INTERNATIONAL PEDIATRIC NURSING

Column Editor: Bonnie Holaday, DNS, RN, FAAN

Narratives of Children With Chronic Illness About
Being Comforted
Charlotte ngstrm-Brnnstrm, RNT, MSc, PhD-student
Astrid Norberg, RNT, PhD
Lilian Jansson, RNT, PhD
The aim of the study was to examine how children with chronic illnesses narrate their experience of being comforted in hospital.
During interviews, seven children, 410 years old described their experiences and made drawings. Thematic content analysis
revealed following themes: being physically close to one's family, feeling safe and secure, staff being there for the children, and
children being there for parents and siblings. Mother was identified as the most important comforter. The findings suggest that
trusting in the staff's knowledge and professional skills is a prerequisite for children to feel at home, and safe in hospital. Being
close to one's family is even more important.
2008 Elsevier Inc. All rights reserved.
Key words: Children; Chronic illness; Comfort; Drawing; Hospital; Narrative
C
HRONIC ILLNESS CAN disrupt the life of
affected children as well as of their family
members and the family as a unit (Sartain, Clarke,
& Heyman, 2000). Children with chronic illnesses
are vulnerable because of their illness and their
limited understanding of, and lack of control over,
what is happening and what will happen to them
(Bricher, 2000).
Hospitalization constitutes enormous stress and
leads to a profound change in the lifestyle of
children as they face separation from their family
(Hopia, Tomlinson, Paavilainen, & stedt-Kurki,
2005; Kaminski, Pellino, & Wish, 2002). The
difficulty can vary with the children's develop-
mental stage (Price, 1994). The experience of
hospitalization may influence children in many
ways. They may experience sadness, frustration,
and anger, as well as missing their family, friends,
and, sometimes, pets. Children may also experience
restrictions, inactivity, and boredom caused by the
hospitalization (Bradding & Horstman, 1999;
Horstman & Bradding, 2002).
Family-centered care of children is based on the
belief that all families are deeply caring and want to
nurture their children (Ford & Turner, 2001) and
that it benefits both the child and the child's family
when parents work together with professionals
(Smith & Daughtrey, 2000). Parents can often best
support their children because there is a trusting
relationship between the child and the parent and
because parents can comfort their child (Shields &
Nixon, 2004). Family-centered care principles are
being applied across health care internationally
(Espezel & Canam, 2003), and in Sweden, parents
usually stay in the hospital with their children and
participate in their care (Hallstrm, Runeson, &
Elander, 2002a).
When scared, tired, in pain, and ill, the
hospitalized child needs to be comforted. Accord-
ing to Kolcaba and DiMarco (2005), children and
their families want to be comforted in stressful
health care situations in pediatric nursing. Accord-
ing to Webster's Comprehensive Dictionary (1998),
comfort is defined as freedom or relief from pain,
From the Department of Nursing, University of Ume, Ume,
Sweden.
Corresponding author: Charlotte ngstrm-Brnnstrm,
RNT, MSc, PhD, Department of Nursing, University of Ume,
S-901 87 Ume, Sweden.
E-mails: charlotte.angstrom@nurs.umu.se, astrid.norberg@nurs.
umu.se, lilian.jansson@nurs.umu.se
0882-5963/$ - see front matter
2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.pedn.2007.04.006
Journal of Pediatric Nursing, Vol 23, No 4 (August), 2008 310
annoyance, or want; anything that contributes to
such relief and relief from sorrow or distress;
consolation; or one who or that which comforts
or consoles.
Various ways of comforting children have been
described in research reports: touching (Bricher,
1999; Chang, 2001), looking in or reading a book,
listening to a story, playing (Darbyshire, 1994;
Devereaux-Jordan, 1997; Haiat, Bar-Mor, & Sho-
chat, 2003), and parents holding the child on their
lap and spending time with him or her (Kankkunen,
Vehvilinen-Julkunen, Pietil, & Halonen, 2003).
Proctor, Morse, and Khonsari (1996) report that
nurses can effectively use their voice to distract
children and get them to hold on and tolerate a
difficult situation a little longer.
