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The effectiveness of therapeutic play, using virtual reality computer games, in

promoting the psychological well-being of children hospitalised with cancer

Article  in  Journal of Clinical Nursing · June 2011

DOI: 10.1111/j.1365-2702.2011.03733.x · Source: PubMed

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U S E O F T E C H N O L O G Y IN C A R E

The effectiveness of therapeutic play, using virtual reality computer

games, in promoting the psychological well-being of children
hospitalised with cancer
William HC Li, Joyce OK Chung and Eva KY Ho

Aims. To examine the effectiveness of therapeutic play, using virtual reality computer games, in minimising anxiety and
reducing depressive symptoms in Hong Kong Chinese children hospitalised with cancer.
Background. There has been an increase in the use of therapeutic play intervention to help children cope with the stress of
hospitalisation. However, it is not clear whether therapeutic play is an appropriate psychological intervention for Chinese
children hospitalised with cancer.
Design. A non-equivalent control group pretest–post-test, between-subject design was employed.
Method. Hong Kong Chinese Children (8–16 years of age), admitted to a paediatric oncology ward for the treatment of cancer
during a 14-month period, were invited to participate in the study. Of the 122 children, 70 formed the control group receiving
routine nursing care and 52 in the experimental group receiving therapeutic play interventions.
Results. The results showed that children in the experimental group reported statistically significant fewer depressive symptoms
than children in the control group on day 7. The results, however, find no differences in children’s anxiety scores between the
two groups on day 7.
Conclusion. The study provides empirical evidence to support the effectiveness of therapeutic play, using virtual reality com-
puter games, in the psychological preparation of children hospitalised with cancer, thus charting a path towards promoting
holistic and quality care.
Relevance to clinical practice. The findings heighten the awareness in healthcare professionals that play is a very important part
of children’s life and that they need play even when they are ill.

Key words: cancer, children, nurses, nursing, psychological, therapeutic play, virtual reality

Accepted for publication: 17 January 2011

2006, Williams et al. 2006). However, children with cancer

Introduction
may not only be at risk from adverse medical effects, their
The diagnosis and treatment of cancer is a stressful and psychosocial well-being may also be severely affected as a
threatening experience for children (Hicks & Lavender 2001, result of the cancer and its therapy (Langeveld et al. 2004).
Penkman et al. 2006). Although survival rates for childhood Over the past few decades, numerous research studies in
cancer are higher than ever before, the course of treatment for children’s health care have focused on different methods of
cancer, such as chemotherapy, surgery or radiotherapy, is still psychologically preparing children hospitalised for cancer
a very stressful experience in the life of a child (Stam et al. treatment (Hicks & Lavender 2001, Dowling et al. 2003,

Authors: William HC Li, PhD, Assistant Professor, School of Correspondence: Dr Ho Cheung William Li, Assistant Professor, 4/F,
Nursing, The University of Hong Kong; Joyce OK Chung, MPH, William M. W. Mong Block, School of Nursing, The University of
Teaching Consultant, School of Nursing, The University of Hong Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong, China.
Kong; Eva KY Ho, BNurs, Research Nurse, School of Nursing, The Telephone: +852 91761546.
University of Hong Kong, Hong Kong, China E-mail: [email protected]

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2135–2143 2135
doi: 10.1111/j.1365-2702.2011.03733.x
WHC Li et al.

