Issue Date: August 2016
Understanding Therapists' Use of Play With Children With Life-Threatening Conditions
Rachel Bambrick; Carole Dennis, ScD, OTR/L, FAOTA; Kimberly Wilkinson, PhD, OTR/L
Pediatric Evaluation and Intervention / Professional Issues / Assessment/Measurement
Poster Session | August 01, 2016
American Journal of Occupational Therapy, August 2016, Vol. 70, 7011500076. https://doi.org/10.5014/ajot.2016.70S1-PO7060
Rachel Bambrick, Carole Dennis, Kimberly Wilkinson; Understanding Therapists' Use of Play With Children With Life-Threatening Conditions. Am J Occup Ther 2016;70(4_Supplement_1):7011500076. https://doi.org/10.5014/ajot.2016.70S1-PO7060
This study examined how occupational therapists use play with children with life-threatening conditions (CWLC). This study outlines the challenges these therapists face and suggests that although therapists value play as an occupation, they are typically using it as a means to another end with CWLC.
Primary Author and Speaker: Rachel Bambrick
Contributing Author: Carole Dennis, Kimberly Wilkinson
The purpose of this study was to determine how and why occupational therapists (OTs) used play when working with children with life-threatening conditions (CWLC) and to gain a better understanding of their view of the importance of play for children who are dying.
Through a qualitative study involving focused interviews with OTs who have worked with CWLC, we can better understand what therapists find important when working with this population, and the steps they may have taken to allow for play during therapy and in the child's life. This will increase our knowledge of occupational therapy care and quality of life for CWLC, specifically from the perspectives of therapists.
Despite the literary understanding that play is one of the most important occupations for children, there is little literature about the importance of fostering play opportunities for CWLC. At the same time, there is a great deal of research about the importance of allowing adults with life-threatening conditions to engage in meaningful, purpose-driven occupations and leisure activities. If we are able to access the perspectives of OTs who have worked with CWLC and understand how they chose to foster play with these children, we will be able to better understand care and occupational therapy for CWLC.
This study used a qualitative, narrative approach to collect and analyze data on therapists' use of play when working with CWLC. This format was chosen to use the stories of the therapists interviewed to explore the use of play with CWLC in occupational therapy. It focused on collecting the lived stories of therapists' daily lives when working with CWLC, told from the perspectives of OTs using semistructured interviews. The narrative approach was important to this study because this format allowed the therapists' stories to guide the data collection process, and through using this format rather than non-narrative interviews, individuals often tell stories that are more meaningful and important to them.
A recruitment statement was sent to local clinic supervisors or rehabilitation directors in the northeastern United States. These individuals forwarded the statement to therapists they believed met the criteria for the study. The clinic supervisors or rehabilitation directors first confirmed that these therapists would be willing to participate and then gave the names and contact information of these therapists to me. Therapists were then contacted via email, and 4 licensed OTs who had worked with CWLC in the past agreed to participate in the study. Inclusion criteria for the therapists in this study were as follows: worked as a registered OT, had worked with CWLC between the approximate ages of 3 and 8 yr and were willing to discuss their time working with these children.
Each therapist was interviewed a total of three times, with the first two interviews taking place over the phone or video chat on the computer and the final interview taking place over the phone, video chat, or in person. One final interview took place over the phone, 2 therapists participated in a video chat focus group for the final interview, and another participated in an in-person final interview.
The focus group was conducted due to convenience of location and to allow the therapists to create an open dialogue and bounce ideas and stories off of one another. All interviews were audio recorded. Interviews lasted between 15 min and 60 min, with the first interviews being the shortest and the last interviews being the longest. The first interview was designed to acquire knowledge about the therapists' background and experience working with this population. The second interview asked therapists to focus on and describe one or two CWLC that stood out to them for a particular reason. The final interview asked the therapist to delve into the specific details of one treatment session with a child and tell an in-depth story of that particular session.
Interview data were manually transcribed and analyzed. I used a process of reading the interviews and looking for cross-case (between different therapists) and within-case (between different interviews with 1 therapist) to code the data. This process allowed me to break up the interview data into conceptual categories.
Once all interviews were completed, I identified codes that emerged in the interviews and created an initial large list of themes based off of these codes. After completing my first read-through, I analyzed the interviews a second time using the same method. In my second read-through, fewer codes and themes were identified. I compared the themes that emerged in both analyses and was able to solidify four major themes that appeared in the interviews. It is important to note that four major themes were identified, but within some of the major themes, minor related themes were identified as well. In developing themes, it is important to note that I continued the process until I reached a point of saturation. At this point, I felt that I had identified a list of major themes and no new information was needed to support or add to these themes.
From the interviews that were conducted four major themes and two subthemes emerged. The themes were as follows: (1) the use of play in therapy, (a) the recognized importance of play; (2) playful moments; (3) condition-dependent limitations, (a) allowing more play at end of life; and (4) reimbursement.
The findings from this study describe how and why OTs are incorporating play into therapy sessions when working with CWLC and the various barriers they face when trying to do so. Play is recognized by pediatric OTs as one of a child's most important occupations, because it provides meaning and value to the child as well as opportunities for learning and development. Despite this recognition, play is primarily used in therapy as a means or motivational tool. Although playful moments do naturally arise in therapy, therapists in this study did not report independently fostering these moments for their own sake and did not document or acknowledge them. This has caused purely playful moments in therapy to become an underground, secretive part of practice that therapists know about but are unable to document and write about.
Play is acknowledged as being an integral part of pediatric occupational therapy practice, but not much work has been done in exploring its use as an ends in practice, particularly with CWLC. Research has shown that there is a role for occupational therapy in end-of-life care in providing ways to engage in meaningful occupations, but all of these studies focus on the adult population. Yet, despite this, many OTs working in an adult palliative care setting also face numerous barriers to providing occupation-based services. Additionally, there is currently no other research on occupational therapy's role with a pediatric population or CWLC.
This study leaves the reader with the following questions for occupational therapy practitioners: What is the balance between allowing play for the sake of play to allow CWLC to still feel like children and occupational therapy being a skilled and billable service that needs to be reimbursed for? What is our role as skilled clinicians in fostering purely playful moments when working with children and their families in life-threatening and end-of-life situations? Is there is a need for education on what an occupational therapist's scope of practice is when working with this population and how to facilitate play and meaningful occupations when working with children at end of life? Do we as occupational therapists need to advocate for broader reimbursement of play-based interventions and for our role in providing playful opportunities for CWLC?
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