Children described being comforted when taking
medicine, crying, and yelling and feeling com-
forted when being with someone close (Hester,
1986), as well as when being close to parents or
someone else whom they trusted and having a
parent with them in the hospital (Plkki, Pietil, &
Vehvelinen-Julkunen, 2003; Woodgate & Krist-
janson, 1996a).
Comforting often is performed in a trusting
relationship between people. According to Morse
(2000), trusting in the nurse is important to attain
comfort. Nurses in pediatric settings work hard to
develop trusting relationships with children in
their care (Bricher, 1999, 2000) by learning about
the child's condition and the child as a person
(Bricher, 2000; Espezel & Canam, 2003; Horst-
man & Bradding, 2002). The staff can let children
participate in their own care and prepare them for
what is about to happen (Hester, 1986; Runeson,
Hallstrm, Elander, & Hermern, 2002). The staff
members are often involved in painful and
frightening procedures for children, and they use
a range of strategies to gain the confidence and
secure the cooperation of the children. Establish-
ing trust takes time, and honesty is reported to be
important. Relationships with children with
chronic illness can span years, and there is quite
often a process of starting where the child and
nurse left off on each subsequent admission
(Bricher, 2000).
In the review of the literature on comforting
children in the hospital, we found no study that
cited narratives of children with chronic illness on
the topic of being comforted in hospital. Therefore,
the aim of this study was to examine how children
with chronic illnesses narrate their experience of
being comforted in the hospital.
PARTICIPANTS AND METHODS
Ethical Considerations
Seven children and their parents were informed
about the study, both verbally and in writing.
Information was simplified for the children. The
parents and children gave their informed consent
and were ensured confidentiality and anonymous
presentation of results. The study was approved by
the Ethics Committee of the Medical Faculty, Ume
University, Ume, Sweden (438/98).
Participants
The study included a purposive sample of four
girls and three boys aged 410 years, admitted to a
pediatric ward at a large hospital in northern
Sweden. The children had the following chronic
diseases: asthma and allergy, scoliosis and heart
disease, myelomeningocele and paresis, kidney
disease, liver disease, endocrinological disease,
and neurological disease. All had previously been
admitted to the hospital at least four times. Two
children were bedridden and five were able to get
up and walk about. The children's mothers were the
primary caregivers. All children had one parent
(most often the mother, but at some occasion, the
father) staying with them in the hospital. The
children stayed in the hospital for 421 days.
The Interviews
Personal interviews were performed. The first
author (C..B.) met each child together with his or
her parent three times. On their first meeting, she
informed them about the study; the second time
around, C..B., the child, and the parent got to
know each other, and on the third meeting, the child
was interviewed. The parents were invited to stay
during the interview, and all but one did. The
children were given the choice of whether they
wanted to be interviewed in a playroom (n = 1) or in
their hospital room (n = 6).
The questions were open ended and concerned
comfort and the children's experiences of being
comforted: Please tell me about comfort! Tell me
about a situation when you needed comfort. Tell me
about a situation when you felt comforted or did not
feel comforted. When you need comfort (like when
you are sad, or in pain) who is it that can best
comfort you? Follow-up questions were asked,
such as What do you mean? Can you tell me more
about that? What did you think? The tape-recorded
interviews lasted 2040 minutes and were tran-
scribed verbatim. During the interview, the children
311 NARRATIVES OF CHILDREN ABOUT BEING COMFORTED
were asked if they could make a drawing about
being comforted and were given paper, pencils,
crayons, and felt-tipped pens. Five children made
drawings and two did not. The children decided
themselves what they wanted to draw. The draw-
ings were discussed and clarified with each child
during and after the interview to understand the
content. The first author (C..B.) combined the
drawings with the interviews to help the children
reflect on and talk about their experiences. The
drawings were used as a strategy to help the
children talk about their experiences. For example,
when the children were talking about their parents,
they draw this, and they talked about the drawing
and their experiences. Deatrick and Faux (1991)
argue that children's drawings are a language, a
means of symbolically communicating their feel-
ings, thoughts, and experiences.
Analysis of the Interviews and Drawings
The interviews were analyzed by thematic
content analysis (Graneheim & Lundman, 2004;
Polit & Hungler, 1999) and involved several steps.
