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“Let's play Doctors and Nurses”: ascript analysis of children's playChristine Eiser aa Department of Psychology , University of Exeter , EnglandPublished online: 09 Dec 2010.

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© 1989 Gordon and Breach Science Publishers, Inc.Printed in Great Britain

"Let's play Doctors and Nurses": a scriptanalysis of children's play

CHRISTINE EISER

Department of Psychology, University of Exeter. England.

(Received 5 May 1989).

Fourteen triads of 4-5 year olds and 8 triads of 7-8 year olds were video-taped playing"doctors and nurses" in a pretend hospital at school. The tapes were analysed in termsof the "scripts" or sequences of activities displayed by the children. These analysessuggest that children were aware of the serial order of activities that occur in medicalexaminations, though this was clearer among the older children. The data arediscussed in terms of the relevance of "script theory" for understandingdevelopmental changes in children's beliefs about hospitals and medical procedures.

Keywords: Children's play, script analysis

INTRODUCTION

While a number of researchers suggest that there are substantial shifts in children'sbeliefs about the cause and implications of illness as a function of cognitive maturity(Brewster, 1982; Campbell, 1975; Kister & Patterson, 1980; Perrin & Gerrity, 1981), themost comprehensive account has been put forward by Bibace and Walsh (1981). On thebasis of interviews conducted with 24 children at each of three age-levels (4-, 7-, and 11-years), they suggest that children's beliefs progress through a series of stages, parallelingthe attainment of more physical concepts, such as space or time. Thus, children in thepre-operational stage adopt global and phenomenological concepts, and it is not until theformal-operational stage that adolescents express physiological understanding of the causeand progress of illness.

While this analysis of children's concepts of illness seems to have been accepted withlittle criticism (cf. Perrin & Perrin, 1983), there is generally much disagreementconcerning the extent to which development can be described in stage terms (Flavell &Markman, 1983). There is some doubt as to whether a sharp distinction between pre-and concrete-operational thought is possible (Gelman & Baillargeon, 1983), and noaccount is made of how the shift from one mode of thinking to another is achieved(Mandler, 1983).

While these general theoretical criticisms also apply to studies concerned with thedevelopment of illness concepts, a number of specific methodological criticisms have alsobeen raised. Burbach and Peterson (1986), for example, point to inadequate descriptionsof samples, instruments and procedures, observer bias and expectancy effects, control of

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confounding variables and issues of questionnaire reliability and validity, as generalshort-comings. In addition, it seems probable that the interview methods employed arenot sufficiently sensitive to uncover younger children's beliefs (Siegal, Eiser & Patty,submitted). Work has also focused on children's understanding of the cause of illness orrationale for treatment. Other, perhaps more familiar, aspects of illness, such aschildren's perceptions of visits to the doctor, or experience of non-threatening illnessepisodes (e.g. chicken pox rather than cancer) have received less attention.

We were struck by children's relative incompetence in answering questions about thecause of illness, or what happens in hospital, compared with observations of children atplay, or indeed the depth of understanding that very young cancer patients appear toshow about the condition (Kendrick et al, 1986). Similar discrepancies have been notedby Nelson (1986), who argues strongly that research should focus much more on whatchildren do know.

According to Nelson and Seidman (1984), children's representations of social eventscan be investigated by analysing fantasy play within a script framework. "Scriptedepisodes in young children's pretend play are seen as interactions in which youngchildren are able to share the representation of socially organized events as a mutualtopic of attention and communication" (Duveen & Lloyd, 1988).

A script can be viewed as "a sequence of actions related temporally and causally"(Nelson, 1985). Nelson and her colleagues (Nelson, 1986) have shown that children asyoung as 3 years of age are sensitive to the temporal structure of events, and that thisinfluences a range of cognitive processes including memory, language and discourse.

