - r e a l i z a t i o n . She s t a t e s : 53 Jean P i a g e t , P l a y , Dreams and I m i t a t i o n i i n C h i l d h o o d , (New York : Ul. Ul. Norton C o . , 1951) p. 149. 54 V i r g i n i a A x l i n e , P lay Therapy . (Cambridge, Mas sachuse t t s : The R i v e r s i d e Press 1947) . C l a r k Moustakas, C h i l d r e n i n P lay Therapy, (New York: B a l l a n t i n e Books, 1953. 56 A x l i n e , op . c i t . , p. 9. - 33 -N o n - d i r e c t i v e p l a y therapy i s based on the assumption tha t the i n d i v i d u a l has w i t h i n h i m s e l f , not Dnly the a b i l i t y to s o l v e h i s own prob lems, but a l s o t h i s growth impulse tha t makes mature behav iour more s a t i s f y i n g than immature behav i ou r .57 The e i g h t b a s i c p r i n c i p l e s o f " n o n - d i r e c t i v e " p l ay therapy r e f l e c t t h i s a s sumpt ion . They i n c l u d e : e s t a b l i s h i n g a warm r e l a t i o n s h i p with the c h i l d ; a c c e p t i n g and r e s p e c t i n g h i s a c t i o n s ; l e t t i n g thB c h i l d choose the s u b j e c t o f p l a y , and r e c o g n i z i n g f e e l i n g s and r e f l e c t i n g them back to the c h i l d . Moustakas f o l l o w s the same l i n e o f thought when he d e s c r i b e s the t h e r a p e u t i c p r o c e s s . He s t a t e s : The t h e r a p e u t i c p roce s s does not a u t o m a t i c a l l y occur i n a p l ay s i t u a t i o n . I t becomes p o s s i b l e i n a t h e r a -p e u t i c r e l a t i o n s h i p where the t h e r a p i s t responds i n cons tan t s e n s i t i v i t y to the c h i l d j s f e e l i n g s , a ccep t s the c h i l d ' s a t t i t u d e s , and conveys a c o n s i s t e n t and s i n c e r e b e l i e f i n the c h i l d and r e s p e c t f o r him.^S Moustakas d i f f e r s from A x l i n e i n tha t he b e l i e v e s t h a t p l ay need not be t o t a l l y n o n - d i r e c t i v e . He says t h a t c h i l d r e n f r e q u e n t l y have to f ace c r i s i s i n l i f e and may respond by behav i ou r s e x p r e s s i n g c o n f u s i o n , a g g r e s s i o n , h o s t i l i t y , hate and a n x i e t y . For such c h i l d r e n , Moustakas b e l i e v e s t ha t c o n t r o l l e d or s i t u a t i o n a l p l a y therapy i s more e f f e c t i v e than n o n - d i r e c t i v e p l a y . The c o n t r o l r e s u l t s on l y from s p e c i f i c t oy s sugge s t i ng a p a r t i c u l a r scene or s i t u a t i o n tha t the t h e r a p i s t knows i s t r o u b l i n g the c h i l d , not from c o n t r o l o f the a c t u a l p l a y . Moustakas makes the comment from h i s c l i n i c a l e x p e r i e n c e t h a t c h i l d r e n , who take p a r t i n s i t u a t i o n a l p l ay t h e r a p y , e s t a b l i s h a r e l a t i o n s h i p w i th the t h e r a p i s t q u i c k l y and express t h e i r f e e l i n g s e a r l i e r and more A x l i n e , op. c i t . , p. 15. Moustakas, op. c i t . , p. ID. - 3k -d i r e c t l y than deep ly d i s t u r b e d c h i l d r e n . He a l s o comments tha t too much s t r e s s has been p l a c e d on re spond ing s k i l l s . He b e l i e v e s t ha t the use o f r e f l e c t i o n a lone may be p e r c e i v e d by the c h i l d as a 59 r e p e t i t i o u s , unsympathet i c s t a t i c r e s p o n s e . I t mould seem tha t both Moustakas and A x l i n e are i n agreement w i th E r i k E r i k s o n i n t ha t a c h i l d needs s o l i t a r y p l ay w i th t o y s , i n the presence of a sympathet i c a d u l t , to he lp him a d j u s t to new and overwhelming s o c i a l s i t u a t i o n s . A l l t h ree views would seem to sub -s t a n t i a t e the a s s u m p t i o n t h a t p l ay therapy c o u l d be s u i t a b l e i n t e r -v e n t i o n to reduce p o s t - h o s p i t a l p s y c h o l o g i c a l upset i n the p r e - s c h o o l c h i l d . Through p l ay therapy the c h i l d c o u l d express h i s f e e l i n g s and h i s b e l i e f s about h i s h o s p i t a l i z a t i o n . A number o f a r t i c l e s have been w r i t t e n on the s u b j e c t o f p l ay i n h o s p i t a l s . In r e c e n t year s a few h o s p i t a l s have se t up p l ay programs f o r c h i l d r e n a u n d e r g o i n g m e d i c a l and s u r g i c a l p r o c e d u r e s . These programs main ly o f f e r the c h i l d an o p p o r t u n i t y to p l a y i n a group s e t t i n g . P l ay takes p l a c e i n a p layroom and the toy s p r o v i d e d are a v a r i e t y o f o r d i n a r y p l a y t h i n g s such as books, games, a r t m a t e r i a l s , d o l l s and wheel t o y s . Some programs a l s o p r o v i d e c l i m b i n g equipment, sand boxes, and dough. A few a r t i c l e s d e s c r i b e h o s p i t a l programs where p l ay i s used to prepare c h i l d r e n f o r surgery and p r o c e d u r e s . S e v e r a l authors have a l s o d e s c r i b e d case s t u d i e s and documented c l i n i c a l o b s e r v a t i o n s o f c h i l d r e n ' s p l ay behav iour a f t e r su rgery or t r a u m a t i c a c c i d e n t s . Brooks , d i s c u s s i n g a program where f r e e p l ay i s a l l o w e d , says Moustakas, op. c i t . , pp. 1-18, k5-k£. - 35 -t ha t "messy med ia " such as dough, c l a y , and p a i n t s are u s e f u l because the c h i l d r e n f r e q u e n t l y use these m a t e r i a l s to r e l e a s e pent -up f e e l i n g s . Brooks b e l i e v e s t ha t as the c h i l d r e n pound dough or sc rub wi th p a i n t s they can reduce the anger or f e a r they may f e e l . ^ ^ She a l s o says t h a t i n u n d i r e c t e d s i t u a t i o n s d ramat i c p l ay most o f t e n takes the form o f d o c t o r s and p a t i e n t s . T h i s aga in demonstrates t h a t c h i l d r e n need to ac t out what has happened to them. I t i s a l s o i n agreement w i th E r i k E r i k s o n ' s o b s e r v a t i o n s t ha t a c h i l d can be counted on to b r i n g u p s e t t i n g e x p e r i e n c e s i n t o s o l i t a r y p l a y . I t would appear t ha t t h i s a l s o happens i n g roup sp l ay . Brooks conc ludes t h a t t h i s form Df p l a y i s not a c a s u a l re -enactment Df the s i t u a t i o n , but a f a c t u a l account o f what has happened to each c h i l d . She s t a t e s : Ope ra t i on s are per formed which r e v e a l s u r p r i s i n g knowledge o f m e d i c a l t e c h n i q u e s , c a s t s made o f masking tape are a p p l i e d as are banda ids and gauze d r e s s i n g s , , o f t e n i n the same l o c a t i o n where the c h i l d has them. However t h e r e appears to be some drawbacks and l i m i t a t i o n s to group p l a y . Adams p o i n t s out t ha t p r e - s c h o o l and e a r l y s c h o o l age c h i l d r e n need the o p p o r t u n i t y to express the tremendous f e e l i n g s o f rage tha t they may have. They may t h e r e f o r e become very a g g r e s s i v e t o -wards one a n o t h e r . T h i s r e q u i r e s s k i l l e d l i m i t s e t t i n g by the p l a y 62 t h e r a p i s t to p r o t e c t themselves and o the r c h i l d r e n from i n j u r y . I t would a l s o seem tha t g rea t s k i l l i s r e q u i r e d to c o n t r o l and d i r e c t group s i t u a t i o n s so t ha t a l l the c h i l d r e n have an o p p o r t u n i t y to vent ^ M a r g a r e t Brooks , "Why P lay i n H o s p i t a l s . " Nur s ing C l i n i c s  o f North America \l: (September 1970) p. 435-436. S 1 I b i d . , p. 436. Margaret Adams, "A H o s p i t a l P lay Program: H e l p i n g C h i l d r e n w i th S e r i o u s I l l n e s s " . American J o u r n a l o f O r t h o p h y c h i a t r y , XLv I : ( J u l y 1976), pp . 416-424. - 36 -a g g r e s s i v e f e e l i n g s i n a s o c i a l l y a c c e p t a b l e manner. Adams b e l i e v e s t h a t a group s i t u a t i o n he lp s the q u i e t and f e a r f u l c h i l d : " . . . t o b e n e f i t v i c a r i o u s l y from another c h i l d ' s c a t h a r s i s i n the g r o u p " . ^ 3 T h i s b e l i e f i s open to q u e s t i o n and does not a cco rd u i t h the t h e o r i e s o f p l ay d i s c u s s e d h e r e . I t i s d o u b t f u l i f a second-hand expe r i ence would he lp a c h i l d work through h i s own f e e l i n g s . Hyde expres ses the b e l i e f t h a t : I t i s not enough f o r a c h i l d merely to expres s h i s emotions through p l a y ; he must a l s o know t h a t h i s emotions are unders tood and accep ted and t h a t i t i s good f o r him to have these e m o t i o n s . ° * T h i s d i s c u s s i o n does not negate the f a c t t h a t group p l a y can be h e l p f u l to many c h i l d r e n , or t ha t i t i s an e f f e c t i v e p a r t o f the t o t a l use o f p l a y i n h o s p i t a l . However, i t would appear t ha t a one - to -one c o n t a c t w i th an upset c h i l d c o u l d have more t h e r a p e u t i c p o s s i b i l i t i e s . A few p e d i a t r i c h o s p i t a l s use p l a y w i th d o l l s and h o s p i t a l equipment as a means o f a s s i s t i n g the c h i l d to unders tand h i s s u r g e r y . B u t l e r e t a l . and Knudsen both d i s c u s s the p robab le s t r e s s - r e d u c i n g e f f e c t s f o r the c h i l d who i s p repared f o r su rge ry i n t h i s way. They r e p o r t c l i n i c a l o b s e r v a t i o n s made by o p e r a t i n g room s t a f f who have observed tha t c h i l d r e n who r e c e i v e p r e - o p e r a t i v e i n f o r m a t i o n about ^ A d a m s , op . c i t . , p. 421. Na ida Hyde, " P l ay Therapy, the T r o u b l e d C h i l d ' s S e l f E n c o u n t e r " . American J o u r n a l o f N u r s i n g , LXXI: ( J u l y 1971) p. 1366. - 37 -t h e i r su rgery seem to demonstrate fewer g e n e r a l i z e d f e a r r e s p o n s e s . Knudson l i s t s f o u r types o f c o n c r e t e i n f o r m a t i o n a c h i l d needs b e f o r e s u r g e r y : 1) What w i l l happen; 2) Uhat i s expected of him; 3) That he i s not to blame f o r h i s i l l n e s s ; 4) Where the organ to be removed or r e p a i r e d i s l o c a t e d , 67 and t h a t no o the r body p a r t s w i l l be harmed. T e s l e r and Hardgrove agree w i th Knudsen i n t ha t they a l s o b e l i e v e t h a t the most impor tant a spec t s o f p r e p a r a t i o n f o r the p r e - s c h o o l c h i l d 6fl i s the "what" o f the procedure not the "why". T e s l e r and Hardgrove a l s o p o i n t out the importance o f under -s t and ing the c h i l d ' s t r a n s d u c t i v e mode o f t h i n k i n g : We make the cause and e f f e c t c o n n e c t i o n s f o r the the c h i l d knowing t h a t h i s e x p e r i e n c e may o therw i se l e a d him to f a u l t y and f r i g h t e n i n g c o n c l u s i o n s . ^ Because the c h i l d ' s thought p roce s se s are p r e - c o n c e p t u a l , i t i s ^ A d a B u t l e r , et a l . " C h i l d ' s P lay i s T h e r a p y " . Canadian  Nurse LXXI: (December 1975) p. 35 -37. ^ K a t h l e e n Knudsen, " P l ay Therapy : P r e p a r i n g the Young C h i l d f o r S u r g e r y . " Nurs ing C l i n i c s o f North Amer i ca , X: (December 1975) pp. 679-686. 6 7 I b i d . , p. 684. 68 Mary T e s l e r and C a r o l Hardgrove, " C a r d i a c C a t h e t e r i z a t i o n : P r e p a r i n g the Young C h i l d " . American J o u r n a l o f N u r s i n g , LXXI I I : T e s l e r and Hardgrove, op . c i t . , p. 82. - 38 -d i f f i c u l t to be sure t h a t he r e a l l y unders tands the i n f o r m a t i o n g i v e n to h im. Hardgrove b e l i e v e s t ha t because o f t h i s i t i s neces sa ry to have a p l ay i n t e r v i e w wi th the c h i l d a f t e r a p rocedure has taken p l a c e . She b e l i e v e s t h a t i n t h i s way c o r r e c t i o n Df m i s c o n c e p t i o n s and r e -assurance can o c c u r . T h i s p l a y i n t e r v i e w h e l p s the c h i l d separa te 70 r e a l i t y from f a n t a s y . A l l the p r e c e d i n g a r t i c l e s r e i n f o r c e the i d e a t h a t p l ay i s a u s e f u l way to teach and p repare the p r e - s c h o o l c h i l d f o r s u r g e r y . P l ay he lp s the c h i l d see what i s go ing to happen tD him and f a c i l i t a t e s the communication p roces s between the n u r s e - t e a c h e r and the c h i l d . However, t he re i s a l s o a b e l i e f t ha t p r e - s u r g i c a l p r e p a r a t i o n a lone does not ensure tha t a l l c h i l d r e n f u l l y unders tand and a cc sp t t h e i r su rgery and h o s p i t a l i z a t i o n . There seems to be a need f o r the p r e -s c h o o l c h i l d to p l a y about what has happened to him i n h o s p i t a l . Dur ing t h i s p l a y therapy f u r t h e r c l a r i f i c a t i o n o f what has happened to him can take p l a c e . A few author s have w r i t t e n about the p roces s o f p l a y therapy wi th a c h i l d who has had major su rgery o r has s u f f e r e d a t r a u m a t i c a c c i d e n t . The c h i l d r e n d e s c r i b e d were demons t ra t ing h o s t i l e , r e g r e s s i v e or withdrawn behav iou r s b e f o r e p l ay therapy was s t a r t e d . Even so , a l l o f the c h i l d r e n were ab le to p l ay through what had happened to them; to i n i t i a t e p l a y sequences w i thout d i r e c t i o n ; and to express t h e i r f e a r s and concerns through p l a y . Bar ton d i s c u s s e s the e f f e c t o f p l ay therapy on a c h i l d who was C a r o l Hardgrove, " E m o t i o n a l I n n o c u l a t i o n : the Three R's o f P r e p a r a t i o n " . J o u r n a l o f the A s s o c i a t i o n f o r the Care o f C h i l d r e n i n H o s p i t a l s V: ( Sp r ing 1977) p. 19. - 39 -demonst ra t ing anx ious and h o s t i l e behav iour a f t e r hav ing a c a r d i a c c a t h e r i z a t i o n . In her f i r s t p l ay therapy s e s s i o n t h i s f i v e year o l d p l a y e d spontaneous ly but w i th s e r i o u s c o n c e n t r a t i o n . She on ly spoke to ask q u e s t i o n s about how the equipment worked. Subsequent l y , she moved on to very a g g re s s i ve p l a y , a c t i n g out e x a c t l y what had happened to h e r . She used the s y r i n g e c o n t i n u o u s l y , a g g r e s s i v e l y i n j e c t i n g the "mother" d o l l . As p l ay s e s s i o n s c o n t i n u e d , her p l a y became l e s s a g g re s s i ve even though she c o n t i n u e d to p l a y through h o s p i t a l p r o -71 c e d u r e s . T h i s p r o g r e s s i o n o f p l ay i s s i m i l a r to the s tages o f p l ay 72 d e s c r i b e d by Moustakas as p a r t o f the t h e r a p e u t i c p r o c e s s . As p l a y became more r e l a x e d , t h i s c h i l d became l e s s r i g i d and f e a r f u l o f t r e a t ments a l though she s t i l l c r i e d and o b j e c t e d when she had p a i n f u l p r o -c e d u r e s . Bar ton b e l i e v e s t h a t the change o f behav iour was not by chance but t h a t : Through p l ay Kathy ga ined a c l e a r e r p e r c e p t i o n o f what to expect dur ing her h o s p i t a l e x p e r i e n c e , and had an o p p o r t u n i t y as w e l l to p l ay out her f e a r s and h o s t i l i t y . 