Penkman et al. 2006). Among all nursing preparations, the viewed as less important for hospitalised children by many
provision of information for parents or caregivers of children Chinese parents and some healthcare staff compared with
with cancer on physiological care in cancer treatment is the physiological care or medical treatment in Hong Kong
most common nursing practice in paediatric oncology units in (Becher & Sing 1997), it is not clear whether therapeutic
Hong Kong. However, in a recent study examining the play is an appropriate psychological intervention for Chinese
impact of cancer on Hong Kong Chinese children’s physical, children and their parents. Given these issues, the purpose of
emotional and psychosocial well-being, the results indicated this study was to examine the effectiveness of therapeutic
that children reported relatively high state anxiety scores on play, using virtual reality computer games, in minimising
admission for cancer treatment and more than half of the anxiety and reducing depressive symptoms in Hong Kong
participants were potentially at risk of depression, or at least Chinese children with cancer.
presented some depressive symptoms during their stay in
hospital (Li et al. 2010). Moreover, semi-structured inter-
Methods
views revealed that nearly all children hospitalised with
cancer expressed different degrees of sadness and worry. The
Design and sample
findings from this study suggested that there is a room for
improvement in existing nursing intervention regarding The study was carried out in one of the largest acute-care
preparing children for the treatment of cancer and hospital- hospitals in Hong Kong with a well-established paediatric
isation. oncology unit. To examine the effects of therapeutic play
During the past decade, there has been an increase in the intervention, a non-equivalent control group pretest–post-
use of therapeutic play intervention to help children cope test, between-subject design was employed.
with the stress of hospitalisation. Therapeutic play is a set of The study was divided into two phases. In Phase one, all
structured activities designed according to psychosocial and participants admitted to the oncology unit received usual care
cognitive development of children and health-related issues to (control group). After finishing data collection for the control
prepare children psychologically for hospitalisation (LeVi- group, we allowed one-month washout period before starting
eux-Anglin & Sawyer 1993). The central goal of therapeutic data collection in Phase two. All participants admitted to the
play is to facilitate the emotional and physical well-being of oncology unit in Phase two received usual care plus thera-
hospitalised children (Vessey & Mahon 1990). Armstrong peutic play using virtual reality computer games (experimen-
(2000) claimed that play may not only allow children to gain tal group).
pleasure, but also may help them act out stressful or Children with cancer admitted to the oncology ward of an
threatening experiences when faced with stressful medical acute hospital for the treatment of cancer, meeting the
procedures and unfamiliar environments. Numerous studies inclusion criteria for the study, were invited to participate in
have described the benefits of therapeutic play in helping the research. The inclusion criteria were as follows: (1)
children cope with the stress caused by illness and hospital- children should be between 8–16 years of age; (2) children
isation (Armstrong 2000, O’Connor & Drennan 2003, Li are able to speak Cantonese and read Chinese; and (3)
et al. 2007). In a randomised controlled trial to examine the children should have been diagnosed with cancer for at least
effectiveness of therapeutic play intervention on outcomes of two months and be currently undergoing active treatment.
children undergoing day surgery, the results showed that The researcher excluded children who with identified cogni-
children reported lower state anxiety scores and exhibited tive and learning problems in their medical records. Indeed
fewer instances of negative emotional behaviours in pre- and younger children may also benefit from therapeutic play
postoperative periods (Li & Chung 2009). Regretfully, the intervention as they are more vulnerable to the stress of
majority of previous research on therapeutic play was case cancer treatment and hospitalisation. However, those youn-
studies, which are based on theories and clinical observa- ger than eight may have limited verbal and cognitive
tions. There is a lack of empirical evidence to determine capacities in expressing themselves and comprehending some
accurately the clinical effectiveness of therapeutic play, in of the terms in questionnaires. For this reason, only children
particular using it to ease the psychological burden of aged 8–16 years were invited to participate in the study.
children hospitalised with cancer. A review of the literature Sample size was calculated to obtain sufficient power to
reveals that there is so far no published study testing the detect differences between the groups. The researcher pre-
effects of therapeutic play intervention on minimising psy- dicted a medium effect size of differences between two groups
chological distress for children hospitalised with cancer in based on one prior study (Li & Chung 2009) testing the
Hong Kong Chinese context. As play has traditionally been effectiveness of therapeutic play intervention on children’s

