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Child-reported hospital fears in 4 to 6-year-old children

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Child-Reported Hospital Fears
In 4 to 6-Year-Old Children
Marja Salmela
Sanna Salanterä
Eeva Aronen
The aim of this study was to describe hospital-related fears of 4 to 6-year-old children. Data were collect-
ed by interviewing 4 to 6-year-old children (N = 90) in Finland, who were chosen through purposive sam-
pling in which volunteers were asked to take part in the study. Data were gathered by semi-structured inter-
view, supported by pictures, and reviewed by quantitative and qualitative methods. Results revealed that
more than 90% of children said they were afraid of at least one thing in a hospital. Most fears were cate-
gorized by nursing interventions, fears of being a patient, and fears caused by the developmental stage of
the child. Children also expressed fears caused by the unfamiliar environment or lack of information, child-
staff relations, and the physical, social, and symbolic environment. The main result was that hospital care
increased the amount of fears in 4 to 6-year-old children. The information is useful in preventing, identify-
ing, and alleviating the hospital fear of healthy or sick children.

eing admitted to the hospital immaturity, young children often have Only a few earlier studies were

B causes fear and anxiety in 4

to 6-year-old children. Ac-
cording to parents, 83% of
p reschool or kindergarten-aged chil-
d ren suffer from diff e rent kinds of anx-
iety symptoms related to hospital fear
even after a minor operation in a hos-
pital (Rossen & McKeever, 1996).
Knowledge about preschoolers´ fears
in the hospital is mostly based on the
information given by parents or nurs-
es and covers fear experienced in a
certain surgical pro c e d u re or situation
in nursing care (Brewer, Glenditsch,
Syblic, Tietjens, & Vacik, 2006;
Coyne, 1998; Mahajan et al., 1998;
Pelander, Nuutila, Salanterä, & Leino-
Kilpi, 2006). Very little is known about
h o s p i t a l - related fear as said by chil-
d ren themselves. Because of their
Marja Salmela, MNSc, RN, is a Lecture r,
Helsinki Metropolia University of Applied
Sciences, Health Care and Social Services,
D e g ree Programme Nursing, Helsinki,
Finland.
Sanna Salanterä, PhD, RN, is a Professor
of Clinical Nursing Science Department of
Nursing Science, University of Turku,
Turku, Finland.
Eeva T. Aronen, MD, PhD, is an Assistant
P rofessor of Child Psychiatry and Senior
Child Psychiatrist, Hospital for Children and
Adolescents, Child Psychiatry, Helsinki
University Central Hospital, University of
Helsinki, Helsinki, Finland.
been underestimated as re p o rters of
their own well being or considered as
u n reliable informants (Coyne, 1998,
2006). However, preschoolers want
and are able to express and discuss
their own experiences. The best way
to get information about childre n ’s
fears to is to ask them. It is difficult to
understand childre n ’s experiences
without including their self-re p o rt
(Coyne, 1998; Lahikainen, Kraav,
Kirmanen, & Taimalu, 2006; Pelander
et al., 2006; Pelander & Leino-Kilpi,
2004).
Although several studies describe
p reschool or kindergarten-aged chil-
d re n ’s reactions and anxiety toward
nursing interventions (Gozal, Drenger,
Levin, Kadari, & Gozal, 2004; Kain,
Mayes, O´Connor, & Cicchetti, 1996),
no studies were found that describe
what in the domains of nursing are the
causes of their fears. Also, very little
information is available on the amount
and content of fears caused by being a
patient in a hospital, the hospital envi-
ronment, interaction between nursing
staff and the child, and nursing inter-
ventions reported by 4 to 6-year-old
c h i l d ren. Earlier studies have reported
that repeated admissions to the hospi-
tal increase children’s anxiety (Brewer
et al., 2006). However, there is no
information on whether the hospital
fears of healthy preschoolers differ
f rom the fears of children of the same
age who are being treated in the hos-
pital.
found to describe the child reporting
fears related to hospital treatment. In a
Finnish study of 5 to 6-year-old chil-
dren (N = 9), participants re p o rt e d
that in a hospital, they were most
afraid of the unfamiliar environment,
the feeling of abandonment, pain,
bodily injuries, and the restriction of
their self-determination and fre e
choice (Ivanoff, Laijärvi, & Åstedt-
Kurki, 1999). In a study concern i n g
children attending day surg e ry, 5 to 6-
year-old children (N = 25) re p o rt e d
being afraid of injections and suturing,
but also of taking medicines and of the
anesthesia mask. Lack of information,
unrealistic fears, as well as nausea,
vomiting, and the need to undergo
another operation also seemed to
cause fear (Flinkman & Salanterä,
2004). Children with diabetes mellitus
1 to 19 years of age (N = 112) and
their parents reported being afraid of
difficult symptoms that limit their
activity and everyday life (Nordfeld &
Ludvigsson, 2005).
According to adult informants in
other studies, about 19% to 68% of
young children were afraid of injec-
tions and needles (Kettwich et al.,
2007; Majstorovic & Veerkamp,
2004). In earlier studies, parents have
reported that pain, separation fro m
parents, unfamiliar people, difficulties
in breathing, blood samples, being
held still, nursing pro c e d u res, and
unfamiliarity with the norms of
accepted behavior cause fear in chil-

PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5 269

d ren (Gozal et al., 2004; Gullone,
2000; Jost, 1996; Koenig, Chesla, &
Kennedy, 2003; LeRoy et al. 2003;
N i c a s t ro & Whetsell, 1999; Snyder,
2004).
In the hospital, a preschooler can
also have typical fears of that part i c u-
lar developmental stage, such as the
fear of darkness, loud noises, unfamil-
iar people, and separation from par-
ents. Preschoolers are also afraid of
f a i l u re, loss of control, being criticized
or rejected, and punishments for real
or imagined misbehavior (Alsop-
Shields & Mohay, 2001; Brewer et al.,
2006; Romino, Keatley, Secrest, &
Good, 2005; Snyder, 2004). Because
of the rich imagination of preschool-
aged children, imaginary fears and
fears caused by the lack of knowledge
are emphasized during this stage
(Deering & Cody, 2002; Flinkman &
Salanterä, 2004).
It is especially important to identify
the possible fears of a child when car-
ing for preschoolers. According to
several studies, preschoolers have
m o re hospital-related fears than older
children because of their developmen-
tal stage (Bevan et al., 1990; Gazal &
Mackie, 2007; Gozal et al., 2004;
M a j s t o rovic & Veerkamp, 2004, 2005;
Rennick, Johnston, Doughert y, Platt,
& Ritchie, 2002; Romino et al., 2005).
The preschooler is not always able to
separate reality from the imaginary,
and the child’s ability to express and
cope with his or her fears is limited
( B rewer et al., 2006; Majstorovic &
Veerkamp, 2004). It is also sometimes
difficult for a young child to know the
difference between pain and fear
(Young, 2005). A child whose fears
a re taken into account and who is
supported in coping with fears is usu-
ally more cooperative and less anx-
ious than other children (Mahajan et
al., 1998). This child will often need
less medication for pain and sedation,
heal faster, and re t u rn home sooner
(Walworth, 2005). For children under-
going surg e ry, the operation can be
perf o rmed more quickly, smoothly,
and with fewer personnel, making it
easier for the child and parents (Kain
et al., 1996; Kristensson-Hallström,
Elander, & Malmfors, 1997).
The first aim of this study was to
describe hospital-related fears of 4 to
6-year-old children using semi-stru c-
t u red interviews supported by pic-
t u res. A second aim was to determ i n e
if children who were hospitalized had
m o re fears, or diff e rent fears, than
children who were interviewed at
kindergarten. The objective of the
study was to describe the amount and
quality of the hospital-related fears
270
e x p ressed by the children themselves.
The re s e a rch questions were:
• What are hospital-related fears of
4 to 6-year-old children described
by themselves?
• What are frequencies of fears in
these children?
• How do hospital-related fears of
healthy children interviewed in
kindergarten differ from the fears
of children who are hospitalized?
Methods of Data
Collection and Analysis
Data Collection
Data were collected by interviewing
4 to 6-year-old children (N = 90) who
lived in the metropolitan area of
Finland (population about 1.5 mil-
lion), of which 63 children were inter-
viewed in a kindergarten class and 27
in two pediatric surgical wards in a
university hospital during the period of
the study from 2004 to 2006. The
c h i l d ren were chosen through purpo-
sive sampling, in which volunteers
w e re asked to take part in the study.
The criteria for participation in the
study were age (4 to 6 years), the
c h i l d ’s ability to communicate in
Finnish, and the child’s typically
developing (evaluated by kinder-
garten and hospital personnel).
A c c o rding to the phenomenological
research tradition, any person fulfilling
the inclusion criteria is a good inform-
