ARTICLE

The Voices of Children:

Stories About Hospitalization
Margaret E. Wilson, PhD, Mary E. Megel, PhD, Laura Enenbach, MSN,
& Kimberly L. Carlson, MSN

ABSTRACT
Introduction: The study explored childrens views of hospitalization through their own voices.
Method: In this secondary analysis, 93 children aged 5 to 9
years told stories about hospitalization using a set of drawings of children in the hospital. Children were recruited in
the hospital and in the community. Themes were identified
through qualitative analysis.
Results: Childrens stories focused on being alone and feeling
scared, mad, and sad. These children wanted protection. Children in the stories were not always facing scary events. They
were simply not at home and feeling bored, lonely, and sad.
They wanted companions. Children displayed awareness of
both good and bad outcomes. The hospital was a unique environment that could be fun as well as threatening.
Discussion: Childrens views of hospitalization were not
invariably negative. The themes of hospitalized and neverhospitalized children were different only in degree of detail.
J Pediatr Health Care. (2010) 24, 95-102.

KEY WORDS
Child, hospitalization, qualitative
Margaret E. Wilson, Associate Professor, College of Nursing,
University of Nebraska Medical Center, Omaha, NE.
Mary E. Megel, Associate Professor, College of Nursing, University
of Nebraska Medical Center, Omaha, NE.
Laura Enenbach, Assistant Professor, Clarkson College, Omaha,
NE.
Kimberly L. Carlson, Clinical Instructor, Creighton University
School of Nursing, Omaha, NE.
Presented at the 18th International Nursing Research Conference,
Sigma Theta Tau International, Vienna, Austria, July 2007.
Correspondence: Margaret E. Wilson, PhD, 985330 Nebraska
Medical Center, Omaha, NE 68198-5330; e-mail: mwilson@unmc.
edu.

Hospitalization has been referred to as a landmark

event in a childs life (Vessey, 2003). Hospitalization
of children has become reserved for increasingly complex care and occurs primarily in specialized childrens
and teaching hospitals (National Association of Childrens Hospitals and Related Institutions [NACHRI],
n.d.). Exact numbers of children hospitalized each
year in the United States are not readily available. However, acute hospital stays in childrens hospitals, which
account for more than 40% of all inpatient stays,
produce $10 billion of annual hospital care costs for
children (NACHRI).
The fact that hospitalization can be a traumatic and
stressful experience for children has been wellknown since the mid 1960s (King & Ziegler, 1981;
Thompson, 1985; Thompson, 1986; Vernon, Foley, Sipowicz, & Schulman, 1965; Visintainer & Wolfer,
1975). A recent search of the literature related to
the psychosocial impact of hospitalization on
school-aged children revealed that the topic has received little research effort in the past 5 years. Current research emphases seem to be the impact of
specific diseases or conditions such as traumatic injuries (Scheeringa, Wright, Hunt, & Zeanah, 2006;
Sturms et al., 2005) and diabetes (Garrison, Katon,
& Richardson, 2005) or particular environments
such as the pediatric intensive care unit (Board,
2005). The results of this search emphasize the importance of revisiting the topic of the impact of hospitalization in general on children given the current
high-technological, complex nature of hospital environments. The purpose of this descriptive qualitative
secondary data analysis was to develop an understanding of school-aged childrens views of hospitalization.

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Copyright Q 2010 by the National Association of Pediatric
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doi:10.1016/j.pedhc.2009.02.008

www.jpedhc.org

LITERATURE REVIEW
Hospitalization as a Stressor
The hospitalization experience has changed considerably during the past 20 years as hospital staff and
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95

