healthcare

Review
Play Therapy as an Intervention in Hospitalized
Children: A Systematic Review
María José Godino-Iáñez 1 , María Begoña Martos-Cabrera 2 , Nora Suleiman-Martos 3, * ,
José Luis Gómez-Urquiza 1 , Keyla Vargas-Román 4 , María José Membrive-Jiménez 5
and Luis Albendín-García 6
1 Faculty of Health Sciences, University of Granada, Avenida Ilustración 60, 18016 Granada, Spain;
mariajosegdns1@gmail.com (M.J.G.-I.); jlgurquiza@ugr.es (J.L.G.-U.)
2 San Cecilio University Hospital, Andalusian Health Service, Avenida de la Ilustración s/n,
18016 Granada, Spain; begomartos90@gmail.com
3 Faculty of Health Sciences, University of Granada, Cortadura del Valle s/n, 51001 Ceuta, Spain
4 Faculty of Psychology, University of Granada, Campus Universitario de Cartuja s/n, 18071 Granada, Spain;
keyvarom@ugr.es
5 Ceuta University Hospital, National Institute of Health Management, Loma Colmenar s/n, 51003 Ceuta,
Spain; mariajose.membrive@gmail.com
6 Andalusian Health Care, Avenida del Sur 11, 18014 Granada, Spain; lualbgar1979@ugr.es
* Correspondence: norasm@ugr.es




Received: 25 June 2020; Accepted: 28 July 2020; Published: 29 July 2020


Abstract: Background: Hospitalization disrupts children’s lives and can produce feelings such as
anxiety, fear, or pain. Playing is an important part of children’s lives. Thus, it is necessary to ensure
holistic care during the process, including play therapy. The aim of this study was to analyze the effect
of therapeutic play in hospitalized children. Methods: A systematic review was performed. The search
was conducted in CINAHL (Cumulative Index of Nursing and Allied Health Literature), CUIDEN,
and PubMed (Medline). The search equation was “pediatric nurs* AND play therapy”. The search
was performed in March 2020. Results: n = 14 studies were included in the review. The studies
reveal that the application of therapeutic play in hospitalized children decreases postoperative pain,
improves behavior and attitude, and reduces anxiety during the hospital stay. Conclusions: play
therapy has a beneficial impact on the care of hospitalized children and should be implemented in
pediatric units after assessing the resources and training needed for pediatric nurses.

Keywords: game; hospitalization; nursing; pediatrics; therapeutic play

1. Introduction
In the European Letter for Hospitalized Children approved in 1986, several rights were adopted,
highlighting the “right of the child to receive information adapted to his age, mental development,
emotional and psychological state” and “the right to dispose of age-appropriate toys, books,
and audiovisual media during his stay in the hospital” [1].
Childhood is a key stage in human life that influences the development of the person. In some
cases, this phase may be interrupted by adverse events such as diseases, pathologies, painful and
invasive procedures, trauma, or prolonged hospitalizations [2].
When hospitalization is necessary, the child may perceive this situation as traumatic and it can
alter their emotional development, as they are separated from their daily and family environment
to face an unknown process with painful interventions and restrictions. During the hospitalization,
the child may experience negative behaviors and emotions, such as stress, fear, anxiety, pain, insecurity,
and uncertainty [3,4].

Healthcare 2020, 8, 239; doi:10.3390/healthcare8030239 www.mdpi.com/journal/healthcare