ant, and thus, purposive sampling was
used (Spradley. 1979).
Interviews were arranged with the
head nurses of the wards in the univer-
sity hospital and with the heads of the
kindergarten classes. The first author
(M.S.) and interviewers informed the
personnel of the wards and kinder-
garten classes of the study. The per-
sonnel then gave parents a data sheet
of the study with a written request for
permission to interview their child. All
c h i l d ren whose parents gave a written
permission, who gave a verbal per-
mission themselves, and who were on
the ward or in the kindergarten class
during the period of the study were
chosen to participate.
Interviews were carried out by 20
trained interviewers who were gradu-
ating nurses in their final semester.
Interviewers were trained to the spe-
cial characteristics of interviewing
c h i l d ren, and they were re q u i red 2 to 3
pilot interviews by interviewing
healthy 4 to 6-year-old children. The
re s e a rcher (M.S.) supervised the
interviewing of the children.
Data were gathered by semi-stru c-
t u red interviews and were support e d
PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5
by pictures. The interviewer discussed
with the children certain re s e a rc h
themes that had been determined in
advance. Interview themes were
f o rmed on the basis of Kim’s typology
of domains or main contents for nurs-
ing (Kim, 2000; Kim & Kollak, 1999),
and were identified as a) fears caused
by being a patient; b) fears caused by
the physical, social, and symbolic
environment of the hospital; c) fears
caused by the patient-nurse relation-
ship; and d) fears resulting from nurs-
ing interventions (Burns & Grove,
2001; Morse & Richards, 2002; Polit,
Beck, & Hungler, 2004). The interview
method was flexible and child-cen-
tered; while interview themes directed
the pro g ress of the interview, the child
was able to specify the content
(Bricher, 1999; Faux, Walsh, &
Deatrick, 1988; Spradley, 1979). The
subjects of the pictures corresponded
to the interview themes drawn fro m
the main domains of nursing (Kim,
2000; Kim & Kollak, 1999). The pic-
t u re subjects were a) a sick child in
bed in the hospital with instruments
and parents nearby, b) a child in an
operating room, c) a child in bed sur-
rounded by doctors and nurses, and
d) a child sitting in a wheelchair in a
corridor in the ward. The younger the
child’s age, the more his or her discus-
sion on certain themes was facilitated
by having some concrete material,
such as pictures to look at and hold
(Doverborg & Pramling, 2000).
During the interv i e w, the interv i e w-
er also observed the child and re c o rd-
ed the findings in a re s e a rch diary.
Children’s answers were sometimes
so short that without the diary, reliable
analysis would have been impossible.
However, the interviewer did not inter-
pret the child’s behavior or answers,
but only wrote down the objective
observation, for example, if the child
shook or nodded his or her head.
Ninety-four children originally
a g reed to participate in the study. One
forbade tape-re c o rding, one fell asleep
before the interview began, and two
did not want to discuss their fears at
all. The interviews of these children
were not used in analyzing data. Thus,
final data consisted of 90 interv i e w s .
The interviews were tape-re c o rd e d
and transcribed to written form. The
length of the transcribed interv i e w s
ranged from 1 to 13 pages, and the
interviews lasted from 20 minutes to
an hour.
Data Analysis
Data were analyzed by deductive
content analysis and categorized into
pre-determined categories. Seven cat-
 Child-Reported Hospital Fears in 4 to 6-Year-Old Children

egories included a) fears related to Ta ble 1.