First, the first author (C..B.) listened to the tapes
and read the transcribed interviews straight
through. Second, the transcripts were read through
several times by all three authors, aiming at
grasping the content in the interviews. Third, the
interview, the child's comments, and the drawing
were seen as a unit, one for each child. Fourth,
within each unit, the interview text was divided into
meaning units that were coded with regard to
content; further, the child's comments and the
drawing were coded. Then, all codes were consi-
dered within the unit and subthemes and themes
were constructed. Fifth, the authors discussed and
compared their findings again, which led to the
final adjustment of the subthemes and themes
representing the content of the interviews, com-
ments, and the drawings.
RESULTS
The Interviews and the Drawings
The following themes were formulated: being
physically close to one's family, feeling safe and
secure, staff being there for the children, and
children being there for parents and siblings. In all,
the children produced 22 drawings, which depicted
their mother, father, and siblings; a rainbow; their
house or home; the hospital and an ambulance; and
their stuffed animals or pets.
Below, the themes are presented and illustrated
by citations from the interviews together with
examples of the drawings.
Being Physically Close to One's Family
All children talked about being physically close
to one's family (Figure 1). They emphasized the
importance of having their families, especially their
mother, staying in the hospital: I don't want to be
here, but my mother is staying with me. When my
mother is here with me, everything is much better.
They said that it was important to have their mother
physically close: Our beds are close to each other
because I want to sleep near her. If I wake up in the
middle of the night then I know she is here. The
children said that their mother knows exactly how
the children want everything and that she is the one
who comforts them in the best way: My mother is
the best to comfort me. She always knows how to
do it; she just does it . When I am sad I can sit on
my mother's lap and I cry for a while and then I feel
better . One of the girls said, My mother is kind
and I want her to stay here with me. I used to long to
be home with my mother when she wasn't here.
The children did not talk about their fathers as
much as about their mothers. The children said that
their fathers visit them, and one of the boys told that
he made frequent telephone calls to his father.
The children also talked about their siblings.
They said that they enjoyed it when their brothers
or sisters came to visit them and talked about an
older sibling comforting them: My sister buys
something for me and she gives me something
Figure 1. Mother and father.
312 NGSTRM-BRNNSTRM, NORBERG, AND JANSSON
when she comes to visit me. She always has
something for me .
Feeling Safe and Secure
The children talked about feeling safe and secure
in the hospital. They took their own toys, blankets,
and clothes with them to the hospital. I have my
doll with me. She's sickcan you see? And she
also has to do blood tests I can talk to my doll if
my mother is not here. One of the girls packed her
own backpack with some special things whenever
she went to the hospital. I always take some of my
own things with methis book, my [toy] dog, and
some other things.
The Staff Being There for the Children
The children described the staff as kind, devoted,
and considerate: When I was sad, the nurse came
into my room and asked if I would like to play a
game with her. We always play that game when I
am here . One of the children was talking about
the night before she was in surgery. She described
the kind nurse who came to sit with her and talk to
her about the operation, telling her not to be
worried: The nurse stayed with me, she sat down
on my bed and talked to me. She showed me what
they were going to do.
The children said that they felt that the staff
members were always available and they had time
for them. When the parents could not stay with their
children the whole time, the staff tried to arrange for
grandparents or a sibling to come and stay. If this
could not be arranged, the staff spent time with the
children. All seven children said that they did not
want to be left alone at the hospital. If I am all
alone here then I'm sad, because I don't want to be
alone. But they come into my room . The
children also said that it is worse to be alone at night
than during the day: The nurse came to me and
read a book to me in the middle of the night because
I couldn't sleep. And she talked to me and
comforted me because I was crying .
The children all felt that they could trust the
staff to take good care of them. They felt
confident that the staff members were giving
them the right treatments, and they subjected
themselves to the examinations and blood tests
even if these caused pain and discomfort: I don't
think I can do it, but then I dobut it hurts . I
don't want to take blood tests, but my mother
says I have to, so I must do it.
The children also talked about getting to know
the staff. They had been admitted to the hospital
many times before that they already knew the
nurses: I know everybody who works here .
