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A review of the literature – The use of interactive puppet simulation in nursing

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DOI: 10.1016/j.nepr.2016.12.001

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Accepted Manuscript

A review of the literature – The use of interactive puppet simulation in nursing

education and children's healthcare

Vanessa Tilbrook, Trudy Dwyer, Kerry Reid-Searl, Judi A. Parson

PII: S1471-5953(16)30257-8
DOI: 10.1016/j.nepr.2016.12.001
Reference: YNEPR 2175

To appear in: Nurse Education in Practice

Received Date: 3 September 2015

Revised Date: 17 October 2016
Accepted Date: 6 December 2016

Please cite this article as: Tilbrook, V., Dwyer, T., Reid-Searl, K., Parson, J.A., A review of the literature
– The use of interactive puppet simulation in nursing education and children's healthcare, Nurse
Education in Practice (2017), doi: 10.1016/j.nepr.2016.12.001.

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A Review of the literature – The use of interactive puppet simulation

in nursing education and children’s healthcare.
Vanessa Tilbrook RGN, Paeds, PCCC, Grad Dip Mid, Grad Cert Ed - Academic Practice, HDR –

Masters Candidate (CQU)

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Midwifery Education Facilitator - Women’s & Children’s Hospital

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Centre of Education & Training

Level 1 Zone E

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72 King William Rd

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NORTH ADELAIDE SA 5006
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E: vanessa.tilbrook@sa.gov.au
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(M) +61 0417 838 769

(W) + 61 08 8161 6178

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Associate Professor Trudy Dwyer RN PhD

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School of Nursing & Midwifery

Higher Education Division

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CQUniversity – Rockhampton

Room 1.36

Building 18

Bruce Highway
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North Rockhampton QLD 4702

E t.dwyer@cqu.edu.au

P +61 07 49232180 (x2180)

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Dr Kerry Reid-Searl (RGN, RM, BHlth Sc, MClin Ed, PhD)

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Professor / Discipline Head

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School of Nursing & Midwifery

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CQUniversity
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Rockhampton Campus Q 4700

E: k.reid-searl@cqu.edu.au
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(W): +61 07 49309741

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(M): 0419292957
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Dr Judi A Parson PhD

Lecturer in Mental Health – Child Play Therapy

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School of Health & Social Development, Faculty of Health

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Deakin University

Locked Bag 20000, Geelong, VIC 3220

E: judi.parson@deakin.edu.au

P: +61 3 52278985
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Corresponding Author: Vanessa Tilbrook

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1. Present address: Midwifery Education Facilitator, Centre of Education & Training, Women’s &

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Children’s Health Network, Level 1, Zone E, 72 King William Rd, NORTH ADELAIDE SA

5006, AUSTRALIA

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Word count
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Full count 4461 (exc ref)

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Full count 5616 (inc ref)

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A Review of the literature – The use of interactive puppet simulation in nursing education

and children’s healthcare.

Abstract

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The use of puppets in health care is emerging as a mode of simulation that combines elements of

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engaging with the child through play whilst at the same time providing education. This review

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examines the impact when nurses use play therapy or puppets as a simulation modality in

nursing education and in the clinical paediatric nursing environment. Electronic search was

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conducted using CINAHL, PubMed, Scopus, Web of Science and PsycINFO data bases, between
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1980 and January 2015 with the combinations of play therapy; puppetry; nursing education;

nursing; simulation; health professionals and puppets. Twelve articles were identified that
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highlight the use of puppet simulation in the education of nursing students and children in the

healthcare environment. Puppet modelling and puppet simulation is predominantly adopted in

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the areas of health education and specifically diabetes education. Identified gaps in the use of
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puppet simulation in nursing, nurse education and puppet simulation as a three-way

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communication process; thus identifying the need for further research on puppet simulation and

its application and benefits in nursing and nurse education.