7 3 Bar ton a l s o s t a t e s t ha t f o r Kathy, p l a y a l s o : " . . . s e rved as an aud v i s u a l a i d to c l a r i f y her p e r c e p t i o n o f past and f u t u r e h o s p i t a l „74 e x p e r i e n c e s . " 71 P a u l i n e B a r t o n , " P l ay as a T o o l o f N u r s i n g " . Nurs ing Out look X: (March 1962) pp. 162-164. 72 C l a r k Moustakas, C h i l d r e n i n P l ay Therapy . (New York: B a l l a n t i n e Books, 1953) pp . 7 -9 . 73 B a r t o n , op . c i t . , p. 164. 74 B a r t o n , l o c . c i t . - 40 -Plank d e s c r i b e s the p l ay behav iour o f a f o u r year o l d g i r l who 75 uas hav ing d i f f i c u l t y a c c e p t i n g the amputat ion o f her l e g . Dur ing p l ay therapy s e s s i o n s t h i s g i r l became very i n t e r e s t e d i n the su rgery equipment and her p l ay c o n s i s t e d o f pe r fo rm ing m u l t i p l e o p e r a t i o n s on the d o l l ' s l e g s . Plank s t a t e s : R u t h i e ' s o p e r a t i o n s were a lmost e x c l u s i v e l y l e g s u r g e r y . In a d d i t i o n to o the r p r o c e d u r e s , a l l p r i m a r i l y on the l e g s , she f r e q u e n t l y gave i n j e c t i o n s i n t o the s o l e s o f the d o l l ' s f e e t , taped the d o l l ' s l e g s t o ge the r and sometimes handcu f fed the d o l l b e f o r e pe r fo rm ing the o p e r a t i o n . ^ Aga in t h i s l i t t l e g i r l a c ted out her f e a r s and h o s t i l i t y wh i le she p l a y e d through what had happened to her i n h o s p i t a l . P e t r i l l o c i t e s one f o u r year o l d g i r l who was s e v e r e l y t r aum-a t i s e d and demonstrated r e g r e s s i v e behav iour a f t e r e x p e r i e n c i n g 77 severe bu rn s . At t h i s p o i n t i n t ime the c h i l d was very withdrawn and d i d not respond to or communicate w i th the n u r s e s . When P e t r i l l o f i r s t encountered t h i s g i r l she would not p l a y . However a f t e r a week o f companionship and s t o r y - t e l l i n g w i th P e t r i l l o she s t a r t e d t o p l a y through h o s p i t a l p rocedures w i th the d o l l s and h o s p i t a l equipment. In the course o f t h i s p l ay t h i s c h i l d began to express her f e e l i n g s e a s i l y . P e t r i l l o s t a t e s : C a r o l i n e became the " d o e r " i n s t e a d o f the h e l p l e s s v i c t i m . In a d d i t i o n she i d e n t i f i e d w i th the r e b e l l i n g 75 Emma N. P l ank , Working w i th C h i l d r e n i n H o s p i t a l , (The Press o f Case Western Reserve U n i v e r s i t y , 1971) . 7 ^ I b i d . , p. 31 . Made l ine P e t r i l l o , " P r e v e n t i n g H o s p i t a l Trauma i n P e d i a t r i c P a t i e n t s . " American J o u r n a l o f N u r s i n g , LXVI I I : ( J u l y 1968) pp. 1469-1473. - 1*1 -d o l l thereby e x p r e s s i n g s i m i l a r o b j e c t i o n s and f e e l i n g s . ^ T h i s c h i l d , l i k e the p r e v i o u s two c h i l d r e n d e s c r i b e d , was ab le to ac t out du r ing p l a y , a l l t ha t had happened to her i n h o s p i t a l . Through p l ay she was a l s o ab le to express h o s t i l e and angry f e e l i n g s . P e t r i l l o a l s o p a i n t s out t ha t p l ay therapy p r o v i d e s o p p o r t u n i t i e s to c l a r i f y the d i f f e r e n c e between f an ta sy and r e a l i t y . She says t ha t du r ing p l a y , when the c h i l d r e n are asked why a p a r t i c u l a r p rocedure i s neces sary they f r e q u e n t l y answer t h a t : " . . . i t i s because o f be ing b a d " . P e t r i l l o b e l i e v e s t h a t : " T h i s g i v e s the nurse an e x c e l l e n t 79 o p p o r t u n i t y to i n t e r j e c t r e a l i t y . " 80 S l 82 83 P e t r i l l o and P lank, l i k e A x l i n e and Moustakas ' ' ' , b e l i e v e tha t p l a y therapy i s more e f f e c t i v e when the re i s a goad r e l a t i o n s h i p between the c h i l d and t h e r a p i s t . The c h i l d ga in s a sense o f t r u s t and becomes secure enough to express h i s t r u e f e e l i n g s . Hott a l s o b e l i e v e s : When the nurse p a r t i c i p a t e s i n t h i s make b e l i e v e , she r e a s s u r e s the c h i l d t h a t h i s p l a y i s v a l i d and m e a n i n g f u l , g i v e s him s t r e n g t h to cope wi th i t , and 7 8 P e t r i l l o , op. c i t . , p. 1470. 7 9 P e t r i l l o , op . c i t . , p. 1472. 8 0 P e t r i l l o , op . c i t . , p. 1470. 8 1 P l a n k , op . c i t . , p. 29. 8 2 \ / i r g i n i a A x l i n e , P l ay Therapy . (Cambridge, Massachuset t s ; The R i v e r s i d e P r e s s , 1947). 83 Moustakas, op . c i t . , p. 10. - kZ -shows him tha t he has a d u l t a p p r o v a l to go on s t r i v i n g f o r mastery i n the p l ay s i t u a t i o n . 8 4 Hott p o i n t s out t h a t dur ing p l a y the c h i l d can take command and c o n t r o l 85 of s i t u a t i o n s . T h i s i s i n c o n t r a s t to the r e a l i t y o f h i s h o s p i t a l s i t u a t i o n where the c h i l d i s c o n s t a n t l y be ing d i r e c t e d . In p l ay the c h i l d becomes a power fu l p e r s o n . Hardgrove b e l i e v e s t h a t : " P l a y i n g ' p r o c e d u r e s ' a f t e r they occur he lp s the c h i l d r e g a i n h i s sense o f s e l f " / 8 6 In summary, the re i s some c l i n i c a l ev idence i n the a r t i c l e s c i t e d tha t c h i l d r e n do want and need to p l a y through what has happened to them i n h o s p i t a l . P lay therapy seems to be an e f f e c t i v e medium through which a c h i l d can express and come to terms wi th a g g re s -s i v e f e e l i n g s and f e a r s . The use o f d o l l s and h o s p i t a l equipment appears to ac t as an a u d i o v i s u a l a i d which f a c i l i t a t e s l e a r n i n g about surgery and p r o c e d u r e s . P lay therapy a l s o appears to p r o v i d e n a t u r a l oppo r -t u n i t i e s to he lp the c h i l d c l a r i f y the d i f f e r e n c e between f an ta sy and r e a l i t y . From the case s t u d i e s d i s c u s s e d each c h i l d seems to ac t out s i m i l a r themes i n the course o f h i s p l a y . The p l ay d e s c r i b e d a l s o tended to be s e r i o u s and i n t e n s e at f i r s t , then a g g r e s s i v e and rough, and f i n a l l y more p o s i t i v e a t t i t u d e s began to e n t e r i n t o the p l a y . These 84 J a q u e l i n e Ho t t , " P l ay P.R.N, i n P e d i a t r i c N u r s i n g " . Nur s ing Forum, IX: (March 1970) p. 295. 8 5 I b i d . , p. 303. C a r o l Hardgrove, " Emot i ona l I n n o c u l a t i o n : the Three R's o f P r e p a r a t i o n " . J o u r n a l o f the A s s o c i a t i o n f o r the Care o f C h i l d r e n  i n H o s p i t a l s V: ( Sp r ing 1977) p. 19. - U3 -87 s tages are s i m i l a r to those d e s c r i b e d by Moustakas. O v e r a l l , p l ay therapy a f t e r su r ge ry would seem to be an e f f e c t i v e method o f h e l p i n g p r e - s c h o o l c h i l d r e n come to terms w i th what has happened to them. Hardgrove b e l i e v e s t h a t : " P l a y a f t e r the f a c t i s v i t a l " . She s t a t e s : P l ay i s the c h i l d ' s avenue to under s tand ing and i n t e g r a t i n g t h i n g s t ha t happen to h im. As he " p l a y s them o u t " , he makes them h i s own and f e e l s l e s s the v i c t i m and more the v i c t o r . Such p l ay a l s o r e v e a l s dangerous m i s concep t i on s and p i n p o i n t s f o r the ob se rve r where the c h i l d needs a b e t t e r p e r s p e c t i v e . S S As Hardgrove p o i n t s o u t , p l a y therapy has p o t e n t i a l both as an i n t e r -v e n t i o n and a d i a g n o s t i c t o o l . C h i l d r e n may be ab le to u t i l i z e p l a y therapy to ac t out and come to terms w i th the t r a u m a t i c events o f t h e i r own h o s p i t a l e x p e r i e n c e . Through the f e e l i n g s and b e l i e f s t h a t c h i l d r e n may expres s i n p l a y , h o s p i t a l s t a f f may ga in i n s i g h t i n t o each c h i l d ' s s p e c i f i c needs and f e a r s . THE CHILD WITH CONGENITAL HEART DISEASE AND HIS FAMILY The pa ren t s o f c h i l d r e n w i th c o n g e n i t a l hea r t d i sea se f r e q u e n t l y l i v e w i th a n x i e t y v a c i l l a t i n g between hope f o r a cure and f e a r o f s u r g e r y . For most peop le a m a l f u n c t i o n i n g h e a r t g i v e s r i s e to f e a r s o f d i sab lement or p o s s i b l e d e a t h . Barnes r e p o r t s t h a t the parent s o f 87 C l a r k Moustakas, C h i l d r e n i n P l ay Therapy . (New York : B a l l a n t i n e Books, 1953) pp. 7 -9 . 88 Hardgrove, op . c i t . , p. 19. - kk -a c h i l d w i th h e a r t d i sea se may expe r i ence many c o n f l i c t i n g emot ions . She s t a t e s : O f ten pa ren t s have g rea t d i f f i c u l t y r e a c h i n g a d e c i s i o n to consent to hea r t s u r g e r y . The su rgery i s viewed as l i f e - t h r e a t e n i n g by the p a r e n t , who s t r u g g l e s w i th the dichotomy o f w i sh ing to g i ve the c h i l d every chance to l i v e a normal l i f e , and the ever p r e s e n t f e a r o f exposure to trauma. N a t u r a l l y , the p a r e n t ' s g r e a t e s t f e a r i s t ha t the c h i l d w i l l not s u r v i v e s u r g e r y . 8 9 Barnes a l s o s t a t e s t ha t p r o f e s s i o n a l s are o f t e n unaware o f t h i s f e a r . They have a tendency to l a b e l pa ren t s who are u n w i l l i n g to l e t t h e i r c h i l d undergo su rge ry as "poor p a r e n t s " who do not ca re about t h e i r c h i l d . P r o f e s s i o n a l s t a f f may not comprehend tha t the problem f o r these pa ren t s may be tha t they ca re too much. Barnes a l s o c i t e s ev idence tha t pa ren t s may be so tense and f e a r f u l tha t they become o v e r - p r o t e c t i v e o f t h e i r c h i l d . The c h i l d may be den ied a c t i v i t i e s w i t h i n t h e i r l i m i t a t i o n s because pa ren t s are a f r a i d o f the c o n d i t i o n becoming worse . Some pa ren t s may a l s o be o v e r - p r o t e c t i v e because they cannot r i d themselves o f g u i l t tha t the c h i l d ' s anomaly i s , somehow, 90 t h e i r f a u l t . In the same a r t i c l e Barnes p o i n t s out t ha t p a r e n t a l a n x i e t i e s may w e l l be i n c r e a s e d by c o n f u s i n g s i t u a t i o n s which occu r dur ing h o s p i t a l i z a t i o n o f the c h i l d . She c i t e s an i n c i d e n t t ha t happened to one p a r e n t : In the f o l l o w i n g yea r , the boy had had th ree c a t h e t e r i z a t i o n s p l u s an admiss ion f a r a f o u r t h , which was u n s u c c e s s f u l . Dur ing t h a t c a t h e t e r i z a t i o n , the machine broke down. Mrs. M i l l e r was c a l l e d to the l a b o r a t o r y , got l o s t , and when q u e s t i o n e d , s a i d , "I thought my baby was dead" . . . The doc to r a p o l o g i z e d Cor inne Barnes , "Working w i th Parent s o f C h i l d r e n Undergoing Heart S u r g e r y . " Nur s ing C l i n i c s o f North Amer i ca , IU: (March 1969) p. 13. I b i d . , pp. 13-14. - 45 -f o r her unnecessary F r i g h t and s a i d , "The nurse who took the message shou ld have t o l d you why you were c a l l e d and shown you the way."91 T h i s type o f i n c i d e n t tends to demonstrate to p a r e n t s t ha t communicat ion networks and team work are not e f f e c t i v e . I t a l s o tends to make the p a r e n t s f e e l t h a t t h e i r c h i l d i s not impor tan t to h o s p i t a l p e r s o n n e l . T h i s c e r t a i n l y decreases the p a r e n t s 1 f a i t h and t r u s t i n the p e r s o n n e l 92 and, t h e r e f o r e , f u r t h e r i n c r e a s e s t h e i r a n x i e t y . Parent s o f c h i l d r e n w i th hea r t d i s e a s e p robab l y do not r e a c t d i f f e r e n t l y from o the r pa ren t s who p e r c e i v e t h e i r c h i l d ' s i l l n e s s as l i f e - t h r e a t e n i n g . F r e i b e r g l i s t e d the most f r e q u e n t l y o c c u r r i n g reasons f o r mother s ' a n x i e t y du r ing c h i l d r e n ' s h o s p i t a l i z a t i o n . They a r e : l a ck o f i n f o r m a t i o n about d i a g n o s i s ; l a ck o f i n f o r m a t i o n about p rocedures and t r e a t m e n t s ; f e a r s about r e c o v e r y o f c h i l d from p r e s e n t i l l n e s s ; f e a r s about the f u t u r e h e a l t h o f c h i l d . 9 3 F r e i b e r g a l s o l i s t e d the most f r e q u e n t l y o c c u r r i n g comments from mothers about the n u r s i n g s e r v i c e . They a r e : not enough t ime spent w i th the p a t i e n t ; 94 nurse s a r c a s t i c to mother or c h i l d . F r e i b e r g a l s o s t a t e s i n agreement w i th the l i t e r a t u r e : Barnes , op . c i t . , p. 15. 92 Barnes , op . c i t . , p. 15. 