It's the little things that can get you far: playing with children is an essential part of a paediatric nurse's work. Team work and creative thinking are key to successful play interventions.

Having nursed children for many years in a variety of settings, both here and in the United Kingdom (UK), it is still refreshing and satisfying when nurses, families and members of the multidisciplinary team get things right. This is achieved through working together and tapping into each other's skills. Working in partnership with children and their families has its advantages, not just for nurses but, most importantly, for the child and their family.

Play has long been advocated as one of the most important tools in paediatrics. When I first thought of becoming a paediatric nurse, I imagined I would be playing with children all day, painting murals and entering their imaginary worlds. Finding opportunities to communicate with children through play is certainly uppermost in your mind as a junior paediatric nurse. But as you become more experienced, "playing" with children becomes almost second nature and part of your everyday work. Even when you give a child panadol, you turn this into a game to help the procedure go smoothly. Over the years I have learnt a lot about playing with children who are in hospital through watching other people's approaches. During my work in a paediatric ontology ward in the UK, I would watch our very experienced pray therapists help the children through pray become more knowledgeable about their conditions and the treatments they were about to have. The knowledge they imparted made our work as nurses so much easier. A knowledgeable child feels in control of their illness and therefore is much more compliant with medical or nursing interventions. Paediatric nursing is not all play of course, but some days it needs to become an integral part of our care. Sometimes it is the little things we do that mean a lot and can get you a long way.

Getting close to Meg

Meg * is five and has had frequent attendances at the paediatric assessment unit (PAU) and emergency department (ED) with recurrent abdominal pain and constipation. She has previously had an antigrade continence enema (ACE) procedure. Her ongoing constipation was exacerbated by her behavioural issues. She had subsequently missed many days of school.

Meg had become reluctant for her parents to do anything with the ACE, or for the nurses to touch it. Her mother had reached the point where she believed the only way forward would be for her daughter to have a colostomy.

Meg and her mother presented to PAU while I was on a morning shift. They arrived from the paediatric outpatient department, having attended an appointment with Meg's consultant. I received a handover from the outpatient nurse about the current issues. We needed to flush the ACE and try to involve the child and family, enabling the family to competently and confidently care for Meg at home. We decided Meg needed to have some control over what was happening when the ACE was flushed.

It was time to put on our thinking caps. In order to get Meg involved in her own care, we needed to get back to the basics of how to nurse children in hospital the philosophy being that children can feel comfortable and control their environment through play.

I felt it was important to involve our play specialists and draw up a plan together that would enable us to overcome the problems previously encountered, eg not being able to access the ACE or touch the catheter in the ACE. I discussed the options facing Meg with her mother and suggested we could use a feed pump to slowly inject water into the ACE, allowing us to flush it. Meg had issues with pain or perceived pain when anyone attempted to access the ACE, so I knew we had to take a creative approach. We decided to take things slowly and at Meg's pace. Most importantly, we decided to make it fun and enjoyable for her. The first step was to introduce the drip stand. I explained to Meg that we needed to flush the ACE and that we were going to use a "robot" for this, but we had to make the robot first. I invited Meg to help make the robot.

In collaboration with Meg's mother and the play specialists, Meg began decorating the drip stand with fancy feathers, streamers, balloons, lollipop sticks and many other decorative pieces. The next phase was to add the pump. I explained the pump was part of the robot and that we needed to add this part to make it work.

Meg promptly helped me attach the pump to the drip stand (first finding a space on the drip stand for it!). The drip stand also needed decorating and I explained that I would be back with the next part of the robot for her to decorate shortly. I left Meg with her mum and the play specialist deciding how best to decorate the pump. Things were progressing well. The next phase was to introduce the giving set and bottle with water. I explained to Meg that we needed this next part to make the robot work.

She promptly pulled up a chair to help me hang the bottle of fluid. She really enjoyed pressing all the buttons, priming the set, and listening to the motor whirr. Most of all she enjoyed the thought that the water might squirt out of the end of the tube and onto her mother!

