DOCUMENT REsopmE
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AUTHOR Hardqrove, Carol TITLE. Parent. Participation and Play Programs inHospitaSk Pediatrics in England, Sweden and Denmark.. SPONS AGENCY Panttmerican,Health Organization, Washington, D. C. PUB DATE 72 NOTE 73p.
DR PRICE ifF-$0076 HC-$3.32 Plus Postage. ESRIPTORS. *Child Development; Family Involvement; Financi Support; *Foreign Countries; Furniture Design; Government Role; Hospitalized Children *Hospitals; *Parent Participation; *Play; Space Utilization; _Yolunteers IDENTIFIERS Denmark; England; Sweden ABSTRACT T. This paper presents the findings fro& a trip to England, Denmark, Sweden, and Holland which was desigied investigate how.hOspitals in these countries facilitate chifdren's healthy development during the stress of hospitalization. The areas specifically discussed are: J(1) initiating and reinforcing family involvement;(2) meeting childre ;'s need for play;(3) adapting space,,furnishihgs, and designs for parent and play programs; and (4) financing and publlcizing programs. Jnformation about the activities and functioning of government agencis, volunteer, and consumer advocate groups in each country are also included. (3MB)
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OF HEALTH. U S DEPARTMENT EDUCATION & WELFARE OF NATIONAL INSTITUTE EDUCATION HAS BEEN REPRO THIS DOCUMENT RECEIVED FROM DUCKED EXACTLYORC,ANtZAT AS/ ION ORIGIN THE PERSON OROF vil W OR OPINIONS STING IT pOINTsNECESSARILY REPRE STATED 00 1.0T OF SENT OFF CINATIONAL INSTITUTE OR POLICY gEOLKATION poSITtON
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PARENT PARTICIPATION AND PLAYPROGRA
IN HOSPITAL PEDIATRICS IN ENGLAI ,SEN AND DENMARK j
Carol ,gardgrove , M.A. Assistant Clinical Professor Department of Family Health Care Nursing University of California San Frbncisco 94123 S. San Francisco, California
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To The World Health Organization who granted me the honor and made possible my travel study; to the program arrangers who understood my mission and arranged intro- ductions to people and programs who helped me learn about parent and play activities, and to tie nurses, psycholpgists, play leaders, physicians,..parents and patients who shared so generously their experience, enthusiasm, wisdom, time and energy;I wish to express my deep' appreciation. I truly learned the meaninof "hands across the sea," and hope that, together, we may adritinue to wok to improve the situation for young hospitalized children and their families.
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TABLE OF CONTENTS
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Foreword v
IntroductiOn vi
Certificate of Award 0 4... vii Objectives viii
' Itinerary ix -(xiv /1. Engldnd 1 Government Polic' Governmental Guidelines Health Services for Children Study Day Conference' Role of the Hospit Play Leader Volunteers and Consumer Glups National Associationor the Welfare of Children in Hospital. Save the Children Fund Noah's Ark Toy Library
Role of Volunteers- 4 Interviews with James and Joyce Robertson Hospital Visits Great Ormond Street Amersham General Hospital Stoke Mandeville it. Mary's /araed Street: Mobile Unit Fulham Hospital.(CharingCrbss) The Nursery Nurse
Denma/rk 23 PreventiveHealth Policy Parent Pol BRIS...Children Rights Organization Hospital Visits Glostrup Counity Hospital Hillerod Rigshospitale Vangede
0 4 Table of Contents (ContinUed)
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4i. .Sweden 314 National Welfare System Parent Accommodations St. Goran's Karolinska Institute Umea Samaritan- Hospital Play History and Philosophy Staff Education and Ro19. Child Nurse Training
Hospital Visits / Samaritan Karolinska St. Goran's Umea
. Holland , 149 Queen Wilhelmina, Utrecht Amsterdam University of Letden: Observatrice Pr6gram
Hospital Based Day Care for Staff Children 51 FUlham Amersham Sweden Denmark Glostrup Hillerod
Conclusion,., 511
References. and Bibliography.? 55
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G0005 A FOREWORD
and to incor- 'My long standing concern with.theneed to involve parents the pediatric hospitalarises from a background porate play into the world of California, San Maternal Child Nursing atthe University of on the faculty in paren4s and chi dren in nurseryschool Francisco, after many yearsworking with bring pa?ents and Work withstudents and staff nurses at UCSF't settings. that can block thesetwo impor- play. into our hospitaluncqvered difficulties tant activities. .); research showed clearlythat many people share Our work and study of the making working to humanize thehospital environment by these concerns and are in England, Sweden, it 'more family andchild-centered. In particular, programs available for importationto the and Denmark suggestedthat innovations were WHO for a travel-studyfellowship and United States. I therefore applied to happily was granted theopportunity to visit.
This report presentsfindings from that trip. with three countries: England,Denmark and Sweden, The itinerary covered have added on my own toHolland. As the three countries a brief excursion of national priorities similar social philotophies,I'hoped to see Vie result because so much of theimpetus on hospitalpediatrics. England was selected of James.and*JoyceRobertson, for family inclusionhas come from the work John\Bowlby,.and Anna Freud. 4 N. I for new designs forplaythings In addition,fanticiPated collecting ideas This very practicalaspect has lots to and furniture to accommodateparents. the hospital. A space-saving bed do with parentinvitation,and acceptance in whete a hundredimpassioned arguments .for wents can openthe ward to parents fail. approved and before thevisits, correspondence and _,1-41 ter WHO funding was several representatives of theMinistries of Health in the counsel came from Nelson (then president of countries as well as.fromJames Robertson, Margaret study fruitful. To them NAWCH) and others interestedin helping to make the I express my sinceregratitude. representatives of Ministriesexplained the organizational On the trip, relationship to hospitals,andto structure of governmentagencies and their Such interviews helped meunderstand the govern- preventive health programs. attending hospitals. Additional time went to menial,philosophy relative to the advo- interviewing representatives ofprivate groups active in conferences and remainder children in the hospital. Hospital visits took up the cacy for young in'England and Scandanavia had philoso- of the time. All the hospitalsvisited psychological well-being. No visits phies based on concernfor the child's rigid visitinghoursv. were made toinstitutions with weekly or twice weekly althoughauch programsstill exist.
00006 INTRODUCTION
I believe that hospipalizaglion can be a positive experience for,the pediatric patient and his family. The child can learn how ptecious he is to his own family and to caring people in the hospital and community.He and ( his family discover strengths they may never have known they had. The crisis t opens them to learning as at no other time. If the child's supports are adequate, 4he hospitalization can beCome an adventure with the patieht emerging'', a triumphant hero. A
On the other hand, deprived of emotional support, the child and his family may have an additional psychological burden placed on the already stressful physicalproblem, thus lowering their ability to cope. The child and the family may become overwhelmed and'not only fail tQp improve. despite the hospital's efforts to help, but may actually be waged by the experience:
It is the responsibility of the professionals who are aware of the research around the subject of.attachment and separation to inform parents of their impor- tance to the child and to help them in their plans to stay. Otherwise, parents, especially those with low'self-esteem, may feel intimidated and uncomfortable and take flight under the pretext that they are only in the way.
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vi 4 00007 PAN AMC:RICAN HEAL H ORGANIZATION full16.1er-him Srlir tory Rh ernswilh.lh:lrhe!1/11!e WORLD HEALTI 01 FANt7A-rioN
CERTIFICATE OF AWAi This is to certify that Carol Hardgrove Foos been awarded a fellowship by the Pan American Health Organizotion to stud] Family Centered Pedintric Care Program in United Kingdom, Denmark and Sweden for a period of four week° Any courtesies and facilities granted during the period of this felloWship will be appreciated. C. Washington, D.C. 18 Mny1972 0G008. vii - or. . a OBJECTIVES I. To see how hospitals in some advanced countries facilitate children's healthy development during the stress of hospitalization by Initiatirig or reinfo4Ing family involvement. MeOling their need for play. Adapting spackVe, furnishings and designs-for parent and play programs. Finaticing and publicizing programs. 2. To study the adiivities and functioning of government agencies, volunteer, and consumer advocate groups. 3. To bring back idelo.s for use in the United States. 1 41 0000.9 ITINERARY W/ England 4. It September 18 - 29,1972 Monday, 18 September Mrs.'C.M.R. Mitchell,Hospital Nursing Offi 'ner. Nursing Officer -Research 4 Miss M. Simpson, Department of Health andSocial Security Alexander Fleming House - Elephant and Castle London SE 1 Tuesday; 19 September Hospital Plgy Leaders"' All day conference6n "Role of Sponsored Sy the HospitalLiaison Committee Hospital Centre king EdwardHospital Fund for London 24 Nutford Place London WIY2AA 0 Wednesday, 20Septe Tavigtock Clinic Intqftiew with Mr.James Robertson, Tavistock"Centre Belsize Lane A 'London NW3 * ilisit'to Great OrmondStreet London- WCI Coordinator and tntenviews with MissJill Greent Play Miss Virginia Newman,Wards A and B Thursday, 21. September Pund Mrs.'Susan Harvey,Save the Children 29 Queen Anne's 'Gate LeIndon SW of Children Representatives of NationalAssociation for Welfare Chairman; Mrs. V.Southerland, in Hospital: Mrs.Margaret Belson, lo Secretary 7 Exton Street London SEI, 8VE 41. 4 , 00010 Itinerary Continud Englaqd . Thursday, 21 September (cbntinued) c James and Joyce Robertsonat home. Friday, 22 September Miss M. Fraser, Nursing Officer,Planning.' Euston Towers, ,Room629 Euston NWI Fulham Hospital .1 St. Dunston's Road London Mond , 25 September Amersham General Hospital Aylesbury, Bucks Interviews with Matron SisterDaniel and'I?r. Donald Garroy. Observations and interviews with parentsand children on the ward. Tuesday, 26 September Stoke Mandeville Hospital Aylesbury, Bucks Interview' with Matron Sister Gilbert Interviews with parents on the ward Observations on the ward Dr. Jane Grubbs,Pediatrician Observation of nursery school programfor children with developmental deviation's and handicappingconditions. Wednesday, 27 September St. Mary's Hospital Praed Street London W2 Tour of rounds made throughPaddingtcnArea with mobile unit team. Interview with Thomas Opp e, M.D., Medical Director' St. Mary's Hospital ..1 Thursday, 28 September Miss S. Earl, Public Health NursingOfficer Miss R. Maguire, Public HealthNursing Officer Discussion of Nursery Nurses and NurserySchool Education, U.K. Alexander Fleming House Elephant and (hustle London SE wt? 1 _ 10 Denmark October 2- 6, 1972 mbliaday, 2 October Briefing, Thg,National Health Service,.NursingDivision Misi Maja Fogel, Chief of Nursing Division .Mies Elsd°Bagger, Public alth._Nursing Division Miss. EliSabeth Hubner, Home Nursing Consultant Dr. natoid KreutzfeldWhief OE.theDivislon 1 St. Kongepsgade DK - 1264 CopenhageWC 4411, 14411.0, Regional Office for Europe Intervieig with Miss Dorothy Hdll, Regional Officer fbr 'Nursing and Vera Fry Maillart, Ed.D. Scherfigsvej 8 2100 Copenhagen 0 Tuesday, 3.October Copenhagen County Hospital, Glostrup Ndr. Ringvej 1 2600 Glostrup Interviews with Miss D, ClodeHenningsen, Director of Nursing Service; Miss Westergaard, Head Nurse, Pediatric O Department; Mrs. Else Rafn, Psychologist Day long visits to children's untts, hobby rooms, demonstratpni; of deices and areas used to teach children about management of diabetes; observations'and visits to hobby room, school room and hospital sponsored day care center for staff members' children. Visit to &top in day care center for 841ings or children of --' patients: Wednesday, 4 October 4s. Udiversity Hospital (Rigsospitalet) Blegdamsvej.3 ti ' 4 2100 Copenhagen 0 Interview with Miss Elisabeth Pederson, Departmental Sister, Pediatrics. Meeing with pstchologists assigned to pediatric departments under leadership of Mrs. Kirsten Skinhoj, Psychologist. Visits tb wards Indibbservations of play. 4 * 14. Visit to Day Care Center on hospital grounds for staff children. a / 9 r Itinerary Continued Denmarik Vedpes 4..OctOber .(continued) - Visit to BRIS headquartersand interviews with volunteers. 7.porns rettigheder i'eamfundet. Fredericiagade 15 1310 Copenhagen Visit with Dr. -Torben Bille and his wife'at the").home regarding prograths in Denmark to encourage early family bonding,'and the aims. and olyectivesand Accomplishments of BRIS. .0 Thursday, 5 October , "Interview with\Bitten Pqelsen, Principal Nursing Officer, Frederiksborg COunty Frederiksborg Amtsgaard. - Kongens Vane 3400 Hillerod Lunch, interviews and observations at FrederiksborgCounty Central Hospital Mrs. Hanne Vesterdal Jorgensen, Head NursePediatric department. Tour of patient areaS, playrooms, himpital day.carecenter. Visit with Mrs. Vesterdal and her husband, a physicianat the hospital, in their apartment on the hospital grounds. Dinner at Miss Poelsen!s with a group of nurses froAfrica, Turkey, Greece, U.S.4., and Malaya; Friday, 6 October Hospital for Mentally Retarded Children Bornehospitalet, Vangedc Sogneve j 40, - 2820 Gentofte Tour of facilities and grounds, including exposureto exciting adventure playground. Visit to Bispebjerg Hospital, Miss Ellen Christensen, Director of Nursing Service Interview with,Child Psychiatrist attached to the hospital's ti psychiatric clinic. xii 0 0.1 3 j t J. Sweden -October 9 - 13, 1972 Monday, 9 October The National.Board of Health andWelfare, Division of Information and International Cooperation. Interview with Mrs. Birgitta Bjork, Secretary,Swedish Committee on Foreign Health Workers; NursingSection. DrOttningatan 71 D Second Floor Stockholm Visit'to Samariten Hospital. Interviews with Miss Ulrica Spens, PlayTherapist. Obsetvations,and interviews. Barnsjukhuset Samariten Ringvagen 21 Stockholm Tuesday, 10 October Karolinska Hospital,'Child Clinic Interviews with Prof. John Lind,Chairman of Pediatrics; interview ,with Dr. Karin StenslandJunker, Department of Pediatrics. Tour of Karolinska facilitiesfor parents and'for pla Tour of Day Care Center for Karolinskaemployees' children. Evening: Dr. and Mrs. BjOrk entertained me intheir home for dinner,where I met Qui Nystrom ofthe Swedish Radio and her husband. I learned a great deal about recent research in Sweden on the subject of parentsand hospitalized children. * Wednesday, 11 October Stadshagsskolan (Nursing School) St. Goran Hospit Child.,Clinit 1 . St. Goransgatan Stockholm Mrs. Ulla Termmeden, Di ctor of Studies...description of Swedish sys f nursing education. . Lunch with nurse-nursery school teacherteam for undergraduate preparation, of Child Nursing program. xiii, 06014 Itinerary Sweden 1,4edneaay,11 October (Continued) Tour of pt. Goran's Hospital with emphasis on parent quarte*S and play program. IntervieW With Dr. Marcel d'Avignon, St. Goran's Hospital Child olinic. f Rehabilitation facilities. Thursday, 12 October Day in Umea visiting Region's. Hospital of llmea and interview with Mrs. Ivonny Lindquist and her staff. Friday, 13 October - Return to Karolinska. Visit to Lekoteket with Karin Stensland Junker. Dinner withOr. Junket at her home. Trips to shops for special play equipment. i,00015 Holland aP October 15 - 16:1972 Sunday, 15 October brief /visit ancieinterview with pediat'ic resident, University HOspttal,Amsterdam. Monday, 16 OctOber Interviews and Observations. Queen Wilhelmina Hospital, Utrecht', Anthony P. Messer, Psychologist p. r Interviewsand Observations. Children'sHospital Universityof Leiden Discussionof program to prepare Observat;ices. Discussion of their activities. Observations of wards and playrooms. :r00 0 1 6 ENGLAND 6 GOVERNMENT POLICY The official poicy of the Mihistry of-Healthin United,Kingdom regarding children in the hospital As outlined in adocument known as the P.att Re- port issued in 1959. The Platt Report followed -the work of Jamesand Joyce Robertson and Dr. John Bowrlyp atthe Tavistock Clinic regarding the potential damage that could come about to childrenand their families due to the separation that hospitalizationentails. The Ministry did not issue directives, but4assumed a consultant role to thehealth care delivery sys- guidelines may be in a tem. However, hospitals that do follow Rlatt Report more advantageous positionwhen new programs are assigned priorities. The Platt Report advises hospitals to encourageparents to visit children -at any-reasonable hour, nd to arrange accommodations for mothers(or fathers) whenever possib e.further recommends that ch dren not be nursed in adult wards, or scattered throughout thehospital, but gathered into a children's unit. It specifically suggests that "allch4ldren's 'departments provide-accommodation for mothers andpossibly on occasion for fathers so that they may stay with theirchildren during assessment, during acute illness and from time to timeduring long stay care. For every twenty children's hospital beds, there be at least fourbeds for parents, free of charge, and that there be additional parent lounge,bat ingsand.titchehette facilities." . Not all hospitals adhere the Platt Report'ssuggestioh, but it does serve as a guide. The hospitals I visited do conform: 'GOVERNMENTAL GUIDELINES 1 In England, as in other countries, programsand attitudes toward play vary from hospital to hospital. In some institutions, play leaders fillchild- ren's days with play schemes. In others, play is vegaected or is relegated to parents or to busy nurses. Standards are high; but salaries are low, so there are fewer play leaders than are needed ordesired. The National Health Service encourages'playprogramsin hospitals. In memo- randa to regional hospital boards, boards of governors,and hospital manage- ment committees NHS stresses that play is'importantand recommends the em-, ployment of nursery nurses to "organize and encourage playfor child en in- dividually and in small groups 4' Ministry guidelines in the form ofhospital building notes recommend design and equipment to adapt children'swards for play, with dayroom space adjacent to multi-bedchildren's-wards on the ground floor whenever possible, to allow access tooutdoor play yards equipped with sand boxes, swings, and climbing frames (when groundloor wards are n))t pos- sible, the Ministry advises that roofs and balconies heused for play yards in addition to play space on the grounds}. At least'thirty square feet of floor area per patient bed issuggested to be -1- used for play, te+tvision, ixerc e, dining, school work, and parent-child play. Recommendations are specific as to kinds of toys, storage, and thd decor for thepchildren's day rooms. HEALTH SERVICES FORCHILDIFNNGAE1TBRITAIN In1948, local'authorities (government) were_given responsibility for health visiting. Today, the health aspect of the child's care is -under Health Serv- ices while the supervision of day care, nursery schools, home help services (homemakers or daily "minders" for hire) are under social services. Home health services provide booklets on child rearing for easy, inexpensiVe purchase or for free distribution as