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1.RESEARCH TOPIC

Restorative Benefits of Paediatric Ward as a Play Environment in Nigerian Hospital

2. RESEARCH AIM

The aim of this study is to investigate the restorative benefits inherent with play

activities in a paediatric hospital setting.

3. RESEARCH OBJECTIVES

The following objectives are formulated, to achieve the stated aim.

i. To identify the problems patients and caregivers are facing due to lack of

play and activities in a hospital ward;

ii. To observe the benefits of play using “loose parts” as it affects children and

improves their restoration towards a feeling of well being; and

iii. To develop a guideline as to how future paediatric hospital settings will be

designed to provide restoration based on children's preferences.

4. ASSUMPTION

There is growing evidence that stress and anxiety has attracted attention from

researchers, health care provider, and designers. Which shows that hospitalized children

are faced with psychological challenges which affect their hospital stay? This is as a

result of their new and unfamiliar settings, which add stress and in return delay their

restoration (Dise-Lewis, 1988; Varni and Katz, 1997; Varni, Rappaport, and Talbot,

1991).

It isfor now an assumption that if the paediatric ward can be changedinto a play

environment, where patients can play with elements and materials from the theory of

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“loose parts” under monitoring in line with hospital and medical protocol. It can

improveon a child's ability in coping with stress, and to adjust their emotional state,

social connection, physical development, trust and acceptance of routine medication.

5. RESEARCH QUESTIONS

i. Why would a paediatric ward being conceived as a play environment have

an effect on patients psychologically, and improve on their feeling of well

being?

ii. What are the measures taken in providing children with play experience in

the paediatric ward?

iii. How would children perceive the hospital ward, looking at setting as a play environment?

6. RESEARCH BACKGROUND

Most of the present paediatric ward settings in Nigerian hospitals deliver health care in

relation to protocols and medical norms. The hospital only considers pathogenic

approach in the format of biomedical treatment of illness and control of the spread of

disease. With emphasis on the provision of equipment and facilities that adds

functionality to some extent, but psychologically inefficient to improving the well being

of patients. The formal introduction of western medicine in Nigeria was dated back to

the 1860s, when the sacred heart hospital was established by the Roman Catholic

missionaries in western Nigeria. The first set of catholic priests arrived in Abeokuta on

the 29th of June 1880 and the first catholic missionary sisters on the 3rd of March 1886.

It was at that time that health care delivery entered Nigeria, by meeting the medical

needs of the communities, especially children at the mission homes. The missionaries

were the first health visitors to bring western medicine to Nigeria, they played a vital

task in providing modern health care in Nigeria inthe 1960s, they operate about 40% of

the total number of missions based hospitals (Manuwa,1971).

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The mission also played a vital role in the training and education of medical personnel

and with further advanced training abroad; these were based in areas that they have

religious influence and other activities. By 1954, almost all the hospitals were operated

by the Catholicmissionaries, the Roman Catholic with the Sudan interior mission

operated other facilities in the northern part of the in the country which remain as part

of health care facilities up to the 1990s (Manuwa, 1971).

Figure 1: The Sacred Heart Hospital, Abeokuta, Nigeria Established in 1880, this

shows the indoor setting of the ward.

The present day architecture and settings of the paediatric hospital environment is of the

traditional missionary style improved upon through the last five decades after

independence. As shown in Figure 1, emphasis is on the provision of medical care, and

prevention of the spread of disease. As such the environment is more for treatment and

housing of medical equipment, beds, cabins, hangers, nurses’ station, and aisle for

movement, toilets and bathrooms, doctors call rooms, dressingroom.As such the

spaceprovided and distance from one bed to the next does not allow for room and

spaces, especially in the children’s ward for free movement and play activities.

There is a lack or minimal consideration givento other environmental and physical

features that naturally improvethe healing process and patients feeling of well-

being.This shows enough reason for caregivers, hospital management and designers to

start looking for avenue of changing the present hospital settings with features and

conditions for creating a restorative environment(Monjour and Yisong, 2012).

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It is evident that the hospital designs have failed to incorporate an enabling

environment to neutralize unsuited seen that positively affects the psychological needs

of patients, caregiver and family members(Monjour and Yisong, 2012). The paediatric

ward design is based on adopted conventional format, adults’ views, health policies and

protocols (Figure 2).

Figure 2: A view of nurses’ station, beds spacing and condition of the hospital ward

The contribution of the physical environment to the healing process has been accepted

for many years. In 1863, Florence Nightingale discovered and practices the benefits of

exposing patients to fresh air, sunlight, water body, vegetation, and animals. Exposing

patients to environmental factors and features, as well as socializing with other patients

and caregivers to enhance their recovery processes. It means that physical settings can

enhance the effect of medical treatment and recovery statue of a patient. Studies in the

field of human medicine and other related areas like human development,

environmental psychology and health care,hasindicated that there is relationship

between nature, human, and well being. The Biophilia hypothesisof (Wilson, 1984).

Stated that human beings have a natural instinct with nature for their psychological,

emotional and spiritual needs (Derr and Kellert, 2012). Human desire for natural

settings has been established by much research work, which shows that nature offers an

avenue for a feeling of well-being and re-cooperating from the effect of acquired stress

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(Joye and van den Berg, 2011). A further study on health outcome and feeling of well-

being is the Antonorsky’ssalutogenic concept, an approach to health. The emphasis here

is that well-being has a relationship with human activities, social relationship andwith a

strong belief and good will from family and friends human health can improvetowards

feeling of well-being (Dunleavy et al, 2012).

