How a health play specialist’s role and work is understood by health play specialists and paediatric multidisciplinary team members: An online qualitative survey study

Sample and recruitment

Survey distribution occurred through key professional networks established on various social media platforms, including X (formally Twitter) and Facebook and therefore used a convenience sampling strategy where participants self-selected if they wished to participate (Stratton, 2021). Participants eligible for inclusion in this study were employed as HPSs within MDTs and healthcare settings in the UK and individuals who were part of UK paediatric MDTs and who worked regularly with HPSs in clinical, patient-facing roles were also eligible. These included professionals such as nurses, paediatricians, psychologists and Allied Health Professionals (AHPs).

Analysis

Data were analysed using inductive qualitative content analysis (Elo and Kyngäs, 2008), carried out across three stages. Firstly, the text was read and re-read to gain an overall sense of the content, or “to obtain a sense of the whole” (Vaismoradi et al., 2013: p401). Second, data were open coded per question by highlighting commonly used words, phrases or statements. Finally, codes were grouped and organised into key categories. Frequencies were used to describe the brief open text responses in line with the qualitative content analysis approach and served a descriptive rather than an analytic purpose. The initial coding was conducted by [insert initials after review] and the identification and organisation of codes were then independently checked by other team members [insert initials after review], refined and then redefined through ongoing discussions. A rigorous and reflexive approach was adopted throughout analysis, team members from mixed disciplinary backgrounds, including one registered HPS, a children’s nurse and a human geographer reflected on their professional and personal assumptions that may have influenced the interpretation of data.

Participants provided consent by ticking a box within the online survey confirming they had read the full study information sheet and understood that submitting responses indicated agreement for their data to be used for study purposes. The information sheet outlined study aims, what participation involved, voluntary nature of participation, confidentiality and data handling procedures, potential risks and benefits of taking part and provided information on where further details could be obtained after participation if needed. As responses were anonymous, participants were informed that they would be unable to withdraw their data once it had been submitted.

Characteristics of participants

A total of 101 professionals participated in the study. Of these, 56 were HPSs working across a range of healthcare settings. 23 (41%) worked in a Specialist Children’s Hospital and 23 (41%) worked in a District General Hospital. 10 participants (18%) worked in “other” settings, including community and hospice settings or in academia.

45 participants were MDT members representing a variety of health professions, including doctors/paediatricians (n = 10, 22%), nurses (n = 19, 42%), and Allied Healthcare Professionals such as physiotherapists (n = 3, 7%), occupational therapists (n = 3, 7%) and psychologists (n = 3, 7%). Less frequent roles included one chaplain, four play workers, one pharmacist and one speech and language therapist.

Key findings

Findings highlight a HPS’s role to be complex, varied and multi-layered in nature. Areas of consensus between HPS and MDT members were highlighted, as well as some divergence in understandings of the role (Table 1 and Table 2). Where survey questions sought a specific number of answers to be given (e.g. “name three things”) (Table 1), data are presented as a proportion and percentage of the total number of participants. Where less structured open text responses were provided, data are presented to show the number (frequency) and percentage of participants who mentioned a particular code (Table 2). These figures are provided for descriptive purposes only. Where consensus between participant groups was identified amongst key codes, this is shown in tables (1 and 2) in bold type.

Study findings are presented under four key categories identified through analysis: understanding of the role of the HPS working within paediatric MDTs; Descriptions of the impact of the HPS’s work; factors that support or facilitate HPS’s work; and issues that disrupt or act as barriers to the fulfilment of the HPS’s work (as seen in Figure 1). Quotations are identified by participant number and job role.OPEN IN VIEWER

Understanding of the role of the HPS working within paediatric MDTs

When participants were asked to describe the “three most important things that HPSs do” as part of their role, HPSs presented 35 distinct examples, and MDT members gave 30. Responses revealed a wide and varied understanding and observations of what HPS’s do, and their role within teams. This indicated an acknowledgement within MDTs that a HPS’s role is complex and that its demands extend far beyond “just” playing. As one HPS explained:

“The role of the HPS is beyond any job description – there are many elements to the role and no one day in the role is ever the same’ (P28–HPS).

Within this category, participants identified practical aspects of the work undertaken by HPSs. While there was agreement on the three most important things a HPS does as part of their role across both participant groups, preparation activities for children for treatment, procedures and admission to hospital were discussed slightly more frequently by HPSs (n = 32, 57%) than MDT (n = 23, 51%) and mentioned more by HPSs in response to open text questions (Table 2), with one HPS sharing that HPSs “prepare children for procedures using an array of tools and techniques suitable for their level of understanding” (P24–HPS). Distraction during procedures, while identified by both groups as an important thing a HPS does (HPS n = 30, 54%; MDT n = 20, 44% (question 1) was discussed more frequently by MDT members than by HPSs across the open text responses (Table 2). One nurse participating in the study noted that;

HPSs can commit more time before, during and after an intervention to ensure they know the patient and what distraction would work well for them (P7-nurse).

