Unpacking the effectiveness of therapeutic play in hospitalized children: A realist review of underlying mechanisms and contextual factors

INTRODUCTION: Rising hospitalization rates are associated with increased anxiety, pain, and delayed recovery for children. While therapeutic play shows promise in reducing these negative outcomes, its mechanisms remain unclear. OBJECTIVE: This realist review aims to unpack the mechanisms and contextual factors undrelying therapeutic play in hospitalized children. By constructing Context-Mechanism-Outcome configurations, it seeks to explain how, for whom, and under what circumstances this intervention produces intended and unintended outcomes. METHODS: This realist review explores how therapeutic play mitigates adverse experiences in hospitalized children, following RAMESES standards. The research process consists of five phases: (1) identifying the initial program theory, (2) searching for evidence, (3) selecting documents, (4) extracting and organizing data, and (5) synthesizing evidence and drawing conclusions. Data sources encompass relevant quantitative, qualitative, and mixed-methods studies from eight major databases from their inception to June 2026: PubMed, CINAHL, MEDLINE, Web of Science, Embase, the Cochrane Library, PsycINFO, and CNKI. This review was registered on PROSPERO (Registration Number: CRD420251026828). RESULTS: 20 studies were included in the analysis. The study identified five mechanisms and constructed five Context-Mechanism-Outcome (CMO) configurations, which elucidate the potential application pathways of therapeutic play in hospitalized children. The specific mechanisms include (1)Cognitive Reappraisal, (2) Attentional Deployment, (3) Cognitive Development Adaptation, (4) Secure Attachment, and (5) The Activation of Descending Inhibitory Pathways. CONCLUSION: This realist review clarifies therapeutic play mechanisms, supporting evidence-based interventions to reduce children's negative emotions and improve hospitalization experiences.