93 Karen F r e i b e r g , "How pa ren t s r e a c t when t h e i r c h i l d i s h o s p i t a l -i z e d . " American J o u r n a l o f N u r s i n g , LXXI I : ( J u l y 1972) p. 127D. 9 4 I b i d . , p. 1271. - 46 -Young c h i l d r e n are s e n s i t i v e to a n x i e t y i n t h e i r pa ren t s and r e a c t to i t w i th i n c r e a s e d f e a r t hemse l ve s . These f i n d i n g s p o i n t out the need f o r a n u r s i n g i n t e r v e n t i o n which can reduce p a r e n t a l a n x i e t y or which can reduce the c h i l d ' s a n x i e t y i n -dependent o f the p a r e n t ' s b e h a v i o u r . C o n g e n i t a l hea r t d i sea se has an emot i ona l as w e l l as a p h y s i c a l impact on the c h i l d . G l a se r et a l . p o i n t s out tha t the e f f e c t o f 96 c h r o n i c d i s a b i l i t y has an a n x i e t y - p r o d u c i n g . e f f e c t on the c h i l d . L inde e t a l . suggest tha t poor adjustment and a n x i e t y i n c h i l d r e n wi th c a r d i a c d i s ea se r e l a t e more h i g h l y to ma te rna l a n x i e t y than to a degree 97 o f i n c a p a c i t y . A study by Barnes et a l . a s ses sed the degree o f a n x i e t y s u f f e r e d by each c h i l d by measur ing l e v e l s o f h y d r a x y c o r t o -c o s t e r o i d s throughout the c h i l d ' s h o s p i t a l i z a t i o n . High l e v e l s o f h y d r o x y c o r t o c o s t e r o i d s were observed throughout h o s p i t a l i z a t i o n w i th an i n c r e a s e b e f o r e p rocedures and a decrease towards h o s p i t a l d i s c h a r g e . T h i s s tudy conc luded tha t i t i s common f o r c h i l d r e n to be anx ious 98 and a f r a i d b e f o r e major su rgery and p r o c e d u r e s . A study by Auer e t a l . g i ve s some i n d i c a t i o n t h a t i t i s d i f f i c u l t f o r c h i l d r e n w i th c o n g e n i t a l hea r t d i s ea se to a d j u s t to t h e i r p h y s i c a l 95 F r e i b e r g , op. c i t . , p. 1272. 96 H. H. G l a s e r et a l . , " Emot iona l I m p l i c a t i o n s o f C o n g e n i t a l Heart D i sease i n C h i l d r e n . " P e d i a t r i c s XXXI I I : (March 1964) pp. 367-379. 97 L. M. L inde e t a l . , " A t t i t u d i n a l F a c t o r s i n C o n g e n i t a l Heart D i s e a s e . " P e d i a t r i c s XXXI I: ( J u l y 1966) pp . 92 -101. 98 Cor inne Barnes et a l . , "Measurement of Anx ie ty i n C h i l d r e n f o r Open Heart S u r g e r y " , P e d i a t r i c s XLIX: (February 1972) pp. 250-259. - 47 -c o n d i t i o n and i t i s r e l a t i v e l y common f o r these c h i l d r e n to have 99 emot iona l p rob lems . A l l the c h i l d r e n s t u d i e d had been h o s p i t a l i z e d s e v e r a l t i m e s . I t i s q u i t e p o s s i b l e tha t the number o f h o s p i t a l i z a t i o n s had as much impact on t h e i r emot i ona l s t a t e as c o n g e n i t a l hea r t d i s e a s e . Most c h i l d r e n hav ing open hea r t su rgery have e x p e r i e n c e d at l e a s t one h o s p i t a l i z a t i o n b e f o r e t h e i r admiss ion f o r open hear t s u r g e r y . T h i s , p l u s the f a c t tha t open hea r t su rgery i s major su rge ry r e q u i r i n g a s tay o f approx imate l y two weeks i n h o s p i t a l , p robab ly adds to the amount of s t r e s s these c h i l d r e n have to d e a l w i t h . Furthermore i n the f i r s t few days a f t e r surgery the c h i l d has to undergo p a i n f u l p r o -c e d u r e s . O v e r a l l , p r e - s c h o o l c h i l d r e n who are admi t ted f o r major hea r t surgery would seem to be p a r t i c u l a r l y prone to s u f f e r from s t r e s s and emot iona l upset du r ing t h e i r h o s p i t a l i z a t i o n . There are a number o f f a c t o r s which may c o n t r i b u t e to t h i s : h e a r t d i s ea se has s e r i o u s im -p l i c a t i o n s f o r the c h i l d and h i s p a r e n t s ; f e a r o f an u n s u c c e s s f u l o u t -come i s p o s s i b l e ; the c h i l d must undergo major su rgery and p a i n f u l f r i g h t e n i n g p r o c e d u r e s ; the l e n g t h of h o s p i t a l s tay i s f a i r l y l o n g . F i n a l l y , the c h i l d may have e x p e r i e n c e d p r e v i o u s h o s p i t a l i z a t i o n which he may not have been ab le to accept or come to terms w i t h . T h i s c o u l d r e s u l t i n even g r e a t e r a n x i e t y d u r i n g h o s p i t a l i z a t i o n f o r hea r t s u r g e r y . Edward Auer et a l . " C o n g e n i t a l Heart D i sease and Ch i l dhood Ad ju s tment . " P s y c h i a t r y i n M e d i c i n e , I I: (January 1971) pp. 23 -30 . - ka -SUMMARY In t h i s rev iew o f l i t e r a t u r e , the ev idence s u p p o r t i n g the f a c t tha t p r e - s c h o o l c h i l d r e n are p a r t i c u l a r l y prone to p s y c h o l o g i c a l up se t , due to h o s p i t a l i z a t i o n , i s examined. The h i gh p r o b a b i l i t y t h a t c h i l d r e n w i th c a r d i a c anomal ies may s u f f e r from adverse emot iona l r e a c t i o n s i s a l s o i n v e s t i g a t e d . In the l i g h t o f the l i t e r a t u r e r e -v iewed, the assumpt ion tha t p r e - s c h o o l c h i l d r e n w i th c a r d i a c anomal ies w i l l be p a r t i c u l a r l y prone to emot iona l problems i s w e l l s u p p o r t e d . A l though no r e s e a r c h s tudy has been found to date t ha t uses p lay therapy s p e c i f i c a l l y as a s t r e s s r e d u c i n g i n t e r v e n t i o n f o r h o s p i t a l i z e d c h i l d r e n , s e v e r a l s t u d i e s use p l ay e f f e c t i v e l y as a method o f p r e p a r i n g the c h i l d f o r su rgery and p r o c e d u r e s . However, the t h e o r i e s o f p l a y d i s c u s s e d and the c l i n i c a l examples o f p l a y therapy c i t e d , g i ve some i n d i c a t i o n tha t p l ay therapy c o u l d be an e f f e c t i v e method o f h e l p i n g p r e - s c h o o l c h i l d r e n cope w i t h the s t r e s s o f h o s p i t a l i z a t i o n . C h i l d r e n appear to ac t out and come to terms w i th the t r a u m a t i c events o f h o s p i t a l i z a t i o n du r ing p l ay t h e r a p y . P l ay therapy may t h e r e f o r e be a u s e f u l s t r e s s r e d u c i n g i n t e r v e n t i o n . C h i l d r e n a l s o seem to express t h e i r own s p e c i f i c b e l i e f s and f e a r s d u r i n g p l ay t h e r a p y . By o b s e r v i n g t h i s p l a y „ i t may be p o s s i b l e to ga in i n s i g h t i n t o each c h i l d ' s p e r -c e p t i o n of h i s h o s p i t a l i z a t i o n . - k9 -CHAPTER II I METHODOLOGY OVERVIEW A d e s c r i p t i v e study was des i gned to i n v e s t i g a t e the themes • f c h i l d r e n s ' p l ay dur ing the r e c o v e r y p e r i o d i n h o s p i t a l a f t e r major hea r t s u r g e r y . S imu la ted or r e a l h o s p i t a l equipment s u i t a b l e f o r p l ay therapy and r e p r e s e n t i n g most o f the equipment t ha t mould be used f o r the c h i l d i n the course o f h i s h o s p i t a l i z a t i o n was c o l l e c t e d . A v a r i e t y o f d o l l s r e p r e s e n t i n g c h i l d r e n and a d u l t f i g u r e s were a l s o i n c l u d e d i n the c o l l e c t i o n o f p l ay m a t e r i a l s . A l i s t o f the complete p lay equipment i s g i ven i n Appendix A. The i n v e s t i g a t o r met each f a m i l y group s e l e c t e d f o r the s tudy immediate ly a f t e r the c h i l d was admi t ted to h o s p i t a l . The purpose o f the study was e x p l a i n e d to the f a m i l y and they were asked to g i ve p e r m i s s i o n f o r the c h i l d to take pa r t i n the s t u d y . The e x p l a n a t o r y l e t t e r which was handed to the pa ren t s on the c h i l d ' s admiss ion and the consent form i s g i ven i n Appendix B and C. Each c h i l d who took p a r t i n the study was v i s i t e d by the i n v e s t i g a t o r on admiss ion day. Subsequent v i s i t s took p l a c e on the c h i l d ' s r e t u r n to the ward from the I n t e n s i v e Care U n i t and then on every c o n s e c u t i v e day u n t i l the c h i l d was d i s cha r ged home. P lay therapy wi th the h o s p i t a l p l ay m a t e r i a l s commenced as soon as each i n d i v i d u a l c h i l d had r e c o v e r e d from surgery s u f f i c i e n t l y to take an i n t e r e s t i n a c t i v e p l a y . U n t i l t ha t t ime the i n v e s t i g a t o r t a l k e d to the c h i l d , read s t o r i e s or p l a y e d s imple games. Each c h i l d had at l e a s t f i v e - 5D -p l ay therapy s e s s i o n s u s ing h o s p i t a l p l ay m a t e r i a l s , which l a s t e d f o r t y - f i v e minutes to one hour . Each p l a y therapy s e s s i o n was t e r m i n -a ted when the c h i l d no l onger a c t i v e l y p l a y e d wi th the equipment. P lay therapy took the form advocated by M o u s t a k a s . 1 T h i s form of p l a y therapy u t i l i z e s equipment uh i ch s t r o n g l y suggest s the s i t u a t i o n b e l i e v e d to be s t r e s s f u l or u p s e t t i n g to the c h i l d . Moustakas s t a t e s t ha t i n t h i s type o f p l ay therapy c h i l d r e n are ab le to make immediate use o f the p l a y equipment to express and e x p l o r e tense and i n s e c u r e a t t i t u d e s . T h i s approach to p l a y therapy i s very s i m i l a r to t h a t advocated by A x l i n e . The major d i f f e r e n c e i s t h a t communication w i th the c h i l d i s not c u r t a i l e d to m i r r o r i n g s ta tements and r e f l e c t i n g back 2 f e e l i n g s . I t was c o n s i d e r e d tha t l i m i t i n g the p l ay t h e r a p i s t ' s r e -sponses to r e f l e c t i n g the c h i l d ' s s ta tements c o u l d r e s u l t i n missed o p p o r t u n i t i e s f o r c l a r i f y i n g or c o n f i r m i n g s ta tements made by the c h i l d dur ing p l a y . Fur thermore , t e a c h i n g o p p o r t u n i t i e s which may occur n a t u r a l l y du r i ng p l ay c o u l d a l s o be l o s t . Moustakas s t a t e s t ha t a l though r e f l e c t i o n o f f e e l i n g s i s a u s e f u l t e chn ique i t may e a s i l y be p e r c e i v e d by the c h i l d as a r e p e t i t i o u s , unsympathet ic and s t a t i c r e s p o n s e . 3 In the form Df p l ay therapy used i n t h i s s t udy , emphasis was p l a c e d on the r e l a t i o n s h i p between the i n v e s t i g a t o r and the c h i l d . That i s , the i n -v e s t i g a t o r at tempted to convey to each c h i l d a f e e l i n g o f r e s p e c t f o r ' ' 'Clark Moustakas, C h i l d r e n i n P lay Therapy (New York : B a l l a n t i n e Books, 1974), p. 45. 2 V i r g i n i a A x l i n e , P lay Therapy (Cambridge, Mas sachuse t t s : The R i v e r s i d e P r e s s , 1947), p. ID. ^Moustakas, op. c i t . , p. 2. - 51 -and acceptance o f the c h i l d ' s a c t i o n s and a t t i t u d e s . Dur ing p l ay each c h i l d chose the d i r e c t i o n and content o f p l a y . Because o f the na ture o f the equipment, the d i r e c t i o n o f p l a y towards h o s p i t a l a c t i v i t i e s was s t r o n g l y sugges ted . A l l forms o f p l ay e x p r e s s i o n u s i n g the h o s p i t a l equipment and d o l l s was a c c e p t e d . P rocedures such as tempera tures , b l ood p r e s s u r e s and us ing the s te thoscope c o u l d be p r a c t i c e d on the i n v e s t i g a t o r or p a r e n t s . The on l y c o n s t r a i n t c l e a r l y d e f i n e d and e n f o r c e d was the use o f " n e e d l e s " or o t h e r p a i n f u l or dangerous p rocedures on p e o p l e . The i n v e s t i g a t o r took p a r t i n the p l a y as d i r e c t e d by each c h i l d and a l s o used p l ay as a means o f communicating w i th the c h i l d . V e r b a l communication c o n s i s t e d o f l i s t e n i n g to each Li c h i l d and t a l k i n g w i th him i n a n a t u r a l manner. SAMPLE SELECTION The p o p u l a t i o n s e l e c t e d f o r the s tudy were f i v e c h i l d r e n b e -tween the ages o f th ree and f i v e years o l d who were admi t ted by the surgeon f o r major surgery on the hear t or g rea t v e s s e l s . C h i l d r e n whose mother tongue was E n g l i s h were s e l e c t e d . COLLECTION OF DATA The v e r b a l and non v e r b a l behav iour d i s p l a y e d by each c h i l d dur ing t h e i r p l ay therapy s e s s i o n s were r e c o r d e d e i t h e r by audio tape or by p roces s r e c o r d i n g s . John A l l a n , " F a c i l i t a t i n g Emot iona l and Symbo l i c Communication i n Young C h i l d r e n : Theory and P r a c t i c e . " Paper p re sen ted at the Conference o f the Canadian A s s o c i a t i o n f o r Young C h i l d r e n , Vancouver, B r i t i s h Co lumbia , November 1976. - 52 -The i n v e s t i g a t o r conducted an u n s t r u c t u r e d i n t e r v i e w w i th each f a m i l y u n i t to c o l l e c t data Dn the c h i l d ' s p l a y behav iour a f t e r h o s p i t a l d i s c h a r g e . I n fo rmat ion was a l s o ga thered about any new f e a r s , a n x i e t i e s or b e h a v i o u r a l changes the c h i l d d i s p l a y e d a f t e r d i s cha r ge from h o s p i t a l . The t o p i c s d i s c u s s e d are l i s t e d i n Appendix D. IMPLEMENTATION The i n v e s t i g a t o r v i s i t e d each c h i l d i n h i s h o s p i t a l room. P lay s e s s i o n s took p l a c e e i t h e r i n the c h i l d ' s own room D T when p o s s i b l e i n the ward p l ay room. The c h i l d was g i ven the s u i t c a s e c o n -t a i n i n g a l l the p l a y m a t e r i a l and was a l l owed to use the equipment i n any way he w i shed . I f a c h i l d d i d not want to " p l ay h o s p i t a l s " he was asked to choose another a c t i v i t y . The i n v e s t i g a t o r s t ayed wi th the c h i l d throughout the p l a y s e s s i o n . Pa ren t s c o u l d j o i n i n i f they w i shed . At the end o f each s e s s i o n the i n v e s t i g a t o r t o l d the c h i l d when she would v i s i t the next day. - 53 -CHAPTER IU DISCUSSION AND INTERPRETATION OF THE DATA