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Furthermore, if the cause of hospitalization is a cancer diagnosis, these issues may be more
complex, as it is a complex disease that can be accompanied by prolonged treatments with intense side
effects and, probably, long and frequent hospital stays [5,6].
In the hospitalization period, play therapy is essential, not only because children like to play,
but also because it facilitates interventions by health professionals [7]. Play is an essential activity in a
child’s life, so, in the context of hospitalization, it can help children to face this unknown situation,
express their emotions and concerns, feel more comfortable and safer, become familiar with medical
techniques, and make decisions [6]. It also helps communication and promotes the development and
recovery of the child’s own individuality [8].
Play therapy can be defined as the set of interventions to promote children’s wellbeing during
the hospitalization or the play activities structured depending on the child’s health condition, age,
and development [6]. Therefore, it is a planned activity with a purpose and not just a recreational
activity [7].
Pediatric nurses can use play as a care strategy for hospitalized children. It is very important for
nurses to know and use play in children’s care, as it can have numerous advantages in hospitalization.
The function of catharsis, which means the relief of anxiety and which is the basis for play therapy, can
be highlighted [9]. Play activities performed by health professionals can also improve the nurse–child
relationship, increasing confidence during the hospitalization period [8].
Therefore, it is important to know the effectiveness of play therapy to transform children
hospitalization units into a pleasant, attractive, and playful environment in order to achieve better
results and the humanization of care [10].
The aim of the study was to assess the impact and effectiveness of play therapy on the care of
hospitalized children. The PICO question that guided this review was what are the effects of play
therapy for hospitalized children?

2. Materials and Methods

A systematic review was carried out following the PRISMA (Preferred Reporting Items for
Systematic Reviews and Meta-Analyses) guidelines.
Information sources and search equation: For the search, the CINAHL (Cumulative Index of
Nursing and Allied Health Literature), CUIDEN, and PubMed (Medline) databases were consulted,
restricting the results to documents published in the last 10 years. The search was performed in March
2020, and the search equation was “pediatric nurs* AND play therapy”. The descriptors of the search
equation were obtained from the thesaurus Medical Subject Headings (MeSH).
Inclusion and exclusion criteria: Primary quantitative studies evaluating the effects of play therapy
on hospitalized children published in English, Spanish, or Portuguese in the last 10 years were included.
Studies that were not related to the topic, that had adult samples, and those in which the opinion of
parents or nurses was studied were excluded.
Selection process, critical reading, and level of evidence: The selection of the studies was conducted
by two researchers independently in four stages. First, the title and abstract of the studies were read.
The second stage was reading the full text. Then, the documents were critically read in order to assess
and identify biases in the methodology. Finally, a reverse search was performed from the previously
chosen articles. A third member of the team was consulted in case of disagreement. The Oxford Centre
for Evidence Based Medicine (OCEBM) classification was used to define the level of evidence and the
degree of recommendation for each study.
Study variables and data analysis: The following variables were collected from each study: year
of publication, country where the study was carried out, study design, sample size, play therapy
intervention, and main results. A descriptive analysis of the studies was performed.
Healthcare 2020, 8, 239 3 of 12

3. Results
The search showed 121 documents, and 84 articles were excluded after reading the title and
abstract because they were duplicated documents or they had no relation to the study topic. After this
phase, 37 full-text publications remained, of which 25 were excluded as they did not meet the inclusion
criteria. Therefore, 12 studies were included in the review. After the reverse search in the previously
selected documents, two more articles were added. Finally, the sample consisted of n = 14 studies.
The selection process is detailed in Figure 1.
The total population in the selected studies was n = 856 children. Of the included studies, six were
clinical trials, one was quasi-experimental, and seven were descriptive studies.
A total of 50% of the studies included in this review were conducted in South America. Regarding
the year of publication, 28.6% were published in 2016. The larger sample size was n = 165 children,
and the smallest was n = 5 children. Regarding the sex of the sample, the male gender predominates.
All of interventions with play therapy were added to the usual care routine as an extra intervention.
Table 1 summarizes the characteristics of the included studies.

Figure 1. Study selection diagram.

