Play with a Purpose

It’s a busy weekday in the Pediatric Emergency Room at Monroe Carell Jr. Children’s Hospital at Vanderbilt. A toddler, brushed by a car while she was in her stroller, has just been brought into a trauma bay and the room is filled with doctors, nurses, emergency medical services personnel and police officers. The child is being examined and the mom is answering questions from many people. There’s controlled chaos in the room with every member of the health care team doing their job, but it’s overwhelming for the sobbing child.

Holly Tugman, a Certified Child Life Specialist for four years, watches from the hallway for a few minutes, then enters the bustling room. Her sole purpose at that moment is to calm the child. She walks up to the tiny child, being held by her mother. One doctor shines a light into the child’s eyes and another examines her limbs. With a soothing voice, Tugman makes eye contact, smiles, calls the child by name, and shows her a colorful kaleidoscope and a flashing ball. Instantly, she stops crying and reaches for the ball. The examination continues, without the tears.

“Traumas are chaotic. There are typically seven to 10 doctors and nurses in the room, usually with one at the head of the bed explaining what’s going on. Everybody’s talking at once. This child needed one voice, for just her,” Tugman said. “Sometimes the parents don’t arrive for a while, depending on where they’re coming from, and it can be very traumatic for little ones. I stand outside and read the room to see if it’s appropriate for me to be in there. If the child is awake and having a hard time, I need to be in there. In this case, I had her focus on me and the toys instead of all the craziness going on around her,” Tugman said.

Tugman is one of 22 Certified Child Life Specialists (CCLS), and four Child Life assistants, on staff at Children’s Hospital. Vital members of the health care team, they are trained professionals with expertise in helping children and their families cope with and be successful in their hospital journey.

In another section of the hospital Child Life specialists have just completed hosting a monthly bingo game for children seated near the Butterfly Stage area, and for those who are confined to their rooms watching on closed-circuit TV. Local radio personalities Woody Wood and Jim Chandler host the once-a-month game, sitting at a table on the stage and happily calling out numbers. Winners get to choose a donated stuffed animal kept in bins in front of Woody and Jim.

Following the bingo game, two Child Life specialists quickly set up tables with dolls and play medical equipment so patients can express themselves through play.

Several children select a doll and pick up a clipboard. Certified Child Life Specialist Katherine Bennett answers a question from a child. “No, we don’t do anything to hurt you. This is all for play,” she says. The doll’s “vitals” are taken and they go through “admissions.” Once the doll is examined and the child determines what the doll is being treated for, she advances to the medication table where the doll will receive appropriate care deemed by the child. This may include a cast or sometimes a shot.

A calendar titled “Lots of fun for everyone,” is designed by Child Life at Children’s Hospital each week and distributed to rooms and posted on elevators. It highlights the week’s activities, which, this week, include Movie Nights (“The Lego Movie” and “Frozen”), a visit from the Nashville Zoo, crafts, dressing up like a queen or a hero, and more crafts.

“Children in the hospital aren’t here because something good has happened,” said Stephanie Van Dyke, director of Child Life and Volunteer Services for Children’s Hospital. “They’re here because they’re sick or injured. We’re here to help them learn, cope and gain mastery during new or difficult circumstances related to health care experiences.

“When a child is hospitalized, it’s a disruption of that child’s ‘normal,’” Van Dyke explains. “We want to position a child in a setting that’s as normal as possible.”

Armed with a strong background in child development and family systems, Child Life specialists promote effective coping through play, preparation, education and self-expression activities. They provide emotional support for families and educate them about the needs of a child experiencing a hospital environment that can be long, stressful and often painful.

“We’re trained to make developmental assessments and follow the child’s cues to help empower them with the necessary knowledge and coping skills to be successful,” Van Dyke said.

Years ago, Child Life specialists were lovingly called the “Play Ladies.” Today, play is a big part of what they do, but “it’s play with a purpose,” Van Dyke said. Child Life specialists staff inpatient areas of the hospital including the Pediatric Critical Care Units, in addition to several outpatient areas such as the Emergency Room, Radiology, Surgery and four outpatient clinics. Child Life Assistants, with the support of Children’s Hospital volunteers, staff the hospital’s seven patient playrooms. Philanthropic support, including major support from the Junior League of Nashville (see sidebar on page 9), adds strength and depth to the program.

