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Getting into the Same Boat – Enabling the Realization of the Disabled Child’s Agency in Adult–Child Play Interaction

Authors:

Johanna Olli ,

University of Turku, FI
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Sanna Salanterä,

University of Turku, FI
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Liisa Karlsson,

University of Helsinki, FI
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Tanja Vehkakoski

University of Jyväskylä, FI
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Abstract

The purpose of this study was to find out how an adult can enable or hinder the realization of a disabled child’s agency in play interaction. We focused on the child’s play invitations, which were constructed as dispreferred by the adult. The data consisted of nine videotaped playing situations with five nurses and five disabled children in a children’s neurological ward. The microanalysis with interventionist applied conversation analysis focused on one playing situation between one nurse and one three-year-old boy with no spoken language. The nurse responded to the child’s play invitations constructed as dispreferred by her in three different ways. Two of them were about trying to control the situation, either through managing the child’s behaviour or by guiding the plot of the play. The third way of responding was negotiating through dialogical playing, which enabled the realization of the child’s agency. The findings can be utilized widely for developing child-centred practices.

How to Cite: Olli, J., Salanterä, S., Karlsson, L. and Vehkakoski, T., 2021. Getting into the Same Boat – Enabling the Realization of the Disabled Child’s Agency in Adult–Child Play Interaction. Scandinavian Journal of Disability Research, 23(1), pp.272–283. DOI: http://doi.org/10.16993/sjdr.790
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  Published on 11 Oct 2021
 Accepted on 21 Sep 2021            Submitted on 01 Feb 2021

Introduction

Play is commonly thought to ‘belong’ to children and childhood. Children’s right to play has been accepted universally (UN 1989: art. 31) and is considered to be ‘of intrinsic value to the child, purely in terms of the enjoyment and pleasure it affords’ (UN 2013). This definition is consistent with children’s own views, according to which play is something that is fun to do (Glenn et al. 2013; Miller & Kuhaneck 2008; Nicholson et al. 2014) where the means are more important than the ends (Glenn et al. 2013). From the perspective of children, play is something for which adults have not defined the goal; the activity is voluntarily chosen and self-directed by the child (King 1979; Nicholson et al. 2014).

Earlier research has mainly approached play from an instrumental perspective by examining the relation of play to various developmental factors or using play as an intervention method (see also Meire 2007). From the child’s perspective, however, it might be reasonable to consider play as relating to the child’s right to be heard (UN 1989: Art. 12; see also Davey & Lundy 2011), because participation with children in play gives adults unique insights into children’s perspectives (UN 2013).

In this study, we focus on the tension between the perspectives of an adult and a disabled child in an adult–child play interaction. The context of our study is a playing situation between a disabled child and a nurse during a (re)habilitation assessment period in a children’s neurological ward, where playing is an important part of nursing care (Olli et al. 2014; see also Eriksson 2001).1 A focus on disabled children’s play and agency is of great importance, because although disabled children have the same basic rights to be heard as other children, earlier research shows that they are more likely to meet challenges with the realization of their agency than other children (e.g., MacArthur et al. 2007). Disabled children’s play is especially often instrumentalized by considering it primarily a tool for diagnosis and therapy (Goodley & Runswick-Cole 2010).

For this study, we focus on one disabled child’s play invitations, which were constructed as dispreferred by the nurse, because a situation in which a child acts against adults’ wishes can make the realization of the child’s agency especially challenging (Iversen 2014). In this study, dispreferred invitations mean the child’s play behaviour that the nurse constructed in her responses as somehow negative and something that should be changed. The research questions of our study were 1) how does the nurse respond to the disabled child’s play invitations constructed as dispreferred by her and 2) how do these responses enable or hinder the realization of the child’s agency?

The Agency of the Disabled Child

Our definition of agency is based on a pragmatic premise: to enable the realization of a child’s right to be heard and to influence decisions concerning his/her life, an adult must presume that every child has their own views (as the United Nations’ Committee on the Rights of the Child (UN 2009) has argued in Article 12 of the Convention on the Rights of the Child). The right to be heard could be connected to the concept of voice (see e.g., Lesnik-Oberstein 2011), but the concept of agency extends beyond this as it also covers the right to influence. We see agency (i.e., the right and the need to have an influence on other human beings) as something that everybody has as a part of every human being’s essence, instead of something that someone has (or does not have) due to his or her competencies or lack thereof (see Olli, Vehkakoski & Salanterä 2012). However, having agency does not yet mean that it can be exerted; therefore, the main concept of this article is not agency but the realization of agency, which is also used in Olli, Vehkakoski and Salanterä’s (2012) study. We utilize Mayall’s (2002) differentiation between an agent, a person whose interaction makes a difference, and an actor, a person acting without this having any consequences on an interaction. Thus, although the child can try to display his/her agency, it becomes realized only when the child’s verbal and nonverbal expressions are being interactionally validated. In this case, although the adult may show their disagreement with the child’s activity or utterances, she/he lets them influence their interaction instead of carrying on along the previous lines. When responding to the child by considering the child’s perspective to be as valuable as the adult’s, the adult participates in a dialogue (whether verbal or nonverbal) that enables the realization of the child’s agency.

