Play, long viewed as a means for children to cope with the challenges of hospitalisation,1 is a way to reduce and prevent stress and anxiety in children.2–4 Play is recognisable, safe and can be used to communicate complex information in an age-appropriate manner.2 Furthermore, play is essential for healthy development, and adopting play interventions into the treatment and care of paediatric patients may reduce developmental regression.2

The WHO’s standards of children’s rights in hospital include the right to play. Recently, the WHO recommended that all doctors and nurses utilise play within treatment and care and that hospitals promote research on using play.5

Rapid turnover of hospitalised children, with few staying for longer periods, limits opportunities for playful relationships and comfortable familiarity with hospital playrooms.6 Consequently, hospital play interventions are often individualised and treatment-oriented. In some countries play facilitated by specially trained staff for selected patients, rather than a normal, everyday activity.6 7 Moreover, hospital resources, children’s health status and treatment needs, expectations about illness and health behaviour influence the implementation of play interventions.2 6 8 Attitudes towards children’s integrity and adult participation in the child’s play and the acceptance of playing with particular toys also affect the practices of play in hospitals.9

While many different traditions and practices exist in hospitals, most countries lack formalised programmes on the use of play interventions. This might stem from a lack of knowledge on when, where and how to best practice play in the treatment and care of paediatric patients. Uniform implementation may be further challenged by continually changing conditions in healthcare.

Previous meta-analyses10 11 and systematic reviews12–21 have examined specific areas of play in hospitals, or specific play solutions for paediatric patients, but reviews on the general use of play in hospitals are limited. Existing reviews are further impaired by non-systematic literature searches and few included studies.22 23 Therefore, this scoping review aims to categorise and synthesise the scientific literature on the use of hospital play interventions in the last 20 years to potentially inform, guide and encourage future efforts in using and evaluating play interventions in the care of paediatric patients.

Of 3711 articles, 297 were included in the final review (figure 1). Detailed information on the included studies can be found in online supplemental tables 2 and 3. Articles originated from high-income countries (78%), particularly the USA, or middle-income countries (22%) (figure 2A). Since 2000, the number of articles published annually has increased steadily (figure 2B).

The studies were generally small, with less than 25 participants in nearly one-third of them (figure 2C). Play interventions were used for all patients aged 0–18 years (figure 2D). We were unable to report age and developmental status-specific findings, because stratification based on these factors was limited. The interventions were mostly directed towards individual patients (94%) as opposed to groups (6%). Used within 13 disease categories (table 1), hospital play interventions were carried out by various professions (table 2).

We identified four clinical contexts where play had distinct roles: A) procedures and diagnostic tests, where play as distraction, preparation and support was used to alleviate pain, stress and anxiety; B) patient education, where play was used as age-appropriate communication and to increase understanding and motivation; C) treatment and recovery, where play could supplement and occasionally replace conventional treatment and D) adaptation, where play provided space to express difficulties about being hospitalised and supported healthy childhood development.

Prior opinion papers and non-systematic reviews have suggested various subdivisions and definitions of play in hospitals, but not in a rigorous manner.2 23 58 59 It is generally recognised that play interventions can be used in the preparatory phase and as a distraction during medical procedures, and that play has a normalising effect.23 58 The term therapeutic play is used inconsistently to describe play with medical equipment, play in preparation programmes,17 and play therapy, similar to that used in child and adolescent psychiatry.22 Other subcategories, for example, directed play, non-directed play and supporting play have also been used unevenly.59 Our framework captures all of these subdivisions and contains a category for play as part of treatment and recovery, including rehabilitation. Previous reviews do not address this category, perhaps because rehabilitation and exercise are often outpatient activities and have only become a focus area more recently.60

Our framework may provide healthcare professionals and researchers with a tangible overview of the literature, while allowing play to retain its indefinable and ambiguous qualities. By summarising main characteristics, outcomes, general effects and potential pitfalls within the four clinical contexts, healthcare professionals and researchers are informed about play interventions similar to their own practices and research. Furthermore, this also informs about the breadth of possibilities and other approaches, which may encourage implementation of play interventions and inspire new ideas.

Our review primarily informs about facilitated and purpose-oriented play interventions in a clinical context. However, it is unknown whether this form of play positively impacts general health and development, which is a known benefit of unstructured play.8 Identifying solutions that allow play to serve as a preventative and general-purpose activity in hospitals is crucial. Whether or not play interventions that support healthy childhood development in non-hospital environments are transferable directly to a hospital context is uncertain. Structural and cultural factors in hospitals challenge the opportunity for unstructured and free play, just as personal factors related to patients’ illnesses and external factors such as an unfamiliar environment have an effect.6

Based on the current evidence, with very heterogenous and small studies, we were unable to draw conclusions on general aspects that could guide the implementation of future play interventions. Thus, additional high-quality research is needed to guide when, where, and what play to integrate into hospitals. Elaborating our proposed framework in a consensus-based study to further clarify principles for play interventions in hospitals, for example, the influence of age and development status on choice of play intervention, could serve to guide future research and play practices.2 Studies are warranted to assess short-term and long-term effects of play integrated before, during and after procedures or treatments, and should address whether hospital play interventions can create an environment for children conducive to normal development. Importantly, input from paediatric patients will be central in informing concepts and future research in this regard.61

Furthermore, previous literature emphasised the significance of paediatric healthcare professionals who promote play,3 62 but there is a lack of formal interprofessional training programmes available.63 64 Our review shows that treatment and care by various healthcare professionals may benefit from the incorporation of play interventions. This necessitates high-quality research evaluating the short, sustained and long-term effects of play interventions in hospitals to help overcome current barriers, such as lack of training among clinical staff.63

Hospital play interventions have a significant potential benefit for patient and family health, and both treatment-oriented and unstructured play activities need to be prioritised. Our developed four-part operational categorisation of hospital play interventions can serve as the first step in enabling stringency in the field as well as inspire further exploration, and thereby support for the needed professionalisation and academisation of the growing research interest in play in hospitals.