“When you see us in the playroom playing, certainly it might be diversionary,” Van Dyke said. “The child might be going stir crazy in the hospital, but often we’ve identified something that we’re working on with that child—socialization, expression or communication. It might look like we’re building with blocks, for example, but we may be working toward a common goal established by the health care team of refining a child’s motor skills,” she said.

“We know that children miss their friends when they’re in the hospital. They are struggling with anger or frustration because they miss being at home. They miss being at school. They miss their friends and they can’t attend their basketball or soccer games or their dance recitals. They don’t want to be sick.”
Erin Munn, a Certified Child Life Specialist since 1995 and at Vanderbilt since 2011, is assigned to the 7A pod of Children’s Hospital where cardiac patients are normally housed. Munn partners with another Certified Child Life Specialist, Annie Hickox, to provide education, therapeutic play and activity for patients with a cardiac diagnosis on 7A, the Pediatric Cardiac Intensive Care Unit (PCICU) and the Cardiology clinics each day.

Jose Gonzalez-Sanchez, 9, is visiting the Cardiac Clinic on a Thursday afternoon in May, his fourth visit since his heart transplant on March 21. Hospitalized from May 2015 until November 2015 when he was discharged to the Ronald McDonald House to wait for his new heart, Munn has often spent time with Jose several times a week. They have a bond, which is obvious watching Munn and Jose play with her child-size green puppet, Hank, who has EKG stickers with leads attached on his chest, as well as a velcroed pouch that sports a scar and opens to show a stuffed heart in his stuffed chest.

Jose has brought Teddy, a tiny stuffed teddy bear, to the clinic. Teddy and Hank (with Munn and Jose providing the voices) have an extended play time in the clinic waiting room while Jose waits to have a blood draw, which is upsetting for him.

Hank and Teddy play hide and go seek and Munn reminisces about prior visits while they play. “Remember when you were in the hospital and Teddy was playing with Hank and the ball you threw went right into the game we were playing and the pieces went flying?” Munn asks. Jose nods. “That wasn’t this Teddy,” he says. “That was another Teddy.”

Jose pretends that Teddy is sick. “Ewwww, did you just throw up on me?” Hank asks Teddy. Munn and Jose talk about many things as they’re playing—about what helps him not be scared during a blood draw, the frustration of a puzzle without all of its pieces and Disney World, where Munn is heading for a conference.

“I have always felt that it is a privilege to be a part of a child’s and family’s health care journey, and that feeling is multiplied when working with them over such long periods of time,” Munn said. “So often I am inspired by how the children and their families cope through such difficult circumstances—the long separations from family, home and community, and the stresses of life-threatening illness, treatments and procedures involved. Jose and his family have demonstrated such resilience and grace throughout their journey that I have been frequently humbled by their abilities to remain positive and focused on loving each other through all of it.”

Customized care

“Every child and family’s health care experience is unique to them,” Van Dyke said. “A child may have the same diagnosis as another child, and there are a lot of similar treatment plans and protocols, but how a child and family respond to their situation is different for every child. I think that’s what makes our service unique. We have the opportunity to find out what a child’s interests are and what calms them when they’re upset. What calms one child might not calm another. Our impact really varies depending on what the patients’ needs are. We can help almost customize how the child and family need to navigate this anxiety-provoking, unfamiliar and often painful unknown.”

On the third-floor Outpatient Surgery Unit at Children’s Hospital, Certified Child Life Specialists Amy Kaufhold and Leanne Lackey check the patient census for today’s procedures.

Patients who will benefit from Child Life services are highlighted.

Kaufhold takes a tote bag filled with toys and distractions to visit a 4-year-old boy having his tonsils and adenoids removed. He is quiet. His mom appears to be anxious. Kaufhold talks to the red-haired boy, dressed in green hospital pajamas and bright yellow hospital socks, about the “sleepy air” he will soon breathe through a mask to anesthetize him for the surgery. He chooses raspberry- scented air (he’s offered several fruity scents to choose from) and an orange Popsicle to nibble on when he wakes up after surgery. But the boy tears up when he realizes he’ll have to leave his mom to go into the surgical suite. Kaufhold asks him if he’d like to drive a Cozy Coupe child’s car around the 22-room holding area. He dries his tears and is soon driving the red and yellow car quietly up and down the hallway with his mom trailing behind.

