A Review of Creative Play Interventions to Improve Children’s Hospital Experience and Wellbeing Free

We conducted a systematic review of play-based interventions following PRISMA guidelines.¹⁷  We did not require approval from a research ethics board because the study does not involve human participants or unpublished secondary data.

We included studies that evaluated the impact of play-based programs that are delivered within the hospital setting on children’s (aged <18 years) hospital experiences, wellbeing, and other health-related outcomes. We defined hospital setting as any unit that saw children, either as inpatient care, outpatient care, or in the emergency department. We excluded studies if the sample included <50% of children aged <18 years or did not include subgroup analyses of our target population. The subject of the evaluation may have included the child patient themselves, their family members (eg, sibling, parent), and/or their health professionals (eg, treating doctor). Interventions were eligible if they used play (including creative play) with the primary role of “distraction,” “preparation and support,” and/or “adaptation,” as defined by Gjærde and colleagues (2021)¹² ; and were facilitated by someone such as a parent or health professional (ie, not a passive distraction such as window murals or self-directed play) in any hospital setting. Table 1 provides a more detailed summary of the inclusion and exclusion criteria.

We conducted the search in December 2021. We searched 2 electronic databases: PubMed (National Library of Medicine) and CINAHL (EBSCO). We also conducted a general search on Google Scholar using common combinations of some of the keywords and checked the reference lists of eligible papers. Although literature reviews were not eligible for inclusion, we retained them for reference mining.

We searched the 2 electronic databases using the following combination of terms: (Pediatric or Pediatric or Child or Adolescent or Parent) and (Illness or Chronic condition) and (Patient or Outpatient or Inpatient or Hospitalized or Hospitalized or hospital) and (Positive distraction or distraction or Entertainment or Recreation or Art or Creativity or Performance) and (Acceptability or Impact or Benefit or Mood or Stress or Anxiety or Coping or Patient satisfaction) and (trial or pilot or evaluation). We limited our search to publications available in English and published between 2011 and 2021 (inclusive) to ensure the most contemporary and relevant results in the rapidly changing healthcare environment. We only included original peer-reviewed journal articles and excluded dissertations, conference abstracts, or editorial and reviews papers and unpublished studies. Two authors (C.S., E.G.R.) developed the search strategy based on a selection of relevant references we deemed necessary to be an included study. Guided by our inclusion and exclusion criteria, we continued to refine our search strategy to ensure it was sensitive enough to capture these relevant references and specific enough to narrow the results to exclude clearly irrelevant studies.¹⁸ 

We exported all citations into an EndNote ×9 (Clarivate Analytics, Philadelphia, PA) library and imported them to the web application Rayyan (http://rayyan.qcri.org/) to facilitate screening.¹⁹  We screened the titles and abstracts of all citations using a checklist based on adherence to the inclusion criteria and noted reasons for exclusion. Two authors (C.S., E.R.) read the full-text articles that appeared to be eligible after title/abstract screening and discussed any discrepancies. We extracted the relevant data from each of the eligible articles into an Excel spreadsheet, including information about the study type, population (eg, participant type, age, sex), reason for hospitalization or hospital visit, intervention type, outcome measures, and key findings (summarized in Table 2 for list of outcomes assessed and Supplemental Table 3 for detailed study findings). We extracted all relevant outcome data, including children’s self-reported, proxy or observed outcomes, or caregiver self-reported outcomes, or health professionals and health service delivery outcomes (eg, procedure duration).

Given the diversity of study designs eligible for inclusion, we evaluated the quality of the eligible articles in this review using the quality assessment with diverse studies (QuADS).²⁰  Two authors (C.V., J.A.) scored each study against the QuADS, which involves a set of 13 criteria assessing key aspects of study quality across different designs and methodologies. A third author (C.S.) was consulted to review and resolve any discrepancies. The total possible score ranges from 0 to 39, with a higher score indicating a better quality of reporting. In alignment with the developer’s instructions, we present the quality scores descriptively and did not use the QuADS as a basis for excluding “low-quality” studies from our review (Supplemental Table 4).