3.1. Therapeutic Play in Surgically Operated Children

Some studies have shown that therapeutic play, in different modalities, produces a decrease in
pain in children after surgery [11–14]. When comparing the level of pain between boys and girls, the
scores were higher in boys and in the youngest (1–3 years) [12]. According to the study by Yayan et
al. [11], the level of pain is higher in those children whose parents have a high level of anxiety.
Regarding the behavior of children in the postoperative period, the study by Kiche and Almeida [13]
shows that after therapeutic play the behaviors manifested by children are those of greater adaptation
and acceptance to the procedures (change of postoperative dressing). Behaviors such as “smile”,
“play”, “relaxed posture”, or “help the professional spontaneously” increased.
Healthcare 2020, 8, 239 4 of 12

Regarding anxiety and negative emotions, two studies [14,15] reported that therapeutic play,
applied before surgery, decreased the levels of these feelings on the surgery day.
The duration of the play therapy sessions for children who were operated on mainly had a
duration of around 1 h and were done before [14,15] the surgery and after [11–13] the surgery.

3.2. Play Therapy in the Care of Children with Acute or Chronic Pathologies
Other studies have pointed out that therapeutic play sessions in hospitalized children can improve
their behaviors, as this distracts and amuses them during their hospital stay [16–19]. In addition, the
study by Al-Yateem et al. [20] informs that play therapy decreases the level of anxiety in boys during
their hospital stay.
Regarding the behavior of children in specific nursing techniques, such as the puncture or
administration of intravenous medication, some studies [18,19] indicate the importance of applying
play therapy. After the sessions, the children were more calm and relaxed, cooperating with the
professional who performed the technique. It also improved the level of trust in the nurse–child
relationship [16–18].
Play therapy helps children express and communicate their feelings and emotions through toys.
It also makes them understand the process and the need for hospitalization [17].
The duration of the play therapy sessions was not indicated in all the studies [16,17,19], and it
was 30 min sessions in the studies that included this information [18,20]

3.3. Play Therapy in Children Diagnosed with Cancer

Some studies inform that cancer produces feelings of fear, anxiety, and insecurity for the future
and depressive symptoms in children [21,22]. Through play interventions, it has been found that
depressive symptoms can be reduced in children with cancer who are hospitalized for long periods [21].
In addition, it helps to express and diminish the feelings mentioned above [22].
Other studies in children receiving outpatient chemotherapy showed that play therapy improved
children’s attitude to the disease [23,24]. The study by Artilheiro et al. [23] showed that, after the
play sessions, children had positive behavior (relaxed posture and smile) and decreased behaviors
that indicated fear, anxiety, and anger (tension, crying, screaming, beating). Furthermore, children
became involved and collaborative in the processes of their disease, increasing their trust in the
professionals [24].
One study had 30 min play sessions 5 days a week [21], other had sessions from 1 to 3 h [24],
and others did not inform about the duration of the session [22,23].
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Table 1. Summary of the included studies (n = 14).

Author, Year of
Study Type Sample Play Therapy Intervention Results EL/RG
Publication and Country
2 phases in the experimental group.
n = 165 children in the
Phase 1: the first days of admission (3 days) children complete an anxiety At the end of the intervention, the
pediatric unit hospitalized
Al–Yateem et al., 2016 [20] Randomized survey and no change was done to their care routine. anxiety scores in the intervention
for at least 3 days. 1b/A
United Arab Emirates clinical trial Phase 2: children play in the hospital or in their beds with different toys group were significantly lower
Mean age: 5.24 ± 1.01.
(balloons, coloring books, face painting, play dough, bubbles and than in the control group.
53% girls.
storytelling) twice a day for 30 min. This phase started the second day.
The children in the experimental group received an individual session (1 h)
of play therapy 3–7 days before the surgery. This session consisted of
Children in the experimental
watching a video using a doll to show preoperative procedures, induction
group showed significantly fewer
to anesthesia, and return after surgery. They received a manual describing
n = 95 children negative emotions prior to
the medical objects and equipment. In addition, each child was given an
He et al., 2015 [14] Randomized undergoing surgery. anesthesia induction and less
O2 mask and a cannula to take home. 1a/A
Singapore clinical trial Age: 9.74 years. postoperative pain compared to
All the children received regular care from health professionals prior to
64.25% boys. the control group. Changes in the
surgery.
preoperative anxiety were not
The play intervention was a specific intervention for the intervention
significant.
group and was not included in the routine care. The data was collected 3–7
days before the surgery and 24 h post-surgery.
n = 122 children admitted The control group received the usual care (information about the cancer
After 7 days using this type of
to the Pediatric Oncology treatment, effects, and complications; diet...).
game, depressive symptoms
Li et al., 2011 [21] Randomized Unit for a period of 14 The experimental group, in addition to usual care, played virtual reality
decreased in the experimental 1b/A
China clinical trial months. computer games for 30 min 5 days a week. In the virtual room, they
group and increased in the
Mean age: 12.1 years. played with videos that were projected on walls, floors, or ceilings with
control group.
52.86% boys. the software Play Motion.
All the participants received information and routine care prior to surgery.
The experimental group received an extra play therapy intervention in
n = 108 children admitted groups of 5 children for 1 h. Children in the experimental
Li et al., 2014 [15] Randomized for elective surgery. The session took place in the operating room, where an explanation and a group showed significantly lower
1a/A
Hong Kong clinical trial Age: 7 to 12 years. simulation of the surgery procedures using a doll was performed for levels of anxiety than those in the
67.45% boys. children and parents and then repeated by the children. control group.
The level of anxiety was evaluated 3 times: before the intervention, after
surgery, and after surgery.
Healthcare 2020, 8, 239 6 of 12