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Key words

Play therapy; Puppetry; Nursing Education; Nursing; Simulation; Health Professionals;

Puppets

Introduction
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The use of puppets has historically provided play therapists, health care professionals and early

childhood educators with a tool to observe, educate and support children (Blumenthal, 2005,

Bratton et al., 2005, Burns-Nader and Hernandez-Reif, 2015, Kalra et al., 2014). Through

puppets, children are provided with a pathway to express their fears, anxieties and emotions

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where previously they may not have been able to have a voice or be able to adequately express

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themselves (Cruz et al., 2012, Jones and Landreth, 2002). Additionally, healthcare professionals

can use puppets to simulate real life scenarios facilitating learning for children and their families

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(Burns-Nader and Hernandez-Reif, 2015, Cruz et al., 2012, Haiat et al., 2003, Pélicand et al.,

2006). This pathway of expression is well documented in a variety of health care contexts

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including; play therapy, psychological and hospital play specialist and child life literature
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(Epstein et al., 2008, Jun-Tai, 2008, Ray et al., 2013). Whilst contemporary literature asserts that
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healthcare professionals use of puppets in play therapy is indeed beneficial (Hall et al., 2002,

Jones and Landreth, 2002, Kenney-Noziska et al., 2012), the impact of puppet simulation across
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the domains of nursing and nurse education is relatively unknown. The aim of this integrated
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review is to report the experiences of nurses and nurse educators who have used puppets.
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Methods
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The research question that informed the search was ‘How are puppets currently being used by
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nurses and nurse educators?’ Boolean operators of AND & OR were used to expand the search

when AND had limited search results. ‘Play therapy with puppets’ was also added to the search

terms, as puppetry is a well-known form of play therapy; when limited results were found.

Literature was reviewed with the following inclusion criteria; peer-reviewed, research studies

English language published between the years of 1980 – January 2015 and focused on
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puppet/doll simulation and/or play therapy or use as an education tool or strategy in nursing care

or education. Articles that focused on mental health or psychotherapy were excluded as this is an

environment that routinely uses puppet therapy. The search terms used to discover the literature

were: Interactive Puppet Simulation; Simulation in Nursing; Play Therapy with puppets; Puppet

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simulation; Puppets use in nursing; Education

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Search Strategy

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Using the documented inclusion criteria, the literature review was conducted using CINAHL,

PubMed, Scopus, Web of Science, PsycINFO and a general search on two university library

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catalogues. The original timeframe of the search 2005- January 2015 was extended to 1980 as

only nine articles were found and so a wider search of literature was undertaken. All articles
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were retrieved and read in full to determine which met the inclusion criteria. Of the twenty-six

articles found, twelve articles on the implementation of or use of puppets to practice met the pre-
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set criteria and were included in the review (see Table 1).
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Table 1: Article Summary

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Literature Review
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Articles were grouped together based on the puppet area of application and reviewed under the
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following headings of diabetes, health education, science engagement, preparation for

surgery/hospitalisation (puppet modelling), undergraduate education and in the traditional

context of play therapy.

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Diabetes

Three studies examined the impact of puppets on children with diabetes compliance with

medications and treatment regimens, peer interactions and learning outcomes (Kalra et al., 2014,

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Pélicand et al., 2006, Sparapani et al., 2012). In the study by Kalra (2014) impacts on improving

care and management were measured after children from below the poverty line were afforded

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access to diabetic equipment and education sessions using the puppets (Kalra et al., 2014).

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Sparapani et al (2012) also implemented puppets to support children with diabetes to facilitate

communication and interactions between the children and the researcher (Sparapani et al., 2012).

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This study was unique in that puppets were constructed by the child and used as the child’s
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voice. Four additional puppets were available to take on extra roles of the friends within the

scenario and the interviewer also used their own puppet to communicate throughout the
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interview. Interviews with children revealed that positive and negative attitudes of friends

influenced the disease management, as did the child’s attitude towards their friends (Sparapani et
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al., 2012). The impact of the puppets was not specifically elicited, only that all children chose not
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to include their parents in the interview and that the process of developing the scenario with the
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puppets facilitated the establishment of the relationship with the interviewer. The authors

believed this interaction helped the children feel comfortable and relaxed with the process.
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Recommendations propose that health care professionals should to be attentive to interactions

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between children with diabetes and their friends and use the puppets to evaluate the child’s

knowledge of their disease and engage with others.

Pélicand and colleagues (2006) evaluated a summer camp therapeutic educational program

where puppets were introduced as a tool for play and as a medium where children with diabetes

could express themselves (Pélicand et al., 2006). Fourteen children were divided into two equal
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groups based on gender and age. One group used their own hand crafted puppets as a tool for

expression, using the puppet to conduct ‘plays’ that showed their experiences with the disease.