We identified 2797 articles in our initial search. After removing 96 duplicate articles, we screened the titles and abstracts of 2701 articles (Fig 1). Of these, we screened 132 full-text articles, resulting in 23 eligible articles identified for inclusion. However, 1 eligible article was subsequently excluded because there were 2 studies reporting on the same program in a pilot study²¹  and subsequent evaluation,²²  and that used the same health-related outcome measures. The most recent publication and with the larger sample size, was selected between the 2 for inclusion. A manual search of Google Scholar and reference lists yielded a further 3 articles for inclusion. As a result, we included a total of 25 articles in this review.

Included studies were primarily conducted in the United States of America (n = 5), followed by Turkey (n = 4). Twelve of the studies were randomized controlled trials, followed by quasi-experimental or nonrandomized controlled trials (n = 4). The included studies represented 1629 children in hospital (aged 0-18 years, 57% male), of whom 948 participated in the play-based interventions being evaluated, whereas the remainder (n = 681) were in control/comparison groups. Most included studies involved children visiting hospital for a variety of conditions (eg, acute illness, minor [non]surgical procedures), with 4 studies involving children with cancer or other chronic illnesses and 3 studies involving children undergoing wound dressing changes. In addition, 5 studies also involved assessment of parent/caregiver outcomes (n = 422 parents in total) and 2 studies also included the perspectives of health professionals (n = 128 in total).

All interventions were child-targeted and typically encouraged parental involvement (Table 2). Most studies evaluated programs that featured professional performers (eg, clown doctors or nurses, n = 8), followed by music therapy (n = 4), unstructured play (n = 3), and programs involving humanoid or pet robots (n = 3). One study evaluated each of the following interventions: distraction cards, poetry writing kits, a “play screen” (for use during dressing changes for wound care), and a sensory room that contained a range of equipment (eg, visual, auditory, tactile). The mean quality assessment score was 28.3 (standard deviation = 6.2; range, 13-36) of a possible 39 points.

Studies most commonly measured the impact of the intervention on the patient’s anxiety (n = 14 studies), followed by their pain (n = 8). Several studies showed evidence in favor of a reduction in children’s anxiety compared with control group following exposure to professional performers,^23–25  music therapy,^26–29  humanoid or pet robot,^30,31  art therapy,³²  after unstructured play,^15,33  or using a kaleidoscope.³⁴  Only 1 study did not observe a difference in children’s anxiety following animal-assisted therapy compared with a control group.³⁵  The included studies also tended to support a reduction in children’s pain levels compared with control groups following clown therapy,^36,37  use of a kaleidoscope,³⁴  or medical play screen.³⁸  However, 2 studies observed no difference in children’s pain after a poetry intervention³⁹  or clown therapy when compared with a control group.²⁷ 

Six studies examined the impact on emotional and behavioral outcomes, generally supporting their effectiveness. Children in 2 studies demonstrated fewer negative emotional behaviors (eg, crying, yelling) after unstructured play,^15,40  and less irritability after clown therapy when compared with controls.²³  However, 1 study showed no difference in children’s positive or negative affect after animal-assisted therapy when compared with a control group.³⁵  Following a poetry intervention, children reported less sadness and anger,³⁹  whereas adolescents in another study self-reported being in better mood and more relaxed after music therapy.²⁹ 

Six studies examined the impact of the intervention on (physiologic) stress and fatigue, for which there was mixed evidence. Three studies demonstrated improved physiologic outcomes (eg, diastolic blood pressure, respiratory frequency, temperature, salivary cortisol, oxygen saturation) after exposure to professional performers.^22,26,36  However, 2 studies observed no difference in physiologic measures such as systolic pressure, heart frequency or C-reactive protein measures after exposure to clown therapy or animal assisted therapy when compared with a control group.^35,36  One study showed that a poetry intervention reduced fatigue in children,³⁹  whereas another study observed no differences in fatigue after children participated in clown therapy.²² 

Four studies evaluated the impact of the intervention on caregivers, in all cases the parent of the child in hospital, with mixed evidence. Two studies demonstrated lower caregiver anxiety after music therapy and art therapy.^28,41  Yet, 2 studies evaluating clown therapy observed no difference in caregiver’s anxiety when compared with a control group.^23,24 