Meg was amazed that the "robot" knew how to stop pumping the water when it got to the end of the tube but was very disappointed that it did not squirt her mother. She decided the pump also needed decorating and so, half an hour later, we headed down to the treatment room with a fabulously decorated robot. Meg controlled the robot all the way down the corridor and appeared to have taken ownership of it.

I then told Meg that we now needed to attach the robot with the water to her ACE so the water could go into her tummy (but not the fish she had stuck on the outside of the bottle!). Calmly and happily, Meg promptly unspigotted her ACE and attached the tube from the giving set to the catheter. She then helped me turn the robot on. Following this procedure, Meg and her robot went happily back to the play room.

Meg's mother was very pleased and could not believe how smoothly the process had gone. After the procedure, Meg was invited to choose where to put her robot ready for the next day so she could show the nurse where it was. All of us had made huge progress within a few hours and, although hard work, it was enjoyable.

Meg was still very excited when she told the nurse the next day about her robot. After all, this was her robot and she was the one in control of it, just as this was her body and she needed to be in control of that too. Demedicalising/normalising her daily routine made the procedure fun for Meg and tolerable for her family.

Play is often the last thing on our minds when we are in the middle of a busy shift, but play is a vital part of children's lives, and I believe it is the little things that can mean so much and get you far.

The plan behind this "robot" was to ensure Meg felt safe with the equipment and with the procedure; that she would be pain free and in control from the start. Over the coming days, we worked with the play specialists (who developed a plan for Meg), nurse colleagues, the family and of course Meg, so that her mother could learn how to use the pump and equipment and, alongside Meg, could use it at home to allow for daily flushing of the ACE after school. Play can normalise activity for a child. It allows parents, siblings and nurses to interact and communicate; it enables a child to deal with the stresses and strains in their lives, and allows them to come to terms with fears and anxieties they may be unable to express in any other form. Play is a basic but fundamental requirement of all children, whether they are well or sick. It is an essential requirement for a child's well-being and development, a vital tool. Playing with a child a great deal will only give positive results, but using play as therapy to only a minor extent may have consequences that continue to affect the child long after the hospital admission.

This article was reviewed by Kai Tiaki Nursing New Zealand's practice article review committee in May 2007.

USING PLAY TO HELP CHILDREN COPE

Play specialists are part of the multidisciplinary team in children's wards throughout New Zealand hospitals. They are all registered early childhood teachers, employed by the hospital but funded by the Ministry of Education.

Play specialists use play as a tool to assist children cope with hospitals and the procedures they face. They run a full play programme in most children's wards and also help with "distract play" in treatment rooms, eg during blood tests, plastering, fitting of nasogastric tubes etc. Dunedin Hospital play specialist, Jackie Christos, was delighted that the plan to help Meg * cope with the flushing of her ACE worked so well and so quickly. "Things don't always work well the first time, but this time it did," she said.

Play techniques are adapted to suit the age of the child and the procedure being undertaken. Techniques may include the use of imagery, bubbles, breathing techniques and toys that make a variety of noises, said Christos. A basic tool she uses is a calico doll devoid of features that the individual child can decorate and change, eg adding bandages or plaster. These dolls then become the child's "buddy". Play is also used in preparation for surgery and in debriefing sessions after a procedure has taken place. "We can play through the experience," Christos explained. "Recently we ran a tea party for a child who had just had her tonsils out and who needed to be encouraged to begin drinking again."

Play is also used for a particular purpose, particularly in conjunction with physiotherapists who may need a child to undertake various movements to aid recovery. Most children's wards have a play room, where no medical interventions are allowed to take place.

* Meg is not the child's real name. Her family has read and approved this article and accompanying photograph for publication.

Angela Milner, RN, trained as a paediatric nurse in the United Kingdom and has worked in Dunedin Hospital's children's ward for the last four years.