One of the girls said, The nurses recognize me
when I arrive at the hospital. When I'm not feeling
well I tell my mother we must go to the hospital.
The ambulance staff takes good care of me. My
mother or father can go with me in the ambulance. I
am not scared when I come to the hospital
(Figure 2). The children also spoke about physical
contact with, and being touched by, the staff.
Sometimes, they sat on a caregiver's lap or got a
hug from one of the staff: I can sit on her lap It is
warm and cozy. Sometimes I get a hug from
the nurse.
Sometimes, the children felt alone and unhappy
and wanted everything to be as usual. They also
said that they longed for home. I long to go home
and be at home . I want to go home to my room
and my toys.
The children also narrated various kinds of
activities and amusements such as playing games,
reading a book, painting, watching a video, and
going to school, sometimes together with their
parents and sometimes with the staff, which made
them feel better during the hospital stay.
The Children Being There for Parents
and Siblings
Some of the children said that they comforted
their parents and siblings. They knew a great deal
about the disease and some of them comforted their
parents by giving them a hug or saying: It's not so
bad! One of the boys told his mother that
everything was going to be all right. He understood
Figure 2. The hospital and the ambulance.
313 NARRATIVES OF CHILDREN ABOUT BEING COMFORTED
that she needed to be comforted: If my mother is
sad I comfort herI talk to her. I never comfort my
father because he is never sad. Another said,
When my little brother is sad, he comes to me and
I comfort him. Sometimes I talk to my sister when
she is sad and then she feels better.
DISCUSSION
The children said that being physically close to
one's family, feeling safe and secure, the staff being
there for the children, and children being there for
parents and siblings were sources of comfort to
them. They said that it was important to have their
families close by at the hospital. It was most often
their mother who stayed with them at the hospital.
Similar findings were also reported by Woodgate
and Kristjanson (1996c) and Young, Dixon-Woods,
Findlay, and Heney (2002). Parents, especially
mothers, play an important role in children's care at
the hospital. All seven children talked a great deal
about their mothers, and they said that it felt good to
know that their mother would stay. When their
mother was not with them, the children thought of
her and waited for her to come. They felt greatly
comforted by her (cf. Horstman & Bradding, 2002).
The father, although important, was not seen to be
as important as the mother.
The children said that their siblings were another
source of comfort. The relationship between
siblings is unique, often lifelong; siblings can
serve as sources of emotional support across the
life span (Brody, 1998). Being a sibling involves
being responsible, caring, listening, and, some-
times, comforting (Baumann, Taylor Dyches, &
Braddick, 2005).
The children also talked about coming home and
about being at home in their own room with their
own things. Children long for the safety of their
familiar environment (Runeson et al., 2002). This
underscores the importance of having a parent at the
hospital to provide comfort. Both children and their
parents are in a vulnerable situation in the hospital.
When a child is admitted to the hospital, it always
affects the family (Shields, Hallstrm, & O'Calla-
ghan, 2003).
When children are admitted to the hospital, they
often bring their own things with them. All but one
of the children in this study had brought something
with them to the hospital. A personal item from
home, such as a blanket or a toy, makes a child feel
secure and safe. In this study, one of the girls said
that she could talk to her doll if her mother was not
there and one of the boys always brought his
blanket with him. According to Winnicott (1971),
such objects represent the bond to the mother and
help the child cope with stressful situations. The
presence of the mother or a mother substitute
increases a sense of security in the child (Alsop-
Shields & Mohay, 2001). Soothing objects such as
blankets, teddy bears, and dolls are associated with
the mother and may serve as residuals of the child's
erstwhile symbiotic attachment to the mother and
symbolize the union between the child and the
mother (Galligan, 2000). Thus, the children in this
study made drawings of their stuffed animals.
Besides needing comfort themselves, children
with chronic illness also comfort their parents and
their siblings. In fact, the ability to do so is a source
of comfort to them. In this study, the children talked
about comforting their mother, by embracing her,
and a little brother, by talking to him.