administrators have made many attempts to improve

hospital environments for children. These improvements include lifting restrictions on visitors and visiting
hours, providing space for children to play and parents
to room-in with their hospitalized child, as well as making Child Life staff available on inpatient units and in
outpatient/diagnostic departments. Today, childrens
units in hospitals are colorful places with active play
rooms, access to computers, movies, and games, and
special therapies such as pet and music therapy. All
members of the health care team value attending to
the psychosocial as well as physical needs of the children (Hasenfuss & Franceschi, 2003).
At the same time that positive changes have been
made in modern hospital environments, the complexity
of care within the hospital has increased. Many minor
illnesses and surgeries for which children were once
hospitalized now take place in the outpatient setting.
Inpatient admissions currently are reserved for children
experiencing severe or chronic illnesses and often involve procedures and repeated hospitalizations, which
may increase anxiety and create lasting effects on children and their development (Grey, 1993; McClowry,
1991; Melnyk, 2000).
Several researchers have identified stressful experiences for children in the hospital. Any painful procedure, particularly those involving needles or shots,
is almost universally regarded as a negative experience
by children (Bossert, 1994; Coyne, 2006; Forsner, Jansson, & Srlie, 2005; Lindeke, Nakai, & Johnson, 2006;
Melnyk, 2000; Wollin et al., 2004). Other stressors involve being sick, not knowing what to expect in the
hospital (Carney et al., 2003), having activity restrictions
and decreased independence, missing school, and being separated from family and friends (Bossert; Coyne;
Lindeke et al.).
Melnyk (2000) reviewed studies documenting outcomes of hospitalization for young children. These outcomes continued after hospitalization and included
regression, separation anxiety, sleep disturbances,
and emotions such as sadness and apathy. Behaviors
such as hyperactivity and aggression were noted in
some children. Sadly, some of these outcomes can
persist for months or years, particularly in children
with repeated or lengthy hospital stays.
These adverse effects of hospitalization continue to
challenge the skills of nurses and other health care providers. Vessey (2003) calls for us to revisit the topic of
childrens responses to hospitalization: Nursing must
reexamine what we know or, more precisely, what
we think we know (p. 192) in order to effectively
meet the needs of hospitalized children.
Techniques to Elicit Childrens Thoughts and
Feelings
Curtin (2001) outlined several techniques that can be
used to elicit childrens views, which include drawing,
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Volume 24  Number 2

storytelling, acting, writing in a diary, explaining a videotape or movie, participating in a focus group, and
talking through a doll or toy telephone. Interviews
have been used to ask direct questions to determine
coping strategies of children having surgery (LaMontagne, 2000), determine childrens descriptions of
hospitalization and their recommendations for change
(Lindeke et al., 2006), and examine childrens opinions of the quality of nursing care received (Pelander,
Leino-Kilpi, & Katajisto, 2007). Less directive techniques (e.g., drawing and storytelling) may be particularly useful in eliciting a childs feelings because
these methods are non-threatening and allow the
child to express perceptions that they may not be
consciously aware of or able to express verbally
(Bellack & Fleming, 1996 , p. 10). Carney et al.
(2003) tested four methods to elicit childrens views
of hospitalization. While they obtained the most concrete information from a structured questionnaire, the
visual structured questionnaire (five drawings of hospital events) was most effective in eliciting feelings
about the hospital experience.
Projective techniques such as storytelling have been
used since the 1940s to obtain information that might be
difficult to obtain through standard interviewing
(Poster, 1989). Stories provide effective and safe opportunities for children to explore frightening situations
(Hudson, Leeper, Strickland, & Jessee, 1987). With
this projective technique, the researcher presents a nonspecific stimulus (picture) to the subject and asks for
a story to be told about it. The child can have multiple
responses to the picture, none of which need to be
the right answer. Results of projective techniques
are assumed to provide insight into the childs inner
emotions, perceptions, and fears (Bellack & Fleming,
1996).
The revised Barton Hospital Picture Test (BHPT) is
one example of a projective technique that uses storytelling to generate text that is then scored for stress
levels. The validation, scoring, and psychometric properties of this instrument are described elsewhere (see
Wilson et al., 2007). The BHPT, a thematic apperceptive
test, consists of eight drawings of specific hospital situations (admission to hospital, separation from parents,
being examined by doctor, being alone in hospital
room, receiving oral medication, receiving an injection,
being in the operating room, and being in the playroom). Childrens input was used in the development
of the picture set.
METHODS
Design
This study is a qualitative descriptive (Sandelowski,
2000) secondary analysis of the stories told by 93
children in response to BHPT pictures during an instrumentation study (Wilson et al., 2007). Qualitative
description involves the presentation of recurring
Journal of Pediatric Health Care