2136  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2135–2143
Use of technology in care Effectiveness of therapeutic play

pre- and postoperative anxiety. To predict this effect size of To produce virtual reality environment for children to
differences between two groups at a 5% significance level play, a PlayMotion system was installed in a playroom of the
(p < 0Æ05) and a power of 0Æ80, 64 subjects in each group are paediatric oncology ward. PlayMotion system (Playmotion
normally required (Polit & Beck 2008). The data collection Limited, Hong Kong, China) is a device that transforms
lasted for 14 months. A total of 122 children participated and ordinary walls, floors and ceilings into wildly interactive,
completed the study. The response and attrition rates in the virtual playgrounds. It combines the flexibility of video
control group were 96% and 98% respectively, while those projectors, the computer vision algorithms and the real-time
in the experimental group were 83% and 85%, respectively. special effects systems of videogames. PlayMotion requires
Of the 122 children, 70 formed the control group and 52 the no goggles, gloves, helmets and markers and thus making it
experimental group. an immediate, totally intuitive and completely natural expe-
rience. Only the shadows of moving arms are needed to enter
exciting, interactive projected play spaces – from flying over
Intervention
a city and creating trance-like waves, ripples and colours to
Besides receiving usual care, children received 30-minute playing football, volleyball or billiards.
therapeutic play intervention using virtual reality computer
games daily (five days a week). The therapeutic play The rationales of using virtual reality technology in
intervention was conducted by research nurse and imple- therapeutic play
mented in small group with maximum four children in one Previous study has showed that virtual reality could provide
group in a playroom of the oncology unit. Previous studies positive and enjoyable leisure experiences during physical
(Cooper & Blitz 1985, LeVieux-Anglin & Sawyer 1993) interactions with different game-like virtual environments
pointed out that school-age children are more peer oriented and potentially lead to increased self-esteem and a sense of
and they could benefit from group teaching and learning. self-empowerment for children with physical and intellectual
Moreover, it offers children an opportunity to interact with disabilities in clinical settings (Weiss et al. 2003). One
their peers and creates a non-threatening atmosphere for advantage of using virtual reality for children to play is that
children to express their concern and fear. To ensure cancer it enables great flexibility in the way it can be interfaced
children could be able to engage in virtual reality computer with children and adapted to suit specific therapeutic goals.
games, the time of implementation was flexible and repeated The child can, in accordance with his or her ability and type
sessions was carried out during the day time. Participants of disease, sit or stand while performing in the virtual
were invited to join the play activities when they were not environment. It is also a real opportunity to provide children
occupied by any medical treatments or physiological care. with a break from the rigours of hospitalisation and treat-
Before commencing the study, the research nurse received ment as well as a sense of control over their illness and have
training on how to implement the intervention. To eliminate fun at the same time. Besides, virtual reality provides a
the experimenter bias effect, the research nurse responsible platform where children with illness and unable to perform
for data collection was independent to the research nurse leisure activities in ‘real life’ settings, may be able to engage
responsible for administering the interventions to the sub- in them.
jects. The effectiveness of using virtual reality as an intervention
tool in rehabilitation has recently been well documented
The content of therapeutic play using virtual reality computer (Schultheis & Rizzo 2001, Kizony et al. 2003). There is also
games some evidence that multi-sensory interactive experiences are
The content of therapeutic play contains a variety of group an effective method of moving children minds away from
playing activities, in particular involves using virtual reality anxiety and pain (Steele et al. 2003).
through interactive stimulations created by computer hard-
ware and software to present children with opportunities to
Measures
engage in environments that appear and feel similar to
real-work objects and events. Some activities are more en- Children’s state anxiety level
ergy-consuming and some are not. The intervener can, in The state anxiety level of children will be measured by using
accordance with children’s sex, age, ability, type of disease the short form of the Chinese Version of the State Anxiety
and general condition, select suitable virtual reality computer Scale for Children (CSAS-C). The short form of the CSAS-C
games for them to play. Besides, children may also have consists of 10 items, which are scored from 1–3, with total
choice on types of play. possible scores ranging from 10–30. Higher scores indicate

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2135–2143 2137
WHC Li et al.