A study by Garvey and Berndt (1977) suggests that children are able to verbalize"what happens when you go to the doctor?" Children were asked to describe either"what happens when you go to the doctor?" or "what happens when you play doctorsand nurses?" Both play and reality reports appeared to be composed of sequentiallyordered acts, although play reports were more elaborate than reports of the real events.In addition, older children's (mean age = 8.5 years) play and realistic reports were moreequivalent than those of younger children (mean age = 5.1 years). This study suggeststhat a script analysis of children's understanding of medical events is possible. However,one of our main objections to the "stage" work is that it focuses heavily on verbaldescriptions, as does this work by Garvey and Berndt (1977). The present study is anattempt to apply the Script theory approach to an analysis of play itself, rather than relyon children's reports of their play.

METHOD

Subjects

The children all attended a small First school (catering for 5-8 year olds) in a ruralDevon town. There is little local industry, and unemployment is relatively high. Theschool, like most others in the district, caters for children predominantly from working/lower middle-class homes. None of the children suffered from any chronic condition, or

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SCRIPT ANALYSIS OF CHILDREN'S PLAY 19

had personal experience of hospital other than as an out-patient. Subjects were drawnfrom the reception class (5-5 1/2 years) and the final year (7-8 years). Children werecollected from the class-room in groups of 3 same-sex triads, selected by the teacher.Selection was random, rather than in terms of friendship patterns or ability levels. In all,14 triads of 5 year olds and 8 triads of 8 year olds took part in the study.

Apparatus and Procedure

A miniature hospital was set up in an empty classroom in the school. It was divided intofour areas.

The reception area consisted of a table and two chairs opposite to each other. On thetable was a telephone, note-pad and pencil. There was also a display-rack containing aselection of health education leaflets.

The hospi tal- ward consisted of two beds made with blankets, and a baby's cot, completewith doll. There was a food table on one of the beds, and a "drip" hanging at the side. Ona small table nearby were several pairs of rubber gloves, cotton face-masks and head-covers (of the type used in surgery). On a series of open shelves was an array of medicalequipment, including a stethoscope, syringe, tweezers, respiratory mask and nursingbowls.

In the x-ray area was a hard table covered with a sheet. Above the table was a pretendlight that could be swung through a semi-circle, and two x-rays were hung on the wall.

In the surgery areas was another hard table covered by a sheet. There was also anothergreen sheet on top, with a hole through which the "surgery" could be performed. Onnearby shelves were a number of green surgical overalls, hats, masks, gloves andovershoes. In addition, there was a set of surgical equipment, including knives, tweezers,scissors, etc.

We also had a selection of dressing-up clothes. There were nursing uniforms of severalgrades (dark blue for sister, light blue for staffnurse, green for students), a doctor's whitecoat, and various "patient" outfits: pyjamas, nighties and dressing-gowns.

Procedure

The children were collected in threes from the classroom, and brought to the "hospital".They were told that a pretend hospital had been set up, and that they could come insideand play "doctors and nurses". They were shown around the four areas of the hospital,and the equipment was pointed out. (The equipment was described as "things doctorsand nurses use", and we did not name any of the items or explain their use.) It wassuggested that one of the children might like to be the patient, and the others could findout what was wrong and make him or her better. However, since many childrenobjected, at least initially, to being assigned the patient role, it was also suggested thatthe doll could be the patient.

Finally, the children were dressed in whichever of the dressing-up clothes they wishedto wear. Play sessions lasted for 10 minutes. They were filmed throughout by a maletechnician, who remained in the room with the children.

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RESULTS

Our analyses necessarily differ from those of Garvey and Berndt (1977) in that their datawere derived from subjects' reports of play activities. However, we have attempted tofollow their analysis as far as possible.Act propositions were defined as any action engaged in by at least two of the children (e.g.one child gives another an injection).Roles indicate the number of people involved. These could include doctor, nurse, child aspatient or doll.Slot fillers were members of the same class of items. (In practice, children used differentitems of equipment one after the other with no accompanying verbalization or apparentgoal. We felt this was analogous to Garvey and Berndt's 1977 description of play reportssometimes being lists of medical procedures.)

