J Child Fam Stud
DOI 10.1007/s10826-017-0688-6
ORIGINAL PAPER
Perceptions of Hospitalization by Children with Chronic Illnesses
and Siblings
Laura Nabors1 Melissa Liddle2
●
© Springer Science+Business Media New York 2017
Abstract Understanding children’s perceptions of their ill-
nesses and functioning when they are undergoing medical
procedures remains an important area for research. Further
research about siblings’ perceptions will also provide
knowledge about how they are coping with a brother or
sister’s chronic illness. The current study examined the
perceptions of children with illnesses and their siblings
using a play interview. Themes in the data indicated resi-
lience in child functioning for both patients and siblings.
Children with chronic illnesses could experience pain,
which often related to fears and other negative feelings
about hospitalization and potentially doctors or nurses, if
they were administering painful procedures. Distraction and
prayer were coping tools for patients. However, most
patients believed their illness and recovery would be a “long
journey.” Brothers and sisters of children with chronic ill-
nesses could experience loneliness. A more common report
was a strong desire to help and be a support for a brother or
sister with an illness. Support from parents was critical for
both patients and siblings and both typically enjoyed child
life activities. A member-checking process, with a different
group of children with illnesses and siblings, was used to
audit themes discovered after reviewing play interviews.
The audit process supported the positive and negative
themes in the data. In the future, examining the impact of
magical thinking on outcomes and conducting studies after
* Laura Nabors
naborsla@ucmail.uc.edu
1
School of Human Services, University of Cincinnati, 2610
McMicken Circle, Teacher-Dyer, Mail Location 0068, Cincinnati,
Ohio 45221-0068, USA
2
Xavier University, Cincinnati, Ohio, USA
the children have gained distance from medical trauma will
be important. Moreover, increasing a focus on resilience as
a hallmark of children’s functioning remains another area
for further research.
Keywords Perceptions of illness Children with chronic
●
illnesses Siblings Play interviews Hospitalization
● ● ●
Introduction
Children’s views of their experiences are essential to
understanding and facilitating their adaptation to chronic
illness and hospitalization and for improving the quality of
hospital services (Coyne and Kirwan 2012). Experts in child
agency within the field of sociology have long held that
children shape their development through their perceptions
of experiences in their environments (James and Prout
1997; Morss 2002). Clark (2003, 2011) proposed that
children’s medical play and stories about illness were a
method of coping through their imaginations with the
stressors related to having a chronic illness. Play therapists,
such as Virginia Axline (1974), have noted that children
express their feelings and work through life issues when
engaging in play. Wikström (2005) noted that expressive
arts and play therapy provide children outlets to express
their feelings about hospitalization. When children recreate
stressful events in their lives, they may gain feelings of
control over the outcomes of these events (Clark 2003).
Moreover, pretend play offers children opportunities to
relieve anxiety, fear, worry and other negative feelings that
they might not be able to express (Moore and Russ 2006;
Nabors et al. 2013).
It is also important to understand how children interpret
their medical experiences to determine the impact of these

experiences on their lives (Canter et al. 2015). Coyne and
Kirwan (2012) examined children’s and adolescents’ (aged
7 to 18 years) perceptions of their hospital experiences
using interviews, a sentence completion technique (e.g.,
“hospitals are”; “doctors are”, p. 295) and asked children to
make three wishes. Children in their sample had either acute
medical problems or chronic illnesses and had at least one
overnight stay at a hospital. During their interviews, chil-
dren expressed both positive and negative views of the
hospital experience and the hospital facilities. Some chil-
dren indicated they wanted more information to learn more
about the hospital and their operations. Most of the children
saw doctors and nurses as healers, who were important to
their care because they provided medications. However,
children did report that it could be difficult to communicate
with doctors and nurses. Responses indicated a need for
caring communications that were free of medical jargon.
Children’s wishes provided a window on their fears and
worries related to hospitalization and uncertainties related to
this experience. Other wishes indicated a desire to become
well quickly or never have to experience an illness. This
study did not include younger elementary school-age chil-
dren or preschool-age children, who may be especially
prone to hospital-related fears and anxiety (Proczkowska-
Björklund et al. 2010), and further research with younger
children is needed.
Nabors et al. (2013) assessed the free play of children
with chronic medical conditions and siblings of children
with chronic medical conditions who were residing at a
local Ronald McDonald House (RMH). These researchers
videotaped children’s play with small hospital figures and
toys produced by Playmobil™. The researchers asked the
children to tell “stories” about what was happening in their
play. Videotapes were transcribed and coded. Findings
supported the idea that coping through imaginary positive
outcomes was occurring during stories told by children with
medical conditions and their siblings. Children with chronic
medical conditions also expressed stress and fears related to
medical experiences; many of the children “retold” their
own medical story during the play. Wikström (2005) also
found that play was an outlet for expressing fear for chil-
dren who were hospitalized. Nabors et al. reported that
children with medical conditions expressed fears of needles
and some procedures. Support from parents was a resilience
factor for children with medical conditions and distraction
and calming techniques were helpful coping tools for
adjusting to stressful procedures or worry about being in the
hospital. The children’s wishes for getting better and getting
well, similar to those recorded by Coyne and Kirwan
(2012), were evident in this study as well.