INTRODUCTION T h i s s tudy was undertaken to answer the f o l l o w i n g q u e s t i o n s : Are common themes expres sed i n the p l ay behav iour o f h o s p i t a l i z e d p r e -s c h o o l c h i l d r e n a f t e r major su r ge ry ? Does the q u a l i t y and i n t e n s i t y o f the p l ay behav iour demonstrated by p r e - s c h o o l c h i l d r e n f o l l o w a s i m i l a r p a t t e r n ? W i l l p r e - s c h o o l c h i l d r e n use p l a y therapy as a medium through which to express f e a r s and concerns about t h e i r h o s p i t a l e x p e r i e n c e ? Do c h i l d r e n tend to ac t out t h e i r p e r c e p t i o n o f what has happened to them i n h o s p i t a l ? To answer these q u e s t i o n s p l a y therapy was conducted wi th f i v e p r e - s c h o o l c h i l d r e n who had j u s t undergone major surgery on the hea r t or g rea t v e s s e l s . Four g i r l s and one boy wi th an age range o f t h ree and o n e - h a l f to f i v e and o n e - q u a r t e r years took p a r t i n the s t u d y . THE CHILDREN IN THE STUDY M o i r a , f ou r and o n e - h a l f years o l d , had an a t r i a l s e p t a l d e f e c t r e p a i r . She has an o l d e r b r o t h e r and s i s t e r and one younger s i s t e r . Her mother and f a t h e r , a l though they were concerned and anx ious about M o i r a , were not ab le to v i s i t each day. A f t e r i n i t i a l shyness , Mo i ra made f r i e n d s e a s i l y and was an outgo ing and q u i t e independent c h i l d . From the f i r s t p l a y therapy s e s s i o n Mo i ra p l ayed e n t h u s i a s t i c a l l y and always con t i nued f o r at l e a s t one hour . Mo i ra had s i x p l a y therapy s e s s i o n s . - 54 -Shaun, f o u r and o n e - q u a r t e r years o l d , had su rgery to r e l i e v e a moderate ly severe s t e n o s i s o f the a o r t i c v a l v e . H i s f a t h e r was w i th him on admiss ion and was ab le to v i s i t f o r a t ime each day. H i s s t e p -mother o f one and o n e - h a l f y e a r s , came to h o s p i t a l on ly on Shaun ' s a d -m i s s i o n and d i s c h a r g e . He had a new s ix -month o l d b r o t h e r . Most o f the t ime Shaun was a sweet and comp l i an t c h i l d but d i s p l a y e d loud p h y s i c a l r e s i s t a n c e i n response to a l l t rea tments and p r o c e d u r e s . He a l s o s t u b b o r n l y r e f u s e d most o f h i s mea l s . He d i d not l i k e to p l ay " h o s p i t a l s " . Shaun had one p l ay therapy s e s s i o n . Lucy, t h ree and o n e - h a l f years o l d , h a d a r e p a i r o f T e t r o l o g y o f F a l l o t . She had f ou r o l d e r s i b l i n g s and enjoyed a s p e c i a l p o s i t i o n as baby of the f a m i l y . Her mother v i s i t e d d a i l y throughout her h o s p i t a l -i z a t i o n and her f a t h e r f o r the f i r s t h a l f o f her h o s p i t a l s t a y . She had a rough p o s t - o p e r a t i v e course and had second surgery to r e l i e v e a c a r d i a c tamponade. She was i n the I n t e n s i v e Care U n i t f o r e i g h t days . Desp i te the f a c t tha t she was s t i l l very s t i f f and sore and q u i t e e a s i l y f a t i g u e d , Lucy p l a y e d " h o s p i t a l s " e n t h u s i a s t i c a l l y . Lucy had l i m i t e d speech f o r her age be fo re admiss ion to h o s p i t a l , but d i d not speak at a l l a f t e r her s u r g e r y . However, du r i ng p l ay her body language and exc l amat ions became e x p r e s s i v e . Apart from dur ing her p l ay therapy s e s s i o n s L u c y ' s behav iour was withdrawn and p a s s i v e f o r most o f her h o s p i t a l i z a t i o n . Lucy had f i v e p l ay therapy s e s s i o n s . Mar i an , f i v e and o n e - q u a r t e r year s o l d , had a second patch r e -p a i r to r e l i e v e a r e c u r r e n t c o - a r c t a t i o n o f a o r t a . She f i r s t had surgery at two years o f age and s a i d she remembered her h o s p i t a l i z a t i o n . Mar ian was very outgo ing and f r i e n d l y and gave the appearance o f c o n s i d e r a b l e composure f o r her age. She t o l d the r e s e a r c h e r t ha t she was go ing to have her hear t sSma'de b e t t e r " . Her mother v i s i t e d d a i l y - 55 -throughout her h o s p i t a l i z a t i o n . As the o l d e s t c h i l d i n the study she seemed to unders tand why her f a t h e r and s i s t e r c o u l d not t r a v e l from c e n t r a l B r i t i s h Columbia to see h e r . Mar ian p l a y e d " h o s p i t a l s " e n t h u s i a s t i c a l l y dur ing her f i v e p l ay therapy s e s s i o n s . J u d i t h , f o u r and t h r e e - q u a r t e r year s o l d , had an a t r i a l s e p t a l d e f e c t r e p a i r . She had an o l d e r b r o t h e r and a new baby b r o t h e r . She was a f r i e n d l y and v e r b a l c h i l d , determined and o u t g o i n g . Dn r e t u r n from the I n t e n s i v e Care U n i t she d i d go through a p e r i o d o f be ing q u i e t , t e a r f u l , nega t i ve and "wh iney " . J u d i t h p l a y e d " h o s p i t a l s " w i th g rea t c o n c e n t r a t i o n u n t i l her d i s c h a r g e home. She a l l owed her room-mate, who was e i g h t years o l d , to j o i n i n the p l ay but J u d i t h very f i r m l y d i r e c t e d the course o f p l a y . J u d i t h ' s mother had a b a b y - s i t t e r f o r the new baby and was ab le to v i s i t J u d i t h every day. J u d i t h had f i v e p l a y therapy s e s s i o n s . OVERVIEW OF PLAY THERAPY SESSIONS In summary the f ou r g i r l s took a very a c t i v e r o l e i n a l l the p l ay therapy s e s s i o n s . T h e i r p l ay tended to f o l l o w the p a t t e r n s 1 2 d e s c r i b e d by Moustakas and D a v i d . ' To beg in w i t h , p l ay was f a i r l y p a s s i v e . A l l the equipment was handled wi th g rea t care and r e s p e c t . The c h i l d r e n were very s e r i o u s i n t h e i r approach to p l ay and looked c o n s t a n t l y at the r e s e a r c h e r to assess her f e e l i n g s about t h e i r p l a y b e h a v i o u r . T h i s was e s p e c i a l l y t r ue about i n t r u s i v e t r e a t m e n t s . As C l a r k Moustakas, C h i l d r e n i n P lay Therapy . (New York: B a l l a n t i n e Books, 1953) pp. 7 -9 . N i c o l e Dav id , " P l a y : A Nurs ing D i a g n o s t i c T o o l . " Ma te rna l  and C h i l d Nur s ing J o u r n a l I I: (February 1973) p. 51 . - 56 -the t r u s t r e l a t i o n s h i p w i th the r e s e a r c h e r deve loped and the c h i l d r e n deemed i t s a fe to express t h e i r f e e l i n g s they moved on to more a g g r e s s i v e p l ay s t i l l c o n c e n t r a t i n g ma in ly on need le p l a y . The p l ay then became more i m a g i n a t i v e as they r e - e n a c t e d a l l t ha t had happened to them. T h i s p l ay was a l s o a g g r e s s i v e to beg in w i t h . As the p l ay therapy con t i nued more tender f e e l i n g s were e x p r e s s e d . At t h i s t ime some p l ay seemed to be d i r e c t e d towards fun and l i g h t r e l i e f . The need to have an under s tand ing a d u l t i n v o l v e d i n the p l ay was demonstrated i n v a r i o u s ways. Mar ian expres sed t h i s need very c l e a r l y . Dur ing one p l ay s e s s i o n wi th her the r e s e a r c h e r was p a s s i v e l y watching Marian p l a y . Mar ian f i n a l l y tu rned to the r e s e a r c h e r and p u t t i n g her hands on her h i p s s a i d i n an exaspera ted t o n e : " A r e n ' t you go ing to p l ay t oday ? " The r e s e a r c h e r s a i d : "I was hav ing fun j u s t watch ing y o u . " "No ! " s a i d Mar i an , "you have to p l ay t o o . " The o the r c h i l d r e n a l s o demonstrated t h i s need by i n v o l v i n g the r e s e a r c h e r i n most o f the p l ay and by c o n t i n u a l l y d i r e c t i n g c o n v e r s a t i o n and comments towards h e r . Even Lucy who d i d not t a l k , i n v o l v e d both her mother and the r e s e a r c h e r by u s ing them to h o l d equipment f o r h e r . She a l s o demonstrated t h i s need by ge s tu re s and e x c l a m a t i o n s . Dur ing the p l ay therapy s e s s i o n s w i th the g i r l s who took p a r t i n the study f i v e r e c u r r i n g themes were expres sed d u r i n g t h e i r p l a y . The themes were d e f i n e d as f o l l o w s : I. I n t r u s i v e p r o c e d u r e s . I I . Re-enactment o f p r o c e d u r e s : t e s t i n g r e a l i t y . I I I . Autonomy: r e g a i n i n g c o n t r o l . IU. S e p a r a t i o n from home and f a m i l y . U. N u r t u r i n g a c t i v i t i e s . - 57 -The remainder o f the a n a l y s i s o f the data w i l l be d i s c u s s e d under these head ing s . Shaun, the f i f t h c h i l d who took p a r t i n the s tudy d i d not demonstrate the p l ay behav iour expres sed by the o ther c h i l d r e n . A l though he d i d express some of the themes i d e n t i f i e d he d i d not do so through p l a y i n g " h o s p i t a l s " . H i s i n t e r a c t i o n wi th the r e s e a r c h e r w i l l t h e r e f o r e be d i s c u s s e d i n a separa te pa rag raph . INTRUSIVE PROCEDURES I n t r u s i v e procedures w i th the emphasis on " n e e d l e s " was by f a r the most common theme expres sed i n p l a y . The p l a y s y r i n g e s were i g n o r e d . Mo i ra was the on ly c h i l d who p l a y e d w i th them and she used them on ly b r i e f l y du r ing her f i r s t p l ay therapy s e s s i o n . J u d i t h , who was r e p o r t e d by her mother to be t e r r i f i e d o f n e e d l e s , found the r e a l s y r i n g e s d u r i n g her f i r s t p l ay therapy s e s s i o n and immediate ly asked i f I had any " r e a l l y " n e e d l e s . A l l the c h i l d r e n demanded some k i n d o f f l u i d to i n j e c t and they a l s o wanted to f i l l the s y r i n g e by themselves from a r e a l rubber capped v i a l . The i n j e c t i o n procedure was p l ayed through a c c u r a t e l y ; c l e a n i n g the s i t e b e f o r e and a f t e r . t h e i n j e c t i o n and p u t t i n g a b a n d - a i d on a f t e r w a r d s . From the second p l ay s e s s i o n M o i r a ' s need le p lay was very a g g r e s s i v e . She main ly used Rabb i t and i n j e c t e d h i s head, f e e t and e y e s . She l i k e d to put the need le r i g h t through the t o y . When asked why Rabb i t had so many need le s she s a i d : " h e ' s been bad - h e ' s a bad bunny" . T h i s s tatement opened the way f o r a d i s c u s s i o n on why c h i l d r e n i n h o s p i t a l had n e e d l e s . Mo i ra made no comment at the time but a few days l a t e r s a i d tD Raggedy Ann: "you have to have a need le now - t h i s i s your med ic ine you know." At t h i s t ime she a l s o acknowledged tha t - 58 -need les hur t and accompanied the i n j e c t i o n w i th c r i e s o f p a i n from Raggedy Ann. Lucy, a l though she was s t i l l very s t i f f and sore from surgery and had d i f f i c u l t y moving her arms, immedia te ly took the r e a l s y r i n g e from the toy c a s e . Lucy d i d not t a l k but made many e x p r e s s i v e sounds. She gave a long " a h ! " , tu rned the s y r i n g e c a r e f u l l y i n her hands and moved the b a r r e l i n and o u t . She then p o i n t e d to the t i p o f the s y r i n g e and s a i d " e h ! " . The r e s e a r c h e r showed her a r e a l need le and she grabbed i t . She c o u l d n ' t f i x the need le to the s y r i n g e so she handed i t to her mother. Her mother then suggested tha t she g i ve Raggedy Ann a need le but Lucy i gno red her and chose R a b b i t . With g rea t care and c o n c e n t r a t i o n she gave Rabb i t a need le i n h i s l e g . When she had f i n i s h e d she looked around s e a r c h i n g f o r someth ing . When o f f e r e d a b a n d - a i d she took i t w i th a grunt o f s a t i s f a c t i o n , and w i th her m o t h e r ' s h e l p , found the i n j e c t i o n ho le and put the band -a i d o n . Lucy then com-p l e t e d the task by d i r e c t i n g her mother to draw a " h a p p y - f a c e " an the b a n d - a i d . Lucy spent most o f her p l ay therapy s e s s i o n s do ing i n t r u s i v e p r o c e d u r e s . She comp le te l y mastered the s k i l l o f g i v i n g i n j e c t i o n s and a l s o p l ayed c o n s t a n t l y w i th the i n t r a v e n o u s equipment. Again the i n t r avenous need le had to go i n t o the d o l l ' s arm and the f l u i d from the i n t r avenous b o t t l e had to d r i p . Her mother asked her why Raggedy Ann was hav ing an " I . U . " . She shook her head . The r e s e a r c h e r took t h i s o p p o r t u n i t y to e x p l a i n how food and med ic ine goes i n t o a v e i n . With head h e l d down, Lucy l i s t e n e d i m p a s s i v e l y . The reason f o r " n e e d l e s " was a l s o e x p l a i n e d , but d i d not e l i c i t a response from Lucy , d e s p i t e her mo the r ' s c o n f i r m a t i o n o f the s t a tement . Lucy was a l s o f a s c i n a t e d by a l l the tubes i n the p l a y k i t . She - 59 -mas i n the I n t e n s i v e Care U n i t much l onger than the o the r c h i l d r e n and had more i n t r u s i v e p r o c e d u r e s . She p l a c e d a l l the c a t h e t e r s and dra inage tubes i n the c o r r e c t p l a c e , always t u r n i n g to the r e s e a r c h e r f o r c o n f i r m a t i o n tha t t h i s was c o r r e c t . When she used the n a s a l c a t h e t e r f o r s u c t i o n she screwed up her f ace and tu rned her head away. The b l a d d e r c a t h e t e r was accompanied by exc l amat i on s o f p a i n . The r e s e a r c h e r e x p l a i n e d the purpose o f each c a t h e t e r and r e c e i v e d a g l a r e from Lucy . L u c y ' s p l a y was g e n e r a l l y very i n t e n s e and a g g r e s s i v e . However, dur ing the l a s t two p l ay s e s s i o n s she d i s c o v e r e d s y r i n g e s made good s q u i r t i n g t o y s . For the f i r s t t ime s i n c e her surgery Lucy l aughed. She