Garvey and Berndt (1977) also identified relational statements and play props, but thesewere not appropriate for our play task.

Act Propositions

Older children used almost twice as many act propositions as young children (mean =16.88 and 9.07 respectively).Roles

Children chose their own roles for their play, though these were restricted partly bythe availability of dressing-up clothes. Initially, none of the children agreed to playingthe part of "patient". This resulted in triads of boys involving three "doctors", though allthe triads of girls consisted of one doctor and two nurses. Once play started, it was usualfor one of the children to adopt the patient role. However, this did not happen in 3groups of 8-year olds and 1 group of 5-year olds. In these cases, the children introductedthe doll as patient.

Slot Fillers

The play of 3 groups of 5-year olds and 1 group of 8-year olds consisted exclusively of"slot fillers". The children in these groups played alone. The play was constructive, butwas characterized by repeatedly picking up different pieces of equipment. The childrennever played together, or defined a goal to the play.

Structure of Event Reports

The play activities engaged in by the majority of children in both age-groups wassequentially ordered, i.e. they matched the order in which they might occur in real lifeand reflect the classic structure of a script report (Gruendel, 1980). Examples from thetwo age-groups are shown in Tables 1 and 2.

Empirical Script Norms

Following Bower, Black and Turner (1979), we attempted to define empirical scriptnorms, or the consensus for each age-group in the type of activities employed.

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SCRIPT ANALYSIS OF CHILDREN'S PLAY 21

Table 1: Examples of a "script" in the play of one triad of 8 year olds

2 nurses with a child patient

Language Activity

patient goes to bed1st nurse: "Do you want a drink?"2nd nurse: "She's got to go to bed; tuck her in." tucks in patient

1st nurse: "Listen to her chest." stethoscope on patient's chest2nd nurse: "I'll put her to sleep, I'll give her the nurse offers cup to patient

medicine."1st nurse attempts to tie identity braceleton patient

1st nurse: "I'll put her to sleep." puts respiratory mask over patient'smouth

2nd nurse: "I'll give an injection." syringe put in patient's chest, then arm1st nurse: "She's asleep now." nurse covers patient with blanket

Table 2: Example of a "script" in the play of one triad of 5 year olds

3 nurses care for a baby doll

Language Activity

1st nurse: "The baby's crying."

2nd nurse: "She's going to be sick."

1st nurse: "I'll give her an injection.'

3rd nurse: "She needs an operation."

1st nurse: "She's going to be alright now."

nurse listens to doll's chest withstethoscope2nd nurse puts respiratory mask overdoll's face3rd nurse uses flat stick to look in doll'sears

nurse sits doll up and holds her over abowlrubs doll's arm with cotton wool swabinjects with syringenurse puts rubber gloves on2nd nurse cuddles babyputs respiratory mask over doll's facedoll moved from cot to bed injected withsyringeswab skin after injection2nd nurse also uses respiratory mask3rd nurse uses tweezers

a) The most popular activities: We calculated the frequency with which differentactivities occurred in children's scripts. The four most popular activities for both age-groups included the use of the stethoscope, respiratory-mask, syringe and flat woodenstick. Thus, among 5 year olds, the stethoscope was used in all scripts and in 72.2% of thescripts of 8 year olds. Table 3 shows the frequency with which other activities occurred inthe games of 5 and 8 year old children

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Table 3: The most popular activities used by 5 and 8 year olds