Four studies, each involving a clown doctor, evaluated the effects of intervention on other procedure-related outcomes, such as time to patient recovery or the operating time and costs (eg, of health professionals’ time). One study in young males undergoing penile surgery demonstrated that compared with a control group, those exposed to clown therapy had reduced induction time for anesthesia, spent overall less time in the operating room, and required less time to recover from the surgery and to be discharged.²⁵  These improvements were also associated with savings in time peri- and postoperatively (up to 155 minutes) and costs ($467).²⁵  Similar findings were shown with children suffering from respiratory pathologies, with children who received clown therapy showing a quicker recovery, compared with a control group, as measured by the earlier disappearance of symptoms.³⁶  In another study, younger children were more compliant with burn dressing changes following clown therapy compared with a control group.⁴⁰  Although costs were not directly measured, nurses participating in an evaluation of unstructured play perceived it to be a cost-effective intervention for regulating children’s behaviors and offering fun and free time.⁴² 

In addition to effectiveness outcomes, 13 studies also assessed the acceptability of the intervention to participants. Studies typically measured acceptability via purpose-designed measures (eg, likelihood of recommending using the intervention again, recommending it to others) and children’s engagement with the intervention (eg, time spent interacting/playing). Three of 4 studies evaluating the acceptability of unstructured play interventions suggested that the activities were positively received, with health professionals and families reporting that they would recommend it to others,^42,43  reporting them as fun and interesting,¹⁵  and perceiving them to increase social support,¹⁵  as well as reduce loneliness and boredom.^15,42,43  Two of 7 studies involving professional performers evaluated acceptability, showing that the majority of parents and health professionals found them to be acceptable,^23,25  although 2 parents (of 80, 2.5%) expressed that the clowns were disturbing.²⁵  Two of 4 music therapy studies evaluated acceptability suggesting that overall children were pleased with their experience and highly engaged,^26,29  although some youth reported feeling nervous, shy, or awkward or experienced difficulty with some musical aspects of the therapy (eg, playing an instrument).²⁹ 

Our review summarized the evidence for facilitated play-based interventions to improve outcomes for children who are hospitalized. Our findings primarily yielded studies assessing the effectiveness of the intervention on children’s outcomes, followed less commonly by parent outcomes, and rarely health professional’s perspectives. The findings overall support the effectiveness of such interventions on a range of outcomes, with the most evidence available for reducing children’s anxiety and pain, and (physiologic) stress. Approximately half of the studies also assessed the acceptability of the intervention to participants and other aspects such as procedure-related outcomes (eg, time to recovery), with generally positive findings. Our review highlights the potential for play-based programs to improve children’s and families’ hospital experiences, wellbeing, and other health-related outcomes, and highlights the need to better prioritize play alongside the focus on a child’s clinical symptoms.^44,45 

The included studies generally support the use of facilitated play-based interventions that are not medically focused (ie, on the illness or related procedures) to improve children’s hospital experiences and health-related outcomes. Our review findings indirectly support the notion that play-based interventions may also help to minimize adverse psychological outcomes in hospitalized children, and can complement Child Life Therapy or related services, particularly in resource-limited settings. There are several potential mechanisms for the observed improvements in our review and related literature, including amusement and distraction from the child’s situation, refocusing their attention on happier thoughts, as well as bringing a sense of normality to their stay through play.¹⁰  However, few of the included studies involved very young children aged younger than 5 years, despite the literature suggesting that they are particularly negatively affected by hospitalization.⁴⁶  This may be due to a lack of interventions focused on this population or the lack of evaluation involving them. The high needs of this group and the potential differences in outcomes yielded compared with older children warrants further efforts to mitigate adverse outcomes in very young children. This is especially important for young children diagnosed with a chronic illness where regular hospitalization is to be expected.