greater anxiety. The psychometric properties of the short On admission to the oncology ward, demographic data
form of the CSAS-C have been empirically tested (Li & Lopez of children and their parents were collected by research
2007). The results showed that the short form of the CSAS-C nurse using the demographic form. Moreover, baseline state
was highly correlated with scores obtained from the full form anxiety scores and depressive symptoms of children were
(r = 0Æ92), had acceptable internal consistency (r = 0Æ83) and assessed. The state anxiety level and depressive symptoms
good convergent validity in differentiating state anxiety of of participants were again assessed on day 7 after admis-
children under stressful and relaxed situations. The results of sion.
confirmatory factor analysis further added evidence of the
construct validity of the short form of the CSAS-C (Li et al.
Data analysis
2008).
The Statistical Package for Social Sciences (SPSS ) software,
Children’s depressive symptom version 16.5 for Windows (SPSS Inc., Chicago, IL, USA)
Children’s depressive symptom was assessed using the Center was used for data analysis. The homogeneity of the
for Epidemiologic Studies Depression Scale for Children experimental and control groups were assessed by using
(CES-DC). The CES-DC was derived from the Center for inferential statistics (independent t-test and v2). Mixed
Epidemiologic Studies Depression Scale for Adult (CES-D) between-within subjects ANOVA was used to determine
developed by Radloff (1977). The CES-D was then modified whether therapeutic play, using virtual reality computer
to become more child-friendly (Weissman et al. 1980). The games, was more effective in minimising anxiety and
CES-DC comprises 20 fully standardised items to evaluate reducing depressive symptoms of children during the first
depressive symptoms. The items consist of short and simple week of hospitalisation.
statements in the first person about the emotional, cognitive
and behaviour related components of depressiveness. All
Results
items are evaluated on a four-point Likert scale in relation to
their incidence during the last week, which were scored from Information on the demographic, clinical and baseline
0–3 (0 = ‘not at all,’ 1 = ‘a little,’ 2 = ‘some,’ 3 = ‘a lot’), characteristics of the experimental and control groups is
with total possible scores ranging from 0–60, with higher presented in Table 1. The results revealed that the experi-
scores indicating greater symptomatology. A score of 16 or mental and control groups were similar with respect to the
greater indicates an individual demonstrating some depres- age and gender of children, education attainment of parents,
sive symptoms (Radloff 1977). The psychometric properties medical diagnosis and baseline state anxiety cores and
of the short form of the CES-DC have been empirically tested depressive symptoms for children, suggesting a high level of
(Barkmann et al. 2008), showing adequate internal consis- homogeneity of variance between these two groups in this
tency reliability, good concurrent validity and excellent study. Almost all participants had been diagnosed with
construct validity. The results of confirmatory factor analysis cancer within the previous 12 months, with only three
showed that there are four factors underlying the CES-DC, diagnosed more than a year before. The mean and standard
which is congruent with hypothesised configuration of the deviation of the state anxiety and depressive symptom scores
factor structure of the CES-D proposed by Radloff (1977). in children across the two time periods are presented in
The four-factor version of the CES-DC is considered to have Table 2.
good factorial validity and stability across age (Barkmann
et al. 2008).
Effect of intervention on depressive symptoms of children

The results of mixed between-within subjects ANOVA

Data collection procedures
(Table 3) indicated that there was a statistically significant
Approval for the study was obtained from the university and main effect for time in the depressive symptoms scores,
hospital ethics committee. Written consent was obtained suggesting a change in the depressive symptoms between two
from the parents after they were told the purposes of the groups across the two time periods. Besides, the results
study. Each child was also invited to put his/her name on a indicated that there was a statistically significant interaction
special children’s consent form. The children and their effect, suggesting that the changes in depressive symptoms of
parents were informed that they had the right to withdraw the children over times depended on the types of intervention
from the study at any time and were assured of the given. The results of between-subject effects showed
confidentiality of the study. that there was a statistically significant main effect for

2138  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2135–2143
Use of technology in care Effectiveness of therapeutic play