facts in the data at a low level of abstraction. However, all analysis involves some interpretation (Sandelowski). In secondary analysis, data generated for one
set of questions are used to answer other questions
(Coyer & Gallo, 2005). Secondary analysis is a strategy
for increasing the usefulness of collected data,
thereby saving time, money, and participant burden
(Hinds, Vogel, & Clarke-Steffen, 1997; Polit & Beck,
2008).
The original BHPT analysis (Wilson et al., 2007) did
not use a qualitative approach but used a predetermined coding system (no stress, anxiety-fear, anxietydefense, dependency, or aggression) to derive a score.
The qualitative analysis reported in this article is a secondary analysis and not part of the instrumentation
study.
Study Participants and Settings
The children who participated in the original study
(Wilson et al., 2007) were selected using quota sampling to achieve 9 to 10 children at each year of age
from 5 to 9 years both in the hospital (n = 48) and residing in the community (n = 45). Five-year-old children
are old enough to respond to the pictures with stories.
Children older than 9 years are more likely to tell stories
they believe the researchers want to hear. The hospitalized children were recruited from one childrens hospital and one university health science center in the
Midwest. The community children were recruited
from both rural and urban settings in the Midwest. In
the original study, a group of children from the community was included to test discriminant validity. We used
the data from the community children in this secondary
analysis because the published research on children
and hospitalization has only included hospitalized or
about-to-be hospitalized children. This data set offered
the unique opportunity to examine the views of hospitalization from never-hospitalized children. The children were predominantly White (88%) and from
middle-class to upper-class backgrounds. Slightly
more girls (58%) than boys (42%) participated. Approximately half of the hospitalized children had chronic illnesses; the others were hospitalized with acute illnesses
or trauma. Inclusion criteria in addition to age group
were the ability to understand and speak English and
being developmentally appropriate for age. Approval
for the study was obtained from the institutional review
boards of the University of Nebraska Medical Center
and Childrens Hospital in Omaha, Nebraska.
Procedures
Following informed consent from a parent and when
obtaining assent from the child, the children were informed that their stories would be audiotaped. Interviews were conducted in hospital rooms and in
childrens homes. Parents sometimes were present
but were asked not to interrupt the data collection
www.jpedhc.org

with questions or comments. The length of the interviews varied widely depending on the age and verbosity of the child. The researcher showed each
BHPT picture to the child, provided a brief introduction to the picture, and invited the child to tell a story
about the picture to the researcher. For example, the
researcher would say, This is a picture of a boy and
his mother going to the hospital. Tell me a story about
this picture. The child was encouraged to respond,
but suggestive or leading comments were avoided. If
the child failed to respond, he or she was asked,
What is happening in this picture? If the child did
not respond after two or three probes, the researcher
moved to the next picture. If the child did not talk
about feelings in the story, the interviewer then asked,
What do you think? How do you think the child
feels? After the last story, each child was asked three
questions regarding his or her own view of hospitalization. These questions were: What is the best thing
about being in the hospital? What is the worst thing
about being in the hospital? and If you had one wish
that could come true, how would you change the hospital to make it a nicer place for children? All interviewers were experienced pediatric nurses who
were trained to collect data via team meetings and review of practice interviews. Review of transcribed
story sets was used to ensure consistency in data
collection.
Data Analysis
Each childs stories were transcribed verbatim. For purposes of this secondary analysis, all codes from the original study were removed. Data were analyzed using
conventional content analysis (Hsieh & Shannon,
2005). Researchers deliberately avoided using the five
category labels from the original study. First, transcripts
were read in their entirety. Each transcript was then
coded line by line in words close to the childs own
words (e.g., scared or lonely). After all story sets
were coded in this manner, codes were sorted and
grouped into more abstract themes or categories. For
example, codes such as making new friends, going
to the playroom, playing with hospital equipment
were eventually grouped into a theme called Hospitals
as Unique Environments. Discussion among the researchers ensued until all researchers were satisfied
that all themes had been developed that the data supported. All themes were supported by data from
many childrens story sets, and all themes contained
data from both hospitalized and non-hospitalized children. The research team (all pediatric nurses and two
with experience in qualitative research) returned to
the stories again and again to confirm that themes
were present consistently in the story sets and included
codes from hospitalized and non-hospitalized story
sets. Because the data were collected using a projective
technique, member checks (returning to children who
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97