7. PROBLEM STATEMENT

The thought of conceptualizing a paediatric ward as a play environment is to

fosterrestoration to hospitalized children in Nigerian paediatric hospital wards. This can

be attained by changing the present hospital ward settings with positive distraction, such

as play activities for paediatric patients as part of their normal hospital ward.This is as a

result of lack of provision of any kind of features or settings that can improve on

children’s coping skills and distract their attention in a positive manner.As children are

taken to hospital, they noticed that the environment is different and away from their

home and school environment,which is familiar and give them room for playfulness,

and to a new environment that is unknown and unfriendly. They are highly introduced

to different foreign objects and different, unfamiliarpeople potentially causing them

considerable fear, stress and anxiety. For a child with a vivid imagination, anything can

be terrifying.The usual practice is set of personnel all dressed up neatly in white

uniforms with hypodermic injections with needles for blood draw, temperature

thermometers and weight measurement scales or posture still for scanning and X-ray

test. As such, they consider the hospital environment threatening and they can develop

additional stress and trauma during a doctor's appointment orhospitalization (Said,

2006).

Children need an environment that can direct their attention away from pain and

anxiety, which can be achieved by exploring the use of structured playusing elements

from loose partsto enhance children's performance. In connection to the

childrenphysical, cognitive and social functioning.Despite the many positive research

carried out in developed economies around the worldson improving children

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hospitalization.In relation to minimizing their stress, painful experience and reducing

their length of hospital stay (i) it is evident that such efforts in the Nigerian paediatric

health care environment have not been givenmuch priority, and (ii) the climatic

condition in the study area does not allow an enabling environment to employ finding

from studies conducted in other developed economies around the world such as

Malaysia in the areas of garden and landscapemostly outside the ward. Because of the

shorter periodof raining season within a year, and lack of enough water provision which

makes it very expensive to maintain either a garden or landscape in almost all the

hospital environment.

Playing in an organized setting in an indoor environment can be used to replace the

outdoor play features that are found in gardens and landscape environments. And

children need not to come out into the harsh whether to play.The provisions of synthetic

loose parts indoors can be used to trigger their attention positively to attain the needed

objective of restoration in relation to their healing. The hospitalenvironment and

settings should be able to assist with their restoration towards improving their physical,

social, and cognitive development.This forms the three main features of human

development which expands during the process of human growth.The physical

development involves physical growth and maturation which include gross motor skills,

which involves large muscles of the legs and arms that are used in running and walking,

and fine motor skills which have to do with fingers, toes, eyes and other parts like the

brainthose are used for activities such as drawing, writing, grasping objects, throwing

and catching. The cognitive development is linked to changes in person ability to reason

which involves stages such as a sensory motor stage, the pre operational stage, concrete

operational stage and the formal operational stage. And the social development is linked

to the changes that occurs as a result of person ability to control his or her feelings. The

three areas of development are different in a way, but they work together and influence

each other.The physical development of the brain, allows cognitive advancement to

progress and think of a solutions in different ways, and the same cognitive involvement

gives room for better social and emotional feelings (Mcdevitt and Ormrod, 2004).

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A child's health care environment restoration can be defined as stress reduction in an

unthreatening environment which allows for physical movement and exercise (Ulrich,

2002). It is as a result of locomotion, physical and social interaction of person with the

features and element of the environment. Which can be explored through play, as play

is the most important activity in the lives of children and as a medium of interaction

with their environment. On the other hand, healing or restorationis defined “as the

casual relationship of man with the environment, the cause is the physical elements and

the natural forces of the environment” (Said, 2006). Studieshave shownthat restorative

environment is conceived as places that provide an avenue for recovering from stress,

and renewal of health, and the ability to focus attention (Hipp and Ogunseitan, 2011).

The health benefits of restorative environment are highlighted by the attention

restorative theory (ART) of Kaplan and Kaplan (1989) and Kaplan (1995).The

theorymaintains that coming in contact with the natural environment has the ability to

improve patient’s cognitive attention, which promotes human interpersonal and social

functioning.The theory argued that an experience in an environment which is

compatible with one's preferencecan enhance physical, psychological and social

wellbeing especially when there is amount of time spent in that environment (Hansen-

Ketchum et al, 2011).

The participants in this study explainthat places in nature or activities that providedthem

with the sense of feeling like being away from the stress of modern life.Relayson

participant preferences which include a chance for unstructured play, view of water

bodies and quietness among others. Further studies on the restorative environment as

explained by (Said, 2008).“Is that the restorative environment, restorative garden,

therapeutic landscape, therapeutic garden, healing garden, healing landscape, often

refers to the same thing and carry a similar meaning, which means, recovery from

illness, diseases, injury, or other impairment.”

Studies in paediatric nursing have shown that medical protocol and the hospital settings,

increase stress and negativehealth effect on children. They show signs of

aggressiveness, fear of pain, emotional regression, loss of appetite and sleep which

further result in adding more illness (Nandineni, 2013).Such problems were due to

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factors like fear of illness, new environment, and changes in their usual activities.