s t a r t e d w i th a g i g g l e and then to a chuck le and f i n a l l y gave a g rea t b i g happy l a u g h . Mar i an , the o l d e s t o f the c h i l d r e n , was l e a s t a g g r e s s i v e when p l a y i n g " n e e d l e s " . She always accompanied the p l ay w i th e x p l a n a t i o n s to the d o l l s : " t h i s w i l l hu r t now . . you l i e s t i l l . . . i t w i l l soon be f i n i s h e d . . . t h i s i s your med ic ine to make you b e t t e r . " Mar ian l i k e d to do e v e r y t h i n g c o r r e c t l y . On one o c c a s i o n she f o r g o t to c l e a n the s k i n . She s a i d : "Oh dear - s h o u l d c l e a n i t f i r s t . " She was the one c h i l d who gave o r a l m e d i c i n e s . T h i s was p o s s i b l y because she r e g u l a r l y took med i ca t i on at home. Aga in Mar ian gave the med ic ine to the d o l l w i t h g rea t t endernes s and accompanied the m e d i c a t i o n w i t h an e x p l a n a t i o n . J u d i t h , l i k e Mo i r a , was most a g g r e s s i v e wi th her need le p l a y . She a l s o p l a y e d f r e q u e n t l y w i th the i n t r a v e n o u s se t and put the need le i n the d o l l ' s arm w i th a sharp j a b . She then t i e d the d o l l ' s arms to the bed and i n an angry v o i c e , t o l d her to be s t i l l . At t h i s p o i n t - 6D -some d i s c u s s i o n took p l a c e between J u d i t h and the r e s e a r c h e r about the purpose o f i n t r a v e n o u s f l u i d s . J u d i t h always l i s t e n e d to e x p l a n -a t i o n s w i th g rea t c o n c e n t r a t i o n and f r e q u e n t l y asked f u r t h e r q u e s t i o n s . She l a t e r e x p l a i n e d to the d o l l : "You have to have t h i s 'cause you c a n ' t d r i nk y e t . " She con t i nued to t i e the d o l l down, but more g e n t l y than b e f o r e . Dur ing her l a s t p l ay therapy s e s s i o n , J u d i t h became much more g e n t l e i n a l l her p l a y . When asked why c h i l d r e n had to have need le s she demonstrated her under s t and ing o f the r e s e a r c h e r ' s e x p l a n -a t i o n by s a y i n g : " I t i s med ic ine you know . . . i f you d o n ' t have i t you d i e - then you get very s i c k . " RE-ENACTMENT DF PROCEDURES: TESTING REALITY Each o f the g i r l s t a k i n g pa r t i n the study p l a y e d through p r o -cedures t h a t had happened to them. They a c t e d out " o p e r a t i o n s " , " a n a e s t h e t i c s " , " b l ood p r e s s u r e s " , " d r e s s i n g s " , " removing t u b e s " and " t e m p e r a t u r e s " . Dur ing t h i s p l ay the c h i l d r e n i n t e r a c t e d c o n s t a n t l y w i th the r e s e a r c h e r seek ing c o n f i r m a t i o n f o r the accuracy o f what they were d o i n g . O v e r a l l t h i s p l a y tended to be s l i g h t l y l e s s a g g r e s s i v e than i n t r u s i v e p l ay and major p rocedures l i k e " o p e r a t i o n s " were done wi th t o t a l c o n c e n t r a t i o n . Mo i ra was a g g r e s s i v e and rough d u r i n g her f i r s t p l a y o p e r -a t i o n . She removed R a b b i t ' s eye wi th a look o f g l e e f u l s a t i s f a c t i o n on her f a c e . Her reason was t h a t R a b b i t ' s eye was broken and had to come o u t . She l i s t e n e d when the r e s e a r c h e r s a i d t h a t doc to r s c o u l d mend broken eyes and tha t they d i d n ' t have to come o u t . Mo i ra s a i d f i r m l y : " t h i s one come o u t " . Dur ing the f o l l o w i n g p l a y s e s s i o n Mo i ra rough ly removed R a b b i t ' s eye a g a i n . However, du r i ng a l a t e r p l ay - 61 -s e s s i o n , a f t e r she had g e n t l y removed Raggedy Ann ' s ches t s u t u r e s and had t o l d her t h a t she was a l l mended and ready to go home, Mo i ra opera ted aga in on Rabb i t and put h i s eye back. She s a i d : "she b e t t e r now - her eye mended - she go ing home." Dur ing o the r p rocedures Mo i ra mould look at the r e s e a r c h e r and s ay : " t h a t r i g h t ? " T h i s k i n d o f s tatement f a c i l i t a t e d a f r e e f low o f comments about the p r o c e d u r e s . Lucy was not i n t e r e s t e d i n do ing an o p e r a t i o n . She l i k e d to remove the ches t tube and always accompanied t h i s p rocedure wi th l o u d c r i e s o f : "ouchy! o u c h y ! " . The ho le was always covered c a r e f u l l y w i th a b a n d - a i d . The r e s e a r c h e r d i d not attempt to g i ve a reason f o r the ches t tube but t o l d Lucy tha t Raggedy Ann was d e f i n i t e l y g e t t i n g b e t t e r now her ches t tube had been taken o u t . Lucy would nod e n -t h u s i a s t i c a l l y i n agreement. Raggedy Ann had s u t u r e s i n her w r i s t i n the same area as Lucy . When Lucy d i s c o v e r e d them she compared them wi th her own w r i s t . She then looked at Raggedy Ann&s ches t and com-pared the d o l l ' s wound w i th her own. She p o i n t e d out t h i s i n t e r e s t i n g d i s c o v e r y to her mother and to the r e s e a r c h e r . Dur ing her l a s t p l a y s e s s i o n Lucy removed Raggedy Ann ' s s u t u r e s . The r e s e a r c h e r accompanied the procedure w i th an e x p l a n a t i o n tha t Raggedy Ann was a l l b e t t e r now, e v e r y t h i n g was mended. When the s u t u r e s were out the d o l l was d re s sed i n her outdoor c l o t h e s and the r e s e a r c h e r s a i d : "See, Raggedy Ann has had her s t i t c h e s out and now she i s ready to go home tomorrow." Lucy spoke f o r the f i r s t t ime ; c l e a r as a b e l l she e x c l a i m e d : "Me too ! me too ! " Mar ian l i k e d to p l ay o p e r a t i o n s . She was always very g e n t l e w i th Raggedy Ann and always opera ted on the c h e s t . She took g rea t care wi th the a n a e s t h e t i c c o n f i r m i n g w i th the r e s e a r c h e r tha t her a c t i o n s - 62 -were c o r r e c t . Ma r i an : Raggedy Ann has to go to s l e e p so i t won ' t hur t eh"? Re sea rcher : "Yes , but i t i s a s p e c i a l s l e e p not l i k e s l e e p at n i g h t " . Mar ian p o i n t i n g to the oxygen mask: " S p e c i a l med ic ine i n here huh?" On one o c c a s i o n Mar ian s t a r t e d the o p e r a t i o n to mend Raggedy Ann ' s hea r t w i thout g i v i n g the a n a e s t h e t i c . She looked very shame-f a c e d and s a i d : "Oh-oh! have to s t a r t a g a i n . " J u d i t h worked her way through a l l the p rocedures and c o n s t a n t l y asked q u e s t i o n s about why t h i n g s were done. J u d i t h : "what the pumper t h i n g (b lood p re s su re c u f f ) f o r ? " Re sea r che r : "That i s to make sure your hear t i s working r i g h t " . J u d i t h : "Uhat the s t e t h a t h i n g ( s t e t h o -scope) f o r ? " Re sea rcher : "That i s to l i s t e n to your hea r t to hear how good i t i s b e a t i n g . Do you want to l i s t e n to your h e a r t ? " J u d i t h : "IMo! I l i s t e n to your h e a r t . " J u d i t h showed a d e f i n i t e p r e f e r e n c e to p r a c t i c e b lood p r e s s u r e s and temperatures on p e o p l e . J u d i t h a l s o l i k e d do ing d r e s s i n g s . She c a r e f u l l y watched the r e s e a r c h e r check the ches t wound to c o n f i r m tha t i t was p r o p e r l y h e a l e d . J u d i t h then c o n -s i s t e n t l y d i d t h i s and always made the same comment as the r e s e a r c h e r : "Yes , tha t l ooks good, d e f i n i t e l y comp le te l y b e t t e r . " AUTONOMY: GAINING CONTROL The c h i l d r e n c o n t r o l l e d the p a t t e r n and content o f a l l the p l ay therapy s e s s i o n s ; however they f u r t h e r demonstrated t h e i r need to take c o n t r o l o f s i t u a t i o n s by s p e c i f i c a c t i o n s d u r i n g p l a y . Dur ing the p l ay s e s s i o n s the c h i l d r e n would man ipu la te c i r cums tances so t ha t they b e -came the a u t h o r i t y f i g u r e and the d o l l the h e l p l e s s p a t i e n t . Uhat they s a i d was how i t would be . Mo i ra had j u s t spent 20 minutes g i v i n g Rabb i t " n e e d l e s " . I t had . - 63 -been a rough and agg re s s i ve s e s s i o n , Rabb i t mas soggy w i th water and p l a s t e r e d w i th b a n d - a i d s . Re sea r che r : "Poor o l d Rabb i t , he has had a l o t o f n e e d l e s . I bet t h a t r e a l l y h u r t . " M o i r a : "No i t d o n ' t , she got to have him m e d i c i n e . " Then Mo i ra s a i d to Rabb i t shak ing her f i n g e r at h im: "I say you g o t t a have the need le s - so you got to t o , s e e ! " Mo i ra made i t c l e a r she was the n u r s e . Lucy d i r e c t e d p l ay from the f i r s t s e s s i o n even though she was e a s i l y f a t i g u e d and so s t i f f and sore i t was hard f o r her to handle the equipment. A l s o , as the youngest c h i l d i n the group, she was not as manual ly dext rous as the o the r c h i l d r e n . Desp i te t h i s she p r e f e r r e d to man ipu la te the equipment by h e r s e l f . She c o u l d n ' t open the i n t r a v e n o u s se t clamp on her own so she a l l owed the r e s e a r c h e r to a s s i s t but i n -s i s t e d tha t her hand was a l s o on the c lamp. She always chose the d o l l and the equipment and wi th the a i d o f exc l amat i on s and body language, made her i n t e n t i o n s c l e a r . When her mother asked her i f she was the d o c t o r , she shook her head. When asked i f she was the nurse she nodded and s m i l e d . Mar ian d i r e c t e d a l l the p l a y and used the r e s e a r c h e r as an a s s i s t a n t . The d o l l s were o r g a n i z e d throughout the p l a y s e s s i o n . Mar ian was ma in ly very n i c e to them but was always f i r m . On g i v i n g need les she would say : "Now you are go ing to have another n e e d l e . . . now you have to l i e s t i l l and i t w i l l soon be over . . . i t go ing to hur t a b i t but you got to have i t . " Ma r i an , l i k e Mo i ra and Lucy, was the n u r s e . They a l l i n s i s t e d on wear ing the p l a y nurse cap and two p l ay watches . Be fo re they s t a r t e d to p l ay they would dress f o r m a l l y f o r the p a r t . J u d i t h , always d i r e c t i n her comments, s a i d to her e i g h t year o l d room-mate, when she t r i e d to take some equipment: "you go away, - Gk -t h i s my t h i n g s . You c a n ' t do n e e d l e s , I do n e e d l e s . " J u d i t h mas u s u a l l y the nurse but when she d i d o p e r a t i o n s she was the d o c t o r . J u d i t h ' s need f o r autonomy was very s t r o n g . A f t e r she had p r a c t i c e d wi th the s t e t h o s c o p e , b lood p re s su re c u f f and thermometer, on the d o l l s , she f e l t ready to do her own v i t a l s i gn s and r e f u s e d to l e t the nur ses take them. One nurse hand led t h i s w e l l by sugge s t i ng tha t J u d i t h and she take each o t h e r ' s v i t a l s i g n s . SEPARATION FROM HOME AND FAMILY T h i s theme emerged i n the c h i l d r e n ' s p l a y from t ime to t i m e . I t was not v o i c e d s t r o n g l y by any o f the c h i l d r e n and was f r e q u e n t l y a s s o c i a t e d w i th n u r t u r i n g a c t i v i t i e s . There seemed to be a d i r e c t r e l a t i o n s h i p between the f requency o f p a r e n t a l v i s i t s and the f requency o f s e p a r a t i o n themes expres sed i n each c h i l d ' s p l a y . M o i r a ' s pa ren t s were unable to v i s i t except on i s o l a t e d even ing s . She expres sed her w o r r i e s d u r i n g p l ay w i th R a b b i t . M o i r a : "You have been a bad boy today so your mummy c a n ' t come i n . " Re sea r che r : "Perhaps h i s mummy l i v e s a l ong way away and c a n ' t come every day. I t h i n k she has to work i n the e v e n i n g " . Mo i ra l i s t e n e d but d i d n ' t comment. L a t e r she s a i d d i r e c t l y to the r e s e a r c h e r , "I want my Mummy and Daddy to come." T h i s p r o v i d e d an o p p o r t u n i t y to d i s c u s s why M o i r a ' s pa ren t s c o u l d not v i s i t o f t e n . A f t e r t h i s Mo i ra would e x p l a i n to Rabb i t or Raggedy Ann i n a sad v o i c e : "Mummy w i l l come soon - Daddy w i l l d r i v e her i n the car - Bobby and J u l i e and Nancy w i l l come too -they w i l l a l l came to v i s i t . " Lucy d i d not express t h i s theme i n p l a y . Her mother was w i th her a l l day and had a l s o been a l l owed to v i s i t Lucy i n I n t e n s i v e C a r e . Lucy had many comfort a r t i c l e s from home i n c l u d i n g p i c t u r e s o f her b r o t h e r s - 65 -and s i s t e r s . Her mother c o n s t a n t l y t a l k e d to her about the f a m i l y and what they would a l l do t o ge the r when they f l ew home a g a i n . Mar ian was ab le to speak to the r e s e a r c h e r about her s i s t e r and f a t h e r at home. Her mother v i s i t e d every day. Mar ian o c c a s i o n a l l y would t e l l Raggedy Ann: "You go to s l e e p now, Mummy w i l l come i n the morning a f t e r b r e a k f a s t . " J u d i t h ' s mother a l s o v i s i t e d every day d e s p i t e the f a c t t ha t she had a new th ree month o l d baby at home. J u d i t h d i d not d i s p l a y any j e a l o u s y or a n x i e t y about her new b r o t h e r . On one o c c a s i o n , r e f e r r i n g to her mother, she s a i d to Raggedy Ann: " s h e ' s on l y gone f o r a smoke, you know, she coming back s o o n . " NURTURING ACTIVITIES A l l the c h i l d r e n moved on from a g g r e s s i v e p l ay to o c c a s i o n a l n u r t u r i n g a c t i v i t i e s dur ing t h e i r f i n a l p l ay s e s s i o n s . A c t i v i t i e s c l a s s e d as n u r t u r i n g were p l ay behav iour s t ha t demonstrated tender concern f o r the d o l l s . Mo i ra washed Raggedy Ann to make her comfor tab le and p a t t e d her when she tucked her i n bed . Lucy p a t t e d Rabb i t and Raggedy Ann and game them d r i n k s o f j u i c e . Mar ian was the most c o n s i d e r a t e n u r s e . She washed, f e