The child’s agency becomes realized in the interaction between individuals, but interaction is shaped by the structures and cultures that either facilitate or hinder the realization of agency and, in turn, are either reproduced or transformed in interaction, as Emirbayer and Mische (1998) argue. The realization of disabled children’s agency is still a rarely researched subject (Vänskä et al. 2016; see also Tisdall 2012), especially concerning small children and those not using spoken language (Vänskä et al. 2016). Yet some recent studies demonstrate that disabled children’s agency is too seldom realized in professional structures that concentrate on children as ‘becomings’ and ignore their perspectives as ‘beings’ in the present (Engwall & Hultman 2020; Nordström et al. 2020). In the habilitation context, disability is seen through a medical model, which directs professionals’ interventions primarily to modifying the child’s skills and emphasizes the professional-originated perspective (Olli et al. 2014).

Children’s agency has often been considered in relation to the children’s competence; whereas, adults’ competence has very rarely been examined in relation to the realization of children’s agency (Moran-Ellis & Tisdall 2019). Our study, however, is based on the principle of the United Nations’ Committee on the Rights of the Child (UN 2009): regardless of the child’s age or competence, every child has the right to be heard and to influence decisions concerning their life. The realization of this right requires adults’ ‘recognition of, and respect for, nonverbal forms of communication including play, body language, facial expressions, and drawing and painting’ (UN 2009). Disabled children also have a particularly articulated right to get appropriate assistance for expressing their views freely (UN 2006). Therefore, adults’ competence in listening to children’s nonverbal communication and their ability to ‘speak the same language’ with the child are essential for the realization of the children’s agency (Karlsson 2020).

According to the previous literature review, in enabling the realization of disabled children’s agency, institutional structures, professionals’ attitudes and their communication are important (Olli et al. 2012). Interaction that enables the realization of a disabled child’s agency is characterized by dialogical communication. This includes the willingness and ability to create a relationship with the child and to change the power relationship between adult and child by engaging in a communication process where meanings and conversation topics are negotiated (Olli et al. 2012). A dialogical encounter is characterized by mutuality and equality, when it could be called an ‘I–Thou’ relationship (Buber 2004), as opposed to an objectifying ‘I–It’ relationship. Another characterization of a dialogical encounter is Freire’s (2005) description of people who are together trying to learn more than they already know. According to Freire (2005), in this kind of encounter, no one is completely ignorant and no one is completely knowledgeable. Thus, in dialogical communication, no one can decide the outcome of the communication beforehand.

The Play of the Disabled Child

Play in the service of habilitation nursing forms one of the structural contexts of our study. For professionals working with disabled children, play seems primarily to be a means for implementing professionals’ aims (Olli et al. 2014; Nordström et al. 2020), instead of an intrinsic value for children, whose right to play without adults determining what play is should be respected (UN 2013). Disabled children are mainly described as ‘deficient, other, lacking in terms of play’ from the traditional professional-centred and medical perspective of normative standards (Goodley & Runswick-Cole 2010; see also Olli et al. 2014). As Spitzer (2003) has shown, the narrow outlook of adults might prevent seeing different kinds of playing as real play.

Recently, a few studies have presented a different perspective, for example, by revealing the rich play cultures of children on the autism spectrum (Burke & Claughton 2019; Conn & Drew 2017; Spitzer 2003) and showing that children with profound and multiple learning disabilities have a high level of playfulness determined by situations and adults supporting the children, not by impairments (Watson et al. 2017). Play has also been demonstrated as a good place for disabled children to exercise their agency (Burke & Claughton 2019).

Despite their playing readiness, disabled children might also need adults to enable their playing (Graham et al. 2018; Watson et al. 2017). The impact of the adult’s presence in play is not sufficiently explored (Graham et al. 2018), but studies have, so far, identified some possible roles of adults in disabled children’s play when it is not the role of an educator. Adults might be assistants of the child (Graham et al. 2018; Tamm & Skär 2000), but they also might hinder the ‘wrong kind’ of playing (Conn & Drew 2017). Furthermore, they may act as barriers to co-playing with other children or ‘take over’ the play in other ways (Tamm & Skär 2000). However, instead of examining the roles of adults as co-players, studies have focused on them as outsiders, even though not only do children generally hope that adults would play more with them (Nicholson et al. 2014), but also play is also an important part of many professionals’ work with disabled children (Olli et al. 2014). Therefore, it is very important to study the roles of adults as play partners and the related consequences for the child’s agency.