FIGURE. Experience of hospitalization.

were interviewed to verify findings) were not considered appropriate. Finally, a diagram of the themes
and their relationships was developed and revised until
the researchers agreed that the data were satisfactorily
and thoroughly explained (Figure). All data analysis
was conducted in team meetings.
RESULTS
The primary theme identified in this analysis was being alone. When children were alone, they were uncertain about what would happen to them; they
were afraid of known scary things; and they were
not at home. Uncertainty and known scary things
led to feelings of being scared, mad, and sad. Children wanted protection. Children reacted to not being at home by feeling bored, lonely, and sad. They
wanted companions. Additional less extensive
themes included being aware of the possibility for
good or bad outcomes and viewing hospitals as
unique environments.
Being Alone
Childrens stories often focused on being alone and
the consequences of being alone. When children
were alone, they could be uncertain about what
was going to happen or they might predict something negative (scary, painful) that could happen
based on past experience. The emotional response
to being alone in these two circumstances was scared,
mad, and sad. Children wanted protection in these situations. Protection did not prevent scary events like shots
from happening but rather provided comfort. Children
told many stories about being lonely. For example:
She was very lonely and her father came to visit her.

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Volume 24  Number 2

After a while her father just left and she was very lonely
and she didnt want to be lonely. Shes mad that her
parents arent there
and that shes alone
Childrens stories
too.
often focused on
The
following
being alone and the
childrens stories reflect feeling scared
consequences of
and uncertain about
being alone. When
both known and
children were
unknown
events.
Stories often exalone, they could
pressed fears or conbe uncertain about
cerns about needles
what was going to
even when the drawing that elicited the
happen or they
story did not contain
might predict
or suggest needles.
something negative
Other fears were
less specific and re(scary, painful) that
flected uncertainty
could happen
about what might
based on past
happen. Past experience with hospitaliexperience.
zation appeared to
make fears more
specific, but children who had never been hospitalized
also voiced ideas about what happens in hospitals:
This girl is very scared because she doesnt know what
theyre going to do and she doesnt have her parents
with her and she thinks theyre going to give her
a shot or something.
There were two little girls on level 9 and they were very
scared. They made friends, but they were both sort of

Journal of Pediatric Health Care

frightened about each other because they were both a little bit mad at each other for doing things and fighting,
causing contention.
He probably feels scared because he might get his tonsils tooken out.

When children in the stories were facing scary events,

they sought protection from parents and nurses. The
majority of stories about seeking protection involved
wanting parents present, but seeking protection from
nurses appeared in enough stories to constitute
a theme:
The girls didnt
Children in the
want it [a shot],
and they got
stories who were
real sad. They
bored, lonely, or
wanted to wait
until their mom
sad wanted
comes and the
companions. They
doctor
said,
Your
moms
wanted parents,
not here, we
friends, siblings,
have to give you
and even staff for
your shot right
now. The other
play, talk, and
girl says, Im
companionship.
not getting my
shot, not until
my mom gets here!
If they were scared or something then the nurses
could tell them stories so that they wouldnt be that
scared anymore.

Children in the stories were not always facing scary

events when they were alone. They were simply not
at home or in another familiar environment. The emotional response to being alone and not at home was
bored, lonely, and sad. Children in the stories who
were bored, lonely, or sad wanted companions. They
wanted parents, friends, siblings, and even staff for
play, talk, and companionship:
She wanted her friends around her. She doesnt
want to be lonely. She wants kids to surround all
over her.
Once my dog was alone in a hospital room and she
whined and whined and whined and whined and
whined. The girl [in the picture] is bored. She wants
something to do.
Theyre probably feeling better because theres another person in his room and they can talk to each other.