being a patient, b) the developmental Hospital-Related Fears Reported by 4 to 6-Year-Old Children (N = 90)
stage of the child, c) unknown experi-
ences and lack of information, d) the Single Expressions
physical environment, e) the social of Fear
and symbolic environment of the hos- Objects of Fear
pital, f) child-staff relations, and g) n %
nursing interventions. All expressions Fears of Being a Patient
of fear were categorized, including the
Pain 51 57
less than 6% of expressions that re p re-
sented unrealistic fears or figments of Staying in hospital 23 26
the child’s imagination. For example,
Being admitted to hospital 17 19
in these cases, the child said he was
afraid because “[the vaccine] is poi- Symptoms of the disease 15 17
son,” or “the needle goes through the
Bodily injuri e s 10 11
arm,” or “if [doctors] don’t have
masks, they smell bad.” Data were Becoming ill 6 7
reviewed by quantitative and qualita-
Fears Caused by the Developmental Stage of the Child
tive methods.
Being left alone 19 21
Ethical Considerations Imagination 13 14
The hospital’s ethics committee Loss of autonomy 10 11
and the City Social Services Unfamiliar people 9 10
Department both granted their
a p p roval for the study. All participat- Other fears caused by the developmental stage 9 10
ing parents received written inform a- Fears Caused by Unfamiliar Environment or Lack of Information
tion on the study before being asked
to consent. After receiving written Lack of information 18 20
consent from the parent or guardian, New and unknown experiences 15 17
the autonomy of the child was
respected by giving him or her oral Physical Environment
information on the study and asking Instruments and equipment 19 21
for oral consent to participate.
Interviews proceeded on the child’s Facilities of the hospital 11 12
terms, and all children received a Noises and smells of the hospital 9 10
small re w a rd (such as a sticker) after
the interview. Parents could take part Social and Symbolic Environment
in the interview if they wished. Each S e p a ration from the family 20 22
participant’s identity was protected so
that individuals could not be recog- Other fears caused by the social and symbolic environment 2 2
nized in the study. Children were Child-Staff Relations
assigned code numbers identifying
their gender, age, and place of inter- Exercise of power by adults 16 18
view (kindergarten or hospital), and Doctors 13 14
they were not requested to identify
themselves by names on the tape. The Nurses 10 11
information given by the child was Nursing Interventions
processed in confidentiality, which
was protected by coding all data and Shots 45 50
keeping all documentation in a safe Sample-taking and tests 29 32
location (Burns & Grove, 2001;
Munhall, 1999). Other nursing interventions 29 32
Operation 12 13
Results Medication 12 13
Results are presented here re g a rd-
ing the amount and types of fears that
4 to 6-year-old children have about
the hospital. Diff e rences that exist in Hospital-Related Fears of a were 8 children (9%) who expressed
e x p ressions of fears in children who 4 to 6-Year-Old Child. no hospital-related fears at all, 34
a re in the hospital at the time of the In this study, the children expressed (38%) who expressed 1 to 3 fears, 20
interview and those who are in kinder- 29 diff e rent types of fears related to (22%) who expressed 4 to 6 fears, and
garten are described, and girls’ and the hospital. Data included a total of 28 (31%) who expressed more than 7
boys’ expressions of fear are com- 441 expressions of fear. The amount hospital-related fears.
p a red. of child-reported fears ranged from no Most fears were categorized in the
fears to 22 fears (mean = 4.9). There category of nursing interventions (see
Table 1). Half of the children re p o rt e d

PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5 271

 Table 2.
The Amount of Hospital-Related Fears
Children in
Amount Kindergarten
of Fears
n %
0 8 13
1 to 3 fears 28 44
4 to 6 fears 12 19
More than 7 fears 15 24
Total 63 100
they were afraid of shots, and 29 men-
tioned tests, sample-taking or exami-
nations, and other nursing interv e n-
tions. The second largest category
consisted of fears of being a patient.
M o re than half of all the children said
they were afraid of pain, and more
than a quarter of them feared being
admitted to a hospital. The third
l a rgest category consisted of fears
caused by the developmental stage of
the child. In this category, the most
common fears were the fear of being
left alone (n = 19) and fears created
by the child’s own imagination (n =
13). This category also included chil-
d re n ’s expressions of being afraid of
the boogeyman, ghosts, grimace
masks, or their own “bad thoughts.”
Of all the interviewed children, 61
expressed they were afraid of the
physical, social, or symbolic enviro n-
ment of the hospital. Forty childre n
said they were afraid of factors related
to the child-staff relations, and 33
w e re afraid of the unfamiliar enviro n-
ment or the lack of information.
An examination of all individual
fears expressed by the childre n
revealed the largest categories were
the fear of pain and shots (57% and
50%, respectively). More than 30% of
the children said they were afraid of
sample-taking and tests as well as
other nursing interventions. More than
20% of the children said they were
afraid of staying in a hospital, separa-
tion from family, being alone, and
instruments. About 20% of the chil-
d ren expressed fears caused by the
lack of information, being admitted to
a hospital, the exercise of power by
adults, symptoms of their disease, or
new and unknown experiences. More
than 10% of the respondents said they
w e re afraid of doctors, things created
by their own imagination, medicines
and taking medicines, operations, the
hospital premises, losing autonomy,
and injuries to the body (see Table 1).
Thirty-four girls (38%) and 56 boys
272
Children in
Hospital Total
n % n %
– – 8 9
6 22 34 38
8 30 20 22
13 48 28 31
27 100 90 100
(62%) participated in the study. The
total number of individual, hospital-
related fears expressed by girls was
151, while boys expressed 290 indi-
vidual fears. The mean of the number
of fears expressed by girls was 4.44
and by boys 5.18. When examining
the percentage distribution of fears,
boys re p o rted slightly more fears than
girls. Boys expressed statistically sig-
nificant more fears toward the re l a-
tions between the child and the staff
(Mann-Whitney U = 739.500, p =
0.017). There was no significant dif-
ference in the number of fears
between diff e rent age groups of chil-
d ren.
Differences in Hospital-Related
Fears Between Children
Interviewed in Kindergarten and
Children Being Treated at the
Hospital
Of all the children participating in
the study, 63 were children who were
interviewed in kindergarten and 27
w e re hospitalized children who were
interviewed in two hospital wards. Of
the children who were interviewed in
kindergarten, 25 (40%) were girls and
38 (60%) boys, and among them were
26 (41%) 4-year olds, 20 (32%) 5-
year olds, and 17 (27%) 6-year olds.
Of the hospitalized children, 9 (33 %)
w e re girls and 18 (67 %) were boys,
and among them were 8 (30%) 4-year
olds, 10 (37%) 5-year olds, and 9
(33%) 6-year olds.
C h i l d ren in kindergarten listed 0 to
22 diff e rent hospital-related fears (see
Table 2). Eight (13%) participants in
kindergarten expressed no fears at all,
but most (44%) healthy childre n
e x p ressed 1 to 3 fears related to a
hospital. Under a quarter of the chil-
d ren who were interviewed in kinder-
garten expressed more than 7 fears.
The number of hospital-re l a t e d
fears expressed by children in the hos-
pital varied from 1 to 14 fears. Among
these children, 22% mentioned 1 to 3
PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5
fears, and 30% mentioned 4 to 6 fears.
Almost half (48%) of the children in
the hospital mentioned more than 7
hospital-related fears (see Table 2).
The mean of hospital-related fears
expressed by children in kindergarten
was 4.2 and by children in the hospi-
tal was 6.48. When examining the per-
centage distribution of fears, children
in the hospital expressed substantially
more fears than children in kinder-
garten (see Table 3). Fears related to
bodily injuries and hospital facilities
o c c u rred more frequently in those
children in kindergarten than in chil-
dren who were hospitalized. Among
the children in the hospital, 70% said
they were afraid of pain, 52% of shots
as well as other nursing interventions,
41% of being admitted to the hospital,
and 37% of sample-taking and tests.
The fears that the children in kinder-
garten expressed most often were the
fear of pain (51%), shots (49%), and
sample-taking and tests (31%). When
the fears of children in kindergarten
were compared with the fears of chil-
dren in the hospital using the Pearson
Chi-Square test, statistically signifi-
cant diff e rences were found in the
fears of being admitted to the hospital
( [1] = 12.021, p = 0.001), doctors
( [1] = 4.114, p = 0.043), other nurs-
ing interventions ( [1] = 6.805, p =
0.009), and operations ( [1] = 5.293,
p = 0.021) (see Table 3).
When examining children’s fears
according to the categories based on
the typology of nursing domains, there
were also statistically significant dif-
ferences between fears of the children
in the hospital and those who were in
kindergarten. Children in the hospital
mentioned significantly more often
fears related to being a patient (Mann-
Whitney U = 586.5, p = 0.007), the
developmental stage of the child
(Mann-Whitney U = 652.5, p = 0.028),
the relationship between the child and
the staff (Mann-Whitney U = 614, p =
0.008), and nursing practice (Mann-
Whitney U = 584.5, p = 0.007) (see
Table 4).
Discussion
The results of this study revealed
that 91% of preschoolers said they are
afraid of at least one subject related to
the hospital or medical procedures.
The percentage is larger than in earli-
er studies (Rossen & McKeever,
1996). Among children interviewed in
kindergarten, 9% expressed no fear,
63% expressed 1 to 6 fears, and 24%
expressed more than 7 fears related to
the hospital. Among the children inter-
viewed in the hospital, little more than
 Child-Reported Hospital Fears in 4 to 6-Year-Old Children