Study findings indicate a shared understanding between both groups that HPSs use play as a key tool in supporting children within healthcare settings (HPS n = 24 (43%), MDT n = 12 (27%), question 2, table 2). However, while the provision of general or “normalising” play, including the creation and maintenance of play spaces and helping children to access play activities was discussed frequently in open text responses by HPSs (n = 27, 48%), there was a lack recognition of this in responses by MDT members, despite this being a fundamental part of the HPS’s role. In emphasising this work as being central to their role, some HPS participants linked it to children’s fulfilment of their right to play. One HPS explained, it is important in order “to meet article 31 of the United Nations Convention on the Rights of the Child (UNCRC)” (P5–HPS) while others included provision of normalising play as a distinct aspect of a HPS’s role with an equal weighting to more specialised and purposefully therapeutic play delivered within their work. This provision was described as a varied spectrum of different techniques and activities by one participating HPS:

From the basic of keeping [children] busy with activities and toys to alleviate boredom to the complicated, empowering them through procedures and treatment (P24–HPS).

Participants also identified qualities acknowledged to be central to a HPS’s approach and work. There was recognition in open text responses from MDT participants (n = 17, 38%) (Table 2) that HPSs have expert knowledge and skills that are observable through their practice. These observations considered HPS’s “specialist and unique knowledge of child development and psychology” acquired by their training that “improves the experience of healthcare and hospital for children” (P33–nurse) and the significance on teams of having:

Hospital professionals with skills to care for the non-medical…needs of children and young people while they are required to have medical treatment (P68-nurse).

An advocacy role of HPSs on behalf of babies, children, young people, and their families was recognised by both participant groups. However, MDT members mentioned it only in response to a question exploring HPSs’ impact on the wider work of MDTs. In contrast, HPSs referred to advocacy in response to three separate questions, describing it in a variety of ways including “giving children choice and a voice” (P54–HPS) and “advocating children and families’ needs and rights to the multidisciplinary team” (P29–HPS), and supporting them consistently “throughout their hospital journey, both at diagnosis and [during] treatment” (P56–HPS). These responses suggest that HPSs view advocacy as a central and ongoing aspect of their role.

The reported impact of the HPS’s work in paediatric teams

Both groups of participants reported in open text responses that HPSs positively improved children’s healthcare experiences through their work (HPS n = 23, 41%; MDT n = 19, 42%) (question 3 Table 2) and that involving HPSs in their healthcare experiences, contributed to reducing children’s trauma, both short and long term (HPS n = 18, 32%; MDT n = 17, 38% (question 3, Table 2). These observations reflected both an immediate view of children’s experiences where HPSs “makes a big difference in how the visit or procedure goes and how [they] view the hospital environment” (P28–HPS) and a longer-term perspective whereby having HPSs working in teams was understood to be “a long-term investment in a child’s interactions with health services” (P52–Paediatrician).

HPSs (n = 19, 34%) (Table 2, question 4) perceived that their work contributed to “faster procedures” (P9–HPS) or better outcomes with “reduced clinical risks” (P86–HPS) for children. Some HPSs shared their observations that the presence of a HPS could “cut down the need for more invasive procedures such as general anaesthetic (GA) or sedation” (P21–HPS) for some procedures including MRI scans. MDT members shared some similar examples, but these observations split across two distinct codes. MDT participants (n = 9, 20%) (Table 2, question 4) discussed their perception that procedures are easier with the HPS’s involvement, and that “the success of certain treatments/procedures can depend on the input of play specialists” (P72–Nurse). These participants (n = 9, 20%) (Table 2, question 4) equally highlighted that having HPSs present contributed to and encouraged a child-focussed approach within teams, due to a HPS being a practitioner who “connects the team to the essence and functioning of the child” (P84–Paediatrician).

Across both participant groups (HPS n = 27, 48%; MDT n = 26, 58% (Table 2, question 4) there was a shared view that HPSs ease the workload of, and are beneficial to, the wider MDT. Participants expressed considerable positive regard for HPSs and their role within paediatric MDTs, with one noting that having a HPS present could “make or break a stay in hospital” (P58–HPS) or invasive procedure.

The factors reported as supporting or facilitating the HPS’s role and work

Key factors strongly identified by both participant groups as supporting or facilitating a HPS’s role and work within MDTs were the education or training of MDT staff to understand the HPS’s role and approach (HPS n = 24, 43%; MDT n = 14, 31% (question 6) and the inclusion of HPSs in MDT planning or handover meetings (HPS n = 20, 36%; MDT n = 20, 44% (question 6).