Awareness of Good and Bad Outcomes

In their stories, children also displayed awareness
of both good and bad outcomes from being in the
hospital. Good outcomes included going home, feeling
well, and being helped. Bad outcomes were death, not
being helped, and staying a long time in the hospital.
Awareness of bad outcomes was not limited to children
with chronic or catastrophic illness, nor was it limited to
children who had been hospitalized:
www.jpedhc.org

The children feel good about being in the hospital

because they want to get better.
Elizabeth broke her arm and had a very big cast. And
her mom and dad are staying there, staring at her
because they thought she might die.
Maybe shell get better from the medicine and maybe
shes scared that it might not help her.
Shes thinking what the operations gonna be like and
if shes gonna make it through the operation.

Hospitals as Unique Environments

Stories included descriptions of the hospital as a unique
environment that could sometimes be fun as well as
threatening. The hospital environment provided new
experiences to explore, to learn, and to enjoy. The hospital may be a venue for making new friends and trying
new games or toys. Children found some hospital
routines odd rather than threatening:
He feels good cause you get to control the bed.
Hes going to pee in a cup cause he doesnt feel well.
After the girl was done operating, she got to go to the
playroom and there was lots of other kids there and she
made some new friends.

Comparison of Hospitalized and Neverhospitalized Children

Only one difference was noted between the stories related by the hospitalized children and those who were
never hospitalized. Children who had hospital experience knew the drill: They used more medical or hospital terminology, and stories often appeared to contain
personal experiences. Examples of knowing the drill
follow:
Everybody kept coming in and asking the same questions over and over and over and over and over and
over again.
Theres gloves because they dont want to touch blood.
This is about a girl who got her central line. She went
to sleep and the doctor was trying to make her to sleep.
Then she waked up and she went back upstairs to go
to her room.

However, the themes as displayed in the Figure and

previously described were present in both groups of
children.
DISCUSSION
Childrens stories reflected fear of being alone in the
hospital, fear of known experiences, and feeling threatened by uncertain possibilities. These fears have long
been expressed by hospitalized children in this age
group. Children respond to these fears by requesting
to have parents nearby, having familiar objects with
them in the hospital, or asking to go home (Coyne,
2006; Forsner et al., 2005; Runeson, Hallstrom, Elander,
& Hermeren, 2002). In addition to parents, children expect nurses to provide care and support (Bull & Gillies,
2007; Forsner et al.; Pelander & Leino-Kilpi, 2004).
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99

Children in an earlier study with the BHPT also described parents and nurses as safety figures (Wilson &
Miller, 1998).
Some childrens stories in our study described being
bored in the hospital environment when alone; the children in the stories needed adults or other children for
play activities (Pelander & Leino-Kilpi, 2004; Runeson
et al., 2002), talk, and companionship. Play and being
in the playroom often were mentioned as the best
thing about being in the hospital as recounted by children in this study and by other researchers (Lindeke
et al., 2006). Eiser and Patterson (1984) interviewed
non-hospitalized children about their perceptions of
the hospital and
Getting better,
found that children
expected to have soplaying with others,
cial interactions with
and enjoying being
other children when
in the playroom, as
hospitalized. A minority expected to
well as learning and
be bored. Boredom
mastering hospital
was a theme in this
equipment, were
study when the child
wanted companionmentioned
ship. The trend in
frequently by the
modern
pediatric
children in this
hospitals to have
only private rooms,
study.
while appealing to
parents and to adolescent patients, may require more attention to the
socialization needs of school-aged children.
Children did not invariably find the experience of
hospitalization as negative and stressful. The childrens
stories also reflected the possibility of good outcomes
while in the hospital. Getting better, playing with
others, and enjoying being in the playroom, as well as
learning and mastering hospital equipment, were mentioned frequently by the children in this study. Observations by Runeson and colleagues (2002) of hospitalized
children during non-threatening situations revealed the
children playing as actively as was appropriate to their
physical conditions and asking questions to learn about
their environment. Making new friends emerged in our
childrens stories; these children as well as those in
other studies noted that having pals (Pelander &
Leino-Kilpi, 2004, p. 146) and more play equipment
would make the hospital a better place for children
(Lindeke et al., 2006). While the purpose of this secondary analysis was not further instrument development, we did examine the themes for consistency
with the coding categories used in scoring the BHPT
(Wilson et al., 2007). The themes of the secondary analysis fit within that coding structure without contradiction. Because we deliberately did not use the coding
structure of the BHPT when conducting the secondary
analysis, the resulting themes have different names.
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Volume 24  Number 2