Siblings may experience vicarious stress as they observe
their brother or sister cope with hospitalizations related to
chronic illness (Houtzager et al. 2004; Sharpe and Rossiter
J Child Fam Stud
2002). Siblings may express more worry about health pro-
blems, feel lonely due to parental attention being focused on
the ill child, or exhibit negative behaviors when a brother or
sister has a chronic illness (Williams et al. 2009). On the
other hand, siblings also may have positive feelings, as they
strive to help their brother or sister cope and collaborate
with their family to help their brother or sister adapt to
living with a chronic illness (Sharpe and Rossiter 2002;
Williams et al. 2009). It is noteworthy, however, that some
siblings may report anxiety related to having an increased
care-taking role related to their brother’s or sister’s illness
(Sharpe and Rossiter 2002).
Nabors et al. (2013) also examined play of siblings of
children with medical conditions. They reported that the
play of siblings often revealed the story of their brother’s or
sister’s illness. Illness was seen as a family affair and
something that everyone helped with. The sibling was a
“helper” in the fight against the illness, which is similar to
the positive role for siblings in facilitating coping and
adaptation mentioned by other researchers (Sharpe and
Rossiter 2002; Williams et al. 2009). Negative feelings,
including fear and anger toward doctors and nurses, were
mentioned by siblings. Experiencing a loss of parental
attention was also a theme in the siblings’ play. Further-
more, sibling play indicated worry over health issues, as
demonstrated by telling stories about other children or
family members feeling ill. Similar to children with medical
conditions, siblings’ stories also indicated hope that ill
characters would recover quickly. Nabors et al. (2013)
mentioned that their study had some limitations, including
the unstructured nature of play and relative lack of struc-
tured interview questions, which could have narrowed the
scope of information obtained from the children. Addi-
tionally, being in a group while telling a story about one’s
play may have inadvertently caused a social desirability bias
in play or possibly caused “copying” of play by other
children.
Further research using play and indirect interviewing
techniques in individual sessions with children may provide
additional insights into children’s and siblings’ perceptions
of hospital experiences. Coyne and Kirwan (2012) recom-
mended using a semi-structured interview process, with
open-ended prompts to learn more about possible negative
experiences to yield more information in order to develop
effective interventions. Thus, the present study was devel-
oped to understand children’s feelings and perceptions of
hospitalization through a semi-structured play interview.
Children with chronic illnesses (i.e., patients) and siblings
completed a play interview and a separate group of patients
and siblings completed a member checking process to audit
themes generated from coding the play interviews. Ques-
tions for the play interview directly assessed children’s
reports of negative emotions, such as worry and sadness.
J Child Fam Stud
Siblings remained a focus of study, to determine their
coping as well as to confirm if they were experiencing
vicarious stress and worry over health problems (Nabors
et al. 2013; Sharpe and Rossiter 2002).
Method
Participants
Children with medical illnesses
Nine children residing at a local RMH, in Cincinnati, Ohio,
completed play interviews. Children ranged between three
and 11 years of age (M = 6 years, 6 months). One boy and
eight girls participated; seven were white, one was His-
panic, and one was Asian. All of these participants were
undergoing medical procedures at a nearby children’s hos-
pital. Diagnoses of the children consisted of cancer (n = 3),
tracheomalacia/ bronchomalacia (n = 2), liver failure (n =
1), pancreatitis (n = 1), mitochondrial disease (n = 1), and
brain surgery (n = 1).
Siblings of children with medical illnesses
Eight siblings (four boys and four girls), also residing at the
RMH, completed interviews. Siblings ranged in age from
three to 12 years (M = 6 years, 3 months). Of these siblings,
seven were white and one was black.
Interviewers
The two authors (both were white females) interviewed the
children. One is a graduate student in a doctoral program in
psychology and one is an instructor from a local university.
Coders
The two authors and a peer were coders. The third “peer
coder” was female, white, and a doctoral student in a psy-
chology program. The peer coder had no knowledge of the
study or literature reviewed for the study.
Participants in member-checking audit
Nine children participated. There were five boys and four
girls, all were Caucasian; average age was 6 years, 8
months, with an age range from three to ten years. Six
children had chronic illnesses: three had cancer, one had an
autoimmune disorder, one had a colostomy bag secondary
to Chron’s disease, and the other had a colostomy bag
secondary to having multiple surgeries for “imperfect anus.”
Three siblings also participated.
Procedures
The interviewers gained permission from a parent or guar-
dian and child assent prior to the play interview. The parent
and child were aware that the child could withdraw from the
study at any time during the interview. Interviews were
conducted over the course of seven 2 h activity groups in
May through August of 2016. The interview began with
building a hospital room. The child was provided with a
shoebox and then the interviewer stated, “We will use this
shoebox to build a hospital room.” Along with the shoe box,
each child received art supplies including: tissue paper, felt,
small boxes, stickers (foam, metallic, and paper), one inch
diameter pom poms, paint daubers, small paper craft cups,
bright colored paper tubes, markers, construction paper,
crayons, glue, and scissors.