The children experienced the staff's taking good
care of them. They were aware of the staff's skill
and knowledge, and it made them feel secure. They
emphasized both the emotional aspects of care, that
they could trust the staff to take good care of them
and that the staff show interest in them through their
constant physical presence, and the staff's profes-
sional skills when they arrived at the hospital,
whether it was planned or otherwise (i.e., they were
brought to the hospital in an ambulance). To our
knowledge, the staff's competence being a source
of comfort has yet to be discussed in the literature.
The children described the care given by the skilled
staff, whom they trusted, as providing comfort.
Taking good care was reported by Woodgate and
Kristjanson (1996a) as being the most important
thing the hospital staff could do for children.
Horstman and Bradding (2002) found that the
nurse's role as comforter was an important image
held by children, second only to the image of the
parent in this role. What is noticeable is that only a
few studies have been done with children in the
hospital. Few studies using both interviews and
drawings have been found (cf. Horstman &
Bradding, 2002; Sartain et al., 2000). The voice
of the children is unheard. More research with
children with chronic diseases is needed so that they
can narrate their experiences and contribute their
perspective on comfort.
Methodological Considerations
When interviewing children, the interviewer (the
first author) saw them as partners contributing their
own thoughts and perspective on feelings. She tried
314 NGSTRM-BRNNSTRM, NORBERG, AND JANSSON
to form a relationship based on equality with the
children before interviewing them and informed
herself about their cognitive and emotional
development. The intention of the analysis of the
drawings was to describe what the children had
drawn and what they expressed about their lived
experiences of being comforted in the hospital,
without considering developmental differences.
She was aware of the fact that there can be an
asymmetrical power relationship between the child
as informant and the adult interviewer (cf. Ireland
& Holloway, 1996). Furthermore, she was not a
staff member.
The fact that the child's mother was present
during the interview, except in one case, probably
contributed to making the interview situation safe
for the child. The possibility that the mother's
presence during the interview affected the chil-
dren's responses cannot be excludedbecause all
the children talked about the importance of their
mother as a comforter. However, the importance of
the mother as a comforter has been reported in other
studies as well (Bradding & Horstman, 1999;
Horstman & Bradding, 2002).
Consequently, to avoid misunderstandings, the
interviewer tried to determine from the children the
meaning of the phrases used during the interview
(cf. Keller, 1995). The interviewer was eager to
listen to the words spoken by the children (and even
notes the absence of it [silence]) and to assess their
facial expressions, gestures, and posture. The
children seemed to understand the questions about
comfort very well, and they talked about comfort
from their own perspective. The concept of comfort
appears to be very basic to children because all
children need to be, and have experiences of being,
comforted in daily life.
The children enjoyed making drawings and
talking about them. They talked with great insight
and enthusiasm about what the drawing meant and
what they thought about it. They said that they liked
the idea that the drawings would be shown to other
researchers. As the communication situation
seemed very relaxed and the children seemed
seriously engaged in narrating their lived experi-
ence of being comforted, we regard the research
results to be valid.
CONCLUSION
This study shows that comfort is a well-under-
stood concept among hospitalized children with
chronic illnesses. The children narrated their
experiences of being comforted by talking and
drawing. They emphasized the importance of their
mother as a comforter. Other comforters mentioned
were the father, the siblings, the hospital staff, and
the children's toys and other personal items, such
as a blanket, brought to hospital. The overall
finding is that feeling at home, as well as feeling
safe by relying on the hospital staff's knowledge
and professional skills, is important for children in
the hospital.
Implications for Practice
Parents should be encouraged to continue
providing the care and support they would have
given at home. Parents play an important role in
their children's care (Hallstrm, Runeson, &
Elander, 2002b; Woodgate & Kristjanson, 1996b).
The finding that contact with family members,
things reminding of home, and the staff's knowl-
edge and skills are important for children's comfort
has implications in nursing children with chronic
illnesses in the hospital. It seems important to
continue changing hospital routines toward an even
closer involvement of family members, and it is
essential that the staff members understand their
own important role as comforters of children and
develop their comforting skills.
ACKNOWLEDGMENT
This project was supported by the Swedish
Foundation for Health Care Sciences and Allergy
Research (Dnr 1999/009). The authors would like
to thank the children who participated in this study
as well as their parents.
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