Adult–Child Interaction in Play

Only a few studies exist on adults’ playing orientation, although we do know that some adults feel that playing is difficult (Greve & Kristensen 2018) and that, according to children, adults do not completely understand playing (Glenn et al. 2013) and do not play enough (Nicholson et al. 2014). We also know that adults might consider their own ideas more important than the child’s own play ideas (Ireson & Blay 1999), intervene in ways that disturb the co-playing of children (Riihelä 2002) or use more time walking around than playing with children (Singer et al. 2014). Adults also often position themselves outside of children’s play by monitoring or supervising the play (Fleer 2015). Even when playing, adults sometimes are not always able to be emotionally available (Emilson & Folkesson 2006; Singer et al. 2014).

However, a few studies have discussed the consequences of adults’ behaviour in the mutual play interaction by examining adults’ playing and interaction styles. Russell, Mize and Saebel (2001) studied the phenomenon from the viewpoint of the playing style of adults. Their first described style was a director’s playing style, which was characterized by an adult organizing the play, taking charge of the play and assuming responsibility for the play. According to Lobman (2006), the adult ignores or negates children’s initiatives when trying to determine the direction of the situation on his/her own. This kind of playing style includes the adult’s serious and dissociated attitude and the lack of attempting to view the situation from the child’s perspective—accompanied by weak opportunities for the children to participate (Emilson & Folkesson 2006).

When moving towards a more child-originated way of playing, Russell and colleagues (2001) have identified a facilitator’s playing style, in which an adult allows children to decide what they want to do, while encouraging and assisting them. An even more child-originated or even mutual playing style is a co-player style, in which the adult joins the play as an equal playmate, and the play is jointly constructed (Russell et al. 2001; see also Lobman 2006). Then, the adult builds the play on the child’s initiatives by matching the interaction directly with what the children are doing and saying (Lobman 2006), resulting in strong participation by the children (Emilson & Folkesson 2006). In addition, the playing is defined by the emotional engagement of the adult and a playful atmosphere (Emilson & Folkesson 2006), where both adults and children are having fun (Russell et al. 2001).

Methodology and Setting

Data

The setting of our study was a children’s neurological ward in one Finnish public special healthcare hospital. In this ward, play was a part of certain nursing functions, such as taking care of the child’s basic needs (the need for rest and recreation) or habilitation nursing (assessing the skills of the child or supporting the child’s development) (similarly as in Olli et al. 2014).

The primary data consisted of nine videotaped playing situations with five nurses and five children (one nurse and one or two children at a time). The children participated in a five-day assessment period at the hospital, which consisted of the assessment of the child’s development by a multiprofessional team. We identified three different means used by the nurses in responding to the children’s undesirable play initiatives from the data. We selected one playing situation for the microanalysis, because it contained the richest illustration of the three different means.

In the chosen situation, one nurse was playing with a three-year-old boy (here given the pseudonym ‘Jesse’) diagnosed with mixed specific developmental disorder. Jesse did not use words to communicate but instead vivid facial expressions, vocalizations and occasional manual keyword signs. He mostly communicated, however, through actions. The period spent in the hospital was meant for assessing his development and habilitation needs. The nurse was an experienced registered nurse covering for Jesse’s primary nurse, but she did not know Jesse very well; they had just met on the day this playing situation was videotaped. The analysed situation is, therefore, an example of an adult and a child getting to know each other. The setting was the playroom of the ward.

Analysis

The data was analysed with interventionist applied conversation analysis (CA) (Antaki 2011). The basic idea of CA is to interpret the meanings of expressions presented by one participant on the basis of the next action or on later turns of other participants (Heritage 2001). Thus, the microanalysis of the ongoing playing episode shows how the nurse and the child locally interpret what is occurring in the immediate playing interaction. This meant that the constructions of playing as (dis)preferred were found by examining the child’s and the nurse’s interpretations of each other’s initiatives and their responses to each other’s verbal or nonverbal turns. For example, if the child’s actions were followed by the nurse’s attempts to control or to guide the child’s behaviour by questioning it or suggesting how he should play, the nurse was interpreted as constructing the child’s behaviour as dispreferred, although she would not have said it directly.

The data were transcribed by applying CA transcription conventions (Appendix 1). As transcription always means making a choice that ‘captures something, but not everything’ and also ‘alters that something’ (Sandelowski 1994), we used both the transcriptions and repeated viewings of the video data in the analysis. We also made an effort to make the simultaneity of various activities visible by marking simultaneous actions with the same line numbers and indicating the timing of them with indentations.

The microanalysis began with making observations of the nurse’s responses to the play initiatives taken by Jesse. We considered initiatives to be his every action or sound, because they all were opportunities for the nurse to react. This phase of analysis indicated the strength of CA to make visible not only what is said or done, but also how it is said or done (Dowling 2007). After identifying three recurring patterns in the nurse’s turns, we analysed Jesse’s reactions to these responses by focusing on how the different patterns were related to the realization of Jesse’s agency. The analysis illustrates how a child’s behaviour becomes constructed moment by moment as dispreferred by an adult, even though the situation was intended for free play. In the habilitation nursing context, free play means that the child is allowed to choose what to do, and it is considered time for recreation. However, typical in habilitation nursing is the habit of constant assessment and attempts to support the child’s development in everything nurses do (Olli et al. 2014).