The child began the project by building his or her own
hospital room. After the hospital room was completed, the
child had an option of placing hospital toys and figures
made by Playmobil™ Corporation in the room. The Play-
mobil™ toys consisted of small figures (children and
adults), hospital beds, intravenous (IV) lines, small doctors’
bags, ambulances, and wheelchairs. Alternately, the child
could decide if he or she wanted to make paper dolls to
place in the room using construction paper and markers,
drawn by the child or the interviewer at the child’s discre-
tion. Next, the interviewer used a protocol to conduct the
interviews in a consistent manner. First, the interviewer
asked the child to, “Tell a story about the hospital room.”
During the “story” the interviewer asked the child to
describe each character in the story and describe how they
were feeling. Second, to ensure that the children explored
negative feelings, the interviewer asked if the characters
were feeling lonely, worried, or sad and why they felt this
way. Finally, the interviewer asked the child what might
happen to the characters in the future.
Interviews ranged from 15 to 40 min in length, and were
conducted on tables in the common area of the RMH.
Parents sat at a nearby table or in a living room area next to
the tables, as their child completed an interview. Children
could complete a card or drawing at an “art table” or play a
game at a “games table” when they were not participating in
an interview. One patient, a girl, decided to withdraw from
the interview and another patient wanted to create a struc-
ture other than the hospital and not complete an interview.
One sibling did not complete the interview because her
father stated that she had to leave early to see her sibling
who was in the children’s hospital. Interviews were tran-
scribed verbatim and then videotapes were destroyed. All
data were de-identified and no names or identifying infor-
mation were shared or recorded. This study was approved
by a university-based institutional review board.

Member-checking interviews
After data coding had occurred, the first author developed a
list of the positive and negative themes in the data. Then,
the first author interviewed children in November and
December of 2016. Each interview lasted about 5 min. The
first author showed each child the list of positive and
negative themes and asked the child if the themes accurately
described his or her experiences. If the child was a sibling,
the first author also asked the child if the themes represented
the experiences of the child in the family who was the
patient. The children provided a “yes” response to those
themes that they believed accurately depicted their experi-
ences or the child who was a patient’s experiences.
Data Analyses
Procedures for recording and coding transcripts
The two authors reviewed the transcripts for themes in the
data using content coding with memos to record themes.
The authors of this paper used these themes as nodes or
coding categories and used the NVivo Program to code the
data a second time. They coded quotes that were consistent
with nodes or representative themes and then held two
meetings to develop their final list of themes and quotes
from the transcripts of interviews.
The peer coder reviewed the transcripts of the interviews
independently and determined themes for the data with
representative sections of text from the transcripts. Next, the
three coders met and reviewed themes within the data. They
also documented quotes in the interviews that served as
examples of each theme. Consensus among coders was used
to finalize coding of the themes and representative quotes.
Verification processes
Creswell (1998) discussed verification procedures to
improve the trustworthiness of findings. Other researchers
have referred to this as accuracy of representation in one’s
findings (Agar 1986) and credibility of findings (Lincoln
and Guba 1985). The researchers conducted several pro-
cedures to verify findings including: (1) using a peer coder
to document themes and quotes in the data (2) conducting
multiple meetings involving opportunities to review
researcher bias and develop protocols before beginning data
collection, and (3) developing a modified member checking
process that allowed for an external audit of themes within
the data. For the peer coding process, the external coder
independently determined themes in the data and then met
with the authors to determine key themes and representative
quotes in the data.
J Child Fam Stud
When developing the study, the authors met multiple
times to review their biases related to working with children
who had chronic illnesses. They developed a protocol for
the interview process to assure uniformity in the interviews.
The transcripts from the videos were coded verbatim, in
order to avoid any bias in recording what children reported.
The authors also developed a unique member checking
process which allowed another group of patients and sib-
lings to audit the themes developed from a review of the
transcripts of the play interviews.
Results
After review of the interviews, the coders discovered two
primary areas for themes—positive and negative experi-
ences. The coders thought that these primary themes applied
to the interviews irrespective of the individual questions
asked in the interview protocol.
Positive themes discovered for stories of children with
illnesses and siblings are presented in Table 1. The themes
presented in Table 1 appeared to represent two main cate-
gories: the value of support from others and being able to
have positive experiences.
The themes in the data (i.e., children’s stories about
different characters) represented positive views of the hos-
pital staff and coping strategies used by the patients. The
patients spoke about child life specialists at the nearby
children’s hospital and the fun and distracting activities they
participated in which were viewed as positive. Parents were
a strong source of support through their presence and their
caretaking of both patients and children. Children with ill-
nesses reported liking having their parents and siblings
close by them or with them while they were in the hospital,
and thus siblings were another source of support for patients
(see Table 1). Doctors and nurses were also viewed as
supportive persons and random acts of kindness were
reviewed, and these acts of kindness made a positive dif-
ference in characters’ lives and emotional states. The acts of
kindness could be either received (i.e., something positive
or “nice” was done for a character) or the child would
describe something he or she could do that was kind to
others. Siblings were more likely to describe doing kind
things for characters, whereas patients were more likely to
discuss acts of kindness occurring for “sick” characters.
Both patients and siblings reported wanting to help their
brothers and sisters and be a support to them, although this
was a more common theme for siblings (see Table 1).