well as the services of a health visitor who teaches face to face as well as in mete formal settings. The home' (or district) nurse is an RN-with hospital training plus additional training in the social and emotional aspects of care. She has had a four - month in-service training in home care to adapt her hospital experience to the home. The health visitor is an RN with obstetrical or4sIdwifery training plus an. additional year of public health nursing. Her job is purely preven- tive medicine.. . "Our main aim. is to keep children out of hospital;because of.the potential emotional disturbance to them there. We feel that the child should not be 'admitted unlessit is for skilled nursing and skilled medical care that he cannot get in the community," according 4,0 Miss -Earl, the Public Health 'Nursing advisor for the Health Services, Children's Division. STUDY DAYS Staff members'are granted several regular "study days" with pay each.year to attend conferences and sessions dealing with subjects related to the well- being of children and their families. A number of volunteer agencies par- ticipate with representatives of the Ministry in presenting such conferences. These study days are planned to offer common experienc s all participants.' and to provide opportunities for representatives of diffe nt discipli s to come together around topics that concern the well-being ofthe'child atient. Course content includes items such as the emotional and developmental needs of children; organization to meet these needs; problems of special groups of children; the role of the parent in the ward, whether visiting-for living-in; the relationships between staff members and family members and relationships among the ward team of.docters, nurses, play leader, volunteers, etc. I attended one such study day sponsored by the Play In Hospital Liaison Com-v. mitten at the King's Fund Hospital Centre* on the subject of "The Role of the Hospital Play Leader." Fifty -eight participants included nursery nurses, * The Centre, an'indePendent charitable organization founded in 1897 as a -2- 00018 occupational therapists, play staff members, botff paid and volunteer, re- se rdh assistants,"representatives from Save the Children, N,6ittl, nursery 4 0 sch ol teacher's, psychiatrists, pediatricians and nurses. Attitudes Toward PARENTS and Play In the course of the conference there was adiscussion of the.;potty irple-- mentation of play programs and of living-in programs for Parent.. (qvne nurses expressed annoyance at being pushed into a villain role as other groups move into the hospital and take overpleasanter aspects of care. Some nurses resent having parents and.play leaders step in to offer consol- ation and pleasure to the child after the nurse has given an inieLtion. Play leaders'and parents were urged to share the "good guy" role by slipping a suet for the nu *se to give or coaching her to pick the child up to`otter comfort following an unpleasant procedure rather than pushing the nurse- aside end admiiistering the sweet and comfort themselves. In hosp tals where nursing staff, play staff, volunteers, and parentsall participate in care, competition for the child's time can he a problem. All see theMselves as important tothe'child's well-being. 'Smetiraes nursery nurses and play staff membersdisagree-about who has responsibility fOr the child's recreation. Consequently, especially where play space is located some distance from the ward,the'play program is less well-used than it might be. Participants at the confeyence agreed that for play programs tobe effective, support from the top is needed.- The moreauthoritative (authoritative here correlated with frequency and familiarity on the unit)the person who touts play, the more play programs are integrated andsupported. The tact that not all hospitals yet accept play as animportant activity' in pediatrics was evidenced by one nurse who rose to say,"We don't need a play program in our hospital because our children are toosick. When they are well enough to play, they are well enough to go home." Another concern arose: the time structure and identityof the play leader, how she might elicit maximum cooperationand harmony with representatives help by of other disciplines within the hospital. For example, should she has doing nursing tasks? By changing diapers? Should she go onrounds7 WAS she responsible for the operation of out -patient' department playrooms? 4, cont. capital memorial to Queen Victoria's Diamond Jubilee,possesses substantial of hospital resources,the income from which is use solely for the benefit forum for the The Centre's ch aims arc to provide a and health services. of discussion of current problems and tolekii accelerate,the introdu:tion land management of healthservices. gt1Rd ideas and practices in the planning e0ibitions; The Centre has four mail% functions: conferences and meetings; and development. Its fac- library and information services, and research at home or ilities aro available to anybody concernedwith health services abroad: -3- 00019. the play leader the logical person to accompanychildren-to the operating' room? how much time should the play staffspendilith children in isolation? What, in other words, was. the bestuse of her or7his time? A Major concern was that the Rlay leader nbt assume the whole burdenof preparing children for major surgery. The group agreed that suchpreparationsshould be by -- teens. Mothers made their plea, too. "Please tern us what to do. Free play is fine for children, but we mothers needmore structure." Another recurrent theme of the conference was the importanceof communication. One volunteer play leader wanted more informationon the significance of the child's diagnosis. "I always feel uncertain about how to handle the children because I knewso little about their medical problemsor how to eve for them. I'm constantly uneasy about whether or not tocarry them or whether they should be allowed to engage in certain activities." Wepresentatives of severalhospitals described their preparationprograms. At Charing Cross, preparation forsurgery is done by play leaders in the presence of the parent with the cooperation of theoperating room team and theward staff. The play leaders use books suchas Paul Goes to the Hospital, developed at Charing Cross for olderchildren. For younger children they use Zozo goes t6 Hospital, by H. L.Roy, and the child plays out the story witha Zozo monkey puppet. They also offer childrena "hospital box" ofiprops for playing out experiences. At Brook Hospital, a tonsillectomy playpreparation program takes place each Monday. At this time, one nurse is assignedto follow the group throughout their hospital stay. She brings a hospital box withprops, dresses up in the garb of the operating room, offers thechildren rides on the gurney, and handles all the nursingcare. She accompanies her patients to the operating room and is with them when they wake in therecovery room. Her voice, having become familiar in the course of previousplay and caretaking, reassures the children when they hear it again inthe recovery rootr. a -4- 00020 VOLUNTEER AND CONSUMER' GROUPS. In addition to Ministry of Health, several volunteer organizations work to help hospitals and families recognize the needs of children in hospitals.: One such organization is-ly Association for the Welfare of Child- ren in the Hospital (NAWCf ,.with'four thousand volunteer members who oper-. ate out oflan office in London with a paid staff of one porton full-time and one half-time. There Are sixty-five constituent groups throughout the United Kingdom and a few members in Denmark, Holland* and South Africa. Two chapters have been organized in the United States. NAWCH was organ- ized following the release of the first films by James.Robertson describing theAplight of children without parents or play in hospitals. The group's ,goal has been to 01,*urage and assist hospitals in adopting the recommenda- tions of the Platt Report and to educate families and communities to seek out those programs that offer appropriate, child-centered care. NAWCH keeps information bout children and hospitals in the public eye by placing posters in publi places, by distributing to hospitals and families litera- ture about good /ways of supporting young children during hospitalization and has developed slide and taped scripts about children's trips to the hos4 pital to be used.by nursery schools. As not, all hospitals conform to the recommendations of the Platt re ?ort, NAWCH 'helps parents find out which hospitals offerparent beds by keeping a record of the policy of ;;ch hospital and the number of parent accommodations. NAWCH conducts play pro rams for hospitals with volunteers who have taken special courses to prepare them as play leaders. The goal of the volunteer work is to demonstrate to hospital administrators and staff members thb value of play so that the NAWCH-led program Can be replaced with a professional staff supported by the administration. In England, salaries are low and standards are high', resulting in fewer play leaders and play programs than are desired. NAWCH groups also provide transport services to enable mothers to 'visit sick. -children; organize child-minder and play-group services for other children; raise .funds for mother and baby units, and provide material and equipment for theunder-fives in hospitals while maintaining friendly contacts with local hospitals. Save the Children Fund Another organization contributing to the welfare of the hospitalized child is the Save the Children Fund (S.C.F.). Save the Children is an independent voluntary organization, professionally staffed andnow more than fifty years old. Its purpose is "the rescue in disaster and the longer term welfare of needy children, irrespective of nationality,race or religion."SCF helps children in nearly fifty countries withteams of over 1,1,00 field workers including doctors, nurses, welfare workers, and qdministrators. Its goals are to create conditions in which children can grow to a healthy maturity and, overseas, totrain local workers, wherenecessary, in the professional and technical skills required for child welfare. Over the years, SCF has raised and spent nearly thirty million pounds. -5- G 0021 I Save the Children Fund prepares play leaders and will, fora brief period, pay salaries for them in a hospital while programs are beginning. This Save the Children subsidy is supposed.to be.replaced by the hospital's administration'onco the program has proven, its worth. 041. Save the Children also finances exchAges of play leadersbetween dif- ferent countries. They will help with placement in a play program'ana with housing for two months and offer consultation to the exchangeperson. Play loaders must paytheiz own faze, but housing and placement as'sistance is provided for the two month visit. * Fundling Save the Children Fund's contribution, as of 1972, has been approximately ten thousand pounds per year for the sixteen hospital playgroups it es.. tablished. A Christmas appeal netted funds for the establishment of play schemes in two hospitals.. Students of Aston University in Birmingham raised money to finance a hospital playgroup in their locality for at least two . years. NAWCH, too, raises funds and finances hospital.playgroups. Indirectly, their educational efforts for the community attract financial help from other individuals and agencies. Toy Library Toy library materials for mentally retarded children were displayed at the study day conference along with descriptions of the Noah's Ark Toy Library program, a service organized and operated entirely by volunteets through- out the United Kingdom to raise funds and buy sturdy toys suiteale for children with handicaps. Local ,organizations tour the countryside placing the toys with families and offering consultation on theiruse. ThOt helps families avoid thepossibility of an expensive mistake in toy purchase. Toys can keep up with the child's development. The representative, of the Toy Library can do tactful guidance to parents in choosing andpre- senting toys. The toy librarians also make a variety of toys to meet special needs. A texture lotto game is an example. * Interested persons may contact Susan Harvey,Savo the' Children Fund, 29 Queen Anne's Gate, London S.W., England -6- 00022- Role of Volunteers Volunteers'play an importantrole in Engliind in helping tohumanize hospital As money is scarce, care in pediatrics,especially where play is concerned. assistance comes from the . their services are neededand encouragement and of course, "Hospital Play LiaisonCommittee, the Friends of Hospital and, courses'for adults NAWCH and Save the.Children. Every lOcal authority runs 'on how to run playgroups. The above organizatjons,supplement.thisknow- ledge.with additional infoimationabout hospitalized children. . the HoApital The following suggestions camefrom the conference sponsored by Liaison Committee for volunteersand play leaders: Play leaders need to knowhow to deal-with' children's emotions intelligently, and how to deal withdeprived children and how.. . to cope with deprivation. knowledge They must understandthe'meanings tests and have 'enough about medical procedurestha? they can supervise children safely and adapt activities to thechildren's particular disability. Good communication among playstaff, medical staff, and parents is essential.. Play leaders must be professionalin maintaining confidentiality, yet'never sharing relevantmaterial with the health care team, gossiping. They must help staff understandplay functions. Play leader's time should not gofor rounds; instead theyshould build enough rapport and trust toenable them to-bxchange necessary information about their childrenin a more condensed form. the Adequate training for volunteersadds to their status and to Knowledge entire play program. Their training should'includel.,A) normal of normal growth and development;2) Experience with well, children; 3) training and experiencewith hospitalized children. o . -.7- f; 0 2 INTERVIEWS WITH JAMES. AND JOYCE, ROBERTSON . o The Robertsons have been working on behalf of young children for many, many years. In-the early 1950's,Mr.,Robertson made his first filrged account to show first medical professionals and then the general public what hospitals wore doing to'their very young'patients When no results werefOrthcoming, insofar as modifying-hospital practice, he took the.filmto television and asked fyitr viewer. respofise. The results of this response 'led to the pubes a licatipn,of a number of case studies'as' wellis to tOe formation of NAWCH. EVentually, the Ministry of Health took heed and their, concern led to the adoption .of the Platt report. The Robertson's work is truly inspiring. Not only has it changed the climate to a large degree.in England, but that influence is' sp ading world-Widb. k . ... I counted myself fortunateincited to have Mr. Robertson's guidance prior to my visit in pointing out programs to visit, and the privilege of chat- O ting with the Robertsons at home was a high point of my trip. Robertsons areT conceed ab t too early separation for the child, whether in hospital orin too arly day care. Their films on Brief Sep- aration point out the damag,, ncurred by a young child when no single . caretaker occupies a centra,place (or the child occupies no central place in the caretaker's scheme). It is their belief that a series of kindly but changing strangers, no matter how well.:trained or well-meaning do notsubstitute,for a central, stable parent or parent equivalent. Mr. Robertson points out. that historically mothers bring their children to the centers at first quite nervous about leaving them and call frequentlyto check on their well-being.--After several weeks, they drop this behavior and soon begin to complain that the center doesn't offer more services ... such as.providing the child's main meal. Often the staff at the centers construe this behavior to mean that the parent is trusting them how,but tie Robertsons view it as gradual erosion of natural paMbntingbehavior so essential to the child'S healthy development. In one of my own later observations at a day care center I wastold by the director that although each four children have a special grown-up to relate to, they soon outgrow this dependence and after a few weeks only seek her out when they need special comforting. As the center was on the same premises as the parents' job, I asked if parents everdropped in to visit. "No. The parents' Lunch and the children's naptimocoinci4e.e4 The damake is silent; the bond is never missed because it neverdevelops, but what is not developed through that missing bond is the child'sdesire to please and to mind; toeark individual styles; to focusand concen- trate...essential to learning; to feel intensely; to love. The lack of early bonding results in later indifference to learning;inability to concentrate; shallow relationships; divorce; disinterestin parenting one's own children, and irresponsibility. r. -8-- 00024 \ Nursery schools are prevalent and important in England,, and the Rebertsons are much in favor of them when they do not usurp the:parentsLrole for long periods of time during the first three years.. Whfat is the parAt to do whO must work to survive financially.orto, keep self - esteem and intellectual life alive? Perhaps a society might find. ,ways of'meeting these natural needs with something other than full-time :I' sepirations between mothers and thoir babies. He suggests that perhaps sick leave might be paid to parents of ill child- ren, eitherin or out of hospital, ini recognition of their interdependence during those early yearsl So far, quite the opposite is true: nurses report that iincreasingly they hive teadmitshildren formerly cared for at home with childhood infectious,diseases requiring isolation becausepar- 4 ents cannot take time off without penalty. Mr. Robertson, hopes that the efforts of NAWCH as well as education through parent centers, nursery schools and-the formal educatiorial system will eventually make parent living-in common practice when children must go to the hospital. Word of mouth is the most effective way of educating the country about children's needs. a His further concern is that too-often people are not allowed to do what they are educated and trained to do... nursery nurses, parents, and all have so many divergent tasks piled' on "to their pritary roles. "We need somebody with major responsibility to manage the wards. This person should have preparation in child development. We must change the conception from a hospital model. to a home model, spare the child constant change of staff." Mr. Robertson would put the child under the wing of a , principal or caretaker, bringing in medical or nursing staff as consul- tants. Children could use the time between treatments to continue their - lives normally. As hospitals gain a reputation for truly wanting parents around, word spreads, but "when the physician feels omniscient enough to choose which parent can stay and which cannpt, parentsare less inclined to ask to stay." S -9- 00.025 r HOSPITAL VISITS Great Ormond'StreetHospitalfor ) The hospitals visitedin England included Amersham, Stokes Mandeville, . Sick Children,Fulham (Charing Cross), Mary's" Praed StreetMobile Unit. Great Ormond Street . buildings surrounding a' 0 Great Ormond is a groupof large old and,newer houses pediatrics, someof the,Wconies courtyard. On the building that form parent al,pc 'A. in overhanging the courtyardhave been enclosed to children's rbomt. Z England dreis to suittheir rank. Here I first observedthat nurses i- high-neck grey uniform of,the Matron Sister Clothing varies from the