Anxiety has been reported to be the most stress related child’s experience, many

developing nations such as Nigeria, have their peculiar problems which increases the

level of anxiety experience among hospitalized children. Examples are lack of proper

funding, high poverty level and implementation of few conducted research. A

compilation of the causes of child hospital stress by Coyne (2006) in(Jolley, 2006).

Found the following as the causes of stress during children hospitalization.

(i) Separation from family and friends:Disruption to the family routine, normal

activities, peer relationships, school achievement;

(ii) Being in an unfamiliar environment:fear of the unknown, strange

environment,professionals, noisy ward, and bright lights at night, hot

environment, inadequate play facilities,and food;

(iii) Receiving investigations and treatments: Fears of operations, needles,

mistakes in treatment, harm to body, pain, dying; and

(iv) Loss of self-determination: loss of independence, restricted activities,

lacking control over personal needs, lacking control over sleeping and

waking time, lacking control over food / meal times, lacking control over

timing of procedures.

Because of the extended family system practiced around the study area in Nigeria.

Where people stay together in a large family house and children grow up among many

age groups and peers, it is very difficult for a child to cope with isolation as a result of

being sick. Being in a different environment, and not use to eating or sleeping alone

without their siblings and friend. Fear of the unfamiliar and unforeseen, not able to play

at will among peers and move around at the child’s own time. Such situations may add

up to his worries and additional stress during hospital stay.

Another study by Wilson et al. (2010) concurred that children felt lonely and scared in

the absences of their siblings in the hospital environment. They are afraid of routine

experiences and unknown possibilities. It's evident from studies that stress has a natural

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attachment to hospital stay, an experience which can accumulate and accelerate patient's

sickness. Children respond to these fears by requesting to have parents nearby, having

familiar objects with them in the hospital or asking to go home.

Feeling of Stress and anxietycan be minimized in the cause of children hospital stay,

when children physical and social environment relates to their perception of assumed

hospital settings (Adams et al, 2010). Same study has shown that when children are

involved in studies about matters that concern them, theirneeds will be further

identified, elaborated and taken into consideration. “Play is a child's way of establishing

authentic relationship with the social and physical world” (Moore, 1986). It is important

that children play spaces are transformable, providing “loose parts”, which are items or

materials that children can move, adopt, control, change, and manipulate within their

play (Derr and Kellert, 2012). They are essential elements of a rich childcentred play

environment, which can enhance restoration, with regard to stress, their emotional state,

social connection, physical development, trust and acceptance of routine medication.

To be able to find out the level of awareness, and to investigate on how children are

coping with stress in Nigerian paediatric hospital settings. A preliminary survey was

conducted on 15th January, 2013, atAbubakar Tafawa Balewa University teaching

Hospital Bauchi. 49 questions were given to caregivers with the Nurses as respondents

(male = 10, female = 39). The question is on their level of awareness as caregivers

about the benefits of restoration for hospitalized children. The questions are, (i) Can

play activities enhance patients feeling towards restoration, (91%) are aware of the

effect of the play on hospitalized children, (ii) Can play environment fascinate patients

to behave like healthy children, (81%) believe that it is possible, (iii) Can the ward

viewed as a play environmentto make children feel at home, (89%) agreed, and (iv) Can

play environment, improve on child psychological well-being, (93%). Based on the

analysed result, it shows that there is a greater level of awareness on the part of the

nurses, the majority of the Nurses reported to understand the advantages ofin

cooperatingplay and play activities in the paediatric settings.From another result of

preliminary study, with mothers as respondents, it shows that the greater percentage of

hospitalized children as at the time of the survey are 75% boys and 25% female, from

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the age of 6 years of 16years which make (57%) of the patient population, on their

length of hospital stay, (62%) have been hospitalized for three weeks. As to their mood

and behaviour during admission, (37%) reported to be in a depressed mood. On the

question of whether the environment can influence changes with regards to their child's

attitude, behaviour, and response to medication, (97%) responded positively as they

equally believe that play can distract and motivates a child when in an environment that

will enable them the chance to be involved in play, especially with their peers.

From the result of the preliminary study, it showed that children do not have the means

of benefitting from any features in the ward environment. As a result, they lack the

needed means of distractions which can improve on their restoration process since their

hospital ward only offers a pathogenesis approach toward medication. This is because

the design and setting of the ward are inclined towards the provision of medical care,

and prevention of the spread of disease.Further discussion with hospital staffs, shows

that the research will be of relevance to the present hospital environment. The

contribution drove from the preferred physical environment towards restoration, and

positive trend towards a feeling of wellness had been pointed by many researchers

(Abbas and Ghazali, 2010). “That the physical environments also contributetowards a

better quality of life not only for the patients, careers and staffs but also the visitors.”

The availability of positive means of distraction can reduce the level of complainingto

the caregivers and equally reduced on their work stress. Having in mind that researches

with children in a hospital context are has a lot of difficulties.Results of similar studies

was conducted by (Bishop and Said, 2012). Lamented on issues that bother around

qualitative research with children, part of it is lack of cooperation from the medical

personals and professionals in the medical circle in accepting this type of research work

looking at it from the point of their professional ethics. Other challenges are associated

with getting the right sample population and for the person conducting the research; he

is faced with the problem of getting ethical approval, having access to the patients at the

appropriate time and the conditions attached to medical protocols. Despite the barrier

between medical norms and play activities in the hospital environment, and if the

research on the restorativeness of play to children is established, then there should be a

way to blind the hospital norms and play together to benefit the hospitalised children.