Siblings appreciated the activities and the opportunity to
stay at the RMH; several siblings and one patient reported
that the RMH was a fun place, because there were activities
to engage in and other children “like me” to play with. For
patients, someone like me, meant other children with
Table 1 Positive themes related to hospitalization for children with chronic illnesses and siblings
Themes
Support of siblings
Support of parents
Support of doctors and nurses
Acts of kindness are impactful 3
Wanting to help my sibling
Ronald McDonald House
Child life and other activities
Distraction as a coping strategy 4
Religion and faith
No. patients No. siblings Representative quotes
3 2 11-year-old Caucasian female patient: “If she is in the ICU then she cannot see her siblings.”
J Child Fam Stud
5-year-old African American female sibling: [How old is your brother?] “8 months old I think. I can’t even go in there, because you
have to be 14.”
3 7 11-year-old Caucasian female patient: “Her mommy (points to the Mommy paper doll) will pretend to be an animal. The Mommy is
going to take care of her in her bed.”
8-year-old Caucasian male sibling: [What about lonely?] “No.” [Why not?] “Maybe not because his parents are there.” [I see in the
story that he has parents there. Why?] “Because he got hooked up to oxygen and stuff.”
3 3 6-year-old Caucasian male patient: “What makes the child in the hospital (in his hospital) strong?When a nurse helps them (he
pointed to all of the characters in his hospital scenario).”
6-year-old Caucasian female sibling: “They [doctors and nurses] take care of him and wrap him up. They feed him. They get special
care there. After a while, they get better. They really enjoy being there and then get better and then later they say it wasn’t so bad.”
4 5-year-old Caucasian female patient: [How does each person in the family help the sick person out?] “By doing kind stuff.” [What
kind of stuff?] “Like getting water and help them eat.”
3-year-old Caucasian female sibling: (Drew on the walls of the room with a crayon) “She will be happy when I do this. I am going to
draw a triangle on it. She will be happy with it. I did it all by myself.”
3 7 4-year-old Caucasian female sibling: “All of the characters (5 or 6) were a family and were in the hospital together.”
3-year-old Caucasian female sibling: “I want to make it really nice for her. The bed will be soft, like soft.”
0 3 8-year-old Caucasian male sibling: [What do you think of staying here at Ronald McDonald House?] “It’s nice. My sister likes the arts
and crafts.” [What do you like about it?] “Playing video games and playing pool with my dad.”
12-year-old Caucasian male sibling: [How long have you been at Ronald McDonald House?] “I’ve been here one week.” [How has it
been?] “It has been good, especially the food. My mom is a good cook, but the food here is good.”
3 1 11-year-old Caucasian female patient: “Another up side is child life.” [What do you like about child life?] “A happy face to look at.”
12-year-old Caucasian male sibling: [How do you think people feel at the hospital?] “I don’t know. That’s hard. It comforts them. Like
the therapy animals. They don’t have them where I live.”
0 4-year-old Caucasian female patient: “A toy will make her happy.” The girl explained that playing with toys made her character happy
when undergoing procedures at the hospital.
11-year-old Caucasian female patient: ”But I like Child Life and they do things like art to take the kids minds off things. They would
cheer me up with games and projects.”
3 1 4-year-old Caucasian female patient: [What makes the little girl feel strong?] “Because Jesus is with her.” [What does Jesus do?]
“Everything.”
12-year-old Caucasian male sibling: [What makes the people in the story feel strong?] “They are with their family and people were
praying for them.”

illnesses, and for siblings, those like me were other brothers
and sisters whose parents were caring for a child in the
hospital. Similarly, patients appreciated the child life
activities at the hospital. Patients appreciated the “fun
activities” that they participated in with child life specialists,
because these activities helped to distract them from
thinking about their illness and negative experiences related
to their illness. Religion was a critical support for three of
the patients, and one sibling. Prayer, believing in “Jesus”,
and having others pray for a loved one who was ill were key
aspects of religious faith that supported children (see
Table 1).
Themes for negative aspects of the hospital experience
for children with chronic illnesses and siblings and these are
presented in Table 2. The negative themes about hospital
experiences seemed to represent two broad categories:
negative impacts of having a chronic illness or being in a
hospital, and negative emotions related to the hospital
experience.
The types of negative themes predominantly mentioned
by patients included not liking the hospital and dealing with
the long course of illness and experiencing pain related to
procedures (often needle sticks or “pokes”). Three of the
patients and two siblings reported not liking doctors or
nurses. Not liking doctors and nurses typically had to do
with perceiving them as those who administered needle
sticks or as persons responsible for painful procedures (see
quotes in Table 2). Five of the patients and two of the
siblings endorsed sadness. Patients often were sad, because
they were confined to bed or to a room and were not able to
carry on with their normal lives. Children with illnesses also
mentioned that the “parents” in the story were sad, because
their child was in pain or ill. Siblings were sad because they
missed their families (missed their family being together).
Siblings’ stories were likely to review experiences of
loneliness, either because a character who was sick had to
stay in bed “alone” or because a character was missing a
mother or father. Some children directly answered the
question as if referring to themselves, as one female sibling
said, “I don’t get to see my parents.” Siblings felt fear and
worry, primarily for their brother or sister with a chronic
illness, because they “didn’t want them to die” or because
they did not want their brother or sister to experience further
pain and medical procedures related to his or her illness (see
Table 2).