Table 1. Cont.

Author, Year of
Study Type Sample Play Therapy Intervention Results EL/RG
Publication and Country
After the play intervention, the
levels of satisfaction of the
n = 30 children in the In the experimental group, children played in a room with unused medical children in the experimental
Pediatric Unit material for creating toys. Children were free to enter in the room and play. group were significantly higher.
Teksoz et al., 2016 [16] Randomized hospitalized at least 3 There was no specific duration for the intervention. In addition, the children showed
1b/A
Turkey clinical trial days. In the control group, the children received nursing routine care and a hospital stay as positive. The
Mean age: 10 ± 1.50 years. attended a room available in the unit where there were a computer and nurse–child relationship was
50% girls. other toys. improved.
The mean duration of the
hospitalization was 4.9 days.
After the intervention, pain was
The researchers informed the parents about the importance of distracting measured using the FLACC scale
the children after the operation and gave them a toy after the operation. at three moments: after regaining
The toy was a plush rabbit dressed as a doctor for two reasons: because consciousness, one hour after it,
n = 95 children who were
children usually show affection towards stuffed animals, and because and two hours after it. The pain
Ullan et al., 2012 [12] Randomized surgically treated.
evidence says that toys symbolically related to healthcare may influence decreased in both groups, but the 1b/A
Spain clinical trial Mean age: 3.9 years. 69%
anxiety levels after surgery. mean of the experimental group
were boys.
The intervention was a specific play intervention for the intervention was always lower than that in the
group (used for two hours after the consciousness recovery) and was not control group. The last measure
included in the routine care. difference was statistically
significant.
After the intervention, the
Play therapy is applied to children on outpatient chemotherapy treatment. children showed a positive
n = 30 children
Before medication administration, the child was invited to play with a doll attitude, cooperating with the
undergoing outpatient
Artilheiro et al., 2011 [23] Descriptive, and the materials used in the chemotherapy (IV catheter, cotton, syringe...). procedures and with health staff,
chemotherapy. 4/C
Brazil quantitative study The researcher showed the child chemotherapy procedures while telling a establishing a relation of trust
Age from 3 to 6 years.
story and inviting them to repeat the game. with them, presenting a relaxed
53.3% boys.
The duration of the session is not specified. posture, and smiling during the
session.
Healthcare 2020, 8, 239 7 of 12

Table 1. Cont.