ado- perched on r head downthrough severs g with a small filmy cap d uni- distinguishable to theBritish professional. Colo tions, quite always been worn inEngland, forms -- still an issuein this country, have There are Super Sisters,,Matron but thereeach- color denotes status. lquises and students, each inher oWn specific Sisters, Sisters, Nursery formal, and the Although professional posturesare erect and costume. in the air. Beatrix buildings themselves austere,thereis something cozy Pooh, Piglet, Kanga, andChristopher Robin adorn Potter characters, and inside Children not in isolation aregrouped together; halls and walls. referred to as "Mums") purses, the rooms babies areheld by mothers (always or nursery nurses. first opened its doorsin 1862 with 10bci-S'iTzNhildren. Great Ormond Street each hospital with 340 bedsadmitting 9,000'thildren Today it is a teaching pal-ant beds- plus an There. are Cmedfcalunits of 20 bedseach, year. each unit. The father additional 2 parent spacesin Oblation rooms for contribueed funds to provideadditional pa ent of one paiient recently decoration of the nurses'sit rooms andservices as well4as for the room-office. floors with childrehgrouped according to age. There are several pediatric infants' and kitchen, for thehospital adjoin the The mothers' sitting'room feeding. One the majority of motherswho stay are breast nursery, because all, the wards and is play suite on a lowerfloor,of'the hospital serves leader and her assistant. The wards themselves presided over by a play to use on with playthings formothers and nursery nurses are also equipped clearing Children's.Kards.have bedssurrounding g-a center the wards. Apr eating and play. where round tablesand,chatrsare grouped h "There is a specialresidential Great Ormond Street'asbrochure states: for mothers who arebreast feeding their accommodation at the hospital their child Accommodation for other parentswho need to stay with babies. worker camive informationon is very limited, butthe medical social However, at leastuffie floor at GreatOrmond hotel accommodationsnearby" Platt Report's suggestionof foUr parent bedslto Street conforms to the given free room patient beds. Parents who ask to stay aro every twenty these facilities arenot and board as long as spaceis available, but -107 66026 i. advertised. Parents who stay eat at no cost in the nurses' dining room. Nurses must pay for their meals, so this.is a sore point with some. Amersham General Hospital James Robertson suggested the visit to Amersham General Hospital in Bucks. County as one with a parent program in full swing.This program was in- 'augurated by Dr. Dermod MacCarthy and the then Matron Sister twenty years ago. Dr. MacCarthy was one of the first physicians who, though at first doubtful of Robertson's message, came to subscribe'to/it wholeheartedly. '---Amersham welcomes "mums," and has open visiting for siblings, grandparents, dads, and all significant others. Amersham is a Small country hospital located in gentle rolling green coun- tryside opposite an ancient stone church. The town of Amersham datei back to William the Conqueror. The hospital is a series or'old flintstone buildings with two modern,concrete and glass structures dfte-a few modules more recently added to house the rehabilitation unit, the nurses' resid- . enceapartments, and the creche (day care center) for staff. The pediatric unit is a long, lovground-floor wing on one side of a quadrangle.Outside, the ward itself is a small square office used as a nursing station, for staff meetings, for record keeping, and for reports. Off the corridor connecting this office to the ward are the parent kitchen and sitting room. The ward itself is a large, windowed area with beds on three sides with par- ent chairs, toys, and chests for children's personal possessionsprominently dis yed. Adjoinifig the ward is a play porch with a T.V., somelEomfortable u olstered roaing chairs; and a welter of toys and furniture very homey - in character. Children and parents wander freely. Meals are served family style and eaten where the diners prefer -- in bed, at the center tables or, in the case of parents, in the parents' lounge. Matron Sister Daniel, nursing supervisor for pediatrics, scoffs at the idea of disallowing parent visiting before surgery. Mothers stay with children and hold their hands as they go under the anaesthetic in the operating room. "Of course they sometimes hate the blood and the smell, but they're mums that's their responsibility," Miss Daniel says. How word of parent accommodations gets out? "After twenty years, it's just general knowledge." Parent education? "Only surreptitiously." "We are a dying breed L- the spinsters married to our work. I don't know who will replace us," said Matron Sister Daniel, who practised nursing as a missionary in Africa until illness forced her to return to England..Hav- ing seen how well African children managed medical treatments including hospitalization when parents stayed with them, she vowed on her return to hospital nursing in England that never again if she could help it would she hear that heartbroken crying of the lonely abandoned child. She felt at home at Amersham with its mothering-in policies. She trusts parents. At Amersham, one consultant pediatrician and various subordinates are cm- , mitted to policies of unrestricted visiting and to the accommodation of 00027 4. . .. mothers With infants from birth tofive yeai nd'Older if necessary). Par- ent-child cubicles line the o ter Wall of the large wards. Each has one door to the ward and one to the o'tside44, toprovide exposure to circulating air and reduce the danger of cross-in ection.Many children whose parents live in are in isolation.' Glass wallstothe cubicles allow two-way observation. Mothers may draw shades for privacy. Each unit contains a parent bed, a crib for the child, a rocker, and a wash basin. As at Great Ormond, an additional parent living room and kitchen are provided. Parents serve them- selves from food carts on which meals are broughtin for-family 'stYle'terv- ing.*They eat with their childrenor,,ifqkhey prefer, retire tb the par- ents',,unit. Ifthere are not enough beds for parents in or near the child- ren's ward, parents are housed in the nearby nurses'.residencehall, a modern, well-appointed high rise on the hospital,grounds.' Norequest for over-night accommodations by a family member has been turned down. Parents, eating and chatting together, usually form a strong social group,listening sympathetically to each other* minding each other's childrenwhen one must return home to check on the family there, andencouraging each other in their day,.to-day encounters with staff - members and patients. When there are .few phys. ians and many parents, the doctorssometimes feel the need to duck the qu stions so many paftnts have atthe ready. Dr. Garrow admitted to a to dency to come threughthe bushes around the outside 9f the building, timing his rounds for just after dusk inorder 'to conserve time and elude some of the more persistent questioners. One mother, interviewed in her cubicle at Amersham,said she had received no advance information eitherfrom the hospital or from the health visitor ab,ut living in. "I heard somewhere ... maybe from the nurseryschool... t't it's good to stay when they are littlelike this." She had been de- ltg4'lk ted to learn that she could stay at no costfor bed or meals; but she had not been prepared. Fortunately, after the Sister informed her andher husband that a bed was avail ble, he husband had found last minute help to care for their child at home, d home and brought back a suitcase for the mother. . * Supper the night I stayed was spaghetti with poached egg,mashed potatoes, white bread and cobbler. -12- 0,0028 Stoke Mandeville b Twenty, miles from Amersham in Aylesbury, Bucks, is StokeMandeville Hos- pital. The pediatric unit, much larger than itscounterpart at Amersham, is one section of a very large hospital that specializesin the treatment of paraplegics. The buildings are arranked so thatspecialties are housed in long units resembling wartime, barracksextending at regularly spaced right angles to the corridors linking them._Again, the pediatric unit is on a ground floor, andsome of the children are able to.play out- side occasionally as evidenced bya play yard with climbers and 'slides. ,Although thhtmosphereis institutional with long,unlovely corridors, bewilderingly complex networks of doors andanterooms, children appear relaxed and comfortable as they wander aroundor sit with their families, including brothers and sisters, most of whomare present. Parent-child cubicles line the outer walls of the unit. A small cozy chintz-decorated parents' room was full of chatting motherstIsharingstories and listening attentively to each other. Even in their small quarters,an additional parent cot had been fastened to the wall to be Pulleddown for extra sleeping space. The consultant pediatrician is Dr. Dermod MacCarthy,physician seen in GOING TO THE HOSPITAL WITH AMER. Stoke Mandeville and Amersham work in unison. Both consultants are, in Mr. Robertson's words, human andenthu- siastic. At Stoke Mandeville the matron-sister conducts dailyparent rounds. She solicits questions; tells family members about-.treatments planned and about the doctors' comments on the child'scare: and treatment; and sug- gests how parents cawhelp during the day.. Matron-Sister Gilbert described her conversionto parent-inclusion by saying: "Nobody could have convinced me that itwas a good idea to have parents around; Dr. MacCarthy ordered me to bring parents In. I hated the idea. Only watching the parents and the children showedme that children do indeed do better with their parents here, -Indthat parents are not as difficult as I had'feared; theyare, for the most part, a help. .1 am, afraid that it is my sisters, thenurses, who object to having parents in the hospital and,We only way to change their attitudeis to bring them to visit wards that have parents and let themsee for themselves that parents help." Mimeographed guidelines are distributed to mothers living in thechildren's ward. The paper includes instructions about food and drink,crib safety, obtaining information, and going home. Some excerpts suggest the flavor of Stoke Mandeville's program: Visiting: "Your cubicle is, in a sense, an outpost ofyour home in which medical or surgical thingscan be done. Your husband or a friend or one of your children (providing Sister is asked)can comp and visit you at any time." -13- 06029 "Some children crynoisily and Behavior of Childrenin HOpital: comes to examinethem or make a groat fusswhen a doctor or nurse behavior, we are quiteaccustomed .do something. This is normal better for a ,child toprotest and cry for to it. It is probably injection§ examined by strangepeople or-undergo, Mummy than to be please don't think we etc. alone withoutanybody to crY to, so badly." shall think yourchild is behaving 'We want you to Playing with or doingthings forother'phildren: occupying etc. of your ownchild, nursing; washing, do the simple However, we these things for anyother child. but not undertake the ward come out andjoin in the life of do like the mothers to children , certainly lots of waysof helping other and there are visitors; especially thelittle who have not gottheir mothers or help here." ones. We welcome your remain home: "Pi6ase don't think you must Going out or going You Are free to ga out orgo-: beside your ,child,thewhole t'me. provided you tell theSister - home for a shorttime` if you c , an sometimesrelieve you." or StaffNurse.Your husband an impressivenumber of During visits toAmershAm and. Stoke Mandeville, Were observed inpatient rooms and parent parent-to-parent encounters the parents tohousekeep and clean up No signs admonished the lounges. seemed to)pitchin and tidy up as premises, butnevertheless, they situation demandedit. . occasional problem Matron SisterGilbert mentioned an At Stoke Mandeville,, One motherlaughed when asked with mothirsfeeling obligated to come. didn't "Did you ever,try totell Dr. MacCarthy you about this, saying: during the parent'sinter- want to stay with yourchild?" .Customarily, doctor says hospitalization isdiscussed, the view with thephysician, when and staying, ofcourse,.aren't you?" something to theeffect of "You are can recommend do feel obligated as aresult.' Social service some families /home care withthe help of home-care givers,but most families manage bring confreres. Often parents relatives, neighbors, ornursery school daily play A NAWCH volunteerwho operated a other children withthem. moved, leaving patients and wellsiblings had recently program for both them (theparents) to be program. "It is hard for the hospital with no trying to keep an eye onseveral other. solicitious of thepatient whilst Matron Sistersaid. active little ones,but they manage," favorite foodsarhome and Parents who wish to maycook their children's East Indian pop- appetites. A growing bring them to thehospital to tempt whom for the manychildren to ulation makes thisespecially important 'English food is foreign. , the wards takes placedirectly on Play at Ameishamand Stoke Mandeville cozy playporch spilling over atAmersham onto a and in the cubicles, Children andparents television. awash with toys,rocking chairS, and grouped together Children of mixedages appear comfortableand at ease. -14- 00030 help each other. One elevqnyear old girl, seen during the Amersham visit, spent alot of time feeding,stroking, and crooning-to a severely retarded deaf-blind baby on the unit, Parents, too, interacted.with each other's children, giving the.Wards avillage -like ambience. Neither Amersham nor oke Mandeville had a "play leader.at the, time of this tour, although both Nue Matrons expressed a desire for more structured and supervised play progr ,Both hospitals ad previously had programs and missed them. Mea 1 arents stay and'reencouraged to bring toys. Be- cause families, includ'g ell siblings; are around, thechildren appear occupied and involved. St. Mary's, Praed Street St. Mary's is in Paddington, a poor section of London. It is a giant red brick 19th century edifice' directly across from a University medical schbol. The visit'here centered on a mobile hospital unit manned by a pediatrician and a nurse. This unit, the only such in London, is designed to bring the 'hospital into the home. Recently improved housing conditions and improve- mentt in the general health of the child population have reduced problems that call for hospital-care.* The mobile unit itself is a large van donated to St. Mary's by the Variety Club, but it usually remains parked outside the hospital becausethe team prefers to use the sister's car. The van is unnecessarily large and harder tb maneuver, and some families object to'having it parked outside their homes. "The best thing about the van is that. it doesn't collect parking tickets," the nurse said. Calls are'made to families living in a wide variety of housing situations throughout the Paddington section of.- London. On the day of the visit the team's itinerary included calls on a frightened West Indian toddler w th an infectedeear, several'young children in crowded flats who submitted to examination cooperatively on their respective mother's lapt, a tiny little:, Vietnamese two-year old with tuberculosis whose family lived on the top floor of an elegant embassy building,,,and an asthmatic East Indian ten-year old whose mother spoke no English. The teamtcame to see him because their, help allowed him to attend school fairly regularly despite his frequent severe attacks of asthma. While the physicians-and nurse were at the boy's home... abrand new housing unit where he lived with his mother they did postural drainage and showed his mother how she could help him in the same way. The boy translated their instructions to his'mother. It was impressive how rich the 'visits were in peripheral instruction to families and to neighbors, as well as the children themselves. At one stop, the doctor chatted and questioned the father while the nurse fetched ,* An increase in working mothers, however, is causing a resurgence of hospitalizations for contagious diseases once managed by families at home. -is- 00.031 She was back in the play yard the little girl homefrom recess at school. before the period ended. Her father and sheproudly displayed the birth- fondness day card ,the nursehad sent her the previous week, and the mutual existing between the nurseand the families wasobvious. The mobile unit has beenin use for 18 years. The home nurse who serves Her training dif- as part of themobile unit team isSick-Nurse trained. fers from the HealthVisitor's in that the Home Nurse extends the hospital into the home, treating theill child. described the Mobile Dr: Thomas.Oppe, Chief ofPediatrics at St, Mary's, Unit and its services: child atome. It The mobile unit dramatizesthe idea of keeping the young squad but more is not for emergencydare,, neither an ambulance nor a flying than a house call by thedoctor. (Doctors in Great Britain still make home general practitienereand fewer, visits,) Great Britain still uses more To some extent themobile unit serves the general prac- pediatricians. give their in-put and titioner by sendingPediatricians- into the field to The Home Nurse reports to theHome. consult to the GeneralPractitioner. the Pediatrician Visitor regularly assigned tothe family's case while 'reports to the General\Practitioner. regular health care team In addition to its service tothe family and the useful for the educationof that follows thatfamily, the mobile unit is medical students andphysicians. both economic and The unit keeps children outof the hospital offering emotional advantages. necessarily be,hospitalized, Akthough_not all patients onhome care would be.there. Caring for the child not all children inhospital realW'need to because parents inhospital are at home is better forparents in many cases instructed as to how tohelp, they fish out oewater. When they are not the child than somepeople bo- tend to just sit. This is less helpful to o lieve, Dr. Oppe thinks. builds.up the confidenceof the mother so Homehrte, on the other hand, Home dare is rush her child to thehospital. that she does not always dying child- children who have seizures,asthma, or for often indicated for sensitive, skilled, The home care doctors and nurseneed to be very ren. and these mustbe made in close and confident. They face hard, fast decisions doctor can managothe task. They contact with parents. Not just any nurse or medical functioning. They cannot have todrestricted-a view of nursing or must be friends of thefamily. out from the initiate her home care. Referrals must go A mother cannot has the case,then the General Practitioner. After the home care unit mother may alert the team ifshe feels there isneed. make referrals executive function. They do not The home care team has no directly to theFamily Practi- for instance, but report to social workers, there. tioner And the regular health crewtakes over from -16- 00032 Fulham Hospital (Charing Cross) At Fulham the pediatric in-patient unit is on the ground floor, a happy arrangement allowing children access to outdoor play yards and offering Views of-greenery and activity. The wards house about thirty children, twenty for middle-aged children and smaller roosts for infants and toddlers occupying the same suite. Adjoining the bed units several play porches offer sand, water, carpentry and clay projects. Many children were up, sitting at the center tables or playing in the anterooms.Parents sat on straight chairs by their c ildren. Parent quarters or accommodations were not in evidence. Child en's art decorated the walls.Many windows gave the rooms a bright, c erful, lively aspect. Fulham's well-staffed, active play program is financed by Save the Child- ren Fund. The three play leaders move amorig the children, parents, and staff ready to help with crafts, to interact with toddlers, or to prepare children for treatments using the battered box of doctor play equipment. The ward is colorful with children's paintings and buzzing with activity. Ply visit found a boisterous group of boys playing in the sand pit while another group built airplanes at the carpentry bench under the watchful eye of two young men trained and placed by Save the Children Fund. In shed-like, structures adjoining the'large ward, a group worked with clay in an art room equipped with materials for all kinds of creative projects. The ward itself had beds arranged so as to leave the center free for small round tables and chairs, wheel toys, and various play projects for younger children. At one end, an Indian boy, about 12, was coming to following surgery. His family and the father of the child in the next bed, restrained him while the nurse administered a shot. Two beds down, a couple of five-year olds played house on their beds sur- rounded by a portable Wendy House made of covered folding screen. They served each other pretend tea in doll cups, resting after hanging out their doll laundry on clothesline strung between their beds. Across from them, an Indian boy in traction watched shyly, taking an occasional swing at a punching ball suspended within his range from the bar over. his bed. In the center, at a table, an eight-year old missing his left arm played a board game with two student nurses. They interrupted the play to take vital signs, then calmly resumed the game. 