The coders discovered three additional themes discussed
by patients and siblings. These themes included: (1) magical
thinking where objects came to life to save a child, (2) a
need to tell one’s own medical story, and (3) needs for
improving the hospital environment by making it more
attractive. Theme one, magical thinking, occurred for two
preschool-age patients (under 5 years of age) and one 8-
year-old sibling. In their stories, objects had magical
J Child Fam Stud
qualities, such as a magical butterfly net that could be
waved like a wand to save a child’s life. An example of
magical thinking was reported by one 4-year-old girl, a
patient, who reported that, “The jewels will make her feel
better. I am putting magic jewels all around her room. The
magic jewels will make her feel better.”
Theme two, needing to tell one’s story, occurred when
children told about their own hospital experiences. For
example, a girl with chronic illness, who was 11-years-old,
reflected on her injury to her arm and having an “IV line in
my arm.” She was playing with a Playmobil™ figure of a
girl with an IV line and said, “Well, she can’t move her arm
at all with an IV in. Like yesterday, my nose was itchy and I
almost knocked myself out because I had an IV in this arm
and could not move it and my cast on this arm.” Some of the
siblings also told stories about the times they had been
hospitalized. These stories often appeared “cathartic” in
nature, and were a chance for children to release feelings
and review what happened to them and provide a happy
ending where they “got better.”
For theme three, children often spontaneously mentioned
that the hospital rooms needed to be more decorated and
have more color. To illustrate needing to improve the
attractiveness of the hospital environment, which four
patients and one sibling reported was important, here is a
quote by an 11-year-old girl, a patient stated, “The hospital
walls are really boring. I will make mine bright colors.” A 5-
year-old patient put better furniture, toys, and decorations in
her hospital room to make it more inviting. Another 8-year-
old sibling (girl) reported that there need to be “shiny dec-
orations wherever you look (in a hospital room).” Another
8-year-old sibling wanted to make the hospital room “an
aquarium” to be more fun for his older brother who was
going to be a patient in the room the next day.
As part of the interview protocol, children were asked
what they thought would happen in the future. Children
thought that the character or characters in their stories
would “get better” and they also reported wishes and hopes
that characters would heal and get better soon. Often, stories
had positive outcomes with a main character who was sick,
then recovered, and thus the family had an opportunity to be
together at home again. Both patients and siblings expressed
strong beliefs and wishes that characters would “get better.”
On the other hand, two children, one patient and one sib-
ling, also expressed through play, feelings of uncertainty
over the outcome of illness.
Member-Checking to Audit Themes
The patients and siblings in the member-checking group
supported the themes discovered for the play interviews.
Table 3 presents the number of patients and siblings
Table 2 Negative themes related to hospitalization for children with chronic illnesses and siblings
Themes No. patients No. siblings Representative quotes

Illness is a long journey 4 2 11-year-old Caucasian female patient: “Here’s me in the hospital every month. I had to lay in bed and not eat or drink. I had water
and Gatorade. I had to try to wait it out. I was always in the hospital and missing field trips. I was sad that I missed out on things
J Child Fam Stud

my school had. I missed out on being with my friends at school.”

12-year-old Caucasian male sibling: “I felt scared. We went to UK (University of Kentucky). Then we came to Cincinnati. They
said he would need a transplant. I have been here for a week. He came here May 1st. (2 months ago)”
Pain 5 1 11-year-old Caucasian female patient: The examiner mistakenly made a paper doll with a smiling face and the little girl insisted
that the paper doll be remade with a sad face and tears. The little girl was feeling “sad” because it hurts.
3-year-old Caucasian female patient: “I don’t like nurses and doctors who poke me. They can’t find me here”
Do not like being in the hospital 2 1 5-year-old Chinese female patient: [Did you like the hospital?“No.” She took the little girl out of the hospital room and did not put
it back inside. She did not want her main character of the story inside the hospital room.
7-year-old Caucasian female sibling: [How do you feel about the hospital?] “I don’t like it”; “I don’t like the hospital and I don’t like
doctors.”… “Kids do not feel good in the hospital.”
Do not like doctors or nurses 3 2 4-year-old Caucasian female patient: “Now the doctor is leaving” [the little girl picks up a Playmobil doctor and shows the
examiner the Playmobil figure walking away from her hospital room] “She’s [points to her little girl paper doll lying in the bed]
glad he’s leaving.” {Why?] “Because she got a shot.”
7-year-old Caucasian female sibling: “I don’t like nurses and doctors who poke me.”
Uncertainty about illness outcome 1 1 11-year-old Caucasian female patient: “Because they don’t know what is going to happen to her.” [What do they think is going to
happen?] “Anything could happen. No one knows exactly.”
8-year-old Caucasian female sibling: “He got a concussion.” [Oh no. He had a concussion. Is he going to be okay?] “Nobody
knows.”
Lonely 2 4 11-year-old Caucasian female patient: [Do you think she feels lonely?] “Yeah probably.” [Why do you think she feels lonely?]
“Because she has to lay in a bed, day after day. She can’t see any of her friends.”
3-year-old Caucasian female sibling: “I don’t get to see my mom anymore.” [Do you feel lonely for your mommy?] “Yes,
sometimes.”
Sad 5 2 5-year-old Caucasian female patient: [How do the girls feel?] “Sad. So do their parents.” [Why do they feel sad?] “Because they
don’t get to play.”
12-year-old Caucasian sibling: “I think it comforted people, so they wouldn’t get sad.” [Why might they feel sad?] “Maybe they
miss their family.”