8year olds 5year olds

stethoscoperespiratory mask

syringe

wooden stick

give food/drink

tweezers

move up bed-table

cotton wool swab

dripput on rubber gloves/masks

make bed

give medicine

ask patient what's wrongbandage

sick bowl

admission procedureplastic tubing

72.2%61.1%55.5%

44.4%

33.3%

33.3%

27.7%

27.7%

27.7%

22.2%16.6%

11.1%

11.1%11.1%

5.5%

5.5%

5.5%

stethoscoperespiratory mask

syringe

wooden stick

cotton wool swab

make bed

bandage

put on rubber gloves/masks

drip

offer food/drink

plastic tubing

sick bowl

tweezersgive medicine

100 %77.6%

55.5%

50 %44.4%

38.8%

33.3%

27.7%

16.6%

16.6%

16.6%

11.1%

5.5%5.5%

b) Identifying a common script: Each activity was then ranked depending on the order inwhich it occurred in the sequence of events, and these ranks were then averaged across allinstances of a given event within each age-group. This resulted in two separate lists ofevents, ordered in terms of primacy of occurrence, one for 5 year olds and one for 8 yearolds. We then attempted to see how much agreement there was between triads in terms ofthe serial order of particular activities. Following Bower, Black and Turner (1979) wemay "designate the group's script to be those events mentioned by more than somecriterion percentage of subjects" (p. 181). Table 4 shows the order in which the activitiestended to occur. Underlined activities were engaged in by less than 25% of triads;activities in lower-case letters by 25-60% of triads, and activities in capital letters weremost popular (more than 60% of triads).

DISCUSSION

The data reported here do not suggest that the "stage" approach to studying children'sconcepts of illness is invalid, but do indicate that research is likely to be enhanced byextending the methods and questions involved. There were differences between 5- and 8-year olds in their "doctors and nurses" play. In particular, the play of older children wasmore elaborate and sequentially ordered. The play of younger children was notqualitatively different. In these respects, our data parallel those reported by Garvey andBerndt (1977) in discussing children's verbal scripts about going to the doctor.

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SCRIPT ANALYSIS OF CHILDREN'S PLAY 23

Table 4: Empirical script norms at three agreement levels

8year olds 5year olds

admissionask diagnosismake bedAIR MASKMASK AND GLOVEStubinggive medicineSTICKbandageSTETHOSCOPEmove up bed-tableOFFER FOOD/DRINKSYRINGEtweezersCOTTON WOOL SWABSdripsick bowl

offer food/drinkSTETHOSCOPEair maskwooden stickbandagecotton wool swabssyringesick bowldripmake bedtubingput on mask/glovesgive medicinetweezers

Activities in capital letters were included by 60% or more of triads, those in small case letters by25-60%, and those underlined by less than 25%

The question remains how children's play relates to their knowledge of the real event.What is the relationship between "doctors and nurses" play and children's beliefs andperceptions of what really happens when you go to the doctor? Evans and Rubin (1983)studied developmental changes in children's reports about everyday games, including"Simon Says" and "Musical Chairs". They found that children reported the rules of thegame in the same sequence as they occur in the game itself, which may suggest thatchildren sequence their play, reports of their play, and everyday events in a similar way.

Despite the fact that children in this study had little direct experience of hospitals, theyhad sufficiently well-developed scripts of how to play "doctors and nurses" that themajority were able to organize a game together. While scripts are thought to developthrough direct experience, they can also be acquired vicariously (Nelson, 1986). Thesedata suggest that young children with very limited experience with the medicalprofession (most of these children only had experience of visits to a G.P. or baby clinic),do nevertheless develop a set of beliefs and expectations about the nature of medicaltreatment. The activities shown by 5 and 8 year olds were qualitatively quite similar,although differing in complexity. At the same time, many of the activities reflect fairlyaccurately what might be expected to occur during the "real event". A central questionfor future work is how direct and prolonged exposure to hospitals and medicalprocedures, such as is experienced by chronically sick children, influences the formationof scripts.

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Previous work has tended to focus on the development of children's beliefs abouthealth issues divorced from developmental changes that occur in other areas ofcognition, particularly memory, learning and information processing. For example,children are often asked their beliefs about illness, treatment and prevention with little inthe way of introduction. In these situations, they must rely on previous personalexperience of illness and adult explanations, which may have taken place some timepreviously. Although children are sometimes able to provide detailed descriptions ofevents in long-term memory (Todd & Perlmutter, 1980), in the absence of retrieval cues,recall can be seriously curtailed (Fivush, 1984). In a study of recall of actions involved ina clay-making task, Smith, Ratner and Hobart (1984) concluded that children canencode many actions from complex events, but have difficulty describing these actionseven where salient cues are present. Reconstruction of the activities themselves arenecessary for children to demonstrate event knowledge.