'The leaders strolled from bed to bed, offering and joining play. A two - year old bustled along behind, bearing the suitcase with the doctor play materials -- a toddy bear, some bandaids, a stethoscope, some syringes, and a mask or two. These are some of the materials the play leaders use to prepare children for procedures they may soon encounter. -17- 00033 THE NURSERY NURSE In England; girls just beyond high school age may take a two yearcourse than prepares them for positions as nursery nurses. Their training par- allels that once offered to prepars "Nannies" who cared for the children' of wealthy English families. Today; while part of their training may in- clude placement with an individual family, they are offereda program that allows them to choose positions in hospital pediatric unitsor in nursery schools. The preparation includes child development and'heaith care. Both of these serve also as pre-parenthpod education and it is theex- pressed hope of program advisors in the Ministry of Health and among the leaders in the volunteer agencies such as NAWCH and SCF that youngwomen so educatmd will be mare aware of their. awn babies' needs fox' support and attachment when they,too,are mothers. Part of the training include's recognition of the young child's play needs and education on the delivery of age-appropriate play to the children. The profession of Nursery Nursing has its counterpart in Denmark (care- taker nurse) and Sweden where the positiok is called Child Nurse. The Nursery Nurse or Child Nurse is different from the Play Nurse who is re- sponsible solely for play. The Nursery Nurse delivers mothering care that includes diaper changing, temperature taking, feeding, and bathing along with play. Both the Child Nurse and the Nursery Nurse positions are first steps on a career ladder. Certified at the end of their two year4pourse, the grad- uates of these programs can stay in that position or can later decide to take course work preparing for more advanced degrees and status in either nursery school education or in nursing. Nursery Nurse. preparation involves three different sets of ih-hospitil behaviors: one-third are prepared to serve on maternity units in the care of the new-born. In-service courses teach them cross-infection prevention techniques, tube feeding etc. They werk as aides to mid-wives. "Pedia- tricians are greedy to get hold of them because they do better with failure- 6-thrives than do nurses or mid-wives," according to the Nursery Nurse governmdnt advisor. A second third have preparation in sick children's units in the hospital.* * At the time of the visits, a work party was studying hospital units to determine the play and companionship needs of the children on the unit.in the light of proliferating services to meet mothering and play needs of hospitalized children. Sometimes competition over the child arises when several groups of interested caretakers, including parents and volunteers, all wish to meet the same needs. Sometimes the'child is missed by all, falling through the cracks. -18-O 4 One-third get training for work in day care andnursery schools. Nursery Nurses also staff hospital day care nurseries.* Candidates for training as Nursery Nurses must beat least sixteen. Stu- dents over the age of eighteen may have theircourse of study shortened from two years to eighteen months. Their training takes place in the particular establishment where they are placed with childrenyounger than seven years. The training p4riod is planned to ensure continuityboth in the training of the student and in thecare of the'children. Every candidate must submit to her training authoritya factual and spon- taneous record of observations of children made throughout hercourse. The significance of the observations is discussed bythe student with members of staff both in the nursery where she is placedand at the train- ing center. Students live and help with the children. They have oppor- tunities, for a substantial period of time,,tosee how children behave, and how they change. This understanding of growth and development is the basis of the training. Students are expected to supplement their observa- tion of young children through informal contacts with thosethey know in their own homes. Each training establiAment has devised, itsowncurricululandkeeps records of each student's practical experience. The government offers -a framework to guide those responsible for the course. This includes the following suggestions: A. Students are expected to learn what young childrenare like at different sta es in their growth and how they should be cared for. Student gain their knowledge through practical and theoretical trning and through suggested reading. B. Some children with whom the students work will havea family background, others will be cared for away from their families, The importance of various aspects of the children's circum- stances should be considered. C. Those responsible for not children must consider themoans whereby the children's ptisital, intellectual, emotional and spiritual needs are met. In addition, students must know about . such everyday matters as food, shelter,.clothing, and other physical provisions. Children need opportunities for play and language development, for companionship and the sharing of in- terests and activities. * The ministry has not encouraged daycare for nurses because, they say, "If you are a good caring person, as you should be ifyou are a nurse, yOu should care for your own before youcare for others."A brochure has been prepared for distribution to hospitals asking them to look at the need and the cost in relation to the long term reward and danger. -19- 00035 D. Students should also realize the importance of continuity of in:- dividual care for the child, the need for responsible, confident relationships among adults and with children, and they should have an awareness of spiritual values. A detailed study of themeans by ' which these basic needs of children are met, from babyhood onwards, is therefore necessary. E. Nougbout training,, as students observe growth and development, they need particular help to understand the inttrdependence be- tween the physical, intellectual, and social-emotional progress of babies and young children. Most of their experience rill be with normal healthy children, but variations in development will be discussed. F. Knowledge of health matters such as good nutrition; prevention and control of infection, both day to day and during outbreaks of 'infection; the prevention of accidents; elementaryfirst aid; and simple steps to be taken when children are ill or con- valescent, are taught. Experiences with care of children indiv- idually and in groups are taught and compared. G. Students areexpectedto assume increasedresponsibility through- out their two-year training, although still working under the guidance of experienced staff members. Students are advised to ;, remember that they should see themselves as one of a group car- ing for children and follow the pattern of life in whatever establishment they, are placed. Advanced students are expected to contribute to the training of other students and young assistants. ,) A H. Students take other course work and are expected to maintain a lively interest in life, taking every opportunity to enrich their own interests. Students younger than eighteen are required to take additional course work arranged under. the general topics, of: I. English and the Creative Arts II. Man and His Environment III. Home and Society I. Every candidate must produce evidence that she will complete a course of study designed to increase her knowledge in vocational subjects and to her own personal knowledge. In addition to study of the ale and development of children, her studies should also cover household arts and management and.the study of certain aspects of social conditions. 41. J. The Department of Education and Science is responsible for approving all establishments seeking to serve as centers.for prictical training of nursery students. -20- 00036 K. Some studenis spend the entire two-year training,period Inan establishment catering to a wide age range of children;,others divide the training between two establishments with not .less . than a year in each It is expected that the choice of two complementary establishments gives the student expexpnce with children in either day.or residential nurseriesor Mrsery schools and either nursery classes or infant schools. L. It is expected that each training establishment devise itson curriculum and that records of a student's practical experience be kept. "Children need the companionship of lively minds and it is hoped that the student will take every opportunity to enrich her own interests. She should be encouraged to expand her own understanding through reading_ and through the development ofher own creative abilities. A course of gen-, eral studies enabling her to do this could be devised In sucha way that consideration of the nature of' man,.the value of life, the wonders of nature, and the place of the arts and sciences in human life and progresS could all be presehted to helfa towards both a personal enjoyment of living and a philosophy of life." The three headings as listed for additional course work are expanded to include the following: I. English and Creative Arts: Aimed at extending the students' powers to use their own labguage and enjoy its literature, and to find ways of self expression through music, art and drama. -To achieve this it,is necessary to create an environment in which the student i is stimulated to use her natural abilities rather than to impose a discipline of work. II. Man and His Environment: I. The nature of the physical world and the use and misuse of man's mastery over his environment is constantly before us. To understand this -it is necessary to have some knowledge of the laws of nature and man's place in the cosmos, together with an appreciation of living things and their interde- pendence. III. Home and Society: Or The is to obtain factual knowledge of how society has doveped, is organized and sustained: to find how to enjoy its benefits and serve its needs; to examine the rights and responsibilities of the individual.in relation to the home as the basic unit of society. -21- 0'0/037. Schemes of work are not provided, so that teachers are tree to developthe subjects under-the three headings in a way most appropriate to their students. In the changing pattern_of adolescent development, in theneed 'for-relevance to,their situation, the-teaching should break, away from traditionaldivi. ti sions,of the timetable'and thd conventional treatment of subjuts. Thepapeirigeson to suggest that modern techniques .,of visual aidsbe em- ploye& and that "peqple of lively minds and varied experience be invited to vist_and contribute to the course', outside excursions are also suggest.ed. 'I In light of the above, Mr. Robertson's comment was: "Our task'now is to see that Nursery Nurses have the opportunity to practicewhat they are taught in the institutions where they later pursue their careers." .4 P r. -22- 00038 DENMARK PREVENTIVE' HEALTH POLICY . prior all deliveries were athome." Mid-wives visited In the 195O's,41661.; of the'health visitor for follow-up to the birth of ababy and then notified followed hra health visitor;Today, care. At that time every birth was home visiting is selectiveand most babies areborn in the hospital and The first hothe Visitingin- limited to homes where thereis a problem. cluded every home and was for oneyear, laterexpanded to three years. visiting Today's emphasis is a compromisebetween the original blanket assessment that and the policies ofselective visiting following early are planned forthe future. only 700 health visitors, One reason that selectivityis important is that Denmark needs 800,to meetall 500 of whom arequll time, areavailable. includingi.school health at aratio of 6,000 population the health needs has neither the funds to one healthvisitor. At present the government applicants to fill all theslots. The birthrate is nor the qualified 80-90 births to rising at a rate of 17 per1,000, and is currently at each 6,000 population. local help with preventivehealth is growing and A move to form teams.to Teams authorities encourage this byproviding space to such groups. physicialf-and a health would be composed of apublic health nurse, a visitor comes Some resistance to theinclusion of the health visitor. practice with them maybe a, from the physicians forfear that sharing medicine. , step toward socialized basis of three daysof Public health nurse8- work outof their homes on a The district nursevisits home visits and two daysof,school.hursing. requested by the privatepractitioner or in the community selectively as department of pediatrics serves the hospital. The chief of the'hospital as consultant. post-basic preparation There are 2200 home nurses,all RNs without the Demand for them is decliningeither be- that the healthvisitors have. becoming more competent orbe- cause health isimproving, mothers are moremotha-s work cause children areincieasingly being hospitalized as butside the home. Division for the According to Miss rajaPaget, Chief of the Nursing Danes are comfortableabout modifying policy National Health Service, the improvement and are according to their experience. They continually seek flexible about adopting new programsand ideas. Our way of cooperationmakes "The Danes characteristically,canimprovise. We aren't dependent onrigid 'life go smoothly because we cancombine. ceiling about something. We find a com- structure. We never go to the of language to avoidthe suggestion promise. We are careful in our use of pressure or force." -23- 0 0 0 3 9 t*end in Denmark is toward decentralizationandmore local responsibil- Ity*Increasingly;... tax funds are directed to localauthoritiE3 rather than, the state. The 22 counties of Denmark are being diminished'W14:which'are . responsible to the focal authorities and thus to the individualcitizen t6 a larger degree than before. 'Hospitals arc under the Bureau of Inner Affairs. Child care institutions such as kindergartens, nursery schools and mother care are nnderthe Bureau of Social, Affairs. Staff Children's activities in play an ',learning within the hospital aro super- vised by nurses, physicians, play ders, care-giver nurses and by psychol- ogists. Each psychologist sees up to patients referred by the physician for screening and continues to work with a smallpercentdge of those seen originally. She refers and consults With other staff members about the remainder. Hospital psychologists may, when appropriatetmcontinue seeing patients after distharge. Glostrup is a community with many young famil- ies; many children come in with psychogenic problems. The psychologist conducts interdisciplinary meetings'io share informationgained during her interviews with parents and children. She also works with the nurses who teach children about diabetes to remind them of the psychosocial aspectsof treatment 'anti modify the strictly medical-management of disease necessary if the patient is to cooperate in hiyelf-care, p The psychologist sees'all diabetiq children to assesstheir ability to com- prehend and profit by inst ction and may also help thechild maintain hil friendships while managing disease by showing him how' to juggle his 1' diet to allow an occasional p za with friends without jeoparding his.well- being. 1 Each ward has a Play Nurse assisted by Care-giver Nurses andstudents in Care-giving Nursing. These young women are the Danish counterparts of the British Nursery Nurses and the Swedish Child Nurses. They are trained to manage the common developmental needs ofyoungchildren in nursery school or hospital. Half Time Shifts in Denmark In Denmark', half time shifts for nurses mean oneweek on duty followed by one week off duty: This has advantagps in that a family can vacation together but for the family with young 4 or catch up on household and family tasks, babies, the longer hours ok separation may be difficult to tolerate,and the longer stay in the day care center operated on the groundsfor staff children may be less deSirable for that age group than a systemsuch as Amcr.sham's. -24- 00040) THE HOSPITAL AND PARENTS Parents do not live in as a practicein Danish hospitals. There is little demand for such services. Sixty percent of Danish mothers work outside their homes. Day care has a 100 year old tradition. Parents share house-- hold and income-producing taNlvFamily time together is usually spent doing thfhgs.together: Parents, unaccustomed to "just sitting around" at home, are not likely to do so in thehospital. _Opinions within the health care professions vary as tothe importance of parental presence. At one hospital where self-care teaching wasemphasized, 'a head nurse said: "Parents interfere with the teaching. We are very good at explainint just what is involved ix aprocedure to the child. Often, just as he understands and accepts,along comes the parent bringing her own fears. She makes a fuss and then all our work is undermined.Thatis why we don't allow parents to see patients onthe morning of surgery." Danish national concern for children'swell-being in the hospital takes the form of heavy self-imposed taxation toprovide quality.care in quality facilities. Living-in is, viewed by, many professionals and parents as not disruption$of-home or hospital routine. . necessary nor worth the attendant 'The attitude toward parenting-in in Denmarkis illustrated in the following statements: A Pediatrician: "It is not good to keep parents at thehospital unless you give time to preparingthsip. Otherwise there is continual irritation between mother and nurSe. It takes time ... it is more time-consumingto discuss leukemia with parents than-it is to treatleukemia in the child. No one is better than the mother forChildren with chronic diseases, but conflicts arise when orientation is neglected. If you bring in parents you must allow time to talkwith them, and they are demanding. Alternate solutions are day treatment, nearby hotelsfor parents so that they can be called as needed. In Denmark the trend is not toward parentaccommodation." they have made their A Danish nurse: "Some parents just won't leave until child Cry; they seem to think thatuntil he cries he doesn't understand that they are going. They keep saying good-bye and comingback until they have him upset." . , to help the "The surgeon plays operating room with the child before'su , child understand what will occur and to develop trustan familiarity be- tween himself and the child. A parent staying would interferewith ;his relationship." the child you A hospital psychologist: "If you use the parent to support child, create at new problem ..'