Fear 4 3 5-year-old Caucasian female patient: [Do the girls feel scared?] “Yes.” [Why?] “Because they are by themselves.”
5-year-old African American sibling: “I’m scared that he will have to have another surgery.”
Worry 3 3 11-year-old Caucasian female patient: “I used to worry a lot because of my pain.” She used to wake up and be scared and worried
because she knew it was coming (a pancreatitis attack).
11-year-old Caucasian female sibling: “But, I don’t want all of my brothers and sisters dying from Leukemia…that is what I want.”
[Do you feel worried?] “Kinda. I just don’t want her to die like my older brother.”
 J Child Fam Stud

endorsing the positive and negative themes from the play Table 3 Member checking: results of auditing the themes endorsed
by patients and siblings
interviews.
The patients and siblings endorsed the importance of Themes Value No. of No. of
caring doctors and nurses. They reported that being patients siblings
involved in crafts and activities with Child Life specialists Support of siblings + 4* 1
at the hospital (for patients) and activity groups at the RMH Support of parents + 6 3
were critical events to foster positive feelings and enhance Support of doctors and nurses + 6 3
feelings of well-being. Three of the children who were Acts of kindness are helpful + 6 3
patients and one of the siblings endorsed the notion that Wanting to help my sibling + 1 3
coping with illness was long and at times trying (i.e., coping
Ronald McDonald House + 6 3
with chronic illness was a long journey). As expected,
Child life and other activities + 6 3
support of parents was critical for both siblings and patients.
Distraction as a coping strategy + 4 2
Doctors and nurses were seen as kind healers and their
Religion and faith + 4 3
support was important for all of the patients and sibling;
Illness is a long journey − 5 2
although one patient stated that she did not like the nurses
Pain − 4 2
when they administered needle sticks. Acts of and words
expressing kindness by others were also viewed as supports Do not like being in the hospital − 4 2
by all nine of the children. Both siblings and patients, were Do not like doctors or nurses − 1 0
reluctant to discuss negative feelings and uncertainty over Uncertainty about illness − 1 0
outcome
illness outcome when questioned directly. Patients did
Lonely − 2 0
endorse pain as a problem, and a negative aspect of their
Sad − 1 0
hospital experience. Siblings endorsed desires to help their
brother or sister who was ill (see Table 3). Fear − 2 0
Worry − 1 0
*Two of the patients were the only child in the family
Discussion

Results of this study add to existing literature indicating that
children with chronic illnesses and their siblings are
experiencing stress and exhibiting resilience when dis-
cussing coping with hospitalization through play (Clark
2003, 2011). Study findings provided new information
about similarities and differences in the perceptions of
hospitalization for children who had chronic illnesses and
siblings of children with chronic illnesses. Similar to Coyne
and Kirwan (2012) both patients and siblings indicated
positive and negative feelings related to hospitalization.
Thus, similar to patients, their siblings also may be trau-
matized by their brother or sister’s hospital experience and
report strong desires to help them (Houtzager et al. 2004;
Sharpe and Rossiter 2002). Moreover, siblings processed
their own previous hospital experiences, and negative
aspects of those experiences during play interviews, with
imaginal play offering opportunities to reprocess previous
experiences (Clark 2003, 2011).
Nabors et al. (2013) and Williams et al. (2009) found that
play interviews allowed siblings to process health problems,
and this study added to the literature indicating that siblings
may process their own medical trauma, long after it
occurred, while their brother or sister with a chronic illness
is undergoing medical procedures. Importantly, most of the
children spoke about support from parents being positive
and also discussed other positive experiences, which is a
testament to their resilience and strength. Children in the
play interview discussed more positive feelings than might
be anticipated given the nature of the questions about
negative emotions in the interview. Almost every child
participating in the member-checking audit did not endorse
or discuss negative experiences. This may have occurred
because children need time to bond with interviewers to
express their feelings, and the children did not have a pre-
vious relationship with the interviewers, whom they met
with one time. Further research is needed to determine if the
techniques yield more negative information when admi-
nistered by professionals who are familiar with the child.
The importance of support from the medical team was
also evident in children’s stories, especially those of
patients. Assistance and care-taking from doctors and nur-
ses were viewed as actions enhancing the resilience of
children undergoing medical procedures. Thus, similar to
results presented by Coyne and Kirwan (2012), members of
the medical team were viewed as healers, who helped
children become well. Children recalled acts of kindness
from others, without direct prompting from the inter-
viewers. Play activities engaged in by child life specialists
were seen as supportive as was the atmosphere and activ-
ities at the RMH. Nabors et al. (2013) have reported similar
positive perceptions of activities at the RMH in previous
research. In this study, children who participated in the
J Child Fam Stud
interviews and member-checking also reported valuing
child life activities to enhance fun while in the hospital as
well as a mechanism for “de-stressing” and distracting
themselves from negative feelings during hospitalization.
Additionally, although primarily mentioned by patients,
faith in a higher power and religion as well as distraction
were presented as positive strategies for coping, which is
similar to the results of earlier research (Nabors et al. 2013).