Table 1 Comparison of experimental and control groups on demo- Effects of intervention on state anxiety of children
graphic, baseline and clinical characteristics (n = 122)
The results of mixed between-within subjects ANOVA
n (%)
(Table 3) indicated that there was a statistically significant
Experimental Control main effect for time in the anxiety scores, suggesting a change
(n = 52) (n = 70) p* in the state anxiety scores of children in both groups across
Gender of children the two time periods. Besides, the results indicated that there
Male 28 (53Æ85) 37 (52Æ86) 0Æ98 ns was a statistically significant interaction effect, indicating that
Female 24 (46Æ15) 33 (47Æ14) the changes in the state anxiety scores of children over time
Education attainment (parents) depended on the types of intervention given. The results of
Primary 5 (9Æ62) 6 (8Æ57) 0Æ98 ns
between-subject effects showed that there was no statistically
Lower secondary 16 (30Æ76) 22 (31Æ43)
Upper secondary 25 (48Æ08) 34 (48Æ57)
significant main effect for intervention, suggesting that there
Tertiary 6 (11Æ54) 8 (11Æ43) was no difference in children’s anxiety scores between the
Medical diagnosis two groups on day 7.
Leukaemia 21 (40Æ38) 29 (41Æ43) 0Æ74 ns
Lymphoma 13 (25Æ00) 17 (24Æ28)
Brain tumour 3 (5Æ77) 2 (2Æ86) Discussion
Germ-cell tumour 9 (17Æ31) 14 (20Æ00)
Osteosarcomas 6 (11Æ54) 8 (11Æ43) The purpose of this study was to examine the effectiveness of
therapeutic play, using virtual reality computer games, in
M (SD)
minimising anxiety and reducing depressive symptoms in
Experimental Control Hong Kong Chinese children hospitalised with cancer. The
(n = 52) (n = 70) p* use of randomised controlled trial represents the most
Age of children 11Æ6 (2Æ1) 12Æ1 (2Æ3) 0Æ74 ns powerful method for establishing cause-and-effect relation-
Children’s state 21Æ04 (4Æ90) 21Æ11 (4Æ66) 0Æ93 ns ships between variables. However, randomisation of subjects
anxiety scores to different groups was not possible in this study, because
Children’s depressive 22Æ31 (6Æ18) 22Æ11 (5Æ62) 0Æ92 ns
there was a possibility of contamination between the two
symptoms scores
different treatment groups in the setting and some partici-
ns, not significant at p > 0Æ05. pants and particularly parents of children might be concerned
*Group comparisons t-test for continuous and v2 for nominal and or disturbed by experiencing a different form of nursing
categorical variables.
intervention. Given these issues, an alternative method,
quasi-experimental (non-equivalent control group), pretest–
Table 2 The mean state anxiety scores and depressive symptom
post-test between-subject design was employed.
scores in children across two time periods (n = 122)

Mean (SD)
Effect of therapeutic play interventions on the state
Experimental Control Total
anxiety of children
(n = 52) (n = 70) (n = 122)
The results of the study indicated that children showed quite
State anxiety on 21Æ04 (4Æ90) 21Æ11 (4Æ66) 21Æ08 (4Æ73)
admission high state anxiety on admission for cancer treatment. The
State anxiety scores 19Æ48 (4Æ73) 21Æ06 (4Æ52) 20Æ39 (4Æ66) results were consistent with a previous study showing that
on day 7 children experienced different degrees of sadness, unhappi-
Depression symptom 22Æ31 (6Æ18) 22Æ11 (5Æ62) 22Æ20 (5Æ82) ness and worry. However, there was a slight reduction in the
scores on admission
state anxiety scores of children on day 7, regardless of
Depression symptom 20Æ60 (5Æ87) 25Æ97 (6Æ32) 23Æ68 (6Æ15)
scores on day 7 the type of intervention. This is understandable, as most of
the children had undergone invasive medical procedures and
cancer treatment on day 7 and their worries and anxiety
intervention, indicating that children in the experimental
might have lessened. Another reason for the reduction in
group reported statistically significant fewer depressive
anxiety level might be that children gain more sense of self-
symptoms than children in the control group on day 7. Using
control over the unfamiliar environment and medical proce-
the commonly used guidelines proposed by Cohen (1992), the
dures on day 7. According to the theory of cognitive
partial eta squared (0Æ06) indicates that the effect size for
appraisal, stress and coping (Lazarus & Folkman 1984),
the intervention was moderate.