. you must preparethe parent to prepare the but then you have a scared parentperforMing the task instead of a con- fident, assured experienced staff member. Which helps the child most?" J -2S- 00041 Parent EncouragemOnt to visit When.DAnish children at hbtpitalized, their parents are reminded daily visits help the regularly andoften. 1rochuresstate thAt frequent cold more than do long week-endvisits. At Hillerod the head nurse she can be available arraDges her schedule sothat several evenings a week about their children to families and fillthem in on bits of information families and children for that delight them. She offers counseling to Parents there, as at Glostrup, whom the separation isespecially painful. feed toddlers their are encouraged to staythrough the supper hour to evening meal, tuck them in and stayuntil the children go to'sleep before encouraged at leaving for the night. Living-in was neither requested nor A few beds available forthe use any of the Danishhospitals sliveyed. of nursing mothers are reported tobe seldom used. The Danes provide the staff; like to leave care to the pro- 'best in buildings, equipment and fessionals, wholly and large agreewith the parents. do pre- ,While a public health nursecomplained that it is difficult to look at un- ventive mental,heaLth with youngfamilies who "do not like to late to take care pleasant things, nor to talkabout them until it is too the reasons so of the situation easily," achild psychiatrist said one of hospital,with symptoms many children are seenin pediatric units of the that parents have no placeelse to turn: "Dan- of a psychogenic nature is when they ish parents don't beat theirchildren? they hospitalize them with such psychogenicdisorders misbehave."Many children are admitted as enuresis, colitis,asthma, and aphasia. hospitalized To summarize, encouragementfor parent involvement with advised and children in Denmark is mixed. On the one hand, parents are Their 'children are encouraged to come visit often,but come as visitors. of the dealt with by professionals. Children's needs are the concern and,'in some-cases, after experts at the hospitaryhilethey are patients families who see disruptive they leave. This idea is acceptable to young of their behavior s unnatural and areaccustomed to sharing the care beginning of life. childrenith others almost from the -26- , 00042 BRIS:, *CHILDREN'SRIGHTS COMMITTEE public about childten'sneeds for early emotional support To educate the professional people has and bonding, anorganization of predominantly RIGHTS. The name in Danish, is been formed, THECOMMITTEE FOR CHILDREN'S Samfundet and goes by the acronym,BRIS. ,BRIS cam- Borns Rettigheder I Members serve paigns thrOugh the media aswell as through study groups. to,acquaint the government,of violations as childadvocates within the system The organization has shownthe Robertsonfilms on of children's rights. by such hospitalization and separation,and arranged television appearances Klaus. crusaders fromU.S.Aii Brofenbrunner, John Holt and Marshall pediatrician and active member I spent an eveningwith Dr. Torben Aille, a work group on "the child in of BRIS, and his wife. Dr. Bille heads a BRIS government officials, the hospital" who talkwith administrators, local of early bonding. hospital staff members, andparents about the importance physicians; nurses, social He is joined by a numberof other professionals, workers, and teachers whoshare his sentiments. hospital ... then we point tothem and say: 'Look "We meet and advance one One goal of the group, 'what they are doing and sephow well it is working.'" children to the curriculum is to add clinicalexperience with hospitalized members. By having them fog future nursery schooland kindergarten staff affect their devote one year to this aspectof education, BRIS hopes to future careers as parentsand as teachers. ei *r. -27- 00043 HOSPITAL VISITS Four institutions vere visited in Denmark: Copenhagen County Hospital in Glostrup; Frederiksborg County Hospitalin.Hillerod; Rigshospitalet (the" University Hospital) in-Copenhagen; and Vangede, an.institutionfor the, retarded, outside of Copenhagen. Glostrup Community Hospital Glostrup is situated in a new suburban community outsideof Copenhagen. The building, of Finnish design, is shaped like a W. The beauty of its design, the space, and the decor are breathtaking. The lobby is hotel- like, with shops, banks, post offices, and other services in agiant, art-filled space. One wall is devoted to an outsized wood carving de- picting little children coming to Jesus And the disciples,all nude. A bornpirking (child parking)for children of visiting parents occupies a large part of the lobby and issupervised by a cheerful young woman who manages to give tender affectionate care toher charges while simultan- eously constructing a number of wall decorations. Children are at tables drawing,-bUilding with blocks, and playing games. A playhouse has been created in one corner of the space, completewith cardboard walls", curtained windows, and a fishnet roof to affordchildren a sense Instead of child- . of privacy without blocking the playleader's view. sized furniture.in the playhouse, brightly coloredfoam blocks and slabs in a variety of,shapes allow children to build their ownfurniture. When they are finished, the area is quickly restored. The patient areas are bright with color, and manywindows bring in as much light as can be captured. Light is celebrated in Scandinavia; with so little sun much, of the year, every possible device is used tobring light in when it is available. Children are grouped in rooms with plenty of space. The furniture is modern and permits each child to have his own thingsnearby. Toddlers' play and eating space, adjoining their sleeping room,is lined with low toy shelves and furnished with small roundtables and chairs, high chairs, and rocking chairs for adults. Appealing mobiles and works of art mit- igate the sterility of the hospital. Small pieces of sculpture, plants, candles and bric a brae stand on low tables in thecorridors and waiting areas; children's; beds are hung aboutwith their greeting cards from friends and family., Before 2:00 o'clock few mothers arevisible, and the youngest children are silent and appear dazed,but in the afternoon as parents arrive to play and feed supper, the roombegins to resound with the babblings and pounding one associates withchildren of this age. Glostrup's pediatric service specializes in diabetes. A case load of approximately 80 families, receive in-hospital andout-patient services in connection with this disease. Children aged three to fourteen are in four-bed wards. Play takes place in the rooms, in adjoining day rooms, and in the large, well-equipped school, crafts, and hobby center. -28 00044 Toddlers in Denmark are called "legeborn" which'translates to"play age." Their toys are plentiful and available on low open shelves forthem to help themselves. As children grow older, they are expected to use play for learning and constructive activity. Inventive devices have been developed by the professional staff to help teach the children to manage their own care. The philosophy in this hospital is that knowledge of the disease is essential. The Nurse-Matron (head nurse) who developed many,of the teaching materials says: "We believe that once the child understands his disease fully.and knows how-to manage it, he'canlead - a normal life without feeling sorry forhimself." Parents and volunteers'participate,far less in the playTiregram or th'i preparation aspect of pediatric care than in the .United States orgngland. Play and preparation-11e the province of the physicians, nurses, or psychologists. Patients get a lot of emotional support. For example, no child goes alone from one area of thehospital to another; his own nurse accompanies him. The school room is presided over by a male teachersupplied by the school district.-He has one a stant. Scbool age children from seven to.four- teen must be in the assroom or in bed every school daybetween 9:00 and 2:00. In the se eral,roomp are an impressive variety oflearning games, audio visual ids, and teaching machines so that children'can pur- sue learning with a maximum of independence. The teacher maintaift\good linkage with the public schools. Adjoining the school room is a well-equipped crafts andhobby 'Center. Children may not drop in but must arrange through their wardstaff for craft times. Parents,' except for those of long-stay patientswell-known to the staff, are barred from the craftssuite. The equipment of the center includes sewing machines, a piano, a sand box, a workbench stocked with all kinds of carpentry tools, and a storage closetstocked with-all kinds of games.and crafts materialP. The young man who supervises the area, keeps a large notebook, each page illustrating aproject that a child can choose. A patient can leaf through the book to decide whathe"wants to try each day. For new patients, the book allows a non-threateningintroduction to the area. During the visit immigrants from non-Danish speakingcountries were coming into the hospital. The project book was.especially useful for communicating with them. One of the nurse-matrons uses cooking projects to teacholder children to manage their diabetes. They codk, using their own cook books, weighing and preparing their own meals in a kitchen adjoining theirward. She has developed age-appropriate booklets and video -tape cassettes. Similar de- vices used by the nursing staff teach children'about.injections. A loose- leaf notebook shows parents and older children what isgoing on in the body of a child with diabetes. For the younger children acolorful car- toon book "Pere and Lisa Have Diabetes" explainsin simpld language what the diabetic child candp and can eat. The plot includes an episode where Pers eats what he shourdn't one day and falls sick. He is confined to bed and Lisa finds someone else to play with. Pers recovers and having learned his lesson, watches his diet more carefully, avoidsfuture illness, -29- 00045 his'friend, Lisa.The chief phys- and is able to resumenormal play with illustrations and the nursewrote the text. The nurse who ician did thd after observing developed this teaching programabandoned group teaching different rate, individual teaching took so that everyone learns at a before found herself puttingin fifteen-hour days much time that she allow parents andchildren developing the books andaudio-visuals that now their own. to teachthemselves and each other on HillerOd The at'HillerOd is quite similarto that of Glostrup. The environment end light. Wards and cor- buildings are older, butpleasant, colorful, assembled by children orstaff ridor's are hung withinteresting mobiles finds children inpeds or sitting at long members. A central play area busy' them with paints and tables with the Playand Care-Giver Nurses fitted with a white wirebasket hooked other crafts. Each patient bed is personal possessions. over the endcontaining that child's about disease has dev sed a way ofteaching her patients One of the nurses A panel over theabdominal and injections with alargwooden figure. reveals brightly paintedinsides. Accompanying.this region when removed, instruments the child may useto are woodenrepresentations of medical give the wooden maninjec ons. XillerOd a ward of 18 patients, 3 -10 years old. I observed on a unit at She works to head nurse, HanneVesterdal Jorgensen. My guide ryas the staying comfortable place forchildren and parents, make the hospital a and don't week in order to speak toparents wiz work for one night shift a form of address and after.3:00. Children use the intimate come in until She asks parents to use call doctors and nursesby their first names. first names, too. three rooms to insurecontinuity of Each nurse, student,and aide cares for Mrs. Jorgensen asksparents of children care,changing,ssignments monthly. he or she bedtime, tuck their childin, and stay until under six to some at hearing re- Because she, as amother herself,'enjoys drops off to sleep. she collects her*own children fromtheir day care teacher, ports about and keep up theirin- anecdotes about theirchildren to interest parents She believes that as so manyparents terest and feelingsof parenthood. lives, such stories notonly delight have worked most oftheir children's awareness aboutchild them but also increasetheir understanding and development. pessimistic interviewed in Denmark,Hanne JOrgensen wasp Like so many others increasing living-in. She has succeeded in about the prospect of parents children several times the numbers of paKentvisits and their calls to member of BRIS, theChildren's during the day. Sho is also an active Rights Organization. -30- 00046 Rigshospitalet (UniversityHospital) old stone of the UniversityHospital is housed in an The pediatric unit occupies of the elegant newhigh-rise hospital that buiding to the side corridors were darker the center of thegrounds. Although the rooms and hospitals visited, thespirit was bright..Child- than those of the newer and occupied with play or schoolaccompanied by play leaders ren were home They rove the hallsfreely and appear to be at Caretaker Nurses. alone the dark-eyed young Greenlanderswho are carried by plane -- even language and little from their homes andfamilies to Denmark with no backs. The Director of more to identifythem than numbers on their under the circumstances Nurses notes that theiradjustment is amazing mothering, and attributes their acceptanceand trust to their early children strapped on their where the practice isfor mothers to carry backs during their first years. is experimenting-with afive- Because of staffingproblems, this hospital All children, go home onFriday and all staff day week treatment program. complained members take days off atthe same time. The director of nurses begin almost immediately that it is hard on thechildren in that tests must period. upon admissionwithout allowing a settling-in from all over Den- Rigshospitalet has a patientpopulation of 97 children housed in seven wards. Only the tiny babies are mark and Greenland units are grouped together according to age. Children in the other six together leads to a grouped family style. "Grouping all two year olds Caretakers begin to changediapers or spoon in food factory feeling. that.we want children according to a schedulethat destroys thb fee, ng explai d. to have here,"the Director of Nurses in the day rooms, thewards, and the corridors. Play takes place all over -- Children who can be up Playthings are available,ample, and attractive. involved in a variety.ofactivities. are dressed and outof their wards, children's own creative efforts -- Rooms and corridors aredecorated with mobiles and three dimensionalwall decorations. assigned to each of thewards except for theinfants' A play leader is kin- in the isolation unit,and there is one ward. Two play people work dergarten teacher. psychologists play a maj9r role onthe As at other hospitalsin Denmark, and pass on the resultsof their inter4 staff. They interview each child well as to the nursesalong with suggestions views to the play staff as unless a play. Doctor play is discouraged for individualized, helpful The psychologists knowledgeable adult is attendingand interacting. is potentiallydangerous believe that such playwithout adult supervision reducing fears. to the children --increasing rather than -31- 4 7 Vangede Vangede is, an institution for'the care of childrenhandicapped by retarda- tion. Located outside of Copenhagen, the low attractivetuildings are grouped close together on large grassy acreage. Three hundred resident patients eat and sleep in family size groups, each intheir own house. In addition to,these cottages, a number of largerbuildings house the occupational therapy program and pool, the school, and anassortment of crafts. Self-help is an important aspect of the program atVangede. Children eat in small groups to develop social and feeding skills. They are encouraged and helped to find their way alone about the grounds. An exciting "Adven- ture Playground" with marvelous climbing structures,lean-to's, bridges, hammocks, and tunnels occupies a prominent place on the grounds. There are structures for house play,andobstacle courses built out of old tires, milk trucks, rope-nettinAs strung between trees, and oil drumtunnels for children to learn to help themselves to mobility and exploration. Ali the equipment is made out of discards and puttogether by the patients and their caretakers. Vangede is'a demonstration center, a respite center,and a day care treat- ment center as well as a resident center. It is designed to help parents keep theit children at home (rather thaninstitutionalize them) b re- lieving parents and to add richness to the children'slives without re- moving them from their families permanently. The cost per child for this well-equipped, well-Staffed center is $10,000 a'year. The trend is to give parents so much help that they cankeep mentally retarded children at home. Help includes respite care. Upon the birth of a retarded child, medical staff members informthe institution and -counsel parents. The hospital keeps the child for the parentswhile they come to terms with facts. No child is ever sent home without pre- paring the faaily. If the parents decide to place their child,they are told that they must visit regularly and that placement cannotbe forever. Too long a lapse between the birth of-the childand homecoming leads to institutional placement. There are ten centers for retarded people in Denmark.,Vangede is the children's section serving the Copenhagen district. Of the 1400 children served, 1100 live at'home with the center helping by providing schools, kindergartens and recreational programs. Services Ire coordinated by 18 out-patient social works whomake\themselves available to the families. Each home that cares for a retarded childgets 800 Kr, tax free, per child to help the family coverall the special equipment needed to keep the child home... In addition, a home nurseis available to the family regularly. The Cope hagen area is divided into districts andeach social worker has parent m etings with speakers and programs tointere*t the families under her wing. In addition, there is a Holiday Home (a reliefhome) that -32- 0 0 0 4 8 accommodates twenty children to allow families who"give home care the oppor- tunity to take vacations while the children have resiAte care% The setting of the Holiday Home is beautiful enough to make the vacation a special pleasure for the children who stay there while their parents are on holiday, too. For the children who live at Vangede, an "Auntie" system of week-end homy, care given by volunteers was tried, but abandoned after awhile because too often the children were dropped after-a very few