Author, Year of
Study Type Sample Play Therapy Intervention Results EL/RG
Publication and Country
Three categories were identified:
meanings attributed by children
to hospitalization and its
influence on nursing care, the
The play therapy model called “Care with Play” (using toys, dolls
perception of therapeutic
representing family and healthcare professionals, hospital supplies, and
procedures through therapeutic
drawing and painting supplies) was used. It has three stages (welcoming,
n = 5 children play, and the importance of the
Caleffi et al., 2016 [17] Descriptive, playing, and concluding) that can be done in one or more sessions.
hospitalized. family in care. 4/C
Brazil qualitative study The welcoming is centered in establishing a link with the child and
Age: 5 to 8 years. Play therapy helps the child to
determining the required care. The playing phase has a more direct
change their negatives views
interaction to determine care deficits, and the concluding phase is when the
about the hospital environment
deficits have been covered and the child is referred to another professional.
and health professionals. It also
decreases fear and helps them to
understand the need for
hospitalization.
The behavior of the children was
observed during the
administration of IV medication
An instructional therapeutic play for 20–35 min after intravenous drug before the play therapy and 2 to
administration. A name for the doll was chosen by the child and then a 12 h after. Children aged 4–6
n = 9 hospitalized story about the doll becoming sick and needing hospitalization was told to years show more rejection and
Dantas et al., 2016 [18] Descriptive,
children. the child. The child was encouraged to assign symptoms and choose what fear of IV medication 4/C
Brazil qualitative study
Age: 4 to 8 years. to do with the available material. administration before applying
The child chose simulating venous puncture and intravenous medication the game.
administration. This intervention was extra to routine care. It was seen that after the
intervention, the children were
calmer and more showed more
confidence.
In the sessions, it was seen that
cancer produces feelings of fear,
Descriptive study, n = 5 children with cancer. Individual dramatic play therapy sessions were performed and recorded.
Fonseca et al., 2014 [22] anxiety, and insecurity for the
qualitative, Age: 3 to 6 years. The play therapy sessions were about a child with cancer using toys (dolls, 4/C
Brazil future. The game helped children
phenomenology 80% girls. cars, hospital supplies . . . )
to express and reduce these
emotions.
Healthcare 2020, 8, 239 8 of 12

Table 1. Cont.

Author, Year of
Study Type Sample Play Therapy Intervention Results EL/RG
Publication and Country
After the intervention, it was
A first dressing change was made to the child, observing their reactions. observed that during dressing
Subsequently, an instructive therapy game was performed, with a changes, the child was more
n = 34 children who were professional simulating the dressing change technique in a doll relaxed, the expression of pain on
Kiche and Almeida, 2009
Descriptive, surgically treated. (instructional therapeutic toy) next to the child and inviting them to repeat their face was lesser, and the
[13] 4/C
quantitative study Mean age: 6 years. it. The next day, the simulation was performed again before changing the child smiled and collaborated
Brazil
58.51% boys. child’s dressing and observing their reaction. with the professional. In addition,
The intervention was done for two months as a routine for children when measuring pain after
admitted for minor surgeries. surgery, the scores were lower
than the previous ones.
Playing activities promoted the
integral and continuous
When children attended outpatient chemotherapy, they did individual
Melo et al., 2010 [24] Descriptive, n = 7 children with cancer. development of children despite
play sessions in the toy library for 1 to 3 h. 4/C
Brazil qualitative study Age: 5.83 years. the situation. In addition, they
The intervention was added to the usual routine.
were involved in the disease and
collaborated in their treatment.
The behavior of children during venous puncture was observed.
The intervention was evaluated
Subsequently, a play therapy session was performed with the children
observing the children reactions.
n = 21 hospitalized simulating a venous puncture on a doll, and then they repeated the
After the play therapy session,
children. procedure and expressed their doubts. The duration of the play therapy is
Santiago et al., 2015 [19] Descriptive, there was an increase in variables
Age: 3 to 6 (52.3%) and 7 not specified. 4/C
Brazil quantitative study that express greater adaptation
to 12 (47.3%). The behavior of the children was observed again during an intravenous
and acceptance to the puncture
61.9% girls. puncture after applying again the play therapy. The time between both
process like shouting, muscle
sessions was less than 48 h.
tension, or crying.
Children included in the study were hospitalized for 24 h at least.
Preparation game: play with dolls and animal figures.
n = 130 children in the
Pain relief game: play with dolls, cars, breathing exercises, and massages. The play therapy decreased the
Yayan et al., 2019 [11] Quasiexperimental postoperative period.
Distraction game: singing, puzzles, video games, watching videos, mean levels of pain in children 2b/B
Turkey study Mean age: 7.6 ± 3.48 years.
crafting your own toys with clinical material. and anxiety in parents.
76.5% boys.
The intervention was added to the usual care routine.
Note: EL = evidence level; FLACC scale = Face, Legs, Activity, Cry, Consolability scale; IV = intravenous; QT = chemotherapy; RG = recommendation grade.
Healthcare 2020, 8, 239 9 of 12