The other group engaged in traditional group discussions and at the end of the workshops made

their own puppets. Supporting children to create their own puppets allowed them to try on

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different personalities and play an active role engaging with the puppet and expressing

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themselves. Clearly children relate to puppets when they are actively involved in their

development and they are used to making inanimate objects come alive (Fisher, 2009, Hartwig,

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2014, Pélicand et al., 2006).

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In the Pélicand et al (2006) study children were given a book to read that introduced them to
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another child’s experience with diabetes. The participating children were then interviewed prior

to participating in a series of workshops (Pélicand et al., 2006). Children were asked to evaluate
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their experience using a modified faces pain chart. Scores were given for all individual and group

responses. The researchers, found that children using puppets developed related skills to the
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management of their disease and were able to progress to make decisions related to self-care of
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their disease (Pélicand et al., 2006). Additionally, the children were able to develop a sense of
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control of their disease as they used the puppet as a tool to distance themselves from difficult and

painful emotions and situations. The puppet was described by the children as a tool that gave
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them pleasure and a vehicle that that could use to express themselves and their knowledge
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(Pélicand et al., 2006). Recommendations of this study support puppets as a technique for

educational play and a successful medium for teaching aspects of the disease and treatment to the

children. Collectively authors recommend that health care professionals implement puppets to

their practice to meet the child’s health priorities, to show the children how to manage their
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disease and treatments as self-reliantly as possible (Fisher, 2009, Hartwig, 2014, Pélicand et al.,

2006).

The impact of two different childhood toys on learning were compared as part of a diabetic care

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program targeting under privileged children (n=4000) in India (Kalra et al., 2014). Children

enrolled in the program were given a game of Snakes and Ladders and a Novo Nordisk Teaches

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to Take Insulin (NOTTI). The NOTTI doll, while primarily an education tool for teaching insulin

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administration, was soft, portable, unbreakable and looked like any other doll. Through playing

with their dolls the children, in addition to expressing feelings of love for their dolls, also

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demonstrated skills in self-care and autonomy in insulin administration. In addition, the health
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care professionals enrolled reported new learned skills in insulin administration. The authors

concluding that play therapy was a useful and interesting strategy for the simultaneous education
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of both children and adults in diabetic management (Kalra et al., 2014). An identified weakness

of this paper was the lack of clarity around the collection and interpretation of data. Regardless
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the use of the puppet be it as a therapeutic tool or for play, puppets support children attaining
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knowledge and control of their disease whilst simultaneously providing an avenue for self-
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expression and stress reduction (Hall et al., 2002, Hartwig, 2014., Kalra et al., 2014, Schaefer,

2001). In each of the studies puppets were chosen as the tool for communication as they were an
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age appropriate toy that suited the child’s level of development; and because children choose to
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engage in activities that involve toys (Hartwig, 2014., Ray et al., 2013, Sparapani et al., 2012).

Health Education

Two articles were found that used dolls or teddy bears as an instrument to educate children and

undergraduate nurses (Campbell and Brown, 2008, DeRowe et al., 2003). DeRowe et al (2003)
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used a single case report of a two-year-old girl who had a tracheotomy created post removal of a

laryngeal tumour. The child displayed anxiety and distress with all aspects for care for her

tracheotomy, specifically during suctioning. Her favorite doll was given a tracheotomy and her

care giver would then provide tracheotomy care, including suctioning, whilst the child played

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with her doll. The authors, reported an immediate reduction in anxiety, distress and compliance,

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all of which remained evident twelve months later (DeRowe et al., 2003). The above case study

outcome is supported by earlier studies that report the implementation of puppets or dolls aids

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children’s understanding of their health experiences and helps communication between

healthcare professionals and the child (Bates, 1986., Ziegler and Prior, 1994).

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The Health Teddy Clinic was implemented to assist the development preschool children’s,

knowledge, therapeutic communication skills (Campbell and Brown, 2008). In this study nursing
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students participated in a six-week rotation at the preschool. During the rotation the nursing

students were paired with a child and the students assessed the child’s development and
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milestone correlation, developmental needs associated with hospitalisation and the nurse’s role
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as comforter in painful procedures. Each child was given a Teddy Bear and then encouraged to
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engaged in a variety of health promotion activities such as hand washing, dental hygiene and

going to the doctor (Campbell and Brown, 2008). The child assisted the nursing student to
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perform these skills and ‘teach’ the Teddy Bears.