visits, and were pain- fully disappointed. Staff members who work at Vangede do often take children home with them for occasional week-ends away from the institution. Dr. Bank Mikkelson, the director of Vangede, is a lawyer and a Ph.D. He has succeeded in making the community,. the parents and the hospital aware of humane ways of dealing with mentally retarded people. They are no longer "forgotten children" stuck out of sight in the country. Today, only about five out of the 300 resident children have no special person tosomq,visit them from outside. There is a strong parent organization and parents are invited to participate in all conferences. Each cottage has parent representatives who it in on all house maptings. Visiting is open with parents encouraged to feel free to come at -any time. :An active chapter of Aid to Retarded Children promotes good liaison between the paients and the professionals. Together they exert pressure on the government for funds to offer good service. The philosophy of the government as well as of Vangede'is to encourage par- -ents to keep children at home in the early days of their life. Betw9en one and two per cent of the population of Denmark is retarded. The organization offers, rather than forces, acceptance of the diagnosis of mental retarda- tion to new parents; A.R.C. and social workers help the family talk and offer home services that must take the place of institutional placement for infants because there are not enough places. Vangede refuses to over- crowd. Authorities at Vangede stress independence, mixed age groupings, mixed sexes and family style living. The institution is well staffed, mostly with young people. The policy of social concern in Denmark, while very expensive, does much to create jotb for the young. -33- 1 00049 +: SWEDEN NATIONAL WELFARE SYSTEM As early as 1774 the first pediatrictextbook in the world was written by Nils Rosen von Rosenstein who recognized that the most important way to lower-the infant mortality rate (only fifty per cent ofSwedish children survived to the age of five at that time) was to educ-atemothdys in childrearing. His pioneer work contributed to the establishment in 1845 of the world's first chair,pf pediatFics at the KarolinskaInstitute in Stockholm. Although a first attempt to organize preventive child care wasmade in 1901 on private initiative, there was Little further.develdpmentuntil the creation of the national welfare system came about in thethirties. The special program for preventive child health began in1938. The infant mortality rate drops steadily. Sweden has the-lowest in the world. In Sweden, benefits begin before birth. Prenatal care and all maternity care is free at nearly all maternityhospitals. Benefits from compulsory national insurance are additional to anycontributions from employers or private insurance companies. All mothers receive a grant from the gov- ernment of $209 at the child's birth and$232 a year until the child becOMes 'sixteen years old, or eighteen if the child remains in school. If the mother is employed during her pregnancy, she receives asix-month leave of absence with a salary-based maternity allowance for sixmonths. She may-take another six months with her former jobguaranteed bUt.without salary if she is able to do so. Parents of handicapped children cared for at home receive State grants. Hospital care is free of charge and consultations atout-patient depart- ments and with practitioners are coveredfor the most part by compulsory insurance. Sweden has a population of eight million anda.nationwide net rk of about 1300 child welfare centers charged withcarrying out the preven ive child care program developed by theNational Board of Health and aro in close cooperation with the medical community. ' Welfare Centers are located at pediatric hospitals orin buildings of their own and serve about fifty per cent of the childpopulation of Sweden. Registration is entirely voluntary, although all newbirths must be reported by the maternity hospitals. The service is free to the family; the annualcost'per child-is about $11.00, shared equally by the national and countyauthorities. 96% of all children are registered during the first yearof life with a steady decline until the figures are 22% at five years. -34- 00050 All registered mothers get ahome visit by a nurse within. twoweeks after the center sometime between.two delivery. They make their first visit to for the first to six weeks and thereonthe visits average from four to seven year and between oneand two for the followingyearsiuntil school age: Service at the centers ispurely-preventive including medicalexAminations, vaccinations and advisory work. If the child is/found to be sick or a . problem comes to light, the familyis.referred Other to'a pediatrician inn pritte practice or an out-patientdepartment at a children's hospital for further examination and treatment. 7 The centers are staffed by aPediatrician holding a part-timeappointment and full-time nurses, speciallytrained, whoOe prepiYation andresponsibili- ties are like that of the PediatricNurse Practitioner in U.S.A. / Advice about nutrition, health andeveryday'roblems of childrearing are thOealm of the nurse, available everyday y phone. Additional advice is offered through pamphlets. In large citeschild.psychologists have been appointed to the welfare centersand. a, ?tempts have been made to arrange groupdiscussions with parents ofchildren with simple behavioral problems such as eating, sleeping andtoileting disturbances. The psychol- ogists also assist personneltoward increased understanding ofbehavioral and psychomatic disorders. breast fed Breast feeding is encouraged. About 90% of the newborn are the tendency to seek advice the hospital. There has been an increase in Wring standard has on minor practicalproblems of child rearing as the become higher and nutritionalproblems have declined. The nursing staff provides the major part of theseadvisory services. fly 4c -35- 00 051 Institute, The hospitals visitedinSweden included the Karolinska Samariten Hospital, St. Goran'sand Umea. PARENT ACCOMMODATIONS Sweden hospitals offer most completephysical accommodations for parents aside space that who choose to live-in.Three programs I visited tot bedrooms theyrcalled Parent Hotels ... inunits containing four or-five and-chair adjoining With baths and amply furnishedwith bed, lamp, desk facilities: a common living roomand kitthen. Some have laundry and sewing some charge $2.00 a night. v. Somehospitals make-no chargb for the rooms; St. Goran's other arrange- St. Goran's has, inaddition to the parent suite, several in a room ad- ments whereby parents can room-in with children or sleep the planning of the joining their child's.Their booklet describing hospital states: planning, we have taken intoaccount-parents' desire to stay at the hospitaland every unit has one or more rooms forparents-with-patient accommodations.",, for their The pre-admission booklet sent toparents to prepare them In fact,. child's hospitalization makes nomention of the parent- rooms. distressed if their it reassures the parents thatthey should not be before the parent child cries when they leave asthe child usually stops visit often. is out the front door. The booklet urges parents to Karolinska parent apartments arelocated on the top floor At the Karolinska Institute kitchen and a living of the building and consistof three four-bed rooms, a nurses' lounge. In the television. Parent quarters adjoin the room with four rehabilitation center 300 metersfrom the Children's Hospital are be procured to for parents. A few c'aise lounges can more twp-bed rooms residence at the time of my set up in patient rooms. No parents were in visit. "The hospital was builtbefore the need wasdiscovered for many parents to staywith the children. Most parents As our play are told tovisit their children everyday. need therapy department hasbecome more efficient, the around all felt b)' the children to.have mother or father and it is the day and the nighthas greatly diminished the tremendously effective complementto the visits of the whole atmosphere parents. The play therapy changes of the ward and much of theanxiety of the sick children A -36- 00052 as well as of theparents has disappeared." Dr. Lind suggests that parentsand nurses must be re-educated about the importance of parent stayswith very young children. "We doctors taught nurses'that parents were not important and the nurses went alongwith us. Now, we have changed our minds. The nurses are used to tieing with- out parents, sochangingtakes a little time."He, himself, believes in telling parents directly whentheir child needs their support and they should stay. Umea -r--- In Umea, in the northern partof Sweden, the hospital facilities are in a parent apartmentsimilar to those at St. Goran's andtheKarolinska, located, on the ground floorand adjoining the play therapy unit. An intercom connects them.with thechildren's units. Few parents take ad- vantage of the rooms. -Onestaff member predicted that when there is a new generation of parentsand child nurses who are educatedregarding the young4thild's need forattachment, hospitals will-offer a welcome to parents so convincing thatMore will make use of the programs. through the The major thrust in-preparingsuch a new generation comes schools of nursing and through encountersbetween families and health visitors who follow mothersand children from pregnancy through the fifth year of life. Samariten stays are . Samariten Hospital in Stockholmallows parents, but overnight infant unit is provided at no de-emphasized. A room just outside the two-bed patient rooms cost and meals are free. Mothers may also share excelit that the space is for with children. The hospital has'no rules C mothers The dormitory for nursingmothers has room for 2-4 mothers only. There is a par- and this space is mentioned inthe hospital's brochure. ent kitchen on each flooralso. with a routine system ofpre-admission This is the only hospital visited visit to each calls. The social worker and nursemake an in-take home They introduce themselves,pick up par- family anticipating admission. hospital hold A planning ent and child concerns and ontheir return to the staff members to develop animiividual- conference with inter-disciplinary At thisvisit, ized care plan based on-findingsfrom the home visit. consider staying, living-in is discussed, but parents arcnot urged to especially if other children arein the home. Lind *Quoted from private correspondencefrom Prof. John -37- 00053 PLAY IN-SWEDEN History andPhilosophy- , ha'e well-establishedplay programs hospitals visitedin Sweden the units, The four by students. All offer play on staffed bypvfessionals assisted and in waiting areas. in separateplay quarters, the efforts Helsinki, Finlandin 1909 through 'programs began in spread to Hospital play Bari Luther. The idea soon of a Ptnnishkindergarten teacher, Princess LoVis'sNurs- began in J912in The Crown Sweden and playacti kindergarten n inStockholm. Up to the 1930's, ing Home forSick Child hos- rovided play andoccupational activity for volunteers in sana- teadhers and Such programs weremost common pitalized childrenwitho t pay. volunteers also hadto sing homes,and often toriums andlong term n en withtheir education. help school-agd ch' employed rn,a h kindergarten teacher was In 1930, thefirst salaried' children's hospitals a activity hasspread to many' ital. Today, play hospitals with. noorganized p1 there are still some clinits, although _Even whereplay leadershave' occupational activityfor patients. material re- or other are slow toprovide space and been hiredsome administrators sources,I was told. carefully in Swedendemonstrated Nevertheless -, thehospitals I visited con.- programs. Play receivescareful lhought:.out andwell-equipped play stage-setting as adevice Play Leadersspeak of sideration inSweden. visiting childrenand-their cooperation from They care- for securinggoodwill and the institution. their firstencounter with They families during where childrenmight wait. appealing toysfor all (areas elevators, andwards. fully select art woikfor corridors, create orcollect interesting cakes in roilveils to ---.baking real triends and The emphasis onreal achievements oneself or for wooden nameplacques for serevisitors, making hospital withexhibitions of work bench,decorating the activities thatbroadens family at the to children's hospital-related art, --lend a dignity enhanced self esteem. "keeping thembusy" to the conceptof play from mere children for newexperiencesor- prepare Games of skill Play activitiesdevelop muscles, growth. mental, physical,and psychological and anxieties add to their of theirannoyances play out some experiences. or chancehelp children of hospital Creative dramaticsallow mastery symbolically. used to transportsmall children's wagons are corridor makes In many of thehospitals, along ahospital A line-up ofred delivery wagons' chairs andgurneys. children. from a line-upof wheel arstatementquite different outsidechildren's and visitorli storage racksfOr all staff play areas. Coat and shoe entering thechfldren's units keep. streetdirt from style withRtzrd ages grouped family Children in Swedishhospitals are All 0114rcn for the very youngbabies. yconger roomingogether, except Babies and personalplaythings. their with tie storage spacefor their own attractive dayroo4nsadjoining children usuallyplay in -38- 00054 -- that they ate-not overburdened with too many different encounters. Older children, who have different needs, are encouraged to leave the wards and 'participate ines-eparate,play areas on separate floors: .These areas in- elude gymnasiums, oillibr.play/rarks,-and rooms for a variety of exercise, . therapy, and hobby. activities. In Sweden playis seen as more than diversionary activity sporadically- offered,to pass-time. Play equipment is chosen and presented-with as much care as is any other equipment used in the treatment and care of children. Play is directed.by trained professionals who'assume responsibility for play care plans as well- thought -out as,are the other patient care plans. 1- "We cannot be everywhere to help the child handle the hospital experience, but we are there symbolically when we make the places pleasant and attrac- .tive. We make the institution softer qnd politer through the toys we have for children to use," says Ivonny Lindqvist, Play-Leader at Umea. Her sentiments were echoed by play - leaders at the other hospitals chosen for study.' While space and equipment are impressive, Mrs. Lindqvist warns, "It is dangerous to think you must have elegance to have'a good prog . Child-- ren can play under beds and tables when the spirit is present. he-, remembers fifteen previous, makeshift headquarters for play in 4°t e hos- pital, when all today's sturdy and bea 'flAlly crafted equipment was pre- figured by things improvised out of ons and crates but available for children's use.. , Staff Education and Role Today's emphasiS.on purposeful play as part of.hospital therapy calls for specialist training in addition to the pre-school teacher's education. Teachers' colleges in Stockholm and Malmo offer a one year course to qualify credentialed teachers as hospital play leaders. This training prepares a play director to bring along the rest of the staff,, acquaintin them with the value of play and of choosing appropriate playthings for patients. The in-service educational aspect of the Play Sister's role is most important, because many children are tucked away in adult units and might be overlooked unless nurses make special efforts to meet their play needs. Child Nurse Training The Swedish equivalent of the United Kingdom's Nursery Nurse is the'Child Nurse. Today in Sweden ninety per cent of all high schdol graduates choose to continue their education. Many young people elect to study Child Nursing. The group enrolled at University of Stockholm at the time of the visits included seventy=five bung women and one young man all be- tween the ages of sixteen and eighteen years. Child Nursing, a two-year INN -39- 00055 people ladder, helpseducate young that is step oneon a career posi program school andhospital assistant as well asfor nursery for parenthood Stockholm, a nurseryschool_teacher Hospital in Pi-an-- tions. At University curriculum thatincludes family educator teamteach a Students and a nurse, Development andChild Health. concepts in Child they ning, beginning periOd to see how in a pre-trainingassessment first participate be assessed astosuitability with youngchildren and to student moves' like working both vantagepoints, the If all goeswell from Nurse. During for theejob. finishes as acertified Child course and the playrooms, into a two-year extensively onthe wards, in participate training, students for siblings,clinic patients, play groups through- and.in thehospital operated students fromthis program St. Goran's uses and staffchildren. clinics. out thehospital and two and ahalfyerirs of experience, the careerladder includes field exper- Step two on to an R.N. After more followed by moreeducation, leading work inpsychology and again returnfor gra4.uate built ience, thestudent may Liberal artseducation is receive agraduate degree. student's sociology and in order toround out the into thecurriculum throughout personality. offersobservational of thehospitals visited The playtherapy department other fields,such,as Speci experiences 'tostudents in Medicine, and and clinical courses inPsychology, Education andUniversity level Nursing. ;;OSPITAL VISITS Samarite hospital on thegrounds of a Samariten isan'old building adoles- Sykbradhusset children --infant:: through Samariten hasbeds for 120 'outcroppings complex. studded with amidgentlysloping grounds covering the cents., andis set at the time ofthis visit, trees whichwere, yard nearthe entrance of rock and leaves. A play A ground with orangeand yellow toward children. hospital'sattitude rocks, first glimpseof the challenging gives the wading pool, some yard into ahillock, asmall because the slide set bOundaries occurnaturally but no fence ... andcontainment. to climb, arranged for easysupervision_ is strategically Thebuilding of children. depicts a scene during anAmor- Over the frontdoor, a frieze Jenny Lind with fundsraised by. family. style, wasoriginally erected mixed agegrouping', Thechildren,' in possible. ican concerntour. clotheswhenever dressed intheir own are upand around, bright pi- lovely color, areasare light with grvunings offurn- and patient, and cozy and The corridors children's artwork ruunJ tures -- manyof them fitted withsmall and corners are are Small alcoves withinchildion'N'gratp iture. chat. Pldythings bright chairsinviting a in:use. -40- ' 00056 Outdoors, a woodsey plot Space is generously allotted tochildren's play. natural terrain just beyond the front entranceoffers slide's, climbers and In Inside play space isintegrated.into th children's rooms. . for play. given over to,the play. addition, the entire top storyof the hospital i hall, a Here equipment fills twolarge rooms, an equally large program. window kitchen and, a homey, wood-paneledconference room with eaves, Only twentYchildren seats, and a fireplace forstories and quietchats. large at a.time are allowed inthe playroom. On the'children's units, dispense 'storaie,cabinets are stocked withtoys for nurses and parents to large.variety of well -used for children who cannot leavethe wards, and a inviting but well-cared-for play and schoolequipment stands ready and materials Mobiles and wall decorationsfashioned' of interesting and unusual themes adorn the Walls. catch the eye. Children's paintings of hospital Samariten operates its play