Although measures of child anxiety or child stress

clearly differentiate between hospitalized children
and children who have not been hospitalized (Clatworthy, Simon, & Tiedeman, 1999; Wilson et al., 2007), the
aspects of the hospitalization experience that are significant to children appear to be the same across groups.
The only difference between groups in this study was
the degree to which the children integrated the vocabulary of the hospital into their stories. This article is the
first report of childrens views of hospitalization in
which hospitalized and never-hospitalized children
are included and compared.
The themes we developed as a result of the stories
told by the children in this study are remarkably similar to themes identified in two recent studies: Dreissnack (2006) examined well childrens fears and
Coyne (2006) studied fears and concerns related to
hospitalization of British children. Using draw-andtell conversations with well children, Dreissnack elicited insights about the fears of children aged 7 and
8 years. Themes that emerged included feeling alone
or isolated, as if nobody was available for help; being
surprised and frightened by things they did not predict; feeling helpless, as if there was nothing they
could do to escape or resolve their situations; and
just waiting and anticipating that something scary
would happen (p. 1426). Coyne conducted interviews
with hospitalized children aged 7 to 14 years and
identified four categories of concerns and fears:
separation from family and friends, being in an unfamiliar environment, fears related to receiving investigations and treatments, and loss of selfdetermination (p. 328).
Limitations
The children who were the participants in this study
were largely White, English speaking, and middle
class, reflecting the community in which the study
was conducted. The themes described in this study
may not reflect the views of hospitalization of poor,
ethnically diverse children. We also did not include
any children with developmental delays. More research can verify the validity of our findings in other
populations. Because this was secondary analysis, no
additional data collection was conducted to further
explore themes identified in this analysis. The descriptions of the hospital experience can be further
developed and raised to a higher level of abstraction
in future research.
Conclusions and Implications
The general areas of fear identified by our study as well
as by Dreissnack (2006) and Coyne (2006) appear universal among school-aged children, regardless of
whether they are currently or were ever hospitalized,
their medical diagnoses, or their gender. Previous research about childrens views of hospitalization has
Journal of Pediatric Health Care

been conducted with hospitalized children. This study is

unique in the inclusion of children in the community and
the finding that their views of hospitalization match
those of hospitalized children except for detail. Further
research is needed to substantiate these results and test
interventions that would be appropriate for hospitalized
children or in the preparation of children for hospitalization. Childrens stories about illness or hospitalization
may provide clues to interventions the children would
find most helpful. For example, assessment of the hospitalized children for fear or boredom when parents or
other support persons are not available could identify
children who might benefit from additional Child Life
intervention, visits from volunteers, or provision of
age-appropriate diversionary activities. Our description
provides insights to areas of teaching and preparation
to address what may be universal fears in this age group.
Pediatric providers may use these results to plan care and
prepare children for hospitalization.
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WANTED: CASE STUDIES

The JPHC is seeking case studies in Primary Care and Acute & Specialty Care that you would like to share with
the readers. Please contact the appropriate editor with your name, address (including email), and topic.
A template for you to follow along with editorial support makes this easy, fun, and professionally rewarding.
Manuscripts can be submitted online at http://ees.elsevier.com/jphc.

CONTACT INFORMATION:
Primary Care Editors
Beverly P. Giordano, MS, RN, CPNP, bevgiordano@aol.com
Donna Hallas, PhD, PNP-BC, CPNP, dh88@nyu.edu
JoAnn Serota, MSN, RN, CPNP, joannserota@msn.com

Acute & Specialty Care Editors

Terea Giannetta, MSN, RN, CPNP, tereag@csufresno.edu
Andrea Kline, MS, RN, CPNP-PC/AC, CCRN, FCCM, akline@childrensmemorial.org
Karin Reuter-Rice, PhD, RN, CPNP, kreuterrice@rchsd.org

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