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Parents of the children were given an email address to provide feedback about the program and

the nursing students completed a clinical evaluation tool and exam. Results indicated that

students increased their general knowledge and confidence in working with children (Campbell

and Brown, 2008). Parents were surprised at the amount of information the children had learnt.
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One parent commented that their child had a reduction in fear of going to the doctor. The

children were excited to be working with the bears (Campbell and Brown, 2008). At the end of

the project, strategies to expand the program to migrant communities and other community

centres were underway. The authors concluding that the Health Teddy Clinic and the use of

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puppets was effective in preparing children in readiness for their interactions with the health care

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sector (Campbell and Brown, 2008). While the Healthy Teddy Bear clinic focused on

undergraduate nursing students and the use of teddy bears as the instrument to connect with

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children, two other studies were discovered which used two handed puppets in simulation

activities with undergraduate student nurses (Hardiman and Pearce, 2012; Reid-Searl et al.,

2014).
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Undergraduate education
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An Australian study using focus groups to collect data, explored the impact puppet simulation on
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the development of interpersonal skills in undergraduate nursing students (n=15) (Reid-Searl et

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al., 2014). All nursing students had had exposure to one of two types of puppets where the

educations sessions delivered within an established pedagogical framework called Pup-Ed™

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(KRS simulation) (Reid-Searl, 2012). Within the framework learning is diagrammatically

represented in Figure 1 and involves; preparation, understanding the learner, play in action, and
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finally evaluation and debriefing (Reid-Searl, 2012). In a more recent paper the authors note that
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successful use of the framework can engender a learning environment that is realistic and

engaging (Reid-Searl et al., 2014). The hand and facial actions of puppets used in the latter study

were controlled by the teacher and had elements that allowed students to practice clinical

procedures such as naso-gastric insertion and catheter insertion (Reid-Searl et al., 2014). Each

puppet had an authentic health history that did not change throughout the student/puppet
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interaction. Student learners were initially introduced to the puppets and their histories via online

learning modules and then in small groups of on-campus simulation sessions. At theses

simulation sessions students were exposed to a variety of nursing skills such as obtaining and

recording vital signs, conducting physical assessments and engaging in effective communication.

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Simulation sessions lasted between 20 and 50 minutes (Reid-Searl et al., 2014). Students

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reported that the puppets were engaging and fun and learning in this way helped them develop

stronger memory connections and recall of theory and practice concepts. Identified limitation of

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the study was a small, self-selected participant group (Reid-Searl et al., 2014).

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Pearce and Hardiman (2012), conducted a qualitative exploratory study, using thematic analysis
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to review the use of puppets, in a ‘hot seating through puppetry’ technique to teach marketing

students regarding corporate interview technique in a simulated sales presentation (Pearce and
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Hardiman, 2012). Educators wishing to participate in the technique only had to show interest,

and practice at home prior to using the technique with students (Pearce and Hardiman, 2012).
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Preparation prior to the activity involved a three stage process. Initially the students prepared by
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reading a short case study describing how a firm was looking to appoint a consultancy. Secondly
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the students were randomly allocated into teams; thirdly allocated teams then had to interview

with the client (Pearce and Hardiman, 2012).

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Pearce and Hardiman (2012) consider that the lecturer, the expert on the topic; was the operator
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of the puppet (Pearce and Hardiman, 2012). The lecturer sat behind the puppet and assumed a

new voice, and responded directly to the questions asked by the students. This is similar to the

Pup-Ed™ (KRS Simulation) framework, except in Pup-Ed™ the operator is part of the

conversation and not hidden or taking an assumed voice (McAllister et al., 2013, Reid-Searl,
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2012). In the third stage students used a journal to reflect on their drama activities and the ‘hot

seating through puppetry’ component of the program (Pearce and Hardiman, 2012). Thematic

analysis indicated that the students were immersed in the exercise, seeing the puppet as a real

person, who reinforced their role of decision maker (Pearce and Hardiman, 2012).

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Play Therapy

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Children’s toy preference was examined in a study of 113 different toys which were used in

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community based clinics as a form of child-centered play therapy (CCPT) (Ray et al., 2013).

Four of the toys examined were puppets that were categorised, for the study purposed, as either

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theatre, people, aggressive or non-aggressive puppets. Sixty-eight children, each around three
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years of age, chose their own toys and were observed as they engaging in the CCPT sessions.

