Therapeutic play is a nursing intervention that is defined as Directive and purposeful use of toys as well as other materials to help children in communicating their knowledge and perception of their world and also assist in gaining mastery of their environment (Medical Dictionary 2015). According to PTI (2015a), the therapeutic play is a discipline that is well established and based upon several psychological theories, and several research indicate that it is effective. During therapeutic play, a safe, caring and confidential environment is created that allows the child to play with minimal limits as possible but also with many that are necessary for emotional and physical safety. The main objective of therapeutic play is to improve the child’s emotional wellbeing through the use of play or creative arts (PTI 2015a). Similarly, therapeutic play can be applied in treating or even assisting in alleviating a one off mild psychological or emotional problem that is preventing the child from normally functioning. Furthermore, it can also be used as a method of detecting problems that are more serious that can be attended by a play therapist, mental health specialist or child psychologist (PTI 2015b).
The role of the key worker in a Therapeutic Setting
The role of the key worker in a therapeutic setting as discussed in this section of the essay. A key worker is a residential child care worker that is specified and is responsible for creating a relationship with the child that has newly arrived in the therapeutic center as well as creating an attachment with the child for the child to begin feeling safe at home (ECI 2015). The essay will refer to the child as a young person aged between 3 years and 11 years. There are several therapeutic settings which include children’s homes, rehabilitation centers and therapeutic centers such as clinics.
To begin, the role of a key worker in a therapeutic setting is to assure continuity and consistency of the care the therapeutic setting provides the child. In performing this role, the key worker ensures the involvement of the child, his school, his family and other community agencies like the health services so as to achieve the child’s care plan goals. The key worker performs these roles with the supervision from her line manager or designated senior practitioner, and support from the colleagues. Additionally, the keyworker works in collaboration with the social worker of the child (Drennan, Wagner and Rosenbaum 2015). Gurr (2006) indicated that the keyworker’s main function from the outset is to create a positive relationship with the child and with time develop this into a caring, sincere, healthy and helpful adult/child relationship. This role of the keyworker is constructed of the following tasks:
- To be responsible, in collaboration with other colleagues, for the planning for the child and caring out the care plans designated aspects
- To be the nominated familiar and welcoming adult for a particular child when the child is admitted to the therapeutic setting with the long term purpose of ensuring the child feels secure ad safe during his or her stay in the therapeutic setting. This also includes remembering and celebrating important dates for the child such as birthdays, religious festivals and important family days (Extra Time 2015).
- To communicate the child’s care plan to the colleagues in the therapeutic setting, to report regularly to them on its progress and also to ensure that the colleagues at the therapeutic setting carry out specific aspects of the child’s care plan.
- To coordinate information about the child which concerns the child’s daily life in the therapeutic setting and from the life history of the child so that it can be communicated to the colleagues in a manner that represents the child as a whole person instead of a fragmented and depersonalized one (Wickham and West 2002).
- To ensure that the meetings that relates to the child and the care plans takes place at the stated time and place and also ensure consultation with the child, the social worker, the line managers or supervisors that the appropriate people get invited to the meetings.
- To have after consultation with the line manager of the keyworker where necessary as well as the child to incorporate application of the special skills of other colleagues in the therapeutic setting to carry out specific care plan aspects (ECI 2015).
- In collaboration with the child, to organize and give information to all the meetings that are relevant and concerns the child.
- Provide written reports of the child’s care plan for review meetings where directed by the supervisor and also after consultation with the child (Drennan, Wagner and Rosenbaum 2015).
- To offer counselling, advice and help in solving problems, care plan evaluation and feedback directly to the child and regularly in the life space and formal key work sessions.
- To be the individual who initiates actions that relate to the child (Gurr 2006).
- To be the advocate of the child in the staff groups and also in review, planning and group meetings.
- To respect the child’s need for confidentiality about the child’s experiences in life and only share information to the people who have the right to know (Extra Time 2015).
- To provide the link with the school, the family and other community agencies so as to provide the child with easy access to his or her natural social setting and the community at large.
- To help the child in preparing to leave the therapeutic setting when it is the right time to move on (Wickham and West 2002).
The considerations that need to be put in place to use Therapeutic play effectively when working with children and adults
1. Limit setting
There are many factors that are considered when defining effective therapeutic play and they include some sessions, frequency and session length among others. According to Landreth (2002, pp. 529-535), among the many skills the therapist may apply in setting the therapy frame, the most import, least researched and hardest is limit setting. Limit setting incorporates the number of sessions, frequency and session length and is a significant factor in the therapeutic process that requires delicate balance (Rosenstein 2012). Too many limits in a therapeutic play can prevent the child from constructively experiencing the play event feelings. On the other hand, insufficient limits can allow the continuance of bad behavior at the expense of the affective and cognitive processes (Landreth 2002; 16).
Kool & Lawver (2010) indicated that for acceptable balance to be reached, the therapist need to understand the limits that are necessary and their purpose. In therapeutic play, limits serve the following purposes:
a. Provide emotional and physical safety and security for the child and the therapist
b. Define the therapeutic boundaries
c. Anchor the therapeutic session in reality
d. Foster an attitude that is positive I the therapist towards the child
e. Promote control and responsibility on the child’s part and this results in consistency and stability in the relationship
f. Express negative feelings safely without retaliation or fear
g. Protect the therapeutic room and entire contents
h. Provide cathartic experience for the kid
i. Maintain professional, legal and moral standards (Hunter 1963; Bettelheim 1953).