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8. RESEARCH GAP

Research on the causes and benefits of restoration, in healthcare environment had been

approached from different perspective of the study.As compiled by Sachs(2013).

Environmental healthcare research that involvestherapeutic,restoration and healing and

is concentrated on the provision of outdoor facilities. Few out of the many studies are

listed in the Table 1.

This shows that most of the researches undertaken are concentrated on the outdoor

environment. Studies in the field of psychological benefits of nature to man have

focused less on the indoor environment(Bringslimark et al,2009).This is a gap that

needs to be attended a research attention, especially in developing countries like

Nigeria, where health institutionscannot maintained a garden or landscape as a result of

finances that will be involved. studyby(Derr and Kellert, 2012).Further stated that less

emphasis is given to indoor environments. Where children activities that involves their

physical, social, and cognitive as well as healing usuallytake place in an indoor

environment, under protection in a conducive atmosphere.

It is evident that stress and anxiety are caused as a result of children's hospitalization

and the need for them to adapt to their new environment, routine and medical

procedures. Moreover, the causes of stresses to children during hospitalization are all

found within the indoor hospital environment. That is why the study tends to look at

how to provide a remedy within the indoor area, not outdoors where restoration can

have an effect after stress and related anxiety has been acquired. The approach in this

study is to provide an avenue fora child’s restoration by looking at the ward as a play

environment in a different dimension from most research and studies on in

therestoration in outdoor environment.

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Table 1: Selected areas of previousstudies thatcentred on childrenrestorationand their

ability toplayin a paediatric hospital setting during hospitalization

STUDIES IN RELATED FIELD

FINDINGS UNIT OF ANALYSIS

CONTEXT PARAMETERS

Building a model of Holistic Healing environment for children Hospital.Fiona de Vos.2006

- Patients require adequate food and sleep.- Freedom of being part of the decision.- To have a sense of security.- Social support from caregivers and peers.- To be provided with positive distraction, so as to be engaged and have their mind off their sickness.- Freedom of choice, mobility and routine.- Changing the environment settings to make it less stressful.

Children's hospital of Westchester medical centre (WMC) and its replacement. The new Maria Fareri children's hospital (MFCH) in Valhalla New York.

-Children's hospital as holistic healing environment.-Comparing the existing and new hospital.-Understanding the impact of the environment on people.

Garden as a restorative environment for children in Malaysian Hospital.(Said, 2006). Ismail bin Said2006.

- From the findings, it is evident that children interact more actively with the play equipment provided in the Garden than with the plant.- Children preferred manipulating play equipment to the one that is non manipulating.- The conclusion here is that the garden properties that foster restoration process are as a result of the play with features and equipment of the garden.

6 -12 years Children's hospital in Batu Pahat and Segamat hospital both in Malaysia.

-Properties and attributes of garden.-Determining behavioural response in the ward.-Determine change of behaviour with experience attribute of the garden.

Play and playfulness among hospitalized children(Ryan, 2011). Katherine S. Ryan2011

- Study shows that children do play during their hospitalization.- They find ways to play without the help of child life support, parent or other health care worker.- It shows that playfulness usually increases as from admission to the time of discharge.

-Hospital paediatric environment and home play environment.

-How does play occur among hospitalized children?-Evaluate play in hospital and home.

From their perspective children and young people’s experience of a paediatric hospital environment and its

Findings show that understanding what constitutes a child friendly environment are feeling of well-being, person environment fit, and environmental congruence.

6 – 19 years Paediatric hospital environment.

-Children participatory research.-Physical environment to

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relationship to their feeling of well-being(K. G. Bishop, 2008). Katherine G. Bishop2008

well-being.-Participatory research for design

9. THEORETICAL FRAMEWORK

In recent decades, various studies on health carehave focused on the effect of the

hospital environment in reducing negative experience of hospitalization of patients,

especially children (Monti et al., 2012). Based on research findings, hospital

environmental settings can positively enhance patients'behaviour, stress coping abilities

and improve on their feeling of well being. Furthermore changes in healthcare

environmental settings, giving consideration to users' preferencescan improve on

patientoutcome (Ulrich, 1984; Venderber and Reuman, n.d;Davidson, 1994; Cesario,

2009; Adams et al., 2010;Monti et al., 2012). Facilitates recovery, reduces pain,

improve acceptance of medication and shorten length of hospital stay (Ulrich, 2002).

The study ofthe human needs of nature in an environment is all centredon the Biophilia

concept of Edward O. Wilson. He stated that “The inherent human affinity to affiliate

with natural system and process” (Wilson, 1984).Wilson added that Biophilia is seen as

“The predictable fantasies and response of individuals from early childhood onward. It

cascades into a repetitive pattern of culture across most or all societies, a consistency

often noted in the literature of anthropology” Hedescribes Biophilia as a rule found due

to stimulation, as a result of contact with nature or representation of nature, which cover

the physical, psychological and cognitive benefits. More recent study by (Kellert et al,

2008). Have further elaborate the study to include human activities such as learning,

physical and social experience which can improve on the relationship between human

and their natural environment. The “Biophilia hypothesis and supporting research tell us

that as a species; we are still powerfully responsive to nature forms, processes, and

patterns” (Ulrich, 1993; Kellert et al., 2008).