Twenty-six higher play therapists participated in the study (Ray et al., 2013). Gender influence
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toy selection, with the boys choosing the scary/aggressive puppets and around one third of the
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children choosing the theatre puppets as a medium to express themselves. The authors concluded
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that children chose puppets as a medium to assist them to express themselves. A finding

substantiated by others who have reported the benefits of children projecting their experiences
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onto and through puppets (Ahlcrona, 2012, Hall et al., 2002, Sparapani et al., 2012). This is the

first quantitative study that researched toy selection in CCPT, highlighting how toy selection is
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purely child based. Anecdotally the authors observed different toy selection in their practice and
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felt that toy selection may be different in different demographic groups (Ray et al., 2013). As

toy selection was dependent on the reason of why the child was in therapy and available toys the

authors made no assumptions regarding the meaning of play based on the choice of toys (Ray et

al., 2013).
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Preparation for surgery/hospitalisation (Puppet modelling)

Sporadically puppets have been used to prepare children for surgical procedures, including

cardiac catheterisation, bone marrow biopsies (Athanassiadou et al., 2009) and more recently

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diabetes and hand hygiene (Pélicand et al., 2006, Sparapani et al., 2012). Puppet play is an

effective technique in psychological preparation for children (Athanassiadou et al., 2009).

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Athanassiadou et al (2009) sampled 91 children, from four to ten years of age to test if puppet

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play was effective in reducing children’s stress and assisted in them coping with hospitalisation.

The groups were randomly allocated to either the control (no pre-preparation) or intervention

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group who received therapeutic puppet play session and the mothers received a counselling
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session. A trained psychologist delivered the intervention the day before the scheduled

procedure. In this study, the child directed the puppets and the psychologist managed the
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situation, assuming the role of the child (Athanassiadou et al., 2009). Parents and teachers were

questioned using the Rutter scale and children were questioned using an age appropriate scale to
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assess the child’s behavior pre and post operatively (Athanassiadou et al., 2009). Reduced
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behavioural disturbances including less aggression and hyperactivity post operatively in the
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intervention group were suggestive that intervention was successful. Puppet play in this study,

was helpful educating and modelling medical procedures which increased the child’s coping
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mechanisms during procedure (Athanassiadou et al., 2009). These observations are reflected in
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other studies that support preparation for hospitalisation and medical/surgical procedures having

a positive impact on the child’s ability to cope and understand the procedures; including a greater

resilience to behavioural and emotional disturbances post-operatively. Collectively these studies

highlight the importance of integrating puppets when providing psychological care alongside

standard medical care.

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An international quantitative study supports and encourages the use of puppets to explain and

teach certain surgical procedures (Li and Lopez, 2008). Li and Lopez (2008) reported that

therapeutic play is an effective and appropriate tool for preparing children for surgery (Li and

Lopez, 2008). Shapiro (1995) used a case study to illustrate how puppet modelling was effective

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settling a child experiencing insomnia secondary to a fear of not waking up (Shapiro, 1995).

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Here the puppet was used by the nurses to model the child’s behavior during clinical treatments.

Accumulative puppet modeling interactions resulted in a reduction in anxiety and an increase in

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compliance during subsequent treatment interventions.

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Science engagement
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A qualitative study examining teachers (n=16) use of puppets impact on student engagement in

science (Simon et al., 2008). Students (n=51), aged between four and seven years of age, and
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teachers were audio taped and videoed as they engaged in their usual science lesson activities.
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The teachers then each selected a human like puppet and having learnt the basics of using
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puppets as a teaching strategy, they implemented the puppet in the classroom. Students felt that

science was easier to understand and they were confident interacting with the puppets to the
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extent that they could blame the puppet if their responses were not correct. Essentially the use of

the puppet contributed a safe learning environment for the children. The teachers believed
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student confidence with the puppets generated more questions for discussion and the quieter
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students were more engaged and vocal in discussions (Simon et al., 2008). Consequently,

teaching techniques moved from a traditional didactic style to one more focus on the

conversations between and with students. Other researchers have also reported that children gain

a sense of control when interacting with the puppets which in turn enables their participation in
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decision making process (Fisher, 2009, Pélicand et al., 2006). The authenticity of the puppets

was important and the character had to be believable or the students would not engage with the

learning experience (Reid-Searl et al., 2014, Simon et al., 2008). Additionally, self-selection of

individual puppets will increase the users reported connection to and feelings of attachment to

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the puppet (Fisher, 2009). All of which increase engagement and authentic learning.