Ta ble 3.
The Amount of Hospital-Related Fears Expressed by Children in Kinderg a rten and in the Hospital

Kindergarten Hospital Chi-Square Tests

(n = 63) (n = 27) (d f 1)
n % n % Value p
Fears of Being a Patient
Pain 32 51 19 70 2.95 0.086
Staying in hospital 16 25 7 26 0.003 0.958
Being admitted to hospital 6 10 11 41 12.02 0.001
Symptoms of the disease 9 14 6 22 0.857 0.355
Bodily injuries 9 14 1 4 2.14 0.143
Becoming ill 4 6 2 7 0.034 0.854
Fears Caused by the Developmental Stage of the Child
Being left alone 11 17 8 30 1.69 0.195
Imagination 9 14 4 15 0.00 0.948
Loss of autonomy 6 10 4 15 0.53 0.464
Unfamiliar people 6 10 3 11 0.053 0.818
Other fears caused by the developmental stage 4 6 5 19 0.121 0.087
Fears Caused by Unfamiliar Environment or Lack of Information
Lack of information 12 19 6 22 0.12 0.730
New and unknown experiences 10 16 5 19 0.095 0.758
Physical Environment
I n s t ruments and equipment 12 19 7 26 0.54 464
Facilities of the hospital 8 13 3 11 0.044 0.833
Noises and smells of the hospital 5 8 4 15 0.99 0.319
Social and Symbolic Environment
Separation from the family 10 16 9 33 2.24 0.135
Other fears caused by the social and symbolic environment 2 3 – – 0.43 0.510
Child-Staff Relations
Exercise of power by adults 8 13 8 30 3.70 0.054
Doctors 6 10 7 26 4.11 0.043
Nurses 5 8 5 19 2.14 0.143
Nursing Interventions
Shots 31 49 14 52 0.008 0.927
Sample-taking and tests 19 31 10 37 0.409 0.522
Other nursing interventions 15 24 14 52 6.80 0.009
Operation 5 8 7 26 5.29 0.021
Medication 6 10 6 22 2.64 0.104

a half (52%) expressed 1 to 6 hospital-
related fears, and 48% more than 7
fears. All children who were inter-
viewed in the hospital expressed at
least one fear related to the hospital.
According to this study, fears
expressed most often by 4 to 6-year-
old children were caused by the prac-
tice of nursing (29%), for example, the
fear of shots, sample-taking and tests,
other nursing interventions, operations,
and medication. Almost as many fears
w e re categorized as fears of being a
patient (28%), such as the fear of pain,
being admitted to the hospital, staying
in the hospital, and symptoms of a dis-
ease. The third largest category con-
sisted of fears related to the develop-
mental stage of the child (14%). In this
category, children most often men-
tioned the fear of being left alone in the
hospital. More than 20% of preschool-
ers mentioned they were afraid of being
left alone in the hospital. Less than 10%
of preschoolers expressed that they
f e a red new and unfamiliar experiences,
the lack of information, the physical

PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5 273


The Expressions of Fears Expressed by Children in Kinderg a rten and in Hospital
Categories of Fear
Fears of being a patient
Fears caused by the developmental stage of child
Fears caused by unknown environment or lack of information
Physical environment
Social and symbolic environment
Child-staff relation
Nursing interventions
Figure 1.
Hospital-Related Fears Reported by 4 to 6-Year-Old Children
e n v i ronment of the hospital, and child-
staff relations (see Figure 1).
It is difficult to compare results con-
c e rning the number of child-reported
hospital fears with earlier studies
because only very little similar informa-
tion on preschoolers is available. In
Ivanoff’s (1999) study, nine 5 to 6-
year-old children were interviewed
about their hospital fears. According to
Ivanoff´s study, the main themes of 5 to
6-year-old childre n ’s hospital fears
were the unfamiliar environment, the
feeling of abandonment, injuries of the
274
Ta ble 4.
Expressions of Fear
Kindergarten
n n
76
36
22
25
12
19
76
body, pain, restriction of self-determ i-
nation, and submission. Similar fears
also occurred in this study; however,
except for pain, children expressed
m o re fears related to nursing interv e n-
tions, such as the fear of shots, sample-
taking, and tests, and only seldom
(10% to 16% of children) expressed
other main fears in Ivanoff’s study. In
the qualitative study by Flinkman and
Salanterä (2004), 25 children ages 5 to
6 years of age were interviewed during
a day surg e ry procedure. In this study,
the children mentioned 24 different
PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5
U-Test (Exact Sig. 1-tailed)
Hospital
U p
46 586.500 0.007
24 652.500 0.028
11 810.00 0.359
14 749.00 0.136
9 778.00 0.254
20 614.00 0.008
51 584.500 0.007
fears, with nursing treatments and
anaesthesia being most important. In
this respect, results were similar to the
results of the present study, in which
the main individual fears reported by 4
to 6-year-old children were the fears of
pain and shots. The result concerning
the fear of injections supports the find-
ings of earlier studies. According to the
study by Kettwich et al. (2007), 68% of
children suffer from needle phobia.
Findings from this study pull
together earlier information on the
hospital fears of young children, but
they also elicit new information. The
study showed that a 4 to 6-year-old
child is capable and willing to discuss
his or her fears with the interviewer.
C h i l d ren expressed 29 different hospi-
t a l - related fears. In the data, there
were 17 fears that had also been men-
tioned in earlier studies and 12 fears
that became evident in this study as
reported by the children. These fears
are familiar from child care literature
but were not re f e rred to in the 200
studies reviewed for the literature
review of this study. These 12 fears
that children in this study expressed
were a) staying in the hospital (26% of
children), b) being left alone in the
hospital (21%), c) being admitted to
the hospital (19%), d) new and unfa-
miliar experiences (17%), e) doctors
(14%), f) the facilities (10%), g) smells
and noises of the hospital (12 %), h)
nurses (11%), i) getting ill (7%), j)
hospital rules (2%), k) falling asleep in
the hospital (2%), and l) other patients
(1%). The only fears that occurred in
earlier studies but were not mentioned
by the children in this study were the
fears of failure and being rejected.
A main finding of this study was
that more fears were present in hospi-
talized children than in their peers,
which may suggest that being treated
in the hospital increases the number of