The perceptionof the restorative benefits of having contact with nature is very old, study

by Ulrich (1984).Tested the effect of window views on hospital patient health outcome,

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where he noted that patients that have their rooms with windows viewing an outdoor

landscape feature.Withtrees and lawns uses less medication and have a shorter length of

hospital stay. Than those that have their windows focused on viewing an outdoor brick

walling. Before undertaking that research, he conducted a preliminary finding using less

stressed patients that viewed images that portrays natural settings.This shows that the

images of natural settings have a positive emotional shift than those that viewed images

of urban settings. This is to show that viewing natural settings improves one'sbehaviour,

coping abilities from fear and anxiety. Another study by (Moore, 1981).Show similar

evidence, where he recorded 24% of additional sickness increase among inmates whose

prison cells are viewing the prison courtyard, than those whose views are directed to the

farmland.The human linkage with nature is natural, which applied to children. Lack of

access to this natural connection can cause a possible disorder to children physical,

cognitive and social behaviour, such barrier from nature can be as a result of child's

hospitalization. Children are confined within hospital ward environments, which pay

much attention to treatment of sickness, with less effort towards their psychological

well being.

Theories on human development can serve as a guide, and stimulate further inquiry or

research about human cognitive development, behaviour, emotional state and social

interaction with other human in an environment. The history of human psychology

cannot be written without discussing the contribution of the psychoanalytic theories of

(Sigmund Freud; 1856-1939). “He postulated that personality development involves a

series of psychosexual stages. Each stage poses a unique conflict that must be resolved

before passing to the next stage. He proposed the 3 stages of being.The id: which seeks

self gratification? The superego: This seeks what is morally proper. The ego: This is the

rational mediator between the id and superego”.

For Freud, the stages from birth to age 7 years were more important to the development

of the basic personality structure, which he said are of two types and referred to as

periods, latency and genital? Latency period corresponds to the middle childhood years,

where children suppress most of their sexual feelings and become interested in games,

sports, and friendship, boys’ associates with their boys counterpart and girls with girls,

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sexual reawakening occurs at puberty. The genital period is where young people begin

to experience romantic feelings, emotions and desires to have a satisfactory sexual

relationship. His emphasis is on the environment, not biology or heredity, the principal

factor in mental health and illness. He is famous for formulating psychosexual stages

and therapeutic “technique to bring unconscious thought and feelings to conscious

experience.”

In contrast to Freud’s views, psychiatrist, Miller thought that relationship are the central

needs of human life, and problems are caused by relationship disconnection. She states

that personality growth occurs within a relationship and that an infant responds to the

emotion of caregivers. The goal is to continue to form intimate relationships not for

anatomy or individualism (Miller and Stiver, 1997). Erik Erikson (1902-1994) built his

psychosocial stages of development;his own findings were that personality continues to

develop over the entire life span. His views emphasis on successes, greatness, and

human potentials, his main concern is the psychosocial development of a person within

a social context. This context can be related to paediatric hospital ward, making the

environment conducive for hospitalized children.To be involved with their peers in a

play activity this will result into physical and social interaction. As a result, they will

not miss that stage of development due to illnessand hospitalization. Erikson developed

8 major stages of development with the 9th theory published by his wife which he

passed through before his death. Each stage poses a unique development task and crises

which individual must resolve, he prefers the term (opportunity). The stage that

involves this study is the Industry vs. Inferiority confusion. 6years to stage of puberty.

Children are at this stages are inquisitive and more Curious about how things are made,

formed or work, they want to try and bring out a new thing. They develop a sense

developing out of what they imagined, mastery and competence (Erikson, 1968a).

Another theory that deals with human development is the Behavioural theory, as the

name implies. It is concerned with the observable behaviour of people, “what they

actually do or say”. Behavioural theory are as a result of responding that separated the

environment into units called stimuli, interest is how people learn to behave in a

particular way. Those that formulated the theories are Ivan Pavlov; (1849-1936).John

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Watson; (1878-1958). B. F. Skinner; (1904-1990).“Says that people do not go through

distinct stages, but do go through a continuous process of behavioural change, due to

respond to environmental influences called external stimuli”. The process whereby an

activity or event strengthens the probability of another activity or event occurring,

e.g.Gift can encourage a child’s school performance. “A psychologisthas understood

that human behaviour is not simply a mechanical process, which involves the bringing

together two activities or events that happen to occur in a context closely in time.

Organisms do not pair events in a vacuum, the environmental context is critically very

important. From cognitive learning perspective, organism only learns when events

violate their expectations”(Watson and Tharp, 2001).

The “third force in psychology in reaction to the established psychoanalysis and

behaviourism is termed humanistic psychology” Human are different from all other

beings, that they can intervene, control and change their destinies, and be able to modify

their environment to suit the way of life. They take a holistic approach, one that views

the human condition in its totality, and each human made-up is more than a collection

of physical, social and psychological components (Maslow, Frager, & Fadiman, 1970).