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Five articles have been published on puppet/doll use in healthcare since the original literature

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search from 1980 - January 2015 (Ackland-Tilbrook & Warland, 2015., da Silva et al., 2016;

Moore, Bennett, Dietrich, & Wells, 2015; Sharkey, Denke, & Herbert, 2016; Sposito et al.,

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2016). These papers support the findings of the original literature search and have not been
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included in the review as they did not fit the original search date criteria (1980-January 2015).

They will now be discussed.

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Recent publications 2015-2016

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One paper reports the use of dolls in simulation as a useful engagement strategy in the education
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of undergraduate nursing students (Ackland-Tilbrook & Warland, 2015). The four other papers

focused on the use of puppets with children. Puppet application in these recent papers included
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storytelling, puppet play and preparation for hospitalisation or treatment. All papers recommend
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the use of puppets as a therapeutic medical play tool (da Silva et al., 2016; Moore et al., 2015;
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Sharkey et al., 2016; Sposito et al., 2016). Moore et al (2015), used puppets as story tellers to

improve the hospitalisation period of children by reducing anxiety, promote mastery in children

by implementing the puppets to inform the children about procedures in a non-threatening

directed play model. This paper recommended the use of therapeutic play by child life specialists

(CLS) rather than nurses as they had specific qualifications in play in relation to paediatric care
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(Moore et al., 2015). This possible gap in knowledge of the power of play and its application to

practice was acknowledged by da Silva et al (2016). These researchers recommended that nurses

need not only to think of play as a distraction agent or a way to pass the time, but need to

consider alternative ways to play with children in their practice; calling for health professional

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education programs to include play training in their university undergraduate training (da Silva et

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al., 2016). These four papers highlight the need for future research on the use of puppets by

nurses and to review the education and training that nurses have on therapeutic play

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models/frameworks.

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Conclusion
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Evidence to date suggests that puppetry is a useful and popular technique used by play therapists
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and health professionals in a variety of contexts. The type of puppets used within the literature

varies greatly, ranging from puppet modelling and storytelling to the child actually creating their
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own puppet. Two studies used a two handed glove puppet that was childlike in appearance and
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behaviour. Yet despite the type of puppet used, the outcomes of the studies reported similar

benefits to the child’s experience. Popularity as a tool to prepare children for hospitalisation
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and/or painful or distressing procedures was well evidenced in this review. Puppets are a
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pathway to provide children with a voice, more so when the child is the operator and they can
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use the puppet as a tool to act out personal fears and anxieties. Despite who the operator of the

puppet is, child, therapist or nurse, this interaction helps to identify the child’s preferences for

care and provides a valuable insight into the child and their individual needs. Communication

between the child and the operator of the puppet is facilitated by puppetry and this appears to

have flow on effects on developing and facilitating the adult-child relationship. There is a
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paucity of empirical evidence of the use of puppetry by healthcare exists despite multiple

recommendations that it is a successful technique.

Education of disease and management of health is now becoming patient managed (Brown et al.,

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2012). This calls for new ways to assist in the education of children and families, implementing

puppets to practice (da Silva et al., 2016., Duffin, 2012., Sposito, 2016). Techniques that

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incorporate the principles of simulation and play therapy implemented within a guided

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framework is showing promise (Reid-Searl, 2012). Integrating puppets into health care is a

useful strategy for engaging both students and children in meaningful learning. Additionally,

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children, family, nurses and educators all report the value and potential of the puppets to reduce
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anxiety and prepare children and their families for the unknown.
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Gaps in the Research

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The literature review highlights that puppets are a traditional form of play therapy and little is
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known about the use of puppets by health care professionals outside the psychological context
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(da Silva et al., 2016., Duffin, 2012, Li and Lopez, 2008, Moore et al, 2015., Parson, 2003,

Synovitz, 1999). This is despite recommendations by this group to expand the practice of puppet
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simulation by other healthcare professionals in their practice (Bates, 1986., da Silva et al., 2016.,
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Duffin, 2012, Li & Lopez, 2008., Moore et al, 2015., Parson, 2003., Sposito et al, 2016). Nurses

and nurse educators and their understanding and current use of play in practice needs to be

understood (da Silva et al., 2016; Haiat, Bar-Mor, & Shochat, 2003; Hopwood, Fowler, Lee,