Patients and siblings often told stories that relayed their
own medical experiences, which were a pure projection of
their own experiences while participating in the play inter-
views. This is consistent with research indicating that
children work through their past experiences and medical
trauma through play when experiencing a hospitalization
(Clark 2003, 2011; Nabors et al. 2013). Children were
expressing their feelings, both positive and negative, and
working through stressful medical experiences through “re-
telling” the story of their experiences (Axline 1974). In the
majority of stories about hospitalization, the ending of the
story was positive, which allowed the child to have control
over and create a positive ending for a very stressful
situation (Clark 2003, 2011). However, two of the children
expressed uncertainty over the outcome of recovery of ill-
ness, and one boy who expressed uncertainty also expressed
worry related to not knowing what would happen in the
long-term, in terms of his sister’s recovery from cancer.
Others expressed worry related to the uncertainty of pain
experiences and painful “attacks.” Children in the member-
checking audit were less likely to endorse uncertainty,
perhaps because they did not understand the question.
However, when children in the member-checking group
were asked about other negative outcomes, they also were
typically unlikely to discuss these feelings. Hence, children
may be more apt to express feelings of uncertainty and
negative feelings indirectly through play.
Although there were commonalities, there were some
differences in the stories told by patients and siblings. For
example, patients appeared more likely to express that
having a chronic illness was a long and stressful journey
compared to siblings. Similarly, pain was viewed as a
negative experience and a detriment to coping more often
by patients who had recently undergone medical proce-
dures. Children who were current patients commonly
expressed fears related to pain from “pokes” (i.e., needle
sticks) or other medical procedures. Both children with
illnesses and siblings did report feelings of sadness and
worry during the play interview. For patients this could be
related to being in the hospital and for siblings this often
involved observing their brother or sister going through a
hospitalization. Wikström (2005) found that expressive arts
and play were an outlet for children to express their medical
fears and negative feelings related to hospitalization, and we
believe that this was a benefit of the procedures for the
current study as well.
In further examining differences between siblings and
patients, it appeared that siblings noted the caretaking role
of parents and feeling lonely more frequently than patients
(Williams et al. 2009). Specifically, siblings were more
likely to mention loneliness in their stories, and missing
time with their parent or parents who were caring for their
brother or sister with an illness. Siblings also were likely to
report wanting to help their brother or sister or take care of
them, and this is similar to findings of previous studies
(Sharpe and Rossiter 2002; Williams et al. 2009). On the
other hand, patients were more apt to mention distraction as
a strategy for coping with medical procedures. As men-
tioned, children with medical illnesses were more likely to
discuss their illness experience as a long journey and
mention pain in their stories. Some of the participants
indicated they were afraid and a few mentioned not liking
doctors or nurses, and both of these typically were related to
experiencing painful procedures.
Pain appeared to intensify feelings of worry and fear for
patients. Consequently, children with illnesses who are
expressing pain and resultant emotional distress may benefit
from supportive counseling to express emotions and con-
cerns (Jones and Landreth 2002; Wikström 2005). Siblings
who are experiencing vicarious trauma and re-experiencing
their own trauma to a degree that worry over uncertainty
and sadness interfere with daily functioning may also ben-
efit from referral for play therapy (Houtzager et al. 2004;
Sharpe and Rossiter 2002).
Participating in a play interview allowed children to
express their feelings indirectly, giving them a measure of
control over upsetting and stressful feelings (Axline 1974).
As such, building the hospital room, using art materials and
playing with the medical toys afforded children a stage and
venue to work through and re-experience stressful events
related to hospitalization, with an adult present to support
them as they expressed their emotions (Clark 2011; Nabors
et al. 2013). Many of the children did not want to stop the
interview, which is an indication that they valued the
opportunity to express feelings and review stressing events
and emotions. We believe that the act of building their own
hospital room afforded children a stage for discussing their
issues, in a venue in which they controlled the outcome.
Taking the time to build the hospital also allowed the
interviewers to establish rapport with the children, so that it
was easier to discuss feelings that might be difficult to
process, such as sadness. It seemed as if patients and sib-
lings had more difficulty discussing negative emotions
during the member-checking audit, which followed a brief
interview format, without the advantage of use of art and
play materials.

Several issues may have limited the generalizability of
results of this study. For instance, our questions did not
address feelings of anger or guilt. Asking about guilt related
to one’s medical condition and guilt related to being a sib-
ling who is a not experiencing any type of medical condi-
tion is an area for advancing knowledge, as we do not yet
know as much about this emotion. More information about
whether siblings who are lonely and miss their parents are
also experiencing anger related to their feelings of isolation
would also advance our understanding of siblings’ percep-
tions. It is noteworthy that different methods were used to
assess perceptions—play and a survey. When the children
were playing they may have felt safe to express their feel-
ings (Axline 1974), whereas they might not have felt as free
during surveys. This could explain why children in the
member-checking group did not report negative
experiences.
Another limitation of this study was that only children
were interviewed, and collecting data from parents or
members of the child’s medical team members (e.g., doc-
tors, nurses) would have provided comprehensive infor-
mation to corroborate or refute the statements provided by
the children. Similarly, we interviewed children and sib-
lings, but did not explore the dyadic relationship between
patients and siblings and this remains an area for research
(Canter et al. 2015). Although the coders believed that there
was saturation in terms of not seeing new themes emerge in
interviews, a potential limitation might be the small number
of interviews in one location. However, results from the
member checking to audit our findings supported the
themes discovered from the interviews. The exception to
this was the endorsement of negative feelings such as sad-
ness and fear, as few of the patients or siblings wanted to
discuss these feelings. It will be important to interview
children who are staying alone, and not at an RMH with
other families to determine if they feel similar levels of
resilience and discuss similar issues related to
hospitalization.