4. Discussion
The aim of the study was to understand the impact of play therapy on hospitalized children.
The results of the studies indicated that it has multiple benefits, such as reducing anxiety and pain,
children having less negative emotions, better children–health professional relations, or improving
children’s collaboration in their treatments. This review includes information about the use of play
therapy for different children’s pathologies or hospitalization reasons and describes different kinds
of interventions. It also suggests what the characteristics of play therapy interventions based on
the reviewed literature should be and what are the main future research lines that have not been
addressed yet.
Play therapy theoretical models indicate that its effectiveness is based on six points: the therapeutic
relationship, the diagnostic opportunities, breaking down defense mechanisms, facilitating articulation,
therapeutic release, and anticipatory preparation [25]. Furthermore, the processes that can be changed
or affected by play therapy belong to three domains: cognitive, affective, and interpersonal [25].
The cognitive domain refers to the awareness and domination of beliefs and ideas which can be
changed with processes such as skill development, schema transformations, and symbolic exchanges;
the affective domain, related to emotion regulation, uses processes such as the abreaction of affective
education; the interpersonal domain, related to relations and support, can include processes such
as support and validation and the corrective relationship with the therapist [25]. The professionals,
knowing which domain of the children they want to improve or change, can focus their play therapy
intervention on the application of those processes inside the games. Based on the literature review,
some characteristics that are common in almost all of the studies [11–24] and that should be taken into
account in a model for play therapy interventions with children at the hospital are the following: the
duration should be between 30 min and 1 and half hour; dolls/toys should be used for symbolic play
(the dolls/toys receive the treatment/interventions that are going to be performed on the child); the
child should repeat the procedures with the dolls/toys after seeing the professional doing it; sanitary
material should be included in the sessions; the child should have the opportunity to ask questions
and decline to play if they want to. Based on these basic standards, the session should be creatively
adapted to what the healthcare staff want to achieve.
Hospitalization periods during childhood can affect children’s behavior, as they are subjected to
unknown procedures without understanding the need for these treatments. Numerous studies show
that play therapy helps to improve these behaviors; this may be due to the fact that, through play,
children can understand and accept the situation they are living in [26–28] and learn to express feelings
and emotions about the hospitalization procedures [28–30]. Additionally, the play interventions
distract and amuse the children, making them forget where they are and transporting them to a world
of illusion and happiness [26–30].
The diagnosis and treatment of cancer in children involves long periods of hospital stay that
can lead to an alteration in their development and psychosocial status, so it is necessary to provide
holistic care that is not only focused on the oncological process. Several studies show that, with play
therapy, children develop a trust relationship with nurses, allowing nurses to know the needs of the
patient during the process [31]. In addition, children develop coping strategies, express their fears and
concerns through play, and gain knowledge about their illness and treatment [31,32].
Other studies show that therapeutic games decreased anxiety in children who experienced the
game session in the hospital environment. After the play sessions, children feel safer because they
learn the environment and the procedures [26,27,30,33,34]. In some sessions, nurse techniques are
simulated in the toys, which allowed the child to move from a passive to an active role, reducing the
fear of these procedures [27,29] and establishing a positive child–nurse relationship [26,29,30].
Similar positive results have been obtained with play therapy in adults and elderly people,
although literature that studies the impact of ludic activities in adults with pathology is scarce.
Despite this, some studies [35–38] show that recreational interventions are beneficial for treatment
in adults, indicating that creative play and psychological and physical therapies (aromatherapy,
Healthcare 2020, 8, 239 10 of 12