Abraham Maslow (1908- 1970) and Carl Rogers (1902-1987).“They are concerned with

maximizing the human potentials for self direction and freedom of choice”; (Maslow et

al, 1970; and Rogers, 1970). The Maslow key concept is the hierarchy of needs; he felt

that human beings have certain basic needs that they must meet before they can fulfil

their other developmental needs. The “fundamental needs are food, water and sex, other

needs that focused on belongings are love and self esteem and the need to realize ones

unique potentials to the fullest which he termed self actualization” (Maslow et al.,

1970). Such stated goals in the case of children can be achieved through play, because it

is an avenue for them to explore their potentials. “The goal of humanistic therapy is to

help a person become more self actualized, that is to guide the client to self directed

change. Building self esteem along the way, in contrast to psychoanalysis and behaviour

modification which are directed more by therapists”.

Cognitive psychologist is interested in the “cognitive structures and processes that allow

a person to mentally represent an event that goes on in the environment”.Jean Piaget;

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(1896-1980). Piaget’s concentrated on changes that occur in the child mode of thought.

Central is the cognitive stage in development, which sequential period in the growth or

individual ability to think, to gain knowledge, self awareness, and awareness of the

environment (Piaget, 1964). Children engage in a continual interaction with their

environment, they act on, transform and modify the world in which they live. In turn

they are shaped and altered by the consequences of these interactions. This interaction

leads to a new perception of the world and the new organization of knowledge.

Basicallyhe saw development as Adaptation, children gradually modify their repertoire

of behaviour to meet environmental demand, by interacting with their environment

during playand other activities, and children construct a series of schemas (concept or

model) for coping with their world. (Schemas are cognitive structures, which people

construct to deal with their environment). Adaptation involves two processes, which are

assimilation and accommodation. Assimilation is the process of taking in new

information and interpreting it to confirm with the current model of the world.

Accommodations is the process of changing one schema to the reality of the world

(Rathunde and Csikszentmihalyi, 2006). A balance between the two is equilibrium.

Another cognitive theory is that of Albert Bandura, “cognitive learning which occurs as

a result of watching other people, we learn new responses without first having the

opportunity to make the responses ourselves”. This process is termed “cognitive

learning” (it is also termed, as observational learning, social learning, and social

modelling) (Bandura, 1975). Further cognitive research is the socio-cultural theory;

“where children socialize to think of themselves as being part of a group or community,

rather than an individual at odds with those in the vicinity” (Views regarding cognitive

and language development). Lev Vygotsky (1896- 1937) is known for his Sociocultural

theory of psychological development. “He assumes that the development of the

individual is determined by the activity group”. The “child will interact with another

person, assimilate the social aspect of the activity and take that information and

internalize it. In this way social values become personal values”(Vygotsky, 1978).

Vygotsky theory “provides a developmental perspective on how such mental functions

as thinking, reasoning, and remembering are facilitated through language.And how

many functions are anchored in the children interpersonal relationship”.

18

Furthermore, other important theory that elaborates on children is theory of play.

“Theoriesof play were first developed during the 18th and 19th centuries”, they show that

“play relates to healing in the physical environment. And there is a relationship between

children and the environment. Play means movement, locomotion, or mobility, play

permits children to learn through experimentation. Means to facilitate children to

explore and manipulate the environment”(Kellert, 2008).

A play which is the most important activity in the lives of children, sometimes more

than eating and sleepingplay is the work, the occupation of childhood, “an

activitypursued without ulterior purpose and on the whole with the enjoyment or

expectation of enjoyment”(English & English, 1958). It aids child’s psychosocial

development (Erikson, 1993). Piaget defines play as “assimilation, child’s efforts to

make the environmental stimuli match his or her own concept”(Piaget, 1962).

According to Cobb,“Play perception is a kind of temporal scanning, a translation of

spatial into temporal pattern”(Cobb, 1959).“Play as an activity which is positively

valued, self motivated, freely chosen, and engaging”(Garvey and Kramer, 1989). Scales

et al. (1991) called play “that is absorbing activity in which young children participated

with enthusiasm and abandon”. According to Mcdevitt and Ormrod (2004) that

“movement is the very centre of children’s life, through movement they perceived a lot

of information about the environment” meaning that children can move and learn about

their environment through play. And of a more recent was study by Said (2006) where

he portrayed play as the physical contact with the environment, and social interaction

with peers. This is possible through a medium where children can have access to play,

and play activities especially in a hospital context.

Other related theories are: Thesurplus energy (Schiller et al, 1967 and Spencer, 1895)

states that “play is the result of surplus energy that exists because the young are freed

from responsibilities, done by the parents”, while Curtis (1915) states that active play is

necessary to get “rid of the surplus”, because children don’t need to expend their energy

on obtaining food, shelter, or provide for living, so the left over energy is being used to

play. They focused on play as a way to recuperate from fatigue experienced from hard

work. In other words, plays restore energy and provide more benefits to the body than

19

idleness. The pre-exercise theory Groos (1985) posits that “play is the necessary

practice of behaviour, which is essential to the later survival”. Examples include playful

fighting of animal or rough and tumble play of children are essential the practice of

skills that will later aid their survival in the future.

Other additional current theories are: Psychoanalytic theory by (Buhler, 1930); Freud,

1937) “they describe play as defensive, as well as adaptations in dealing with anxiety”.