d and cudd led a l l the d o l l s . She a l s o s t a r t e d t h i s p l a y du r ing her t h i r d p l a y therapy s e s s i o n . J u d i t h was more rough. She demanded the d o l l s eat t h e i r d inner t e l l i n g them tha t t h i s would make them w e l l more q u i c k l y . However when she put them to bed, she tucked them i n very g e n t l y and spoke to them i n a s o f t and l o v i n g way. THE CHILD UHO DID NOT UANT TO PLAY HOSPITALS Shaun, the on ly boy t a k i n g p a r t i n the s tudy , d i d not expres s - 66 -h i m s e l f through the medium o f p l ay t h e r a p y . I t seems u n l i k e l y t ha t t h i s was due to sex d i f f e r e n c e . The l i t e r a t u r e does not support t h i s i d e a . A l s o , du r i ng a p r e v i o u s p i l o t s tudy , the r e s e a r c h e r observed a f o u r year o l d boy demonstrate the same p lay behav iour as the g i r l s i n t h i s s t u d y . Shaun was the one c h i l d t a k i n g p a r t i n the s tudy who had an un s t ab le home s i t u a t i o n du r ing h i s f i r s t f o u r y e a r s . H i s mother de -s e r t e d him when he was two years o l d . H i s f a t h e r formed a common-law r e l a t i o n s h i p one and o n e - h a l f years ago and Shaun had a s i x month o l d s t e p - b r o t h e r . On f i r s t meeting Shaun was sweet and a f f e c t i o n a t e and d e l i g h t e d to hear tha t the r e s e a r c h e r was going to p l a y w i th h im. The next meet ing took p l a c e when Shaun r e t u r n e d to the ward a f t e r s u r g e r y . He was dy spne i c and l ay q u i e t l y i n bed w i th h i s oxygen mask on . LJhen asked i f he would l i k e a s t o r y he sm i l ed and nodded. He chose one o f h i s own books and sm i l ed at a l l the funny r e p e t i t i v e p h r a s e s . On the second v i s i t Shaun was s t i l l t i r e d , a p a t h e t i c and r a t h e r wi thdrawn. He r e f u s e d a s t o r y about h o s p i t a l s and chose a f a m i l y s t o r y about a "daddy" cook ing supper . C o n v e r s a t i o n about Shaun ' s home was i n i t i a t e d . When asked i f h i s daddy cooked supper , he laughed f o r the f i r s t t ime and s a i d : "Only when Daddy i s madewith Mummy." Shaun was f i r s t shown the p l a y equipment on the t h i r d v i s i t . He opened the case and h i s f a c i a l e x p r e s s i o n changed to a w o r r i e d l o o k . He p o l i t e l y pushed the toy s away and s a i d i n a weepy v o i c e t h a t he d i d n ' t want to p l ay now. Shaun was happy to t a l k about h i s f a t h e r and the fun they had t o g e t h e r . The r e s e a r c h e r took the o p p o r t u n i t y to t a l k about Shaun ' s r e t u r n home. Dur ing h i s h o s p i t a l i z a t i o n Shaun was nega t i ve and a c t i v e l y o b s t r u c t i v e about a l l p r o c e d u r e s . He l o a t h e d - 67 -r e c t a l temperatures and i n c o n v e r s a t i o n w i th the r e s e a r c h e r comp le te l y den ied tha t he had h i s temperature taken tha t may. He a l s o r e f u s e d h i s food a l t h o u g h , a c c o r d i n g to h i s f a t h e r , t h i s was a long s t and ing b e h a v i o u r . Shaun s u f f e r e d u r i n a r y r e t e n t i o n p o s t - o p e r a t i v e l y and had to be c a t h e t e r i z e d . He was a l s o i n c o n t i n e n t o f u r i n e on s e v e r a l o c c a s i o n s . Dur ing one u n s u c c e s s f u l p l ay therapy s e s s i o n Shaun threw the c a t h e t e r to one s i d e . The r e s e a r c h e r attempted tD e x p l a i n the use o f c a t h e t e r s but Shaun tu rned h i s head away and r e f u s e d to l i s t e n . On the f o u r t h v i s i t Shaun s t i l l found the p l a y equipment too t h r e a t e n i n g to touch so the r e s e a r c h e r d e c i d e d to read a h o s p i t a l s t o r y book. Shaun l i s t e n e d to p a r t o f the s t o r y then r e f u s e d any more. When he was p l a y i n g w i th the tape r e c o r d e r he heard the s t o r y aga in wi th h i s comments. He was g r e a t l y i n t r i g u e d to hear h i s v o i c e . Shaun then repea ted the s t o r y wi th the a i d o f the t ape , t h i s t ime r e l a t i n g w e l l to the s t o r y book boy. However Shaun s t i l l would not con t inue to the pa r t o f the s t o r y where an o p e r a t i o n was pe r fo rmed. Dur ing the next v i s i t Shaun, w i th h i s f a t h e r ' s encouragement, gave a very h a l f - h e a r t e d i n j e c t i o n to R a b b i t . Shaun then asked h i s f a t h e r to g i ve a " n e e d l e " and chose the "mother" d o l l . He asked f o r the need le to be g i ven i n the stomach. Shaun i n i t i a l l y laughed at t h i s but then grew anx ious , pushed the h o s p i t a l toys away and p i c k e d up a toy car and p l ayed a i m l e s s l y w i th i t . Again he r e f u s e d to touch the p l a y equipment. On the next v i s i t Shaun r e f u s e d to Dpen the s u i t c a s e and did not want to t a l k to the r e s e a r c h e r . H i s i n t e r e s t was aroused on ly when a game o f b a l l o o n h a n d b a l l was sugges ted . He then consented to be f r i e n d s w i th the r e s e a r c h e r once more and asked her to come back and - 68 -p lay the next day. Shaun consented to p l ay w i th Raggedy Andy on the e i g h t h v i s i t . He had j u s t had h i s ches t wound c l eaned and was s t i l l very u p s e t . He was immediate ly i n t r i g u e d to f i n d tha t Raggedy Andy had a ches t wound j u s t l i k e h i s . He responded to the sugge s t i on tha t he cou ld do the d o l l ' s d r e s s i n g . For the f i r s t time Shaun became i n v o l v e d i n the p l ay and was ab le to t a l k about o p e r a t i o n s . He removed Raggedy Andy ' s s t i t c h e s w i th g rea t c o n c e n t r a t i o n and asked q u e s t i o n s about the s u t u r e s . When he had f i n i s h e d the d r e s s i n g he gave a s i g h , then looked at h i s f a t h e r and s m i l e d . Raggedy Andy was then dres sed i n outdoor c l o t h e s and the r e s e a r c h e r pronounced him ready to go home. Shaun however, s t i l l r e f u s e d to g i ve need le s a l though he d i d p i c k up the p l a y equipment and examined each a r t i c l e . On the l a s t v i s i t Shaun had a l r e a d y had h i s s u t u r e s out and knew he was go ing home. He c o u l d h a r d l y c o n t a i n h i s e x c i t e m e n t . He t a l k e d about h i s d r e s s i n g and commented tha t i t was j u s t l i k e Raggedy A n d y ' s . He then announced tha t he was go ing home t o o . The nurse r e p o r t e d t h a t , a l though Shaun had c r i e d throughout the p rocedure , he l ay s t i l l f o r the f i r s t t ime . In the course o f c o n v e r s a t i o n wi th the r e s e a r c h e r Shaun p i c k e d up the p l a y thermometer and s a i d : "I had t h i s i n my bum-bum". He then laughed i n a r a t h e r embarrassed way. The r e s e a r c h e r agreed wi th Shaun tha t i t was a s t range p l a c e to put a thermometer. Some c o n -v e r s a t i o n then took p l a ce on why temperatures were taken r e c t a l l y when you were s i c k . Shaun ' s response was somewhat i n c r e d u l o u s but he seemed to accept the e x p l a n a t i o n . He then took Raggedy Andy ' s t r o u s e r s o f f and put the thermometer between the d o l l ' s l e g s . Aga in as he p l a y e d through t h i s p rocedure , he g i g g l e d and put h i s hand over h i s f a c e . As Shaun now seemed ready to l i s t e n to an e x p l a n a t i o n about - 69 -the reasons f o r h i s h o s p i t a l i z a t i o n the r e s e a r c h e r endeavoured once more to e x p l a i n t h i s to Shaun. For the f i r s t t ime Shaun d i d not t u r n h i s head away and seemed to l i s t e n to the i n f o r m a t i o n . POST HOSPITAL BEHAVIOUR A l l f ou r g i r l s uho took p a r t i n the s tudy c o n t i n u e d to p l ay " h o s p i t a l s " a f t e r they r e t u r n e d home. " N e e d l e s " con t i nued to be an impor tant theme i n t h e i r p l ay but p l ay s y r i n g e s seemed to be s a t i s -f a c t o r y . In a f eu ueeks h o s p i t a l p l ay d i m i n i s h e d and o the r s o c i a l p l ay took o v e r . Lucy uas r e p o r t e d to have f o u r n ightmares i n the f i r s t tuD ueeks . Lucy and J u d i t h both got up at n i g h t to j o i n t h e i r pa ren t s i n bed . Mo i ra and Mar ian uere r e p o r t e d to have no s l e e p d i s t u r b a n c e s . Mar ian a t f i v e and o n e - q u a r t e r y e a r s uas r e p o r t e d to have been u e l l s i n c e d i s c h a r g e and to have improved i n her s c h o l a s t i c performance at s c h o o l . She t a l k e d i n a happy uay about her f r i e n d s at the h o s p i t a l . Mo i ra uas r e p o r t e d as a c t i v e and i n c l i n e d to be more dominant i n her i n t e r a c t i o n s u i t h her b r o t h e r s and s i s t e r s . Lucy uas r e p o r t e d as a c t i v e and r a t h e r a g g r e s s i v e . For a f eu days she uas r e l u c t a n t to l eave her mother but q u i c k l y became more independent . Her p r e - h o s p i t a l speech p a t t e r n r e t u r n e d and she i n c r e a s e d her v o c a b u l a r y . She d i d not l i k e to go pas t the l o c a l h o s p i t a l . When she r e t u r n e d to Vancouver seven ueeks l a t e r f o r an o u t p a t i e n t v i s i t , she uas q u i t e at ease u i t h the d o c t o r s . She uanted to e x p l o r e the o u t -p a t i e n t department on her own and to p l ay u i t h the toys p r o v i d e d . J u d i t h ' s mother r e p o r t e d t h a t her daughter had changed from a q u i e t g i r l to an a g g re s s i ve c h i l d . J u d i t h d i d respond to the normal d i s c i p l i n e used i n the home but c o n s t a n t l y t r i e d her mother ' s p a t i e n c e - 70 -by do ing t h i n g s tha t mere not a l l o w e d . The r e s e a r c h e r found J u d i t h as f r i e n d l y and v e r b a l as e v e r . When asked what had happened to her i n h o s p i t a l J u d i t h announced t h a t : "God mended my h e a r t . " Shaun was r e p o r t e d as hav ing n ightmares f o r a feu weeks. He a l s o had a coup le o f bed-u ie t t ing i n c i d e n t s . H i s f a t h e r r e p o r t e d a feu temper tant rums. When Shaun r e t u r n e d f o r a checkup f i v e months a f t e r surgery he seemed q u i t e at ease i n the d o c t o r ' s o f f i c e . He p l a y e d q u i e t l y u i t h some toy c a r s . He looked u e l l and had groun over one i n c h . Shaun g r e e t e d the r e s e a r c h e r as an o l d f r i e n d . H i s p l ay p a t t e r n at home d i d not r e l a t e to h o s p i t a l s . When asked uhy he had been i n h o s p i t a l Shaun shook h i s head. The r e s e a r c h e r s a i d : "Doctor mended your h e a r t , d i d n ' t he? IMou you can p l ay a l l day u i t h your f r i e n d s i n s t e a d of hav ing to s l e e p i n the a f t e r n o o n . " Shaun opened h i s eyes u i d e , sm i l ed and s a i d : " Y e p " . He then l i f t e d up h i s s u e a t e r to shou h i s ches t s c a r , then push ing out h i s ches t l i k e a m i n i a t u r e T a r z a n , banged i t u i t h h i s f i s t s . DISCUSSION OF FINDINGS Four out o f the f i v e p r e - s c h o o l c h i l d r e n uho took pa r t i n t h i s s tudy uere ab le to a c t i v e l y p a r t i c i p a t e i n p l ay t h e r a p y . The f i f t h c h i l d , the on l y boy i n the s tudy , p a r t i a l l y p a r t i c i p a t e d i n p l ay therapy on one o c c a s i o n o n l y . T h i s took p l a c e du r ing the second l a s t v i s i t u i t h the r e s e a r c h e r . Dur ing the f i n a l v i s i t h i s examinat ion o f the p l ay equipment and the thermometer p l ay uas r a t h e r l i k e the o ther c h i l d r e n ' s p l ay behav iour du r ing t h e i r f i r s t p l ay therapy s e s s i o n . In r e l a t i o n to the f i r s t q u e s t i o n posed i n t h i s s tudy the g i r l s c l e a r l y expres sed f i v e common themes i n the course o f p l ay t h e r a p y . They u e r e : i n t r u s i v e p r o c e d u r e s ; re -enactment o f p rocedures and t e s t i n g - 7 1 -r e a l i t y ; autonomy and g a i n i n g c o n t r o l ; s e p a r a t i o n from home and f a m i l y ; and f i n a l l y , n u r t u r i n g a c t i v i t i e s . Each of these themes r e c u r r e d u i t h d i f f e r i n g f r e q u e n c i e s throughout c h i l d r e n ' s p l ay therapy s e s s i o n s . A l l the i n t r u s i v e t r e a t m e n t s , most p a r t i c u l a r l y g i v i n g " n e e d l e s " was by f a r the most f r equen t p l ay b e h a v i o u r . Each c h i l d gave " n e e d l e s " many t imes du r ing each p l ay therapy s e s s i o n . Other i n t r u s i v e p r o - 1 cedures tha t each c h i l d had, such as i n t r a v e n o u s therapy or r e c t a l temperature t a k i n g , a l s o appeared f r e q u e n t l y i n t ha t p a r t i c u l a r c h i l d ' s p l a y . The next most f requent theme expres sed i n the p l ay of these c h i l d r e n uas the re -enactment o f p r o c e d u r e s . M o i r a , Mar ian and J u d i t h a l l p l a y e d " o p e r a t i o n s " u i t h g rea t en thus i a sm. Mar ian a luay s ope ra ted on the c h e s t ; J u d i t h opera ted on the ches t and once i n the d o l l ' s head; Mo i ra ope ra ted once on the c h e s t , the o ther o p e r a t i o n s uere on R a b b i t ' s eye . Lucy removed Raggedy Ann ' s ches t tube and s u t u r e s . The c h i l d r e n a l l s t a r t e d r e - e n a c t i n g p rocedures from the second p l ay therapy s e s s i o n and i n c l u d e d at l e a s t one procedure dur ing each sub -sequent p l ay therapy s e s s i o n . The theme o f autonomy and g a i n i n g c o n t r o l uas apparent i n many a c t i o n s and a t t i t u d e s t ha t the c h i l d r e n demonstrated i n t h e i r p l ay b e h a v i o u r . Mo i r a and J u d i t h expres sed the need to be i n c o n t r o l more a g g r e s s i v e l y than the o ther tuo c h i l d r e n . Houever, the o t h e r tuo c h i l d r e n a l s o expres