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2135–2143 2139
WHC Li et al.

Table 3 The results of mixed between-within subjects ANOVA on state anxiety and depressive symptom scores in children across two time
periods (n = 122)

State anxiety scores Depressive symptom scores

Eta Observed Eta Observed

F-value p-value squared power F-value p-value squared power

Main effect for time 33Æ03 0Æ00 0Æ21 0Æ96 17Æ18 0Æ00 0Æ13 0Æ94
Interaction effect 28Æ52 0Æ00 0Æ19 0Æ97 115Æ74 0Æ00 0Æ49 0Æ98
Main effect for 3Æ48 0Æ07 0Æ05 0Æ68 6Æ04 0Æ02 0Æ06 0Æ81
intervention

the individual’s evaluation of the threat is influenced by his/ local study (Li et al. 2010) showing that the course of cancer
her perception of control over a potential threat. Therefore, it treatment has a tremendous impact on children. The results
was reasoned that if children believed that they had adequate were also consistent with studies conducted in Western
control over the environment or an upcoming medical countries (Dejong & Fombonne 2006, Matziou et al. 2008),
procedure, the perception of threat would decrease. Owing providing further evidence that children with cancer are at
to the transitory nature of anxiety, the state anxiety score of a high risk of depression.
child may vary in intensity, fluctuating from time to time as a The findings suggest that there was a change in the
result of exposure to different situations. However, although reporting of depressive symptoms in both groups across the
children in the experimental group had lower mean state different time periods. However, changes over the different
anxiety scores than children in the control group on day 7, times were dissimilar between the experimental and control
the differences were not statistically significant. One possible groups. Following the admission to a paediatric oncology
explanation lies in the difficulty in determining whether unit, the mean depressive symptom scores among children in
children’s state anxiety could be expected to respond to the control group increased, as measured on day 7. Because
therapeutic play interventions, which had a more precise hospitalisation and painful medical procedures are anxiety-
effect on reducing children’s depressive symptom, while state provoking events and can be emotionally devastating for
anxiety might be less responsive to such intervention. children (Li et al. 2010), common emotional responses like
Nevertheless, when examining the effect size and power of worry, fear and uncertainty are likely to be meticulously
therapeutic play intervention on children’s state anxiety reported after admission to hospital. Unlike the CSAS-C,
scores, we found that the effect size was between small and which asks children to indicate the degree to which they are
moderate (Eta squared = 0Æ05), indicating therapeutic play experiencing a particular feeling at the current moment, the
intervention might well be effective. Additionally, the result CES-DC asks them to rate the frequency of depressive
of the power analysis was only 0Æ68, indicating a high chance symptoms during the past week. This probably explains why
of committing a type II error (32%). The results suggest that children in the control group reported more depressive
the relationship between type of intervention and children’s symptoms on day 7 than on admission. Nevertheless, in
state anxiety scores on day 7 might have been affected by the contrast to the control group, children receiving therapeutic
limited sample size. It would therefore be interesting to see if play intervention, using virtual reality computer games,
further studies using larger samples could find a significant reported statistically significant fewer depressive symptoms
relationship between therapeutic play intervention and chil- than children in the control group. This concurred with the
dren’s state anxiety. results of a previous study where therapeutic play was found
to be effective in helping children cope with the stress of
hospitalisation.
The effects of therapeutic play on children’s depressive
Indeed, implementing therapeutic play for children with
symptoms scores
cancer during their hospitalisation has particular advantages
The results showed that most children presented some because serious illness and its accompanying stress and
depressive symptoms during their stay in the hospital. The physical restriction interrupt the natural play and socialisa-
overall mean depressive symptom scores for children on tion which are essential for children’s normal growth and
admission and on day 7 were higher than the cut-off point development. Moreover, owing to low body resistance and
(16). The findings concurred with the results of a previous susceptibility to infection, most children have relatively a few