programwith only two fulltimeplay leaders former nursery school 'for 120 child in-patients. Miss Ultiqa,Spens, a directed the program teacher with a degree inOccupational Therapy, has have'rt- for more than seventeenyeah. Her years of staff development well-stocked sulted in good collaborationwith the nurses who use the children, and stores of toys on eachunit to manage play for the younger . for health-care teaching., maintains equipment in theout-patient depart- The play staff selectSand around ments as well as on theplay floor. They trundle their equipment conveyers.. the hospital using infantbassinettes and shopping carts as the older patients After children are, acquaintedwith play,staff.membets, selected with make their own appointment tochoose activities which are work out a suitable play the careful consultationfrom the play staff to prescription for each child. make them appealing Each head nurse decoratesherlown unit and corridors to 'to children. psychologist and one full-time Two public, schoolteachers, a part-time team. social worker serve thein-patient departments as a and a nurse call Pre-admission home visits areroutine. The social worker ques- patients during the weekprior to admission to answer on prospective "Why do you think you arecoming tions and ask some oftheir own, such as: think about the hospital?""What to the hospital?""What does your child The team offers thefamily writ- do you 'want the hospital 'todo for you?" and what to bring. Information from the ten guides on what to expect conferences and the group visit is shared with the restof the staff at ward plans for the child'sforthcoming admission. Samariten includestwelve 'equipment in the top floorplay department at sewing machines4 an adultkitchen, ping -Fong looms of assorted sizes, papier mache, finger- tables, trays of sand,buckets of dirt and water, kilns, an extensive paint, easels and watercolors, clay, wheels and shelves stacked with gamesof every description, library, whole walls of for tools and workbenches forcarpentry, propS hobby and crafts materials, areal broadcasting dramatic-play, dolls and dollhouses of all sizes,, and -41- 00057 a system to alf6w play leaders andchildren to transmit stories and dramas to the bedside of children on the floors below. Large looms, sometimes reinforced to make the pull even stronger, areused for children with obesity,problems.who respond much more positiVely to weaving a rug or asbag than they would,to callisthenics. For diabetic Children who need to maintain a stable reeme of exercise each day, ping- pong and other active games help not only forfun and release but also to regulate their energy expenditure.. The therapist at Samariten believes thatchldren reveal their concerns,, ask their questions, play out their own dramas, and work out their own therapy if the right materials are supplied and caring, observant, well- trained staff members are available for observation and consultation. For example, messy and organic supplies arc displayed and readily available for children,oith problems such as encopresiswhich are helped by the con- structive use of mud, sand,.water, finger paint, and papier.mache. Out-. 'doors,"childrenmay climb hillocks and slide down,splashing into a wading pool in the summer or sliding'on ice in the winter. Carpentry also allows release while life size or miniature dolls stand ready tohelp children play out concerns therapeutically. Karolinska This hospital, also set among lehfy,sloping grounds, is part of a complex enhanced by the use of color, of hospitals. A warm, inviting atmosphere i$ sculpture, paintings, and plants that dispel.the depersonalCzed institu- tional air. When' aguest enters an office, the hostlights a candle. Karolinska Institute operates its play,programfrom a central ground level room lind with equipmentthat the play staff transports to thechildren, on the tfrds as appropriate-totheir needs. Larger equipment, like the The looms, can be used in the play center ormoved to the units diheeded. play center is used for crafts by patients,play staff, and students plan- ning activities and creating decorationsfor the units. Karolinska-has developed booklets describinghospitalization through the is for two-to- eyes -of small children. One version, mostly pictures, three-year olds; the second is for olderpre-schoolers. These booklets play deal.not only with "what to expect" in termsof hospital routine and activities, but-also weave a story of the youngpatient's anger and shyness with other in the face of his mother's daily departuresand his encounters, children. 11 Karolinska has a play staff of professionalswhose work includes the super- vision of students. The Lekote that it shares the 'Another program, somewhat related tothe Institute in from karolinska professional services of a psycholygistand a pediatrician -A 2- 00058 is the Lekotek or ToyLibrary. sylvan in two buildings onthe King's Grounds in a The Lekotek is housed by the Boy Scouts water. This program, financed setting overlooking the where toys are used todiagnose of Sweden, is a libratyand school program and hearing-connected and treat autism, aphasia,and other communication- problems of young children. of autism, speech lags, Toys at the Lekotek areused to identify symptoms Following the screening,parents and staffmembers or otherdeviations. library's toys, as additional confer and determine a programfor Use of the and includes parent coun- stimulation for the child. This service is ftee residual hearing abilityand communica- seling. Some tests for determining and be present in aninfant have been developed tion disorders that might From re- throughout Sweden,and in anumber of other countries. are in use children some new programsfor search at the Lekotekinvolving parents and communication imMediatelyfol- encouraging the developmentof mother-child For example, atKarolinska, new mothers-are lowing birth have evolved. and croon- slings to hold theirbabies so that speech provided with canvas observe the line to the baby,and the infant can also ings go in a direct between the ttitt begins. mother's lips and eyes asverbal communication St. Goran's buildings as building within acomplex of medical St..Goran's is a new is bordered museum of modernart. The giant lobby beautifully designed as child to sit seats big enoughfor a parent and by wide, low comfortable available, but Wheeled vehic4es fortransporting patients are together. partition so thatvisitors are not Stored behind anattractive lattice bistros, with hospitalequipment. The lobby houses immediately confronted grows that carefor well banks, a post office,and a barnparking.(play attend, medicalappointments). children while parentsvisit patients or murals, sculpted,and painted, Walls are decoratedwith hangings and woven One handsome tapestrydepicts children's depicting scenes aboutchildren. colored Rube Gold- clinic. A giant, brightly experiences in hospital or feet, the dominates the lobby,rising at least ten berg-like sculpture of water, This mobile sculpture,set in ,a pool size of a small house. on the waterwhich has trigger controls achild can operate to turn causing funny facesto pop out, activates paddlewheels,ropens windows, captivating gyrations. and setting inmotion numerous other building in Swedenmust go to One per cent of thecost.of every public expensive building,and one its art and decor. St. Goran's was a very per centbought a lot of art. sunlight into built around courts so asto allow direct St. Goran's is equipped for play. Each unit has all patient areas. These courts are playroof of the lowerbuildings.. Three:dimensional direct access to the level walls on a children'sunit at their movable abstracts decorate exploration, andmanipulation. ready to be poked orrearranged, inviting -43- 0 0 0 5 9 O The large St. Goran's specializes inthe treatment,of handicapped children. adapta- swimming pool,-gym, and occupationaltherapy rooms all have special tions to serve children withhandicaps. However, all equipment.is shared with other patients since exerciseand emotional release takehigh priority at St. Gora's. ti varyihg size and The pool features an adjustablefloor, so that children of ability may use'it. The occupational therapyunit has child-proportioned kitchens and hdUsekeeping rooms withadaptive tools to allow handicapped as well as non-handicapped children todevelop motor skills as they play. out such normal household activities ascooking and washing up. work, Additional rooms house looms forweaving, wheels and. kilns for pottery carpentry, handicrafts, and even asmall auditorium with a stage forim- , promptu dramatic productions. and storage St.. Goran's with 229 patientbeds, has space designed for play roofs and for toys throughout thehospital. Play takes place outdoors on the anterooms where children courtyards. Each 'specialty"Clinic, as well.as designed to, wait for x-ray, surgery, andother tests or procedures, are level is given over to playrodmsand offer play. One whole area at ground bottom. rehabilitation facilities completewith a pool With an adjustable siblings permits parents to leavetheir well children. A playroom for visiting day while they visit hospitalizedchildreh. Space used by the psychiatric the fireside treatment program doublesby nf.ght for in-patients who use where the day room for songfests andjam sessions. One room with a stage to use for patients meet becomes availablefor young hospitalized, children impromptu dramatics in the evenings. includes Thefoccupational therapy unitadjoining the rehabilitation center working kitchen. a child-sizedhousekeeping center complete with a provided on Four classrooms house schoolactivities with additional space several of the wards. , central waiting Most children coming to theout-patieot clinics play in a suspected infections wait in smallisolation rooms. area but those with rest comfort- These curtained cubicles havebeds so that sick children can ably while waiting to be sewn. several The building is''designed withvarying levels and built around for play as is the rooflevel of courtyards. Some courtyards are used bordered with bushes,and the parking garage. The outdoor _play areas are offer ample space for wheel toys,for beds and buggies, school teachdrs in St. Goran's employs trainedplay leaders or nursery iincluding x-ray every area of thehoSpital where children may bepresent, It is the job of these teachersto soothe and to and waiting stations. Tan's distributes procedures. The.booklet that St. Go prepare children for on'the staff of follows: "Play therapists talks about Play Leaders as for the pediatric hospitals, help decreasethe'stress of a hospital stay -44- . 00060 and anxiety great help inrelieving children's stress child. TheOre of child goes into the before surgery and serve aspart of the team as a consulted about the design of operating room. The play therapists were r- the rooms." Ume4a14 and more concrete thaneither Umea is a newerhospital with less greenery The ground floorplay department opens to a Samaritan or Karolinska. slides, and sand pits. Bumps courtyard equipped withclimbing structures, side of the courtyard tosat- of plexi-glassskylights adorn the opposite The skylights servethe basement lsfy the Swedish hunger'forsunlight. of the hospital. full and boisterous useduring this The play floorand corridors were in in play in cozycorners. The play areas visit. Twosomes were engrossed Parents can so mothers areoften around. adjoin the parent apartments, Accommodations are heir quartersiO visit. invite their childrenin the Only one parent wasin residence at luxurious and well -appointed. staying,was that her home was time of the qbservationand her reason for too far away toallow regularvisiting. for children andtheir play per- The attitude of welcomeand understanding equipped with All the hospitalwaiting rooms are ' meates theinstitution. if we are not there, we are toys and decoratedwith art "so that even Leader said. being kind through thematerials," she Play month pre- number of studentsinvolved in their four Three teachers and a Considering that the made up the playstaff,at Umea. practice experience directly and in- fair more than 100children each day play program cares However, by givingcareful attention directly, the play staffis small. by working with parentsand to stocking all areaswith playthings and the expertise of thesmall play staff members fromother disciplines, staff is extended toreach many children. stays to of children come tothe playroom, their nurse When large, groups also stay in order to Very young ordisturbed children's nurses help. Play Leaders takeplaythings for very maintain familiarrelationships. be unnecessarily the nurses so thatthe babies will not young children to Leaders help the nurses burdened with new, ,encounters. In return the Play ttleir allies and advocateswhen the out on the wards,and=also serve as -- coloruniforms, for example. nursing staff iscampaigning forsomething family ties bywelcoming parents The play staff memberswork to maintain mother is promptedtactfully by a Play 'in the playroom. An apathetic A mother watchirigher child Leader to appreciateher child's efforts. observe the PlayLeader's techniques. at play can tr young," Mrs. Lindqvistsays, "It is easier to helpif you are not so with authority aswell as "because you must talk toparents and staff kindness." -45- 0 0' 0 6 1 decor are used extensively. Each light; tasteful and interesting Color, but similar in its useof child- waiting area and wardplay space is unique oriented art. friendly environ- important that childrenarc met by a "We consider it very What they see mustin- they come into thehospital door. ment as soon as invitations," the PlayLeader vite activity. That's all we have here ... comrltsnt s. pine cone mobiles, from nature ... mosses,leaves, acorns and Materia world outside ... areused extens- reminders of thewoods and the natural such as Mobiles constructedfrom unlikely materials ively in the'decor. of all kinds, plus medicine cups, egg cartons,and styrofoam structures and swirls adorn thewalls, collages of lids gluedin intricate patterns sports a hanging ofstuffed, multi- tables, and ceilings. A clinic doorway with a strands like fat bellpulls, each ending colored, multi-textured large bell. indeterminate beds in the pediatricunits plus an .Umea has seventy-five The play program serves number of childrenwho are in adultwards. children daily, eitherdirectly or indirectly, approximately one hundred nurse. by placing toys inin areassupervised by mothers or the play area. well as parents canvisit patients in Brothers and sisters as relaxed and homey- and comfortable. Children appear The atmosphere is observe,from the fringes asthey absorbed in play whilemothers quietly do their own handwork.. throughout the hospitalis chosen with the Play equipment inpatient areas For example, particular chilUrenserved in mind. therapeutic use of the feature interesting children with eyeproblems, playthings in wards for units have bed-heightdoll- sounds and textures;children in orthopedic to allow bothsocialization and height doll housesand similar equipment activity. hospital Units that serveschildren Each waiting area orday room on the for toys fothechild patients in has child sizedfurniture ana storage that area. gymnasium'opens for play on theground floOr a large In the area reserved which can be dividedinto many smaller to the rightof a long, wide hall of the space allowsthe play staff to arrange spaces. The adaptability The gym children they will see onany particularday. for the kinds of muscle play, carpentry,block and the corridor maybe used for large Space is so arrangedthat small areas can building and hobbypurpUits. nooks inviting make interestingalcoves and smaller be screened off to companionship form and encouragingthe feeling of olose small groups to find in a largeinstitution. To the and privacy soimportant yet hard to containing the director'soffice. A one- left of the corridoris a suite it fromthe playroomfor younger children. way visionmirror separates conference-observation roomand as'hospitality center, The office doubles members, staff membersand classroom for universitystudents, .community -46- 06.062 the hospitalized child. Observa- parents who meet tolearn about play and The play room is arrangedin tions of children atplay. trigger -discussion. according to their own interest. zones to invitechildren to group themselves suite. One contains icomplete working Two partitionedalcoves complete the the other a living roomwith low comfortablefurniture. kitchen, child-sized; with storage shelves and Throughout she play area,walls are honeycombed 'cupboards, both open andclosed. board at Umeastates:/Theart of A note on thePlay Leader's buletin amusing the patientwhile nature cures the disease." medicine consists of profusion and variety of play Adherence to this principleis evident in the Toys for children of all agesare placed equipment throughoutthe hospital. that children are eager toreturn for check-ups, in clinic waiting areas so. the doll pram or thebig remembering, according totheir parents' reports, truck rjither than thefinger pricks. equipment one might hope tofind in a hos- In addition tothe standard play community organizationsdonate presents and sur- pital serving children, whether or not' individual children .mayhave their own toys prises so that handmade Dolls, doll houses,.and boxes of delicately parents bring them. of delight with materials moreper- doll clothes affordchildren long hours toys. UmeA's program putsmuch, sonal than even thebest made commercial individualized approach toplay, not as an alter- emphasis on the petsonal, for. but in which is encouragedand amply provided native to group play, shopping carts andbaby addition to group play. Play staff members use the play department tothe bassinettes on wheels totransport toys from wards. miniature folk touch'is the collectionof antique and Another home-like Children arc encouraged glass shelves in'theplayroom. toys displayed on the theory thatthese ask about and tohandle the things, on to look, to the outside: "My grandmother pretties will remindthem of their life on Children too weak or toolonely for active this " has a doll like these pleasantassociations. play gain a senseof involvement through polyurethane foamchairs, In the living room cornerof the playroom, low who might covered in orange-redallow children child-sized and brightly Just sitting onsuch anything else to jointhe group. be unallp to do or a wheel like play thanwatching from a gurney furniture feels more with a swirlingpatterned On the floor, athick foam rug covered chair. maneuver andchange their per- terry cloth letschildren who cannot walk spective in acomfortable, stimulatingatmosphere. tables, puzzlesand paints, The play equipmentincludes sand and water di%abilities materials. Children with as well asblocks and construction cutnuts because standingboards with can have funwith the materials at the watertables unable to stand alone towork in groups allow children Sturdy lowwooJen buggies other children as theyplay. and socialize with children, whocannot otherwise with sand bags to keepthem steady allow manage, to ambulate asthey push them along. They form roomdividers, Doll houses are veryImportant in this hospital. -47- 00063 allow bedridden patients toplay together by are used asplayhospiell7and sides. Much of the furniture using bed. height dollhouses which open on two is hand crafted. structure for the youngerchildren is shaped like a 'A fibreglass climbing domed top. The lower part serves as aKiding'place mushroom with a removable for use as a with'round port holes to peek outof; the top can be inverted