In summary, the play interviews provided opportunities
for children undergoing stressful hospital experiences or for
siblings who were observing their brother or sister endure
procedures an opportunity to express feelings and review
their experiences in a non-threatening situation where the
children themselves could have control of the outcomes of
events they discussed (Clark 2011; Moore and Russ 2006;
Nabors et al. 2013). To that end, most of the children
expressed positive endings in their stories for the character
that was in the hospital. These endings were positive in that
the main character of their story, typically a child with an
illness, became well and no longer suffered from pain or
had to go to a hospital. The children’s positive responses
during a very stressful period may indicate children’s hope
for positive outcomes.
J Child Fam Stud
Further research into resilience and hope expressed by
young children will advance knowledge about positive
functioning under very stressful circumstances. Contrary to
our expectations, younger children, in the preschool-age
range, did not express more fear-related themes than older
children. Our findings did indicate that younger children,
and one older child, engaged in magical thinking. This type
of thinking may be related to a lack of understanding of
medical procedures and medical outcomes, which could be
related to expressions of fear. As such, we concur with
researchers recommending more research into young chil-
dren’s fears about hospitalization (Proczkowska-Björklund
et al. 2010), and also recommend further play- and art-based
research to understand the relations among magical thinking
and medical fears for young children. Moreover, we do not
know how long patients and siblings are remaining stressed
after hospital stays are over. Therefore, studies assessing
children’s perceptions after a follow-up period, such as 6
months after the child with an illness is released from the
hospital, will be important to determine if patients and
siblings remain attuned to the stressor (i.e., hospitalization)
over time.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no compet-
ing interests.
References
Agar, M. H. (1986). Speaking of ethnography. Beverly Hills, CA:
Sage.
Axline, V. M. (1974). Play therapy. New York, NY: Ballantine
Books.
Canter, K. S., Wu, Y. P., Stough, C. O., Parikshak, S., Roberts, M. C.,
& Amylon, M. D. (2015). The relationship between attitudes
toward illness and quality of life for children with cancer and
healthy siblings. Journal of Child and Family Studies, 24(9),
2693–2698.
Clark, C. D. (2011). In a younger voice: Doing child-centered quali-
tative research. In C. G. Coll, & P. Miller (Series Eds), Series:
Child Development in Cultural Context. New York, NY: Oxford
University Press.
Clark, C. D. (2003). In sickness and in play: Children coping with
chronic illness. Brunswick, N.J.: Rutgers University Press.
Coyne, I., & Kirwan, L. (2012). Ascertaining children’s wishes and
feelings about hospital life. Journal of Child Health Care, 16(3),
293–304.
Creswell, J. W. (1998). Qualitative inquiry and research design:
Choosing among five traditions. Thousand Oaks, CA: Sage.
Houtzager, B. A., Grootenhuis, M. A., Caron, H. N., & Last, B. F.
(2004). Quality of life and psychological adaptation in siblings of
paediatric cancer patients, 2 years after diagnosis. Psycho-
Oncology, 13, 499–511.
James, A., & Prout, A. (Eds.), 1997. Constructing and reconstructing
childhood: Contemporary issues in sociological study of child-
hood. 2nd ed. London, UK: Falmer Press.
J Child Fam Stud
Jones, E. M., & Landreth, G. (2002). The efficacy of intensive indi-
vidual play therapy for chronically ill children. International
Journal of Play Therapy, 11(1), 117.
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverly
Hills, CA: Sage.
Moore, M., & Russ, S. W. (2006). Pretend play as a resource for
children: Implications for pediatricians and health professionals.
Journal of Developmental and Behavioral Pediatrics, 27(3),
237–248.
Morss, J. R. (2002). The several social constructions of James, Jenks,
and Prout: A contribution to the sociological theorization of
childhood. International Journal of Children’s Rights, 10, 39–54.
Nabors, L., Bartz, J., Kichler, J., Sievers, R., Elkins, R., & Pangallo, J.
(2013). Play as a mechanism of working through medical trauma
for children with medical illnesses and their siblings. Issues in
Comprehensive Pediatric Nursing, 36(3), 212–224.
Proczkowska-Björklund, M., Gustafsson, P. A., & Svedin, C. G.
(2010). Children’s play after anaesthesia and surgery: Back-
ground factors and associations to behavior during anaesthetic
induction. Journal of Child Health Care, 14(2), 170–178.
Sharpe, D., & Rossiter, L. (2002). Siblings of children with a chronic
illness: A meta-analysis. Journal of Pediatric Psychology, 27(8),
699–710.
Wikström, B. (2005). Communicating via expressive arts: The natural
medium of self-expression for hospitalized children. Pediatric
Nursing, 31, 480–485.
Williams, P. D., Ridder, E. L., Setter, R. K., Liebergen, A., Curry, H.,
Piamjariyakul, U., & Williams, A. R. (2009). Pediatric chronic
illness (cancer, cystic fibrosis) effects on well siblings: Parents’
voices. Issues in Comprehensive Pediatric Nursing, 32(2),
94–113.