Ethics of the study

The study was approved by the ethical committee of the ethical committee of University of Turku. Adult participants and the guardians of the children gave their written informed consent, and the children gave their assent with the help of picture communication to obtain their perspective of the participation. The process of gaining assent from children is described in detail elsewhere (Olli 2019). Throughout the study, we carefully examined our attitudes towards the child and adult participants and also considered what kind of representations the study produces of disabled children and their nurses. We also will disseminate the study findings to the participants by delivering the study reports to the adult participants and pictured study reports to the children.

Findings

In the playing situation chosen for the microanalysis, Jesse makes three kinds of play invitations that are constructed as dispreferred by the nurse. They are related to the aggressiveness of the play (e.g., crashing the mopeds), the unconventional use of toys (e.g., sitting on a moped that is too small) and the use of the adult as a toy (landing the moped on top of the nurse). The nurse’s responses to Jesse’s invitations take three different forms, which either enabled or hindered the realization of Jesse’s agency. In the beginning of the situation, the nurse tries to control the situation through managing Jesse’s behaviour or through guiding his play. Finally, after 10 minutes of playing, the nurse positions herself as a player and does not return to her previous means.

Controlling through behaviour management

Managing Jesse’s playing behaviour refers to the nurse’s actions of directing Jesse’s attention to the particular features of his play constructed as dispreferred by the nurse through questions, explanations, requests, orders, suggestions and physical interventions. When managing his behaviour, the nurse does not play herself but positions herself as an outside observer commenting on the ongoing play and setting the appropriate frames for it.

The following Extract 1 is preceded by a transition in which another child has stopped playing with a hut together with Jesse and left the room. The nurse has suggested playing with cars on a ‘car mat’ to Jesse, who first starts playing with them and then finds mopeds and a Moomin boat from the car box. After showing the boat to the nurse, Jesse starts playing with the mopeds.

Extract 1

Controlling.


1 Jesse ((moves on top of the moped towards the moped the nurse is driving and gets them to crash))
2 Nurse oooh(.)*did they crash*(2.53)
((holds the moped on the mat with her right hand))
                    ((Jesse continues pushing his moped against the nurse’s moped))
3 Nurse *did it hurt *(1.48)
((looks at Jesse, who raises his eyes and smiles at her playfully))
4 Jesse heeh= ((gives a little laugh))
5 Nurse =are you a little bit too big on top of that moped
((switches the moped to her left hand keeping the moped still))
                    ((points at Jesse’s moped with her right hand))
((Jesse pushes his moped against the nurse’s moped))
6 Jesse ((sits down behind his moped))
(1.50)
7 Nurse can you drive that small moped(2.24)
((Jesse returns back on top of his moped))
                    ((the nurse points at Jesse’s moped with her right hand))
8 Jesse edeee=
((with a delicate voice, bending down over his moped))
9 Nurse =it seems to be a litt[le too big driver(1.30)
10 Jesse                     TEEE] ((emphatically))
11 Jesse DEEE=
           ((moves forward with his moped and crashes into the nurse’s moped again))
((63 seconds of text excluded))
12 Jesse ↑Uiiiiiii
((lifts his moped aloft))
13 Nurse *Prryyym*
((drives with a car forward))
14 Jesse ((puts down the moped on the nurse’s back roughly and starts driving down along the back))
15 Nurse Ohhoh(.) it was a wild hill(0.9)
((they look at each other, the nurse loses her grip on her car))
          ((Jesse lifts his moped aloft and lands it down on the nurse’s temple))
                    ((the nurse grabs Jesse’s wrist and moves the moped away from her face))
16 Nurse Let’s drive a little(.) Jesse let’s drive here on the mat so that no accidents happen
                               ((points at the mat))

In this extract, Jesse invites the nurse to play with him through crashing his moped into the nurse’s moped. The nurse does not accept the invitation by synchronising her playing to that of Jesse but instead verbalizes Jesse’s activity by asking a closed-ended question did they crash (line 2). In this way, she positions herself as a reporter outside of the play. Immediately after this, however, she offers a more negative interpretation of the incident and its possible consequences, still in the form of a question: did it hurt. It is not clear if this is asked inside or outside the play. Jesse, however, responds to the question by looking at the nurse with a smile and a little laugh, thus conveying enjoyment in the play. The nurse does not join in having fun but indicates that Jesse’s way of playing is dispreferred through questioning it with interrogative clauses: are you a little bit too big on top of that moped (line 5) and can you drive that small moped (line 7). For a very brief moment, Jesse seems to take the nurse’s concern seriously and stops sitting on top of his moped. Then, however, he goes back to crashing his moped by avoiding eye contact with the nurse and concentrating on his moped instead. In this phase, Jesse and the nurse act side by side but focus on different things. Jesse babbles when sitting on the moped, but his vocalizations are hard to interpret; he continues what he was doing: crashing the mopeds into each other (lines 8–11).