2140  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2135–2143
Use of technology in care Effectiveness of therapeutic play

opportunities to engage in leisure activities. The lack of diseases, some parents did not encourage their children to
opportunity to play often leads to the development of engage in close social contact with other hospitalised
dependent behavioural patterns, learned helplessness and children. One more limitation of this study was related to
depression (Weiss et al. 2003). Implementing therapeutic the recruitment issue. There was an outbreak of human swine
play for children with cancer during their hospitalisation can influenza (H1N1) in Hong Kong at the time of data collection
provide more opportunity for children to engage in leisure in Phase two. According to the Hong Kong Hospital
activities, greater involvement which can improve children’s Authority’s policy, all non-medical-related activities, includ-
coping skills, decrease their stress and eventually link to ing therapeutic play intervention, were suspended during this
better psychosocial adjustment to illness and hospitalisation. period and as a result only 52 subjects were recruited to the
Implementing therapeutic play intervention with virtual experimental group before the policy commenced.
reality computer games may require some extra resources,
such as those needed in the short run to purchase necessary
Conclusion
equipments. However, this will certainly enhance the hospi-
tal’s capacity to promote quality health in the long run. Notwithstanding these potential limitations, the study has
Indeed, it only takes about half an hour a day of a staff nurse’s addressed a gap in the literature by systematically researching
time to provide a creative recreational and psychosocial the effects of therapeutic play intervention, using virtual
intervention to make the child’s cancer journey a less difficult reality computer games, on the outcomes of children hospi-
one. Clearly, it would be economically feasible for the talised with cancer. Its most important contributions is
healthcare system to consider and use this intervention as part empirical evidence to support the effectiveness of using
of routine nursing care for children hospitalised with cancer. therapeutic play intervention in helping children hospitalised
There was a considerable amount of positive feedback with cancer ease the burden of cancer treatment and making
from children receiving therapeutic play intervention in the their cancer journey less difficult.
study hospital. One of their comments was as follows:

I was so sad because of the disease and the environment around me Relevance to clinical practice
even made me feel more depressed as the ward was full of medical
Results from the present study provide empirical evidence of
equipment and sick people. It was really boring to stay in bed all day
the benefits of incorporating therapeutic play in helping
long without anything to do. I never thought there would be some
children ease the psychological burden of cancer treatment
virtual computer games introduced to the ward. It occupied my time
and hospitalisation, thus charting a path towards promoting
or at least let me forget any unhappy event ahead… I was so relaxed
holistic and quality care. It is anticipated that the findings of this
while I was playing.
empirical study will promote awareness in nurses and parents
that play is a very important part of children’s life and that
Limitations
they need play even when they are ill. Additionally, the find-
This study was limited in that all data were collected in one ings will contribute to promoting nurses’ accountability and
setting, which might limit the ability to generalise the result. responsibility for patient care through evidence-based practice.
Another limitation was that, in contrast to the control group,
the response rate was comparatively low, but with a higher
Acknowledgements
attrition rate in the experimental group. There are some
factors that shed light on these issues. First, some children The authors thank PlayMotion Limited for lending the
refused to participate in the play activities after receiving Playmotion system and providing technical support through-
chemotherapy. Indeed, fatigue after chemotherapy was one out the study period.
of the most common physical concerns reported by child
cancer patients that prevented them from joining any energy-
Contributions
consuming activities (Whitsett et al. 2008). Second, there are
some misconceptions about therapeutic play interventions Study design: WHCL; data collection and analysis: EKYH
among parents. Some parents showed reluctance to let their and manuscript preparation: WHCL, JOKC, EKYH.
children join the intervention as they thought that resting
rather than play was the most appropriate method for their
Conflict of interest
recovery, particularly during the acute phase of cancer
treatment. Moreover, for fear of their contracting infectious No conflict of interest has been declared by the authors.

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2135–2143 2141
WHC Li et al.

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2142  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2135–2143
Use of technology in care Effectiveness of therapeutic play

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