Landreth (2002, pp. 529-535) suggested that the therapist when setting the limits, should deliver them in a language that is developmentally appropriate and try to be specific as possible. For example, the therapist should not leave it up to the child to find out how hard something is hard when she or he is acting their aggression in play that involves hitting. The therapist should simply tell the child that the behavior is inappropriate or if the behavior is appropriate, say nothing at all. I can give an example of limit setting from my experience when I visited one of the therapy rooms for children. There was this child called David who took a small wooden hammer and started tapping the pegs into the holes onto a toy. The therapist commented, but David hammered the pegs harder and then moved to the doll house. The therapist set the limit by telling him, “David, I know you feel powerful and angry but remember not to break or damage things. But you may hammer that pillow at the corner.” From that scenario, the therapist set the limit by remaining David of the limit of his behavior and then redirecting his aggressive behavior by suggesting an alternative that is acceptable.
2. Choice of play material
This is also another significant consideration that need to be put in place to use effectively therapeutic play when working with the children. The choice of game or toy by a child can give an insight into the ability of the young kid to express himself or herself and the degree or type of play in which the therapist is to engage with the child. Given that there is no specifically approved toys list, therapists must try to find commonality in the toys selected that facilitate positive engagement with the child, testing limits, a wide range of expression, self-control, insight and positive self-image (Landreth 2002, pp. 529-535). Kool & Lawver (2010) pointed out three categories of toys that broadened the child’s range of expression as shown in the table below. They include creative expression toys, aggressive toys and real-life toys
REAL LIFE AGGRESSIVE CREATIVE EXPRESSION
Matchbox cars Handcuffs Play-Doh
Generic dolls Ropes Scissors
Dollhouse G.I. Joes Paper
Cash register Toy guns Crayons
Play money Nerf darts Blocks
Boats Toy swords Puppets
Planes Super hero figures Legos
Toy kitchen Plastic armor Felt
According to Kool & Lawver (2010), real-life toys are targeted for the children that are withdrawn that may be introverted, shy or timid. The play is not committal, and therefore feelings are not drawn out instantly. These ice-breaker or real life toys such as airplane, boat, car, doll house, dolls, utensils, furniture and telephone among others comes with their rules and also need minimal setting of limit.
The aggressive toys according to Kool & Lawver (2010) facilitate the release of hostility, irritability, anger and other emotions that can be vented out through destruction. The toys such as ropes, handcuffs, toy soldiers will need more setting of limits compared to the other categories. The set limits on throwing, smashing and knocking down of the toys will majorly depend on the judgement of the therapist.
Creative-expression toys provide a wide range of emotions expression that foster creativity and permit the children to be messy. The toys such as scissors, crayons, puppets, craft materials will also require setting of limit to avoid damaging of the room or even other items in the area of play (Landreth 2001).
The child, therapist and creativity combine with elements available to allow multiple possibilities for play, both along the novel ones and the classical use of toys (Hall, Kaduson & Schaefer 2002, pp. 515-522).
3. Process of efficient interpretation
The opportunities for interpretation will come in the midst of the play. Kool & Lawver (2010) pointed out that efficient interpretation process can shorten the treatment and connect therapy behavior effectively to outside behavior. To interpret effectively, the therapist must develop an initial formulation that is comprehensive that details the maladaptive behavior and the sustaining factors that perpetuate this behavior. To test these interpretations, O’Connor(2002, pp.523-528) indicated that the child must be informed appropriately of the therapeutic process in addition to being reassured that any form of transient discomfort during the therapeutic play session will be out weighted in future by greater gains. These interpretations are then used in guiding the play and delivering it in a calculated manner to avoid overwhelming the child. The reaction of the child is gauged when it is delivered, and the interpretations rejected or strengthened based on the reaction of the child. The correct interpretations will be helpful to the therapist and the child through interpersonal, affective and cognitive processes.
4. Cultural considerations
In between the technical aspects of therapeutic play, cultural considerations must also be factored. In a society of many different cultures, the therapist must affirm and respect diversity without assimilating the child under his or her care into the dominant culture. According to Pedersen (1994), culture embodies gender role, sexual orientations, religion, sex, physical or mental disability, age, social class and ethnicity. The therapist needs first to understand his or her own culture before respecting the boundaries of another culture. In his work, Pedersen (1994) asserted that the therapist must take inventory of the culture in which she or he identifies with as well as how the population of the patient may identify her or him. This may include perceived nationality, profession, religion, gender among others. This is a necessary step for the therapists to avoid erroneous assumptions across different cultures and define limits better placed on oneself (O’Connor 2005).
In conclusion, therapeutic play as a nursing intervention to children is significant for the children to communicate their knowledge and perception of their world. The essay examined the role of the keyworker in a therapeutic setting. The keyworker does a significant role of working as a guiding role with the families of the child. Moreover, the keyworker acts as a central point of contact for the child’s family and helps them in coordinating their care within the healthcare system, education, recreation, social services, transportation and financial resources systems. The considerations that need to be put in place to use effectively therapeutic play when working with children or adults include limit setting, choice of play material, efficient interpretation process and culture.
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