In the second part of this extract (lines 11–12), Jesse continues the crashing play. The nurse has just left her moped and taken a car out of the toy box. She concentrates on driving the car until Jesse’s moped lands on her back. The nurse does not scold Jesse but instead wonders about the episode emphatically: Ohhoh(.) it was a wild hill (line 15). Jesse, however, continues what he was doing: energetically driving his moped and landing it next on the nurse’s temple. The episode is followed by the nurse’s first physical intervention: she grasps Jesse’s wrist and moves it away. After this, she suggests driving on the mat with an explanation: so that no accidents happen.

In summary, in this extract, Jesse displays his agency by inviting, through his actions, the nurse to play a crashing play and to have fun with him. By positioning herself as a controller of the play, the nurse repeatedly overrides Jesse’s invitations by not taking them as a part of her own play but, instead, questioning them. Thus, she constructs Jesse’s way of playing as dispreferred by particularizing her own playing norms through trying to change Jesse’s behaviour and using the toys according to them. This approach neither enables the realization of Jesse’s agency nor leads to shared play between Jesse and the nurse. The nurse and Jesse seem to be speaking different languages or to be playing in different scenes of action. The power relationship is very traditional: the adult is the one whose ideas should direct the child’s behaviour.

The nurse’s management style is, however, persuasive rather than authoritative. This appears in her way of resorting to questions and suggestions instead of using direct commands or prohibitions. She does not scold Jesse even though he is driving his moped on her but restricts him physically and gives an indirect command. What is noteworthy, however, is that when controlling the child’s behaviour, the nurse stops her own play.

Guiding through developing the plot of the play

Besides managing Jesse’s behaviour, the nurse responds to his play invitations by trying to guide the plot of the play instead of joining Jesse’s. In this case, in Extract 2, the nurse withholds responses to Jesse’s behaviour. Instead, she switches to leading the play by instructing Jesse and modelling using toys in other ways constructed as socially acceptable by her.

Extract 2

Guiding.


1 Jesse ((pushes the moped the nurse is driving with his own moped while sitting on it, then lifts his moped aloft))
2 Nurse let’s ride on these roads(.) look(1.12)
((starts riding her moped on the road))
                    ((Jesse rides his moped with his hands and crashes it fast into the nurse’s moped))
3 Nurse look here is the road(.) do you see(.) prrym(.) road(1.22)
((points at the road on the mat and holds her moped with the other hand))
((Jesse crashes his moped into the nurse’s moped, then puts it down on the mat and rides on – not on the road))
4 Nurse then let’s drive here äännnnäännnnäännnn(1.17) äännnnäännnnäännnn=
((drives her moped on the road))
                                        ((Jesse turns his moped in front of the nurse’s moped and crashes into it, then lifts his moped aloft – the nurse keeps on driving))
((86 seconds of text excluded))
5 Jesse ((makes quiet driving sound, drives slowly behind the car the nurse has left on the edge of the mat and pushes it off of the mat))
((the nurse looks at him))
6 Jesse ((reverses his moped in front of the nurse)
((the nurse looks at the Moomin boat))
7 Nurse Here comes the boat, look=
             ((takes the boat in her hand))
((Jesse moves the moped between his legs and makes a quiet driving sound))

In Extract 2, Jesse continues inviting the nurse to the crashing play through physically orienting himself towards the nurse and by bringing their toys together. Although the nurse still does not accept the invitation, her responses differ from her earlier ones. Here, she does not focus on Jesse’s behaviour as such but on the plot of the play by making many suggestions for how they could (or should) continue playing. The suggestions are typically presented by directing Jesse’s attention to alternative ways of playing through the request look (lines 2, 3 and 7) and by using the suggestion form let’s (lines 2 and 4). The requests to look at what the nurse is doing are accompanied by indicating the preferred place to play (e.g., then let’s drive here, line 4) and making an inviting driving sound (line 4). Jesse, however, holds on to his original idea—crashing—and even when he drives, he does not drive on the road. The nurse persistently ignores Jesse’s invitations by showing what she considers the preferred way to drive and shortly after tries to use a distraction technique and suggests a totally new idea for the play: the Moomin boat (line 7). The idea of the boat does not seem to interest Jesse, even though he had taken the boat out at the beginning of this playing situation.

In this extract, the nurse constructs Jesse’s play invitations as dispreferred by ignoring them. By modelling how the playing should happen, she positions herself as an expert of play who has the right to determine what the right way to play is. Although the nurse now also plays with her moped part of the time, she and Jesse do not play collaboratively, only in parallel. The guiding approach neither enables the realization of Jesse’s agency nor produces the consequences the nurse seems to pursue: to stop Jesse’s actions constructed as dispreferred.