sed t h i s need s t r o n g l y i n the course o f t h e i r p i a y . None o f the c h i l d r e n had any d i f f i c u l t y i n d e c i d i n g uhat to p l ay next and a luays c l e a r l y d i r e c t e d the r e s e a r c h e r or parent on hou they uere to take pa r t i n the p l a y . T h i s theme ran through a l l the p l ay therapy s e s s i o n s . The theme o f s e p a r a t i o n appeared l e s s f r e q u e n t l y than any o f the - 72 -• t h e r themes. Lucy was the one c h i l d who d i d not seem to express t h i s theme at any t ime dur ing p l a y . However her mother s t ayed w i th her more than any o f the o ther pa ren t s and took p a r t i n a l l the p l ay therapy s e s -s i o n s . Lucy a l s o enjoyed a l o t o f c u d d l i n g and t ouch ing wi th her mother . Mo i r a , the on l y c h i l d who d i d not have p a r e n t a l v i s i t s every day, e x -p re s sed t h i s theme at some p o i n t du r ing every p l ay therapy s e s s i o n . The o ther two g i r l s expres sed t h i s theme i n a few p l ay therapy s e s s i o n s but always i n a p o s i t i v e way to comfort a d o l l . The f i n a l theme, n u r t u r i n g a c t i v i t i e s , appeared i n the p l ay behav iour of the c h i l d r e n du r ing l a t e r p l a y therapy s e s s i o n s o n l y . T h i s theme was expres sed i n the c h i l d r e n ' s p l ay when a gg re s s i ve p l ay was beg inn ing to d i m i n i s h . As n u r t u r i n g a c t i v i t i e s were expres sed more f r e q u e n t l y , need le p l ay tended to be l e s s f r equen t and l e s s a g g r e s s i v e . A l s o , the s i t e s chosen f o r i n j e c t i o n s were s i m i l a r to those used i n r e a l i t y . In r e l a t i o n to the second q u e s t i o n posed i n t h i s s tudy ; the q u a l i t y and i n t e n s i t y o f the c h i l d r e n ' s p l a y behav iour d i d seem to f o l l o w a p a t t e r n . The p l ay was q u i e t , i n t e n s e and s e r i o u s to beg in w i t h . P l ay then became agg re s s i ve and i n t r u s i v e . Next, p l ay became more i m a g i n a t i v e as s e v e r a l p rocedures were ac ted o u t . Agg res s ion then d i m i n i s h e d and more p o s i t i v e tender f e e l i n g s were e x p r e s s e d . At t h i s p o i n t p l a y a l s o became l e s s i n t e n s e and o c c a s i o n a l l y humour would en te r i n t o the p l ay b e h a v i o u r . T h i s p a t t e r n o f p l ay behav iour seems to suggest tha t the t h e r a p e u t i c p r o c e s s , d e s c r i b e d by Moustakas, i s t a k i n g place." ' ' That i s , by moving through the s tages o f p l a y the c h i l d r e n , C l a r k Moustakas, C h i l d r e n i n P lay Therapy . (New York: B a l l a n t i n e Books, 1953) pp . 7 -10. - 73 -as A x l i n e p o s t u l a t e d , " p l ay o u t " f e e l i n g s and problems j u s t as a d u l t s " t a l k o u t " t h e i r d i f f i c u l t i e s . 2 In r e l a t i o n to the t h i r d q u e s t i o n posed i n t h i s s tudy , the f i r s t f ou r themes expres sed i n the c h i l d r e n ' s p l ay seem to r e f l e c t some o f t h e i r major f e a r s and concerns about t h e i r h o s p i t a l e x p e r i e n c e . These themes a r e : i n t r u s i v e p r o c e d u r e s ; re -enactment o f p r o c e d u r e s ; autonomy; and s e p a r a t i o n from home and f a m i l y . The f requency w i th which need le p l ay and i n t r u s i v e p l ay occu red demonstrates how deep ly the c h i l d r e n are impressed by t h i s type o f p r o c e d u r e . Two o f the c h i l d r e n , Mo i ra and J u d i t h , seemed to connect need le p l ay w i th ptlmishment. Lucy, who had so many i n t r u s i v e t r e a t -ments, spent a lmost her e n t i r e p l ay therapy s e s s i o n s doing i n t r u s i v e p r o c e d u r e s . Each c h i l d seemed to have a need to r e - e n a c t p rocedures to g a in a b e t t e r under s t and ing o f what had happened to her i n h o s p i t a l . The c h i l d r e n c o n s t a n t l y sought c o n f i r m a t i o n from the r e s e a r c h e r t ha t t h e i r a c t i o n s were c o r r e c t . They made comments about what they were doing but the comments were o f t e n phrased as an e n q u i r y . The c h i l d would con t inue p l a y i n g out the procedure a f t e r they r e c e i v e d c o n f i r m a t i o n or c l a r i f i c a t i o n from the r e s e a r c h e r . Even Lucy who c o u l d not v e r b a l i z e q u e s t i o n s , would f r e q u e n t l y g i ve an i n t e r r o g a t o r y " e h ! " as she r e -enacted p rocedures and nod h a p p i l y when she got i t r i g h t . The theme o f autonomy and l o s s o f c o n t r o l e n t e r e d i n t o the c h i l d r e n ' s p l ay b e h a v i o u r . The c h i l d r e n p l a y e d the p a r t o f an V i r g i n i a A x l i n e , P l ay Therapy . (Cambridge, Mas sachuse t t s : The R i v e r s i d e Press 1947) p. 9. - 74 -a u t h o r i t y f i g u r e , u s u a l l y the n u r s e . Dur ing p l ay a d u l t s uere d i r e c t e d by the c h i l d r e n ; d o l l s , who uere the p a t i e n t s , had to do what they were t o l d . The f requency w i th which t h i s theme e n t e r e d p l ay p robab l y r e f l e c t s each c h i l d ' s concern w i th l o s s o f c o n t r o l . In agreement w i th P e t r i l l o , each c h i l d made use o f the o p p o r t u n i t y d u r i n g p l ay to become the " d o e r " r a t h e r than the v i c t i m . " 3 Sadness because o f s e p a r a t i o n from pa ren t s and f a m i l y , was e x -p re s sed du r ing p l ay by Mo i ra who d i d not have r e g u l a r p a r e n t a l v i s i t s . Dur ing p l ay she v o i c e d her b e l i e f to Rabb i t t h a t , bad c h i l d r e n cannot have pa ren t s v i s i t . Mar ian and J u d i t h f e l t the need to r e a s s u r e t h e i r d o l l s t h a t p a r e n t s would r e t u r n . Lucy d i d not express t h i s concern du r ing p l a y . Her mother took pa r t i n every p l ay therapy s e s s i o n and was w i th her each day from b r e a k f a s t u n t i l bed t ime. In c o n c l u s i o n , i t appears t h a t each c h i l d who took p a r t i n p l ay therapy was ab le to express some i n d i v i d u a l f e a r s and concerns about h i s h o s p i t a l e x p e r i e n c e . The g r e a t e r the c h i l d ' s f e a r and concern about an even t , the more f r e q u e n t l y t h i s event appeared i n the c h i l d ' s p l a y . In r e l a t i o n to the f o u r t h q u e s t i o n posed i n t h i s s tudy , the c h i l d r e n d i d tend to ac t out t h e i r p e r c e p t i o n s of what had happened to them i n h o s p i t a l . In the course o f p l a y therapy each c h i l d ac ted through s p e c i f i c p r o c e d u r e s , so p l ay behav iour was o f t e n a f a c t u a l account o f each c h i l d ' s h o s p i t a l e x p e r i e n c e . Lucy e x p e r i e n c e d many more i n t r u s i v e procedures than the o ther c h i l d r e n and had to endure a l l Madel ine P e t r i l l o , " P r e v e n t i n g H o s p i t a l Trauma i n P e d i a t r i c P a t i e n t s . " American J o u r n a l o f N u r s i n g , LXVI I I : ( J u l y 1968) p. 1470. - 75 -o f these p rocedures l onge r than the o the r c h i l d r e n . She i n s i s t e d tha t the i n t r a v e n o u s i n f u s i o n ran i n t o the d o l l ' s arm throughout each p l ay therapy s e s s i o n . She a l s o i n s e r t e d n a s o - g a s t r i c tubes f o r s u c t i o n i n g and a luays i n s e r t e d the f o l e y c a t h e t e r between the d o l l ' s l e g s . Lucy, Mo i ra and Shaun a l l put r e c t a l thermometers i n the d o l l s . J u d i t h and Mar ian d i d not have t h e i r temperatures taken r e c t a l l y . In p l a y , they p l a c e d the thermometer i n the d o l l ' s a x i l l a . Lucy was the on l y c h i l d who p l ayed wi th the chest t u b e . She had her awn ches t tube i n much l onger than the o the r c h i l d r e n and seemed to remember very c l e a r l y when i t was removed. Mar i an , who took o r a l m e d i c a t i o n at home and con t i nued to take the same m e d i c a t i o n i n h o s p i t a l , gave the d o l l s p i l l s . J u d i t h always t i e d the d o l l down when she s t a r t e d an i n t r a v e n o u s i n f u s i o n . On check ing w i th the nurses the r e s e a r c h e r d i s -covered J u d i t h had fought a g a i n s t t h i s p rocedure and had both arms r e s t r a i n e d . Shaun, the boy who d i d not want to p l a y " h o s p i t a l s " seemed to be so overwhelmed by h i s h o s p i t a l i z a t i o n t h a t the p l ay therapy equipment was f r i g h t e n i n g to h im. A f t e r e i g h t days on the ward, when a more t r u s t i n g r e l a t i o n s h i p had deve loped wi th the r e s e a r c h e r , Shaun uas ab le to i d e n t i f y u i t h Raggedy Andy ' s ches t uound. Nine days a f t e r h i s r e -t u r n to the u a r d , uhen he kneu he uas r e a l l y go ing home, Shaun uas f i n a l l y ab le to t a l k about hav ing h i s temperature taken r e c t a l l y . At t h i s t ime t o o , he seemed to be r e c e p t i v e to l i s t e n i n g to an e x p l a n -a t i o n about h i s s u r g e r y . At t h i s p o i n t Shaun may have been ab le to take pa r t i n p l a y t h e r a p y . Shaun uas the on l y c h i l d i n the study who had s u f f e r e d the l o s s o f h i s mother when he was tuo years o l d . He r e f u s e d to t a l k about h i s s t ep -mothe r . From h i s behav iour i n h o s p i t a l i t uou ld seem t h a t h i s l e v e l o f a n x i e t y uas g r e a t e r than tha t o f the - l e -ather c h i l d r e n i n the s t u d y . The reasons f o r h i s h i gh a n x i e t y and h i s i n a b i l i t y to p l ay h o s p i t a l s uas not i n v e s t i g a t e d . Houever, W i n n i c o t t s t a t e s : "There i s a degree o f a n x i e t y t ha t i s unbearab le and t h i s d e s t r o y s p l a y i n g " . T h i s may have been a f a c t o r u h i c h c o n t r i b u t e d to Shaun 's i n a b i l i t y to take p a r t i n t h i s type o f p l ay t h e r a p y . The data c o l l e c t e d Dn the c h i l d r e n ' s p o s t - h o s p i t a l behav iour uas i n s u f f i c i e n t to reach any c o n c l u s i o n s as to the e f f e c t o f p l ay therapy on the degree of p o s t - h o s p i t a l p s y c h o l o g i c a l upset s u f f e r e d by the c h i l d r e n . In summary the data c o l l e c t e d on the p l ay behav iour expres sed by the f ou r g i r l s i n the study does i n d i c a t e f i v e common themes: i n t r u s i v e p r o c e d u r e s ; re -enactment o f p r o c e d u r e s ; autonomy; s e p a r a t i o n ; and n u r t u r i n g a c t i v i t i e s . The data a l s o suggests t ha t p l ay may f o l l o u a p a t t e r n from agg re s s i ve p l ay to more g e n t l e p l ay and from i n t e n s e p l a y to more r e l a x e d p l a y . Some p l a y b e h a v i o u r s no ted i n the course o f p l ay therapy suggest t ha t these c h i l d r e n d i d express some i n d i v i d u a l f e a r s and concerns about t h e i r h o s p i t a l e x p e r i e n c e . The p l a y behav iou r s observed a l s o suggest tha t these c h i l d r e n tended to ac t through t h e i r p e r c e p t i o n o f uhat had happened to them. One c h i l d , the on ly boy i n the s tudy , d i d not uant to p l ay " h o s p i t a l s " . The reasons f o r t h i s c h i l d ' s r e f u s a l to take pa r t i n p l ay therapy are u n c l e a r . D. W. W i n n i c o t t , " P l a y i n g : I t ' s T h e o r e t i c a l S t a tu s i n the C l i n i c a l S i t u a t i o n . " I n t e r n a t i o n a l J o u r n a l o f P s y c h o a n a l y s i s , XLIX (1968) p. 598. - 77 -LIMITATIONS OF THE STUDY The r e c o g n i z e d l i m i t a t i o n s o f the s tudy u e r e : The themes i d e n t i f i e d i n p l ay may on ly be common to c h i l d r e n hav ing major hear t s u r g e r y . G i r l s on l y i n t h i s s tudy p a r t i c i p a t e d a c t i v e l y i n p l a y t h e r a p y . One boy on ly took p a r t i n the s t u d y . The reasons why the boy uho took p a r t i n the s tudy d i d not want to p a r t i c i p a t e i n p l ay t h e r a p y , was not i n v e s t i g a t e d . The t o t a l sample o f c h i l d r e n was very s m a l l . - 78 -CHAPTER \1 CONCLUSIONS AND IMPLICATIONS FOR NURSING PRACTICE AND RESEARCH CONCLUSIONS T h i s d e s c r i p t i v e study found t h a t the p r e - s c h o o l c h i l d r e n e x -p re s sed common themes i n t h e i r p l ay behav iou r a f t e r major hea r t s u r g e r y . The themes i d e n t i f i e d i n the p l ay behav iour o f the c h i l d r e n s t u d i e d have a l s o been d i s c u s s e d by v a r i o u s w r i t e r s . F l o r e n c e E r i c k s o n has d e s c r i b e d c h i l d r e n ' s f e a r o f i n t r u s i v e p r o c e d u r e s . 1 E r i k E r i k s o n has 2 d e s c r i b e d p r e - s c h o o l e r s p r e - o c c u p a t i o n w i th t h i s m o d a l i t y of b e h a v i o u r . P e t r i l l o , Ho t t , and Barton have a l l d e s c r i b e d c h i l d r e n ' s need to r e -3 4 5 enact p rocedures and o p e r a t i o n s . ' ' Woodward and Jackson s t a t e t ha t h o s p i t a l i z e d c h i l d r e n g e n e r a l l y f e e l t h a t they have l i t t l e c o n t r o l over F l o r e n c e E r i c k s o n , "React ions-sof C h i l d r e n to H o s p i t a l E x p e r i e n c e " . Nur s ing Out look , UI: (September 1958) p. 501. 2 E r i k E r i k s o n , Ch i l dhood and S o c i e t y (Rev i sed E d i t i o n , New York : W. W. Norton C o . , 1950) pp. 194-195. "^Madeline P e t r i l l o , " P r e v e n t i n g H o s p i t a l Trauma i n P e d i a t r i c P a t i e n t s . " American J o u r n a l o f N u r s i n g , LXVI I I : ( J u l y 1968) p. 1470. J a q u e l i n e H o t t , " P l ay P.R.N, i n P e d i a t r i c N u r s i n g " . Nur s ing  Forum, IX: (March 1970) p. 295. P a u l i n e B a r t o n , " P l ay as a T o o l o f N u r s i n g " . Nurs ing Out l ook , X: (March 1962) pp . 