Children have very limited experience of hospitals and medical procedures, andtherefore cannot be expected to retrieve information easily. However, these data suggestthat young children are sensitive, at least to the sequential nature of medical encounters.In the future, researchers need to acknowledge the social and cognitive task demandsinherent in research paradigms. Only in this way can we build a more complete pictureof how the child's beliefs about health and illness develop within the context of social,cultural and personal experience.

References

Bibace, R. & Walsh, M.E. (Eds.) (1981). Children's conceptions of illness. In R. Bibace & M.E. Walsh (Eds.)Children's conceptions of health, illness and bodily functions. San Francisco: Jossey-Bass.

Bower, G.H., Black, J.B. & Turner, T.J. (1979). Scripts in memory for text. Cognitive Psychology, 11, 177-220.Brewster, A.B. (1982). Chronically ill hospitalized children's concepts of their illness. Pediatrics, 69, 355-362.Campbell, J.D. (1975). Illness in a point of view: The development of children's concepts of illness. Child

Development, 46, 92-100.Duveen, G. & Lloyd, B. (1986). Gender as an influence in the development of scripted pretend play. British

Journal of Developmental Psychology, 6, 89-96.Evans, M.A. & Rubin, K.H. (1983). Developmental differences in explanations of childhood games. Child

Development, 51, 1559-1567.Flavell.J.H. & Markman, E.M. (Eds.) (1983). Handbook of Child Psychology, Vol. Ill: Cognitive Development. New

York: Wiley.Garvey, C. & Berndt, T.R. (1977). The organization of pretend play. Catalogue of selected documents in psychology,

7, No. 1589.Gelman, R. & Baillargeon, R. (1983). Review of some Piagetian concepts. In Flavell.J.H. & Markman, E.M.

(Eds.) Handbook of Child Psychology, Vol. Ill: Cognitive Development. New York: Wiley.Gruendel, J.M. (1980). Scripts and stories: A study of children's event narratives. Unpublished doctoral

dissertation. Yale University.Kendrick, C , Culling, J., Oakhill, T. & Mott, M. (1986). Children's understanding of their illness and its

treatment within a paediatric oncology unit. Association for Child Psychology and Psychiatry (Newsletter), 8,16-20.

Kister, M. & Patterson, C. (1980). Children's conceptions of the cause of illness: Understanding of contagionand use of immanent justice. Child Development, 51, 839-846.

Mandler,J. (1983). Representation. In Flavell, J . H . & Markman, E.M. (Eds.) Handbook of Child Psychology,Vol. Ill: Cognitive Development. New York: Wiley.

Nelson, K. (1985). Making sense. In I.Bretherton (Ed.) Representing the Social World in Symbolic Play: Reality andFantasy. New York: Academic Press.

Nelson, K. & Seidman, S. (1984). Playing with scripts. New York: Academic Press.Nelson, K. (Ed.) (1986). Event Knowledge: Structure and Function in Development. New Jersey: Erlbaum.

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Perrin, E. & Gerrity, S. (1981). There's a demon in your belly: Children's understanding of illness. Pediatrics,67, 841-849.

Perrin, E.C. & Perrin, J.M. (1983). Clinicians' assessments of children's understanding of illness. AmericanJournal of Diseases of Children, 137, 874-878.

Siegal, M., Eiser, C. & Patty, J. (submitted). A re-examination of children's conceptions of contagion.Smith, B.S., Ratner, H.H. & Hobart, C.J. (1987). The role of cuing and organization in children's memory for

events. Journal of Experimental Child Psychology, 44, 1-24.Todd, C. & Perlmutter, M. (1980). Reality recalled by preschool children. In M. Perlmutter (Ed.) New

Directions for Child Development, Vol. 10: Children's memory, San Francisco: Jossey-Bass, pp. 69-86.

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