Negotiating through dialogical playing

The third response by the nurse to Jesse’s play invitations is to negotiate through her playing. What is striking in this interaction is the nurse’s way of joining Jesse’s activities and responding to them by taking the role of a fictional character. Before the following Extract 3, the nurse moved one metre away from Jesse and silently watched Jesse’s playing and other events in the room for 1 minute and 26 seconds (which is the longest quiet time for the nurse in the whole dataset). During that time, Jesse has started to play with the Moomin boat. The nurse joins in the play by taking the role of the Moomin figures and speaking with their voices. When she expresses an idea about how the plot of the play could continue, she negotiates this with Jesse.

Extract 3

Negotiating.


1 Nurse ((takes Moominmamma out of a bag and starts walking it towards the boat Jesse is playing with))
2 Jesse ((turns and looks at Moominmamma))
3 Nurse @*would I get in the Moomin boat please(.) ((softly, in a begging voice))
((keeps walking Moominmamma towards the boat))
                               ((Jesse moves his moped beside the Moomin boat to the other side of himself))
4 Nurse @*may I get aboard*@(0.9)
                    ((nurse leaves Moominmamma beside the boat))
                    ((Jesse looks at Moominmamma))
5 Nurse @*may I get in the Moomin boat@(0.8)*
((rummages in the bag and takes a new character from it))
((Jesse looks at the bag))
                                 ((Nurse looks at Jesse))
6 Jesse *eeee* ((softly, looking at the nurse))(1.3)
7 Nurse @I would like to go sailing a little@(1.2)
((takes Moomintroll out of a bag and walks it to the boat))
                                        ((glances at Jesse))
8 Jesse ((reaches for the Moominmamma, but then backs away))
9 Nurse @could you take me for a drive@
((keeps walking Moomintroll towards the boat))
((Jesse takes the moped again in his hand, lifts it up and looks at the Moomintroll, then moves towards the boat)
10 Jesse (6.1)
((takes Moominmamma in his hand and gets it to kick Moomintroll away))
((the nurse is rummaging in the bag))
11 Nurse @I would like to come along too@ ((in a slightly deeper voice))
((takes Snufkin out of the bag and walks it to the boat))(1.1)
12 Nurse @I have always dreamed of getting@
((bounces Snufkin in front of the boat))
                    ((Jesse makes Moominmamma jump in front of Snufkin))
13 Nurse @to a big sailing trip@
              Jesse: VRÄÄ VRÄÄ VRÄÄ VRÄÄ
              ((snarls and hits Snufkin with Moominmamma many times so that it falls out of the nurse’s hand))
14 Nurse @>don’t be so snappy, Moominmamma <@ ((in a slightly impatient voice))(3.0)
((lifts Snufkin to standing and holds on to it))
((Jesse looks at Moominmamma in his hand))
                    ((Jesse jumps Moominmamma defiantly on the floor))
                    ((nurse walks Snufkin a bit farther))
15 Nurse @>will you let me board that boat =I would like to see if Moominpappa is there in the boat< @ (1.64)
((walks Snufkin to Moominmamma))
((Jesse lets Moominmamma stand against Snufkin))
16 Jesse VRÄY VRÄY VRÄY
((snarls and jumps Moominmamma over Snufkin)
            ((Nurse lifts Snufkin a little))
                    ((Jesse lifts Moominmamma aloft))
17 Nurse @>Moominmamma don’t be so angry=I want to join the trip<@ ((in a positive tone))
((bounces Snufkin in front of Moominmamma))

In the beginning of Extract 3, the nurse follows the definitions of play initiated by Jesse. First, this appears in the way she takes from the bag a Moominmamma figure, which belongs to the same group of toys as the Moomin boat chosen by Jesse. Second, she does not join in the play as her real self but talks with her play figure’s voice, and third, she tries to make eye contact with Jesse. She also starts with actions, not with words as before. Moominmamma’s voice remains the same in lines three, four and five, where she asks in a quiet, pleading tone permission to board the ship. Jesse, however, gives Moominmamma only a short look and does not respond to the nurse’s proposals until line 6. Jesse’s response eeee is also produced with a similar soft voice as the nurse’s and sounds like the negative ‘ei’ (= no) in the Finnish language. It might also, however, mean something else, because Jesse uses similar sounding vowel expressions in different meaning contexts.

The nurse reacts to Jesse’s possibly negative answer by making a new attempt to invite Jesse to join in collaborative play by taking a new toy figure, the Moomintroll, from the bag. First, she presents the Moomintroll’s wish with a brisk voice in the form of a declarative sentence (@I would like to go sailing a little.@, line seven) and then in the form of a question (@could you take me for a drive @, line nine). The use of the conditional form is a polite way of both asking and stating one’s desire. Despite this, Jesse’s answer is now even more active and clearer: he kicks the nurse’s toy figure with another toy figure (Moominmamma). The nurse does not, however, comment on the kicking but takes up a new toy figure, Snufkin, who also wants to go boating.