satisfyingly large but lightweight water table.The whole structure is enough,to be easily moved. and rug, is especially The reading room, withpolyurethane foam furniture cerebral palsy. Because many such 401dren hospitable to children with chill with Umea; theelibrary has apicture story book of a arc seen at It is entitled Cerebral Palsy who comes to aspecial treatmentschool. PLATS FOR VANNA(Place for Vanna) . aggression are absent.'Release comes Toys for theexpression of direct "Mousetrap" (highly recommended) about through the useof games such as washing up, painting, carpentry, and through activitiessuch as cooking, and waterplay. kindness in the environment.,She The play leaderspeaks of the need for materials, comfortable,yielding explains that this meanscolorful, soft furniture, and materialsfrom nature. the importance of everypatient's need to create some- She also stresses are limited in whatthey are able thing to give someone,especially if they step by step to usewhat little hand or She teaches paraplegics to do. "What it means to someonewho have to makesomething. foot control they saying 'thank you' toothers to at has had to lie inbed year after year 'thank you' to himfor a present!" last be able to makesomeone say for child-sized kitchens ... onefor pretend, one The playroom has two Visitors children don chef's capsand aprons. real. In the real kitchen, hear- of these chefs,appropriately garbed, are oftengreeted by a parade cookies. When there is no company, ing a fancy bundtcake or a platter of orderlies. they make partiesfor the porters and anxious mothers areas, wheretension can build as In the clinic waiting both parent andchild to relax. wait with anxiouschildren, toys permit in with them to take a toyfrom the waiting area Children are encouraged medical staffmembers es- while they see thedoctor. This also helps child throughthe toy. tablish quick rapportby relating to the -48- 00064 re HOLLAND QUEEN W[LHELMINA HOSPITAL,UTRECHT there in 1600. I Utrecht is a medieval city. The University was founded through visited the Queen WilhelminaChildren's Hospital there, escorted psychologists who assist the program by one of thelarge staff of social model for play in with the play program. He inforthed me that'the modification and operating use there waseclectic, employing behavior University from an experimental psychology.framework in contrast to the Bowlby, Robert- of Leiden hospital's programwhich is based on the work of ion and Anna Freud. psychologist Regarding parent involvementwith pediatric patients, the domain of the remarked that as play and playtherapy are considered the who tend to staff of play therapistsand social psychologists, parents; encouraged to focus on the child and preventhim from playing, are not stay around. AMSTERDAM department in Amsterdam whereI made a very At one hospital pediatric attempted in hospitals brief night visit, I wastold that rooming-in was Dutch throughout Holland in 1958 andabandoned as unsuccessful because hospital. Most mothers are too home oriented tospend the night in the deliveries still take place athome. "Besides," my informant added, the children?" "If-you fill up the bedswith parents, where will you put UNIVERSITY OF LEIDEN A corps of Leiden attachmentlisthe underlying concern. At the University population of 40 hospital- of 20 observatrices(including students) serve a teachers, usually women over22 years ized children. These are credentialed qualities from subjectiveobservations by the of age selected on personal prepares them tobe- health care teams. A further special two year course of teachers. come observatrices. Salaries are equal to those of encounters It is their job to encourageattachment and reduce the number -chile relationship the young children mustexperience.They keep the mother person-social going or sUbstitute forthe mother. They provide appropriate the infants' contacts to afew meaningful stimulation including limiting techniques in play Observatrices coach parentsregarding appropriate ones. parents are instructed and other assistance oftheir children. For example: children for procedures orparticipate in tests and not to immobilize their times a day. They arc advised to visitbabies at least three treatments. compensate for the ) It is the belief here thatthose frequent short'visits mothers' not living-in. -49- 000.65 child only Mothers come after 10:00 A.M. They feed and play with their own If a mother needs help learn- and do not participate inbathing the child. ing feeding techniques, sherooms-in afew days. and Observatrices look at thehospital.situation through the child's eyes "It is emotional intervene with their ownspecially,skilled knowledge. of, the ob- suffering the child experiencesin the hospital, and the role servatrice is to help prevent this,PI was told. She (or The observatrice tries to get-atotal impression,of the child. accompanies he) keeps records on the child'sreaction to treatments as she experiences as well as other the child to each one. Potentially frightening the next day are recordedand tests and treatments thatthe chlild.is to face Observations are followed up.with apprall;iateplai preparation and suppot. treatments, the observa- relaygd to the doctors. In preparing children for going to trices use a doll, a bear, or thechild himself to show what is then go over happen.t With older children, theyelicit past experiences and white box) with in detail the new experiences. A play hospital (a twb room representing parents, a ward and anoperating room with dolls to scale syringes and physicians, nurses, babies,is.used along with masks, tubes, anaesthd!ia as soon other paraphenalia. Children hold their own masks for handle their feelings," was as they ax old enough. "We prepare them to the observatrice's descriptionof the procedure. There ha has Each child spends one or twohours each day in theplay room. sand. Child- the opportunity to express'angerand aggression with water and and large, ward play is limited ren may use messyplay on the ward, but by children are to the less boisterousactivity. On the ten bed ward, most Each child has.a box of his owntoys stored underhis bed up and playing. in the and a bed table to use forplay. Tables and chairs are arranged Carts with special center of the ward with gamesand an aquarium visible. packing activities are wheeled daily ontothe wards. An outside yard has boxes and climbing equipment. which has its own Three workers are assigned tothe ten bed isolation unit special play.equipment. in the early 1950's. The prdgram was developedby Professor G.M.H. Veeneklaas and psycholog- Today, as nursing care becomesincreasingly patient-centered respective ically sophisticated there are someconflicts arising over the Because of the intensity roles of the observatriceand the nursing staff. patients, there arc occasionaldifficulties in of the involvement with the regular group keeping staff. Regular consultation withthe psychologist plus The Head Observatrite meetingslare scheduled to dealwith these problems. coordinates and teaches in thetraining program. -SO- 4v, 00066 DAY CARE CENTERS Although hospital connected day, care centers were not the focus of this study, I could not help but be interested in such programs when I en- countered them during my visits. Day care programs for staff children operate in England at,Felham and at Amersham. Stoke Mandeville had none. "Nurses are supposed to be nurturing people." the Matron Sister said. "What are we doing when we entice young mothers to lye their children to come care for someone else's?" FULHAM (CHARING CROSS) At Fulham Hospital in London, st ff children share facili*es and some parts of the daily progfam wi children from the Child Development day. Care, Center. When activ* es are suitable for the mixed group of handi- ti capped and non-handi apped, the group gathers as a whole. Where the differences in abilities and interests make a total group experience inadvisable, they divide. AMERSHAW, In place of the spinster mArried 'to her career is today's young nurse graduate, married and with a baby or two. At Amersham Matron Daniel has - established a creche on the hospital grounds for the infants and children of these young women. She was forced by circumstances to provide child Care because, one day the inevitable happened: I had no theatre sister. No one, and we had surgery scheduled. I called all the-women who had been working here in the theatre (operating room) earlier and begged each in turn to come help me. The answer was always the same ...'I'd love to help you -out, but I have no one to leave the baby with.' So I said, bring the baby here to me and I'll care.for That was the beginning of the creche where. children are cared for four or five hours while mother works. If mother works at night, she may bring the children to play while she catches up with her sleep. The children enjoy their stay and mothers have more time for play. and for concentrat- ing on their families because less of their home-time energy is spent in continuous cooking and child care. Matron Daniel arranges four hour shifts for all her staff who have young children so that they will not jdeprive their children of adequate mothering. Since the adoption of this plan, Miss Daniel said she has had less dif- ficulty keeping a full staff with more than twenty young mothers/sharing -51- 00067 ...AO!. recently trained nurse shifts. The plan .allows the hospital to use the without diminishing her effectiveness aseither nurse or mother. SWEDEN A In Sweden, each'hospital I visitedoffered gay care for children of staff, but discouraged infant care.. Pi commonfamily plan for'child care, I was told, is for 'each parent to carry onehalf-time job, share lousehold.and child rearing and use day care centers to cover anyremaining time needed. Day care centers are plentiful, wellstaffed and well equipped. DENMARK I visited three hospital based cent.rcin Denmark: one at Glostrup, one at HillerOd and one atRigshospitalet. Glostrup Glostrup Day Certcr is houses in twolow attract c buildings reachedby way of a wooded walk across the hospitalgrounds., Infants and pre-school age children are housed in one building;'the school alters in the other. In the infant and pre-school center, each roomhas its own color scheme and allthe belongings of that room are colorcodbd for easyidentification. In addition, each child has,his or her own symbolwhich is 'carried out on all hj.s possess- ions in each area ... for eating,bathroom and sleeping areas. Small., child height portholes offer children glimpses,their own size, of the world out- Innovative structures have been side. Toys are plentiful and beautiful. designed by a Finnish designer, Utti Lutker. One such storage unit has steps to allow a child to climb andsit while his shues are put onand in- cludes A series of low cubbies for the olderchildren and higher storage space for the yuungest. The whole edifice makes an attractiveand efficient multi-purpose island in one of the anterooms. Babies sleep outside year-round in a line-upof blue wooden buggies hooded to keep off the snow'andcovere& with infant size eiderdowns. Their mat- tresses are stored in a warming closetwhen.not in use, so that they will sleep warm during the winter, too. Much thought is devoted to maintaining goodparent-child and staff-child relations. .Frequent get-togethers take place atthe school. .,The occasions are social rather thaneducational. The director has plans'for a bistro area so.that parents willlinger when arriving and leaving, makingthe link between home and school even more associatedwith the parents. Children still bn the bottle get alltheir food requirementsinOuding formula for thb/pazent to take home from the nurseryschool This is to allow continuity of quality and save. parentstime for more playtime with their children. The older children get only a snackof dark bread sand- wiches at the end of the day in anticipation oftheir sharing dinner at -S2-. 06P68 ;01,11111,11 home with their family. Children breakfast at the Center at 8:30, have mid- morning salad, mid - afternoon juice and fruit. The older children have an exciting playground with many of the adventure "junk" materials so popular in Denmark. This includes a large row boat. The daycaXe center at HillerOd has, in addition to the manyexciting and beautiful p aythings for the infants and children, a specia.lvehicle room for the use of pare1ts in transporting their children to and from the t center on their way to work Many of the families who use-the center live on the hospital grounds in?partants built for the use of staff memberS. The vehicle room features wooden wagonS and buggies. A parent may leave his bicycle at the center at night, borrow a wagon and tuck his child or children in and trundle them home. Next day,fhildren return in the wagon, Dad .or Mother pick up their bikep and spin off "to work. The staff-chld relationship is'very good, and thatmosphere in the Cen- ters is comfortable. Pediatricians in Denmark stress tfie importance of keeping the Mother-child coupe together during the first years. Families get a child allowance' every three months to suppdrt mothers and enablethem to stay home. Mothers whp work are more likely to bring someone into the home for the youngest babies during their first year, but infant care in the centers is booming, and I was told that the centers cainotIlOpep up' with the demand. -53- 00069' CONCLUSION rt Intractable Problems Considered There.ar countriegSherethe entire family moves in and"sets up housekeeping when aember is hospitalized. This more prevalent in underdeveloped countrie than those with advanoed medicaltechnology where, since the days of Flore c Nightingale, hospitals maintain controlover patients' visitors andconsiderparents as visitors. Parental belief:in yielding responsibilityfor their child's supportto the expert profeisional has becomepart of many cultures evenas many con- cerned health p;Trfessionals now recognize the importance of the paientfor the. child during the crisis ofhospitalization. Hard as it once was to push parents out, it wouldnow take heroic efforts on the. part of the 'W stitution to turnaround the parental diffidenceand/or indifference that now exists. Unfortunately hospitals still relyon the parent to decide whetheror not to stay. That this decision cannot be fairly'placedon the parent was. dramatized in a survey conducted by severalSwedish hospitals with differing, visi'ing'hotrs. Each family was asked what hours seemedmost appropri-ate f them and each answered that ttre best hourswere those in practice at the ospital where they had their family member. Today, hospitals and professionalsare called upon to see what they can and are obliged to do in order to serve theii communitiesas centers of psycho- logical as well as physical healing. The child's need for care and attention remains the same no matter_how valid ard theparents' reasons for leaving him. Unless our institutions can proftte caring andintimacy, bring famine.) in and,help them see low important theyare to their individual members, we are threatened with a,society of indifferent, uncaring peoplea generation from now. . It would appear that organizations of consumersassisted by professionals are the most effective- agents for public education with regard to the nec- essary services parents should request of their institutions and theeffec- tiveways in which pressure can bennilled in order to bring about the meassaTy changes. NAWCH in England _and ACCH-in Canada and the U.S. are . good examples of such agencies. Happily, the trend is toward increased family involveMent. The mechanics an he good-will exist. e largest block remaining.is that of community d ca ion and communication. .5\ -54- 00070 REFLRENCES -1 England of Love, Pelican,1965. Bowlby, John. Child Care & the Growth Children in Hospital," British Brain, D.J. "Controlled Study of Mothers and 196-8;pp. 278-280. '"'"'" Medical Jburnal, 3 February, Office: Cathays Park, Cardiff Department of Health andSocial. Security, Welsh #23 and Appendix E, Children's CFI 3ND, England. Hospital Building Note 1964. / Ward, Published by HerMajesty's Stationery Office, Social Security, WelshOffice: Cathays Park, Cardiff -1/partment of Health and Children,'April 1971, Published CFI 3ND,i England..Hos-oital Facilities for by Her Majesty'sStationery Office. Wards: How Is It Working Dicker, Kathleen. "Unrestricted Visiting in Children's Out?," Midwife and RealthVisitor, 7:5:185, 1971. "ComparativeStudy of Fostering aProxy ParentalRelationship," Forbes, M. Prof. University. Unpublished Study, Departmentof Archeology, Cambridge, Play in Hospital, Faber &Faber, 1973. Harvey, Susan, andHales-Tooke, Ann. (About Great "Accoiiinodation for Mother Ina.Children's Hospital," Howlett, M.R. Oaks, 1971,36:406:162. Ormond Street) HospitalManagement Supplies, Seven ChrOnic Sick at Home and inHospital," Health Bulletin, MacLennan, W.S. "The Young pinburgh, 1972. 70:2:110. P1 ce Road, London,S.W.1WOSX, National Nursery ExaminationBoard, 90 Buckingham Your Career." England. "Nursery Nursing:. Make Children Hospital. Coming into Hospital, National Association forWelfare of Children in Farber, 1967. Noble, Eva. Play and the Sick Childf Lane, The Penguin Press,1971. Oswin, Maureen. The Empty House, Alan in Hospital, HMSO49 High Holborn, The Platt Report,1959. The Welfare of Children London WC2. k istbck, 1970. Robertson; James. -YoungChildren in Hospital, . Ta Parent'sye View, 0ollan&z,162. Robertson, James. Hospitals& Children: A Hospitals, Rosemary; Robinson, Davidand Pill, Roisin. Stacey, Margaret; Dearden, Paul, 1970. Children and Their Families,London: Rutledge and Kegan -55- 00071 REFERIENCES Denmark Junker, Karin S. Leko Teket:1 A Programfor Training through Systematic Play Activity, Stockholm. 1971. Junker, Karin S. Boel, Stockholm, 1972. Abdingdon Press, New York, Junker, Karin_ . The Child in the Glass'Ball, 1961. ,Dunker, Karin S. Selective Attention in Infants andConsecutive Communicative Behavior, Almquist and Wiksel, Stockholm,1972. wo Sweden Lagercrantz, Rutger, M.D., and Groth,Carl G., M.D. Departments of Pediatrics Essentials of the Swedish and Surgery, Karolinska Institutet\, Stockholm. of National Program for Preventive ChildCare, Issued by the National Board Health and Welfare, 1971. Holland II World Medicine, March 24, 1971, Bunyard,. Peter. Urgent Need of Attention, 4, -56- 00072 REFEMENCES Children's Books Dalstrom, Lean and Gydal, Monica. Ola Kommer till njukhnus, (Oln Comen'To The Hospital), Karolinska Institute, Stockholm,Sweden. Dyr10v, Kirsten, R.N.(et al. Per og Lise Har Sukkersx.ge. (Perand Line Hnve- Diabetes), Brochure from GlostrupCommunity Hospital, G1'ontrup, Denmark.. Jones, Anthony. Dan Berry Goes to Hospital, Chatto &Windus, 1967. Ladybird Books. The Nurse. National Association for the Welfare of Children inHospitals. Simon Goes to the Hospital. Rayner, Clare What Happens in Hospital, Hart Davis. Rey, M. & H.A. Zozo Goes to. the Hospital, Chatto & Windus, 1967. Films Details for ordering films'from Concord Films Council: Nacton,Ipswich, Suffolk in England. Robertson's films are also obtainable in U.S.A. through: New York Un versity Film Library 26 Washington Place New York, New York Outlook, BBC-2. "Your Child in Hospital." Lowenstein, H.& MacCarthy, Dr. "Parents and Staff in a Children's Ward." Lowenbtein, H.& MacCarthy, Dr. "Separation and Reunions." ,J r Scrutiny, BBC -l. "Children in Hospital." James Robertson's Filmson/BriefSeparation: "Johp!' "Jane" "Thomas" "Kate" "Lucy" ( Hardgrove,). "Care Through. Creating Space in Pediatrics," Univer ity of California Extension Media Center, 2223 Fulton Street, Berkeley, Ca. 972 . -.., 4.0 -57-