Rossiter, & Bigsby, 2013; Moore, Bennett, Dietrich, & Wells, 2015; Potasz et al., 2014; Sposito

et al., 2016)
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Recommendations

Further study into the implementation of puppets, using an established pedagogical framework to

guide their use is required. Evaluation could focus on the clinician’s perspective to review if this

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is a useful tool and if it is an effective therapy to provide children a voice to relay their fears or

anxieties in regards to their experience. All operators should undergo training in the technique

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prior to implementation of the puppets to practice. Research into interactive puppet simulation

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could explore the experiences of the nurses and nurse educators when implementing puppet

simulation into their practice to determine if health care professionals perceive this to be an

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effective teaching strategy. Additionally, research into nurse and nurse educators understanding
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of the power of play and the impact of play on their practice should be better understood to help

facilitate the facilitation of puppet simulation to practice.

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Author
Shapiro, D.E., 1995.
DeRowe, A., Fishman, G., Leor, A.,
Kornecki, A., 2003.
Pélicand, J., Gagnayre, R., Sandrin-
Berthon, B., Aujoulat, I., 2006.
Simon, S., Naylor, S., Keogh, B.,
Maloney, J., Downing, B., 2008.
Campbell, A., Brown, S.T., 2008.
Li, H.C.W., Lopez, V., 2008.
Athanassiadou, E., Tsiantis, J.,
Christogiorgos, S., Kolaitis, G., 2009.
Sparapani, V.D.C., Borges, A.L.V.,
Dantas, I.R.d.O., Pan, R., Nascimento,
L.C., 2012.
Pearce, G., Hardiman, N., 2012.
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Ray, D.C., Lee, K.R., Meany-Walen,
C
K.K., Carlson, S.E., Carnes-Holt, K.L.,
Ware, J.N., 2013.
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Reid Searl, K., McAllister, M., Dwyer,
T., Krebs, K.L., Anderson, C.,
Quinney, L., McLellan, S., 2014.
Kalra, S., Chugh, S., Dinakaran, P.,
2014.
Table 1: Article Summary of literature included in the literature review 1980- Jan 2015
ACCEPTED MANUSCRIPT
Methodology Topic Outcome/
Recommendations
Case Study Puppet modelling for children Puppet modelling results in a reduction in
undergoing stressful procedures anxiety and an increase in compliance
during subsequent treatment
interventions.
Case Study Compliance with healthcare via Implementation of puppets or dolls with
implementation of doll/teddy bear similar medical diagnosis aids
as an instrument to educate communication between healthcare
children and undergraduate nurses professionals and the child
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Mixed method Compliance with treatment in Type Health care professionals implement
1 Diabetes puppets to their practice to meet the
child’s health priorities, to show the
children how to manage their disease
and treatments as self-reliantly as
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possible
Qualitative Study Puppet impact on Engagement Student confidence with the puppets
with science generated questioning for discussion,
students were more engaged and vocal
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in discussions
Funded project Health Teddy Clinic – community Health Teddy Clinic and the use of
education with pre-schoolers puppets was effective in preparing
children in readiness for their interactions
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with the health care sector
RCT Surgical procedure preparation – Therapeutic play to be effective and
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play intervention appropriate as a tool for preparing
children for surgery
RCT Surgical procedure preparation Therapeutic puppet play to prepare
using therapeutic puppet play children for hospital has a positive impact
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on the child’s ability to cope, understand
the procedures; including having a
greater resilience to behavioural and
emotional disturbances post-operatively
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Exploratory study Impact of friends on children with Puppets facilitated a relationship with the
Type 1 diabetes interviewer that made the children feel
comfortable to not require their parents
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present at interview
Qualitative exploratory Marketing – Hot Seat through Students were immersed in the exercise,
study puppetry seeing the puppet as a real person, who
reinforced their role as the decision
maker
Quantitative Toys used in CCPT Children chose puppets as a medium to
assist them to express themselves in
CCPT
Qualitative Evaluation Interpersonal skill development in Students reported that the puppets were
using a focus group undergraduate students engaging and fun and learning in this way
method helped them develop stronger memory
connections and recall of theory and
practice concepts
Qualitative Diabetic Education in Children Play therapy is a useful and interesting
using a NOTTI doll strategy for the simultaneous education
of both children and adults in diabetic
management
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Appendix 2: Pup-Ed™ KRS simulation: acronym explained
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