And the Sociocultural theory of Vygotkys, “states that play actually facilitates cognitive

development, children not only practice what they already know, they also learn new

things”. Playing is a behaviour that children participate to explore and learn in their

environment, play develops a number of skills, including fine and gross motor skills,

sensory knowledge, exploring of different roles, development of language skills and

development of social skills, cognitive skills, problem solving and thinking skills. The

value of play is to help children understand the world around them, all children need to

play. The “impulse to play is innate”, the play is a biological, psychological, and social

necessity, and is fundamental to the healthy development and well being of individual

and communities, which can be achieved through complete play cycle during childhood

(Social services directorate - children’s services, 2012).

10. UNDERPINNING

The research underpinnings to this study area are the Psycho-physiological Stress

Reduction Framework by Ulrich (1999) and the Theory of Loose Parts by Nicholson

(1971).

10.1. Psycho-physiological stress reduction framework involves two theories: Attention

Restorative Theory (ART) by Kaplan and Kaplan (1989) states that compatibility is

from the quality of a setting that fits and supports one’s inclinations or purpose, and the

kind of activity supported, encouraged or demanded by the settings (Herzog et al,

2003). In a hospital setting, child associated outdoor space to play it is compatible with

20

children needs because they get the sense of freedom by playing at their own pace, and

time. Therefore, nature matters to children well- being (Whitehouse et al., 2001).

Stress coping reduction theory, SCRT (Ulrich, 1999) proposes that stress is mitigated,

when a person perceives un-threatening natural environment, and the environment

affords him or her following factors;

- Sense of security; to feel secure, children and caregivers from intruders and

other factors related to their environment.

- Sense of control; to have control over their situation, coping with hospitalization

stress and anxiety.

- Social support; emotional support, in form of play from caregivers and peer’s.

- Physical movement and exercise; movement is play of children, and engage with

others in play.

- Access to nature and other positive distraction; having contact with nature, as

play is part of children natural needs.

The theory shows that play relates to restoration in the physical environment, and there

is relationship between children and the features of the environment. Because both

theory deals with the adaptations of human psychological and physiological response

capabilities to natural environment (Persons and Hartig, 2000). People tend to prefer the

natural environment than the built environment, reviewed by (Knopf, 1987); (Hartig,

1993; Ulrich, 1993). An example of such theories that relates to play in stress reduction

is the study of influence of forest topography and vegetation on the physical activity of

playing and motor development of young children. In terms of children environment

interaction, the theories views environment as a source of sensory stimulation and

feedback that triggers the cognitive functioning of the children through play.(Fjørtoft,

2004)

10.2 The theory of “loose parts” by (Nicholson, 1971) posits that loose parts are items

or materials that children and young people can move, adopt, control, change, and

manipulate within their play. He said that “in any environment, the degree of creativity

21

and inventiveness is directly proportional to the number of variables in it”. A beach is a

good example of loose parts environment, with plenty of moveable and adoptable

materials, i.e. sand, water, rock, shell, (that is why children can be able to play for hours

on a beach). Other examples are pine cones, stones, grass, straw, cushions, blankets,

sand, logs, paper, ropes, balls, baskets, crates, boxes, seedpods, fabrics, etc. Children

are drawn to new, interesting and novel items, and have a natural drive and the ability to

decide on what to do with them in their play. (Leave a pile of loose parts, let children

knows they can use them, and keep adults intervention to a minimum). Loose parts are

springboards for play, and are essential elements of a rich child-cantered play

environment which can enhance restoration.

11. Scope of study

The study is about human psychology, in relation to the perceived physical

environment, that includes factors and features that may enhance children restoration in

ahospital context. Observing children, physical, social and cognitive development, the

study will investigate the restorative benefits of play, using loose parts in hospital

settings. Through children’s perception on how their hospital settings should be

arranged, looking at the ward as play environment.

The unit of analysis is the middle childhood paediatric patients; middle childhood is

generally regarded as age range of 6 to 12 years. Studies that have contributed to our

learning and understanding of child development at this period of human development

are Piaget, Erikson, and Harighurst (Piaget, 1962). Explain middle childhood as a stage,

where a child develops a new form of thinking, which he term as stage of concrete

operations. Where logic structures how children understands the relationship in their

settings. One of the major ideas is the concept of reversibility; this is the idea that some

changes can be undone by reversing to an earlier action (Erikson, 1993). Refers to

middle childhood as the most decisive stage, where division of labour occurs. “Stage of

inferiority and confusion where childrenare curious on how things work, they develop a

22

sense of mastery and competence” (Havighurst, 1972). His finding divides the age of

middle childhood into three different stages, which he termed “thrust out of home, into

the peer group, a physical thrust into games and work requiring neuromuscular skills,

and a mental thrust into adult concept, logic, symbols and communication”. At this

stage, human development is of importance, and has relevance to later behaviour,

during adolescence and adulthood. The age range for this refers to children of school

age period. This can be looked at as a period of a child’s learning, adapting to new rules

and routines from new people in a new environmental setting.

The study will be undertaken in two different paediatric wards of Abubakar Tafawa

Balewa University Teaching Hospital in Bauchi. The reason for selecting this hospital is

because it is one of the state specialist hospitals that were built about four decades ago,

and have undergone different phases of administration and development. As a result, it

is now upgraded to university teaching hospital, but nevertheless the system of medical

treatment and procedures have not taken psychological benefits of healing into much

consideration.The result of the study will be applied alongside the conventional medical

routine and protocol in relation to the treatment of patients in the paediatric ward in all

the related hospital in Nigeria.