The included studies less commonly assessed the potential impact of creative play interventions on outcomes beyond the patient’s measured outcomes, but these may also have broader benefits for the patient, their family, the hospital, and/or even the health care system. For example, anxiety and fear are some of the most commonly reported reactions to being hospitalized as a child, which the evidence clearly illustrates is related to other adverse outcomes such increased experience of pain, a higher likelihood for pharmacological intervention, increased susceptibility to infections, and ultimately a longer period of recovery.⁴⁷  Anxiety and fear are common responses in both children in hospital as well as their parents, which evidence suggests are strongly positively correlated.^48,49  That is, children’s experiences are linked to their parents’ and can become negatively affected by their parents’ adverse experiences. Recent evidence also suggests that increasing parental participation in their hospitalized child’s care also increases parent satisfaction with the health care received, stressing the value of involving and acknowledging parents and caregivers.⁵⁰  It is worth noting that no studies in our review assessed the broader family impact of a child’s hospital experience, including on their healthy siblings or extended family such as grandparents (who may also act as caregivers), which can often be underestimated.^4,51,52  Further efforts are therefore vital to validate family-based support interventions that focus on increasing coping skills during hospital visits and reducing distress of the child, as well as their broader family unit.^8,53 

Despite the promising evidence for the impact of play-based interventions on patient/caregiver outcomes, few studies prioritized or concurrently evaluated other outcomes to aid our understanding of the broader potential benefits to health professionals and the health care system. Only 3 studies included health professionals’ perspectives, focusing on their overall experience and/or satisfaction with the intervention, any concerns and perceived benefits, and whether they would recommend it to others.^25,38,54  Assessing health professionals’ perspectives and the cost-effectiveness of the intervention is essential to ensure the optimal delivery of the service in practice. Further consideration is needed to establish the best approach to integrating these interventions and their sustainability in the long term after research trials are complete. Despite the promising evidence supporting their effectiveness, the uptake of such interventions may be low potentially because of practical (eg, availability, parental consent) or personal barriers (eg, fear of dogs, personality preferences). For hospitals, an already burdened health care system may lessen the priority of resourcing play and creativity initiatives. This may be especially true after the COVID-19 pandemic, in which resources are more finite and hospitals reduce the number of supportive staff, such as volunteers and nonprofits, who contribute to play-based support.⁵⁵  For lower cost interventions, limited champions to drive the uptake of these interventions may also be a key barrier.

Yet, only 1 study reported on the intervention costs,²⁵  and none evaluated their cost-effectiveness. Understanding the direct cost implications of any intervention and the resources needed to administer them (eg, staff time) is critical. With government expenditure on public hospitals increasing by an average of 4.5% each year (adjusted for inflation) in Australia,⁵⁶  opportunities to reduce costs without cutting patient care is a top priority.⁵⁷  As such, play-based interventions may not often be considered the most valuable based on marginal costs and benefits. Hard evidence that examines costs and benefit to families is needed so that resources can be appropriately allocated. Cost and health professionals’ perspectives are especially important to assess in a constantly evolving health care system, as is the intervention’s acceptability, which impacts the likelihood of effectiveness and success.⁵⁸ 

Our study contributes to the growing research in the space of play-based interventions in pediatric health care. However, in most studies included in this review, children had limited exposure to the intervention (eg, interaction with a professional performer on 1 occasion) typically because of short hospital stays or acute procedures. Repeated exposure or longer term interventions may affect the outcomes observed, potentially yielding greater benefit with ongoing participation particularly for children with chronic illnesses, requiring longer anticipated stays or multiple admissions. We did not include other “passive” improvements to hospital spaces in our review (eg, art displays, spatial arrangements, sound/lighting), although these simple measures may further complement efforts to improve a child’s hospital experience.⁵⁹ 

There was considerable heterogeneity between the included studies, including the measures, settings, patient factors, and interventions themselves, making it difficult in many instances to directly compare and contrast child/caregiver’s outcomes or to perform further meta-analyses. This diversity of the included studies coupled with typically modest sample sizes, also makes it difficult to draw clear recommendations to guide the implementation of play-based interventions generally and in different clinical settings. By limiting our review to include studies published in English only, the generalization of our findings are potentially only relevant to English-speaking populations. Patients from culturally and linguistically diverse backgrounds may have additional support needs that should be taken into consideration when providing opportunities for play-based interventions while a child is in the hospital.

This review captured evidence of the growing area of research in play-based, nonmedical interventions for children who visit the hospital. Overall, the evidence supports the use of play-based interventions for optimizing the hospital experience and health outcomes of children, as well as their families and potentially health professionals. Further research on the impacts of such interventions for the health care system is also warranted to ensure their successful adoption and sustainability in a clinical setting.