“There are 10 to 15 people in and out of the room before his surgery. Stranger anxiety in an already emotionally charged atmosphere adds to the stress many children and families experience when coming for surgery,” Kaufhold says. “A lot of a children experience anxiety due to lack of control when they’re in a strange place. Any control we can give back is helpful. Driving a Cozy Coupe normalizes the environment. We have princesses driving down the hallway and waving to the staff every day.”

Child Life specialists, whose profession began in the 1920s, have degrees in child development or a related field (the names vary depending on the university), but the one thing they all have in common is that they’ve completed at least a 480-hour Child Life internship under the supervision of a Child Life specialist, and have passed a national professional certification examination. Vanderbilt accepts eight to 10 students each year, including practicum students and Child Life interns.

Van Dyke said the Children’s Hospital’s Child Life team works as much for the family as for the child. “Sometimes we work with siblings. If we have a child who is going to die, we do legacy building and memory making for their families. We talk to brothers and sisters and help empower family members to talk with siblings or other family members about death. Sometimes it’s working with friends who have come to say goodbye to a friend who has been in a tragic accident or who is dying.”

Scott Bilbrey and his wife, Elizabeth Bednarcik, know firsthand how valuable a Child Life specialist can be to the entire family.

In 2014, their 2-year-old daughter, Ella, lost most of her right foot when she slipped under a lawnmower. Because of the injury and 13 subsequent surgeries at Children’s Hospital for skin grafts, and to remove dying tissue, she lost most of her foot except for the heel.

Certified Child Life Specialist Stephanie Hegel was the family’s “go-to,” Scott said. “She was at most of our appointments in the clinic and was there after each surgery. She took care of everything.

“We leaned on her a lot during that first year. I don’t know what to say about her, because there’s so much to say about her. She sat with Ella when she saw how scared she was. She’d blow bubbles for her or read a book to her. She calmed her. She was an unbelievable resource for us, preparing us for what was coming. She took care of every little thing we needed, and trips to the hospital became easier when we’d tell Ella she’d get to see Ms. Stephanie. She was a consistent and familiar face.”

Although she has a prosthetic foot, Ella, now 4, prefers to wear a shoe filler instead, her father said. “She’s a miracle kid. They told us she might not walk for a year. Less than a week later she had already worn out the plaster on her first cast. She’s had 15, none for more than 10 days, because she’s always on the go. She plays soccer, T-ball and gymnastics. She doesn’t limp. She calls her foot her ‘Super Stomper,’” Bilbrey said. “She truly thinks of it as a superpower and likes it because nobody else she knows has one.”

Hegel is working today in the fourth-floor Doctors’ Office Tower Orthopaedics Clinic. She is in her office preparing a rolling orange backpack stocked with toys and tools of distraction. A Certified Child Life Specialist for five years, she works in a bustling clinic which sees over 100 patients each day. She focuses her work on children who may experience painful or anxiety-provoking procedures or need specific education about upcoming surgery or treatment. Chip, a teaching puppet, is seated nearby, equipped with gauze that can be unwrapped to show pins, plates and screws that children might have inserted for fracture repairs and a foot that even comes off to demonstrate amputations. Today, a few minutes before she presents a patient education document she has prepared to the Patient Education Committee for approval, she visits a young boy, his sister and his parents who are waiting to see the pediatric orthopaedist. The boy, who slipped on a wet floor, has an open fracture to his right thumb, and he’s waiting to have the dressing changed. Hegel makes the assessment that some distraction is needed during the procedure, which will likely alleviate the need for sedation, making the procedure safer and shorter for the patient. But for now, Hegel gives the boy and his sister crayons, encouraging them to draw on the paper lining the examining room table while they wait. The sister asks for a coloring book instead. Hegel returns to her office, grabs a coloring book, then goes back into the examining room. The physician is running behind.

The crayons and coloring book will offer a good distraction for the children.

Van Dyke, who began her Child Life career with Vanderbilt 23 years ago, has dozens of notes and drawings sent to her from grateful Children’s Hospital patients and their families. One, written in a child’s handwriting, is tacked to her wall. The young boy who wrote it is now out of college.

It says, “Thank you for making it fun.”

“He had cancer, and there’s nothing about cancer that’s fun,” Van Dyke said. “But that was his thank you to me.”

– Nancy Humphrey