12. SIGNIFICANCE OF STUDY

The significance of this study is to be able to address the problem statement and

research gap which are being outlined in the earlier part of this research proposal.

i. The study will add to the existing body of knowledge that features and

factors in an environment, which relates with children basic need such as

play, can improve on the child’s performance. Physically, cognitively,

socially, and their ability to cope with stress and anxiety during

hospitalization.

ii. The study will point out the importance of the need for positive distraction

as a vital component of development and surviving skills as anadult in later

wider world.

23

iii. In terms of policies and future designs, it would reveal the importance of the

ward as a restorative environment, from the child's perception as a model for

future development.

iv. A model based on the child's perception and responses on a hospital ward as

a play environment will be used to establish the importance of

restorativealongside medical treatment in the hospital environment. The

model could be proposed to the relevant authorities, for use in future design

and settings of paediatric hospital ward.

13. RESEARCH DESIGN AND VARIABLES

The aim of the research is to investigate the restorative benefits of a paediatric ward as a

play environment, in the context of present day Nigerian paediatric hospital ward. It

will investigate the benefits of play activities using the elements of “loose parts” by

(Nicholson, 1971). In a paediatric ward as a (independent variable) looking at the ward

features like space, size, and form on children’s performance, as a result play activities

and their level of incline positive behaviour physically, socially and cognitively, as the

(dependent variables). It is an established knowledge that play is innate in children, and

very important for a child to undergo a complete cycle of play before adulthood (Perry

et al., 1997). As such, there is a need for children in a hospitalized environment, without

access to any means of positive distraction to benefit from play during their hospital

stay. The anticipated change of feeling from fear full, depression, to a more cheer full,

coping to routine medical procedure is the important consideration in this study.

Play activities during childhood is related to various physical and psychological benefits

leading to research with different approaches to improve on children physical activity

(Active healthy kids Canada, 2010) (AHK).Theconcepts of play activities enlist,

“leisure, occupational, commuting”, which are either structured or unstructured. The

study will look at structured leisure play, which is more inclined toward providing a

change(Tobin et al, 2013).

24

The lack of positive distraction as a prominent feature of the ward, in the form of

structured activities that would improve on patient behaviour in the environment, can be

accessed through thecaregivers, mother by the use of interview questionnaire. The data

will then be analyzed to establish the level of problems encountered as a result of

limitations to providing the needed setting that can improve on patients’ psychological

wellbeing.

For the benefits of play using “loose parts” towards children’s restoration, data would

obtain by means of structured observation as a main tool employing the systematic and

planned procedure. Information about the physical environment and human behaviour

can be directly recorded without anticipating account of others. The observer may be

able to see what participants cannot, it can provide an environment and behaviour of

those that cannot speak for themselves or take part in an interview or complete a

questionnaire.Examples are babies and young children (Taylor, 1984). This relates to

this study as it tends to look at children of middle childhood, it can be used to check

information obtained from another source like interview questionnaire. Data concerning

the duration, the unit of analysis involved, the context in which the behaviour occurs,

and to text pre- existing theories like the loose parts as it is mostly used in children

learning environment,by using “hypothetico-deductive” method(Sapsford and Jupp,

2006).

The third objective will be a participatory method, which involves children showing

their preference through sketch drawings. They would be required to sketch play

element and features on how their hospital ward should be designed as a play

environment. Part of the method will involve, Watcha clip – Draw – and tell. The

explanation of what they draw will be attached to each drawing transcript and analyse

using Nvivo. Data will be collected from children in the controlled experiment ward,

and from children in other ward, this is to get a deeper understanding on children's

preference respond.

25

.

.Figure. 3: VARIABLES AND PARAMETERS

To achieve the stated objectives, the under-listed stages would be followed.

i. Define the study background, related theories on restoration, and the effect

of play on child development.

ii. Define the criteria for types of structured play, materials and elements for

children’s restorative environment.

iii. To undertake a field survey, and data collection.

iv. To analyze the responses of caregivers on play value in an environment such

as a hospital, using descriptive data analysis.

26

v. To analyze the observational behaviour and activities of children, in-terms of

physical activities, social interaction, and cognitive development using

inferential data analysis.

vi. To analyze the perceptual preference responses of children, looking at how

they prefer the wards as a play environment using descriptive data analysis.

vii. To synthesize the needed criteria for a restorative hospital ward for

children’s performance, this can contribute to their coping skills, and

response to routine medication.

viii. Documentation of research findings on the restorative benefits of a

paediatric ward as a play environment, then conclusion of study.

27

Figure 4: Research operational frameworks

14. ANTICIPATED FINDINGS

The study will draw attention to the restoration and its benefits, inherent with play in a

structured children setting, such as hospital context.

i. Positive response to child’s coping ability to hospital stress, anxiety, and

medication routine.

ii. Adapting to changing circumstances.

28

iii. Freedom for physical activities, social interaction and cognitive

development.

Expected findings from this research, will en-lighten us on the need for a

restorativepaediatric hospital ward environment, and form a model for future paediatric

hospital ward environment design.

Fig. 5: showing positive feelings of well being as a result of play in a hospital ward

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