In the middle of Snufkin’s second utterance, Jesse raises his voice and growls somewhat aggressively simultaneously when hitting Snufkin with Moominmamma (line 13). What is noteworthy is that the nurse takes Jesse’s reaction as a part of the plot of the play and continues the storyline initiated by Jesse. She does not restrict the child from taking an adult position but remains consistently in Snufkin’s role, even though Jesse resists her suggestions and behaves aggressively with his figure of Moominmamma. Then the nurse makes Snufkin urge Moominmamma not to be so angry and asks again for permission to board. The same follows in lines 14 and 17, where the nurse’s toy figures also give reasons for their wishes. Note that although Jesse’s character Moominmamma still remains angry and continues her aggressive behaviour, the nurse tolerates this by continuing to ask permission without switching back to controlling the situation or guiding the play outside of the play role.

In this extract, the nurse’s way of responding to Jesse’s play invitations by positioning herself inside the play and as Jesse’s playing partner deviates from her ways of intervening in Jesse’s play. This time the nurse enables the realization of Jesse’s agency by listening to his reactions in a responsive way and by building the play by including Jesse’s various initiatives in it—even those that she has constructed as dispreferred. Thus, when positioning herself primarily as a player, although still being very active in constructing the storyline, the nurse does not take a traditional adult role but elaborates on the plot of the play collaboratively with the child. She is, in other words, throwing herself into playing and communicating through playing, which could also be called play interaction. The new way of acting also bears fruit, because the power struggle between the nurse and Jesse finishes quite soon after this extract. After sharing the power and allowing the child to take the position of captain, the one who decides on the boat, there is suddenly room for peaceful collaborative play between the nurse and the child—play in which both of the players listen to each other and communicate in gentle voices.

Discussion

This study provides a rare analysis of the realization of a young disabled child’s agency during the play interaction between a nurse and a child, and it simultaneously gives an example of how to respect the child’s perspective in a conflict situation. The child’s play invitations were mainly constructed as dispreferred by the nurse, who tried to control them through engaging in behaviour management or guiding the plot of the play. This did not prevent the actorness (see Mayall 2002) of the child, but it did hinder the realization of his agency, because his play invitations were taken as problems to correct, not as meaningful actions to respond to. What is noteworthy, however, is that the nurse’s responses changed from the use of problem-oriented and disabling strategies to less restrictive and more engaging strategies, beginning with silently watching the child’s play and progressing to playing together with the child.

Constructing the child’s playing as an object of assessment and education refers to the (re)habilitation ideology typical of traditional, paternalistic nursing care. Harnessing the play (or play-like activities) for the purposes of habilitation or education refers to the image of a child as vulnerable and in need of protection, thus positioning the child more as a human becoming rather than a human being. This orientation has been found to be dominant in habilitation nursing (Olli et al. 2014) and also in other fields of habilitation (Nordström et al. 2020). Interestingly, although the nurse in this study reproduced this traditional orientation at the beginning, during the play situation she moved to an interaction that was more dialogical and more respectful of the child’s agency.

The nurse’s responses raise questions about the dialogicality of adult–child play. An adult-centred form of interaction was characterized by the nurse placing herself outside of the player position and attempting to make the child act according to the prevalent norms of adult culture, which could be seen as an objectifying encounter. It is questionable whether that kind of activity could even be called play—at least from the child’s perspective (see King 1979; Glenn et al. 2013). Instead, the nurse’s way of negotiating the play could be seen as play, as the nurse positioned herself as an equal player and mutual partner in interaction, not as a director from the outside. In this situation, enabling the realization of the child’s agency happened only when the nurse engaged in the play interaction (i.e., communicated through playing), which was the language the child had been using from the beginning.

When the findings concerning the nurse’s way of playing that enabled the realization of the child’s agency were compared to the analysis of the literature, we found and named three significant elements of dialogical play that are mutual and equal rather than objectifying (Buber 2004). First, throwing oneself into playing seemed to be important. This required the nurse to be an active part of the play, for example, by using a ‘play voice’ (see Emilson & Folkesson 2006) or being in the same scene with the child (Lobman 2006). Second, sharing power was another important element. Sharing entails equality in an interaction, which meant that the nurse and the child participated in peer-like interactions (Russell et al. 2001) on equal terms; they both took initiative (Emilson & Folkesson 2006) and collaborated to create a joint activity (Lobman 2006). In this situation, the nurse refrained from being over-controlling (Greve & Kristensen 2018) and focused on what was happening in the moment rather than on a predetermined goal (Emilson & Folkesson 2006; Lobman 2006).

The third element was responding through listening. This required the nurse to read the child’s nonverbal signals carefully (Greve & Kristensen 2018), to share his reality (Emilson & Folkesson 2006; Lobman 2006) and to respond to the child in a way that was suitable for that particular child, whether verbally or through actions, gestures and voices (Emilson & Folkesson 2006). Note also that the nurse adjusted her own ideas to the initiatives of the child (Emilson & Folkesson 2006) and accepted even ‘bad’ initiatives as material for play instead of considering them to be problems to solve before the play continued (Lobman 2006). As a consequence of this, the nurse and the child were in tune with each other (Russell et al. 2001).