Education of healthcare staff was discussed many times by participants (HPS n = 24, 43%; MDT n = 14, 31% (question 6)) but was emphasised more by HPSs as a key facilitator to being able to carry out their work and this, in turn, was acknowledged ultimately to be beneficial to children receiving healthcare. One HPS expressed that “teaching…doctors…about our role helps raise our profile and helps more children” (P21–HPS). Another HPS shared that teaching focused on play benefits and the specific role of HPSs should be delivered to “all Trust staff, not just ward staff” (P24–HPS). MDT participants also emphasised a need for the role to be better understood widely throughout healthcare teams and that “education of the wider MDT as to the scientific basis for [having an] HPS in children’s services” (P75-Pharmacist) was key. Different suggestions were made by both HPS and MDT members about when and where this training could or should be delivered, including “being part of the induction for all new staff” (P38–HPS), something that should happen for nurses and doctors “at university level” (P16–HPS) and that a “bigger national voice” (P5–Nurse) is needed to educate others “as to the scientific basis for the HPS in children’s healthcare services” (P75–Pharmacist).

Ensuring that HPSs are involved in MDT planning was reported as being of benefit to all involved by both HPS and MDT participants. Attendance at meetings should be “consistent” (P49–Occupational Therapist) and a space for two-way sharing, for HPSs “to share their knowledge of a child or family” (P43–Psychologist) and because equally this may “help them plan [their work] better” (P35–Paediatrician). Ultimately, integration of HPSs into whole team planning was important since they “should be seen as part of the team just like any other specialist” (P52–Paediatrician). MDT members also expressed a view that HPSs should;

[Have] a seat at the senior management table so that the voice of children and young people, which Health Play Specialists are uniquely placed to give, is heard consistently (P101–Chaplain).

HPSs also reported adequate funding or resources (n = 14, 25%) (question 6) and good teamwork (n = 14, 25% (question 6)) as additional positive factors influencing an ability to deliver their work effectively.

The issues reported as disrupting or acting as barriers to the fulfilment of HPS’s work

Across both participant groups, factors most frequently reported that were identified as disrupting or acting as a barrier to HPS practice were a lack of understanding around a HPS’s role (HPS n = 28, 50%; MDT n = 19, 42% (question 7)) and issues arising from HPS availability within healthcare settings, staffing or team structures (HPS n = 14, 25%; MDT n = 16, 36% (question 7)). Health play teams were reported to be “small teams spread too thinly” (P25–HPS) across clinical services with the hard reality of understaffing in health play provision being expressed by both HPSs and their MDT colleagues who stated that there are “too few of them” (31-paediatrician) and that “we miss them in the evening and at weekends” (P65–Nurse).

Both groups of participants also shared a point of view that the HPS’s role is not respected or appreciated within healthcare teams and settings (HPS n = 19, 34% (question 5), n = 14, 25% (question 7); MDT n = 11, 24% (question 5), n = 11, 25% (question 7)). This issue was commonly discussed in a question that asked specifically about how the structure of organisation with hospital settings impacts a HPS’s role and practice. Reasons for this difficulty were broadly attributed to hierarchical structures within the health service and HPSs not being perceived as skilled practitioners within a paediatric MDT;

People not understanding the value of play specialists and the depth of knowledge they have about each individual child they work with (P57–Paediatrician).

HPSs also reported that not being used appropriately acted as a barrier to practice (n = 14, 25%). Specific examples from practice were shared to illustrate this point with HPSs sharing that other MDT members “always leave calling us to the last minute or after they have distressed the child” (P24–HPS). Such frustration was expressed many times by HPS participants recounting “being called too late and [then] being expected to ‘wave a magic wand’ when it doesn’t work like that – preparation takes time” (P64–HPS).

Limitations

Whilst this study contributes an important understanding of the role of HPS, the data are from a voluntary and self-selecting sample, and therefore, the responses may reflect perspectives of individuals with a particular interest in the topic and not represent the views of all health play specialists. The study focussed on the role of HPS in the UK, and whilst some findings may be transferable to other international settings the role and context is unique to the UK.

Implications for practice

Findings from this study highlight that better and clearer national guidance and an increase in funding that can be sustained is needed to support the inclusion of HPSs and other health play staff within MDTs. Dedicated education sessions developed with and, where possible, delivered by HPSs should be included within undergraduate health professional training programmes, clinical skills training and trust-wide hospital induction sessions. More HPS led research is needed to examine the unique role and approach of HPSs in paediatric MDTs as well as evaluate the observable outcomes from HPSs being integrated into the complex and clinical aspects of children’s healthcare.