162-164. - 79 -t h e i r env i ronment .^ The c h i l d r e n i n t h i s s tudy r e p e a t e d l y demonstrated t h e i r need to c o n t r o l s i t u a t i o n s i n the course o f t h e i r p l a y . C h i l d r e n ' s concern wi th s e p a r a t i o n from home and f a m i l y has been d e s -7 8 c r i b e d by Robertson and Bowlby. ' T h i s theme o c c u r r e d most f r e q u e n t l y i n the p l ay o f the one c h i l d who d i d not have p a r e n t a l v i s i t i n g every day. Dur ing l a t e r p l ay therapy s e s s i o n s each c h i l d began to expres s the theme of n u r t u r i n g i n t h e i r p l ay b e h a v i o u r . These a c t i v i t i e s demonstrated tendernes s and concern f o r the d o l l s and r e p l a c e d rough and a g g re s s i ve b e h a v i o u r s . Moustakas suggest s t h a t the t h e r a p e u t i c p r o c e s s , which takes p l a c e du r ing p l ay t h e r a p y , f o l l o w s a r e g u l a r p a t t e r n . In the f i n a l s t ages o f t h i s p r o c e s s p o s i t i v e f e e l i n g s which g are t y p i c a l o f n u r t u r i n g a c t i v i t i e s , emerge. The q u a l i t y and i n t e n s i t y o f the p l a y behav iour demonstrated by the c h i l d r e n f o l l o w e d a p a t t e r n from i n t e n s e to more r e l a x e d and from agg re s s i ve to more p o s i t i v e tender f e e l i n g s . T h i s p a t t e r n o f p l ay i s s i m i l a r to t ha t d e s c r i b e d by M o u s t a k a s . ^ The c h i l d r e n i n t h i s s tudy d i d express some f e a r s and concerns about t h e i r h o s p i t a l e x p e r i e n c e . These f e a r s and concerns were p a r t ^Woodward and D. Jackson , "Emotion Reac t i on s i n Burned C h i l d r e n and t h e i r M o t h e r s " . B r i t i s h J o u r n a l o f P l a s t i c Su rgery , X I I I : (1961) pp. 316-324. 7 J . Rober t son , Young C h i l d r e n i n H o s p i t a l s . (London: T a v i s t o c k P u b l i c a t i o n s , 1958). g John Bowlby, " S e p a r a t i o n A n x i e t y . " I n t e r n a t i o n a l J o u r n a l o f  P s y c h o a n a l y s i s , XL I : (196Q) pp. 89-113. g C l a r k Moustakas, C h i l d r e n i n P lay Therapy . (New York: B a l l a n t i n e Books, (1953) p. 8. 1 0 I b i d . , pp. 7-9. - 8 0 -o f the f i r s t f o u r themes i d e n t i f i e d . L i n n d e s c r i b e s s i m i l a r concerns and f e a r s expres sed by h o s p i t a l i z e d c h i l d r e n i n the course o f puppet t h e r a p y . She s t a t e s t ha t i n j e c t i o n s are the most common p l a y behav iour and tha t c h i l d r e n f r e q u e n t l y f ocus t h e i r anger on " n e e d l e s " . L i nn a l s o i d e n t i f i e s l o s s o f autonomy and s e p a r a t i o n as major concerns f o r h o s p i t a l i z e d c h i l d r e n . 1 " 1 " A n a l y s i s o f the c h i l d r e n ' s p l ay behav iour d i d demonstrate t h a t they tend to a c t out s p e c i f i c p rocedures t h a t have happened to them. T h i s i s i n agreement w i th P e t r i l l o and Plank uho both c i t e case s t u d i e s i n which the c h i l d r e n act out t h e i r p e r c e p t i o n o f t h e i r own surgery 12 13 and t r e a t m e n t s . ' In summary t h i s d e s c r i p t i v e s tudy d i d gather f u r t h e r i n f o r m -a t i o n about the na ture and content o f p o s t - s u r g i c a l p l ay behav iour i n the p r e - s c h o o l c h i l d . The data c o l l e c t e d d i d suppor t the q u e s t i o n s a sked. The i n f o r m a t i o n c o l l e c t e d on p o s t - s u r g i c a l p l a y behav iour i s i n agreement w i th o ther w r i t e r s on the s u b j e c t . IMPLICATIONS FOR NURSING PRACTICE P lay therapy would seem to be a u s e f u l t o o l f o r n u r s i n g p r a c t i c e , Ob se rva t i on o f c h i l d r e n ' s p l ay behav iour du r ing p l ay therapy p r o v i d e s i n s i g h t i n t o each c h i l d ' s f e a r s and c o n c e r n s . As c h i l d r e n tend to ac t out t h e i r p e r c e p t i o n of what has happened to them i n h o s p i t a l a c h i l d ' s 1 1 S u s a n L i n n , "Puppet Therapy i n H o s p i t a l s : He lp ing C h i l d r e n Cope . " J o u r n a l American M e d i c a l Women's A s s o c i a t i o n XXXIII (February 1978) pp . 61 -65 . 1 2 P e t r i l l o , op . c i t . , pp . 1469-1473. "^Emma N. P lank, Working w i th C h i l d r e n i n H o s p i t a l , (The P res s o f Case Western Reserve U n i v e r s i t y , 1971) p. 31. - 81 -m i s concep t i on o f a s i t u a t i o n may be i d e n t i f i e d . In t h i s way p l a y therapy may serve as a d i a g n o s t i c t o o l to i n d i c a t e what i n f o r m a t i o n or suppor t a c h i l d may need to he lp him d e a l w i th h i s h o s p i t a l i z a t i o n . P l ay therapy f a c i l i t a t e s the communication p roces s between the nurse and the c h i l d . A p r e - s c h o o l c h i l d can expres s f e e l i n g s i n p l ay t h a t he cannot express i n words. Aga in t h i s a spec t o f p l ay therapy a s s i s t s the nurse i n g a i n i n g i n s i g h t i n t o the c h i l d ' s needs . In the course o f p l ay therapy a c h i l d can move through the 14 s tages of the t h e r a p e u t i c p roces s d e s c r i b e d by Moustakas. That i s , as p l ay therapy c o n t i n u e s , a c h i l d may beg in to demonstrate tender concern f o r the d o l l s r a t h e r than a g g re s s i on and anger . T h i s behav iour may i n d i c a t e t ha t a c h i l d i s ab le to come to terms w i th a l l the u n -p l ea san t and p a i n f u l p rocedures he has had to bear i n the course o f h i s h o s p i t a l i z a t i o n . In t h i s way p l ay therapy may se rve as a t h e r a -p e u t i c n u r s i n g i n t e r v e n t i o n . P lay has been used as a t e a c h i n g t o o l i n the p r e p a r a t i o n o f c h i l d r e n f o r s u r g e r y . However, i n the course of p l ay therapy f u r t h e r t e a c h i n g can take p l a c e . P rev i ou s surgery and p rocedures can be c l a r i f i e d and procedures which have yet to take p l a c e can be ac ted th rough . By h e l p i n g each c h i l d unders tand what i s happening to him, p l ay therapy may a l s o he lp reduce a c h i l d ' s a n x i e t y . A l s o , when a c h i l d has some under s tand ing o f the "why" and "how" o f a procedure he i s much more l i k e l y to be c o - o p e r a t i v e . Dur ing the course o f p l a y therapy the nurse responds to the c h i l d ' s f e e l i n g s and accept s him as he i s . Parents may then p e r c e i v e Moustakas, op. c i t . , p. 8. - 82 -p l a y therapy as one way i n which the nurse demonstrates concern f o r t h e i r c h i l d ' s w e l f a r e . T h i s may he lp pa ren t s e s t a b l i s h a r e l a t i o n -sh i p o f t r u s t w i th the n u r s i n g s t a f f . . P lay therapy would appear to be a u s e f u l t echn ique f o r n u r s i n g s tudent s to l e a r n . I t c o u l d he lp them form a f r i e n d l y r e l a t i o n s h i p w i th t h e i r young p a t i e n t s . As n u r s i n g s tudent s take p a r t i n p l ay therapy they may sharpen t h e i r s k i l l s i n o b s e r v i n g c h i l d r e n ' s b e -h a v i o u r . From t h e i r o b s e r v a t i o n s the s t u d e n t s may e s t a b l i s h a da ta base from which tD base f u t u r e n u r s i n g i n t e r v e n t i o n s . In c o n c l u s i o n p l ay therapy i s a u s e f u l t echn ique f o r n u r s i n g p r a c t i c e and f o r n u r s i n g e d u c a t i o n . I t has p o t e n t i a l as a d i a g n o s t i c and communication t o o l and as a t h e r a p e u t i c n u r s i n g i n t e r v e n t i o n . P l ay therapy may i n d i r e c t l y he lp pa ren t s e s t a b l i s h a t r u s t i n g r e l a t i o n s h i p w i th n u r s i n g s t a f f . Nur s ing s tudent s may f i n d p l ay therapy a u s e f u l a i d to he lp them ga in more i n f o r m a t i o n about the c h i l d r e n under t h e i r c a r e . INDICATIONS FOR FURTHER RESEARCH From t h i s d e s c r i p t i v e s tudy the re i s some i n d i c a t i o n tha t p l ay therapy he lp s to reduce the s t r e s s o f h o s p i t a l i z a t i o n f o r the p r e -s c h o o l c h i l d . F u r t h e r study i s needed to i n v e s t i g a t e the i n c i d e n c e o f upset behav iour i n h o s p i t a l and o f post h o s p i t a l upset i n c h i l d r e n who have p l a y therapy compared to c h i l d r e n who do not have p l ay t h e r a p y . A l though c l i n i c a l o b s e r v a t i o n s suggest t ha t p l ay therapy reduces s t r e s s i n the h o s p i t a l i z e d c h i l d t h i s h y p o t h e s i s i s yet to be t e s t e d . T h i s s tudy d i d not demonstrate t ha t boys expres s s i m i l a r p o s t -surgery p l ay behav iour to g i r l s . A f u r t h e r study w i t h a sample - 83 -p o p u l a t i o n i n c l u d i n g a number o f boys would p rov i de f u r t h e r i n f o r m -a t i o n on the p a t t e r n and content o f t h e i r p l a y . F i n a l l y , t h i s study d i d not pursue the q u e s t i o n o f why some c h i l d r e n may not want to take p a r t i n p l a y t h e r a p y . I t would be u s e f u l to know i f an i n a b i l i t y to ac t out h o s p i t a l e x p e r i e n c e s i n p l ay i s a r e l i a b l e i n d i c a t i o n o f extreme a n x i e t y and s t r e s s i n a c h i l d . 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The E f f e c t o f B r i e f Puppet Therapy on the Emot iona l  Responses o f C h i l d r e n Undergoing C a r d i a c C a t h e t e r i z a t i o n . Unpub l i shed D o c t o r a l D i s s e r t a t i o n , Northwestern U n i v e r s i t y , Ch i cago , 1963. Reports S t a t i s t i c s Canada. H o s p i t a l M o r b i d i t y 1975. Cata logue 82-206, Canada: 1975. - 89 -APPENDIX A PLAY THERAPY EQUIPMENT DOLLS IS" Raggedy Ann ) n ., . . . . . , 3 a y x Both w i th outdoor c l o t h e s and , , , , • . „ . x h o s p i t a l gowns 16" Raggedy Andy ) K 3 18" " R a b b i t " type s t u f f e d toy w i th long arms and l e g s and d re s sed i n o v e r a l l s 4 " B a r b i e " and "Ken" type d o l l s 12" h i gh (The d o l l s were d re s sed to r e p r e s e n t ; a n u r s e , a d o c t o r , a f a t h e r , and a mother . ) REAL HOSPITAL EQUIPMENT S te thoscope B lood p r e s s u r e c u f f 1.1/, b o t t l e , t u b i n g , need le and s tand S y r i n g e s , 3cc and 5cc Needles w i th b l u n t ends Rubber capped med ic ine b o t t l e s f i l l e d w i th water Complete d r e s s i n g s e t L o t i o n b o t t l e s f i l l e d w i th water Masks, caps , g l oves Oxygen mask F o l e y s u c t i o n c a t h e t e r Chest tube Med ic ine cups Tongue dep re s so r s A l c o h o l swabs B a n d - a i d s , d r e s s i n g s , bandages - 90 -PLAY HOSPITAL EQUIPMENT Bed and bedding S y r i n ge s B lood p r e s s u r e c u f f S te thoscopes S e l e c t i o n o f p l a y ins t ruments? hammers, f o r c e p s , s c i s s o r s s c a l p e l s , p robes , head m i r r o r , d e n t a l m i r r o r Thermometers R e c e i v e r s , t r a y s , b o t t l e s Xray machine N u r s e ' s cap Nurse 1 s watch - 91 -APPENDIX B Addres s : S c h o o l o f N u r s i n g , U n i v e r s i t y o f B r i t i s h Co lumbia, Vancouver, B.C. Dear I am t r y i n g to deve lop b e t t e r mays o f h e l p i n g c h i l d r e n under -s tand t h e i r h o s p i t a l e x p e r i e n c e . I hope to ga in i n f o r m a t i o n from the pa ren t s and c h i l d r e n to a i d i n de te rm in ing which methods w i l l bes t he lp the c h i l d and h i s f a m i l y cope w i th the h o s p i t a l e x p e r i e n c e . ' Dur ing the p e r i o d i s i n h o s p i t a l I would l i k e to ask your p e r m i s s i o n tD v i s i t each day f o r t h i r t y m inu te s . T h i s t ime would be used to p l ay w i th . A c t i v i t i e s such as r e a d i n g s t o r i e s , p l a y i n g games and p l a y i n g w i th toys and p l ay h o s p i t a l equipment w i l l take p l a c e . You have my assurance tha t any i n f o r m a t i o n tha t you g i ve me w i l l be kept t o t a l l y c o n f i d e n t i a l and anonymous. You w i l l a l s o have the r i g h t to withdraw from t h i s s tudy at any t i m e . I f you do so , any i n f o r m a t i o n you have g i ven to me w i l l be d e s t r o y e d . I would a l s o l i k e to assure you tha t t h i s s tudy w i l l not i n t e r f e r e w i th the e f f e c t i v e n e s s o f m e d i c a l and n u r s i n g ca re g i ven to . The d e c i s i o n to take p a r t i n the s tudy i s e n t i r e l y y o u r s . Thank you very much f o r your h e l p . Yours s i n c e r e l y , Mar jory R a l s t o n , R.N., B.S.N. - 92 -APPENDIX C CONSENT FORM I have read and unders tand the e n c l o s e d l e t t e r e x p l a i n i n g the proposed s tudy to he lp c h i l d r e n b e t t e r unders tand t h e i r h o s p i t a l i z a t i o n . I hereby g i ve my p e r m i s s i o n f o r and myse l f to take p a r t i n t h i s s t u d y . S i gned R e l a t i o n s h i p - 93 -APPENDIX D I n te rv iew ui ith pa ren t s about the c h i l d ' s behav iour a f t e r h o s p i t a l  d i s c h a r g e . The format o f the i n t e r v i e w was u n s t r u c t u r e d . T o p i c s D i s cu s sed Does your c h i l d p l ay every day? (a) What games does he p l ay most o f t e n ? (b) Does he p l a y Doctors or H o s p i t a l s ? ( c ) What a spec t s o f h i s h o s p i t a l expe r i ence i s ac ted out i n p l a y ? What s i t u a t i o n s or events make the c h i l d a f r a i d ? (a) Be ing l e f t a lone? (b) Be ing away from pa ren t s ? ( c ) Any new f e a r s ? Changes i n behav iour or con t i nued behav iour s such a s : (a) temper tantrums (b) j e a l o u s y (c ) t i c s or mannerisms (d) extreme shyness (e) d i s t u r b e d s l e e p p a t t e r n s , n ightmares ( f ) changes i n t o i l e t h a b i t s , bed we t t i n g (g) s eek ing p a r e n t s ' a t t e n t i o n Any changes i n the c h i l d ' s behav iour t h a t the pa ren t s may have n o t e d . 

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