hypnosis, physical activity...) performed in adults with cancer can relieve stress, anxiety, and pain
intensity; achieve a greater adherence to treatment; promote positive coping skills; and improve the
quality of life [35,36]. In addition, the Bellin Health Cancer Center has developed a program called
“Bellin Expressive Arts in Medicine” that consists of providing patients with comprehensive care [38],
encouraging creative activities in order to promote a healing environment, and increasing the hope of
these patients [39]. Additionally, other researches show the effectiveness of playing activities in adults;
the study by Mimi et al. [36] shows an improvement in patients with chronic pain, and the study by
Saywell et al. [37] points out the effect of recreational interventions in the rehabilitation of adults with
acquired brain injury, improving the balance and independence of these patients. On the other hand,
some studies show the benefits of doll therapy in elderly people with dementia [40,41]. This therapy
decreases negative behaviors (anxiety, agitation...), increases positive behaviors and happiness, and
improves the well-being of these people.
It is important to take into account that the effectiveness and effects of the play therapy can vary
depending on the professional’s competencies and ability to engage and the children’s development
level [25].
This study has some limitations. First, half of the studies included in this review are observational
studies that have a lower level of evidence. Finally, we could not do a meta-analysis because the study
variables and the way that they were measured were different between the studies.
The research indicates a trend of using play therapy mainly in children who are in the perioperative
period and in children with cancer. Most of the games are based on showing the children different
procedures that they will receive during their hospitalization [5–11,21–24]. Some major problems
that should be covered it is the influence of play therapy for chronic and psychological pathologies’
acceptance and management in children and not only for hospital procedures. It would also be
interesting to develop studies to verify whether the pediatric units have the necessary resources to
carry out the play intervention, and studies to verify the knowledge of pediatric nurses regarding
therapeutic play. Additionally, cost-effectiveness studies would be of interest.
The most important implications for the practice of this study is to publicize the beneficial effects
of play therapy on hospitalization during childhood and the main characteristics that play therapy
should have, as indicated above. The results of this review will make parents and nurses see the
importance of playing to improve the well-being of children, despite illness.
In addition, this study will raise awareness of the importance of developing a relationship of trust
between the nurse and the child through play, avoiding health professionals being seen as enemies
by children and becoming people with whom children can express their feelings, fears, and concerns.
Finally, it is important to emphasize the importance of children participating in the disease process,
because in this way they better understand and accept the situation.

5. Conclusions
Play therapy has shown benefits in hospitalized children, such as reducing anxiety during the
hospitalization process; reducing pain; improving the relationship with health professionals; improving
the behavior and attitude of children to the disease and the procedures; and relieving feelings of fear,
anxiety, and insecurity. Pediatric units should train their staff in the use of play therapy in order to
obtain its positive effects. Additionally, future research should analyze which play therapy/games are
more effective, comparing different sessions to each other instead of comparing only the play therapy
with the usual care.

Author Contributions: Conceptualization, M.J.G.-I., N.S.-M., and J.L.G.-U.; methodology, J.L.G.-U. and L.A.-G.;
software, K.V.-R.; validation, M.B.M.-C.; formal analysis, M.J.M.-J. and L.A.-G.; investigation, M.J.G.-I.; resources,
J.L.G.-U. and M.J.G.-I.; data curation, N.S.-M.; writing—original draft preparation, M.J.G.-I. and K.V.-R.;
writing—review and editing, M.B.M.-C.; visualization, M.J.G.-I. and M.J.M.-J.; supervision, L.A.-G. and J.L.G.-U.
All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Healthcare 2020, 8, 239 11 of 12

Conflicts of Interest: The authors declare no conflict of interest.

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