In answer to our research questions, we thus found that dialogical play enables the realization of a disabled child’s agency by giving the adult space to encounter the child in a way that enables the child to be heard. Stepping out of the traditional adult and professional position allows the child to be seen from a different perspective. In other words, daring to participate in play in a dialogical way changes the adult, as Rainio (2008) and Stetsenko and Pi-Chun (2015) have also noticed. As Sidnell (2011) suggests, the adult might begin to see the child as an expert of play. We could argue that play is a strength of children and that it is worth the attempt to surrender to their direction.

Strengths and Limitations

Videotaping proved to be a useful method for documenting the small details and nuances of complex play interaction. The use of videotaping and CA also allowed studying nonverbal interaction, which enabled examining the perspective of a child who was able to express himself through his actions. Transcribing the video data was challenging due to the rapid-fire nature of the interaction with extensive bodily language as well as much overlapping talk and the simultaneous use of play objects. However, the videotaped data enabled us to check the details many times and, therefore, enhanced the trustworthiness of the results.

Because the CA method does not allow examination of the larger macro-context around the interaction, it might have been useful to collect ethnographic data (Antaki 2011) for understanding the larger picture of the institutional cultures that direct nurses’ interaction with children. The question of the study was not to point to an individual professional’s choices of action, and we presume that her actions also reflected institutionally shared practices of professional-originated interventions targeted toward improving the child’s abilities in the (re)habilitation field (see e.g. Vänskä et al. 2016; Olli et al. 2014). The chosen data extracts indicate a phenomenon visible throughout the larger data: how the realization of the child’s agency is not a consequence of the child’s or the adult’s characteristics but of the interaction between them, especially of the interaction practices of the adult, who has the power in the institutional situation. Therefore, the findings concerning the ways of playing that enable the realization of the child’s agency seem to be applicable to a wide range of children in a variety of circumstances. Although the nurse’s playing practices are influenced by the (re)habilitation and nursing culture and hospital structures, it is also possible to deconstruct and change them through increasing awareness of the practices that disable rather than emancipate children. Therefore, it is worthwhile to study these practices and to make both the drawbacks and good practices more visible.

Conclusion

Because play has such an important role in children’s lives, the role of play in disabled children’s and professionals’ encounters should be critically examined. Our study examined play in a children’s habilitation nursing context and suggests that play can be a valuable space for nurses in getting to know the child. Seeking the child’s perspective is essential if professional practices aim at being client-centred. In habilitation, professionals have traditionally been interested in what the child can or cannot do (Rosenbaum & Gorter 2011). In contrast, a dialogical way of playing allows for asking who the child is, or at least how he/she is and why. It also allows for understanding the effect of the situation and the interaction partner on the child’s behaviour. Dialogical play would be a good place for professionals to learn to respect the child as he/she is.

It seems typical, not only for nurses, but also for adults in general, to define some ways of playing as undesirable (Conn & Drew 2017; Greve & Kristensen 2018; Lobman 2006; Rainio 2008) and to try to change them through control. In seeking the child’s perspective, it would be most beneficial to conform to the child’s way of playing, no matter how absurd it seems in adults’ eyes. Spitzer (2003) managed to see the meaningfulness (from the child’s perspective) of the actions of a child on the autism spectrum, in spite of how strange they first seemed. Perhaps every adult should sometimes stop educating children and start listening with all the senses. At the very least, adults should remember the child’s right to play and be careful not to ruin that play—perhaps even without noticing itby always trying to control the child. This kind of approach in research and professional practice could also contribute to increased respect for the perspective of the child on a societal level.

Notes

1In this article we use the word ‘habilitation’ instead of ‘rehabilitation’ because these children are born with their impairments. 

Appendix 1: Transcription Symbols 
Ascending intonation
(.) Pause, less than 1 second
Pauses of 1 second or more
[ Start of simultaneous talk
] End of simultaneous talk
Indentation The starting point of the simultaneous voice/action
= No discernible pause between the end of a speaker’s utterance and the start of the next utterance
>text< Accelerated, talk between > < is spoken more quickly than surrounding talk
: An extension of the preceding vowel sound
TEXT Text that is spoken more loudly than surrounding talk
text Text is spoken with emphasis
*text* Whispering or quiet voice
@text@ Changing one’s typical voice (Here: play voice)
((text)) Comments from the transcriber

Acknowledgements

We want to thank the study participants for their valuable contribution.

Funding Information

This study was supported by research grants from Finnish Association of Nursing Research, Finnish Brain Foundation, Finnish Cultural Foundation and Varsinais-Suomi Regional Fund, Finnish Foundation for Nursing Education, Finnish Nurses Association, Olvi foundation, Oskar Öflund Foundation, Päivikki and Sakari Sohlberg Foundation and Tukilinja Foundation sr. None of the funding sources contributed to the study design, data analysis or the drafting of the present report.

Competing Interests

The authors have no competing interests to declare.

Author Contributions

All authors contributed substantially to this article.

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