h o s p i t a l - related fears in 4 to 6-year-
old children. Children who were in the
hospital reported fear of being admit-
ted to the hospital more often than
children interviewed in kindergarten.
C h i l d ren in the hospital also reported
the interaction between children and
staff (especially between children and
doctors), nursing interventions, and
operations more often than children in
kindergarten.
In this study, results were classified
into categories drawn from the
domains of nursing (Kim, 2000; Kim
& Kollak, 1999). Kim proposed a sys-
tematic framework that can be used to
examine elements in the fields of nurs-
ing. The typology is composed of four
domains: client, client-nurse, practice,
and environment (Kim, 2000; Kim &
Kollak, 1999). When examining the
present results according to the
domains of nursing, it is obvious that
about a half of the fears (49%) can be
categorized to the client domain: fears
related to being a patient, the develop-
mental stage of the child, unfamiliar
experiences, and lack of information.
Another main domain that causes fear
in children is nursing interventions
(29% of expressions). Less than 14%
of all expressions of fears were related
to the facilities of the hospital. The
main individual fear in this category
was the fear of separation from family.
Fears related to the symbolic enviro n-
ment of the hospital (for example, the
fear of rules and regulations) were
mentioned by one child only. Earlier
studies on the hospital fears of chil-
d ren using the domains of nursing for
categorization were not available. The
categorization used in this study
p roved to be functional. It was possi-
ble to classify all expressions of fear
by the children, and no category was
left empty. Because the categorization
is based on the main domains of nurs-
ing, these results can be used when
p reventing, identifying, and relieving
the fears of hospitalized preschoolers.
Only a few methods of data collec-
tion are suitable for young children,
t h rough which it is possible for the
child to describe his or her own
thoughts and experiences. Some stud-
ies have used draw-and-tell conversa-
tions (Driessnack, 2006), children’s
drawings (Brewer et al., 2006), and
different Visual Analogue, Fear,
Anxiety, or Aversion Scales (Kettwich
et al., 2007). In this study, researchers
were interested in hospital-re l a t e d
fears expressed by the children them-
selves, which is why data were collect-
ed by semi-stru c t u red interviews sup-
ported by pictures. Because of its flex-
ibility, the semi-stru c t u red interv i e w
PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5
Child-Reported Hospital Fears in 4 to 6-Year-Old Children
was suitable for 4 to 6-year-old chil-
d ren. During the interv i e w, it was pos-
sible to take into account the child’s
vocabulary and individual way of
communicating. The pre requisite for a
successful interview was interaction
between the child and the interviewer,
and also the confidential and friendly
a t m o s p h e rein which the child had the
courage to express his or her thoughts
(Deering & Cody, 2002).
The questions were well-defined
and simple, and the interviewer used
c o n c rete and action-oriented words
familiar to the child. When forming
questions, the child typically answer-
ing “yes,” “no,” or “I don’t know” was
c o n s i d e red. It is also often difficult for
a child to disagree with adults; thus,
they may be likely to answer in the
way they think is acceptable. The
interviewer emphasized to the child
that everything he or she said was
important and that there were no
w rong answers (Burns & Grove, 2001;
Carney et al., 2003; Docherty &
Sandelowski, 1999; Eder
Fingerson, 2002; Zoppi & Epstein,
2002). In this study, the use of pictures
b rought out rich information on hospi-
tal-related fears. The pictures served
as a stimulating basis for the interview,
and helped the child become intere s t-
ed in and concentrate on the conver-
sation, as well as connect his or her
own experiences to the subject and
express his or her own feelings
(Carney et al., 2003; Doverborg &
Pramling, 2000; Styles & Arizpe,
2001).
Limitations of the Study
In this study, some factors limited
tru s t w o rthiness during data collection.
First, it was not possible to control the
selection of children. Second, several
interviewers were used at the data col-
lection stage. Finally, because nurses
p rovided parents with information on
the study, it was not possible to control
the distributed information, especially
because kindergarten personnel and
the nurses’ commitment to the study
may have fluctuated. Conversely,
tru s t w o rthiness was increased by the
first author and interviewers giving
oral and written information on the
study to nurses (Burns & Gro v e ,
2001). Results of this study cannot be
generalized to all 4 to 6-year-old chil-
d ren because of the data collection
method.
Differences in the children’s per-
sonality and developmental stage
might decrease the trustworthiness of
the results. The children’s ability to
concentrate and their interest in the
subject varied as well as their individ-
ual ability to verbalize their feelings
and thoughts. However, pictures made
it easy for children to identify with the
hospital experience and discuss their
own thoughts. The pictures had
cheery motifs and colors, which might
d e c rease the tru s t w o rthiness of the
results. The use of other, perh a p s
more realistic and possibly alarming
pictures might have brought out more
hospital fears.
The interrater reliability of the inter-
viewers was not established, another
limitation of the study. However, the
t ru s t w o rthiness of the data collection
was assured by training the interv i e w-
ers to the special characteristics of
interviewing children, requiring pilot
interviews, and instructing the process
of the interview in advance in a sys-
tematic way (by first author M.S.). All
interviewers had studied the nursing
care of children and re s e a rch meth-
ods, a fact that increases the trustwor-
thiness of the results. They had stud-
ied the developmental stage of a 4 to
& 6-year-old child, especially the child’s
way and ability to express him/herself
and interact with adults. Further, the
t ru s t w o rthiness of the interviews, data
analysis, and reporting was assured
by listening to all re c o rdings of the
interviews and by checking that the
transcripts had been made reliably (by
first author M.S.). The interv i e w e r s ’
observations of the children were
added to the data to be analyzed in the
cases when needed to clarify the
child’s answer (Burns & Grove, 2001;
Cohen & Knafl, 1993). Tru s t-
worthiness of the data collection
might have decreased by the different
circumstances of each interv i e w. It is
also difficult to estimate or control the
significance of how parents and nurs-
es contributed to the interview.
One aim of this study was to give
the preschoolers themselves the
opportunity to discuss their hospital-
related fears. Neither the earlier hospi-
tal experiences of the children nor the
socio-economical background of their
families were controlled, which may
limit the exploitability of the results.
Conclusions/Clinical
Implications
The results of this study revealed
that more than 90% of children were
afraid of at least one thing in a hospi-
tal. These results suggest a gre a t
number of hospital-related fears
among 4 to 6-year-old children. In a
hospital, the main fears of children are
the fears of pain, different treatments
(especially injections), sample-taking,
and tests. Alleviating pain caused by a
disease or treatment decreases the
275
child’s fear and increases his or her
feeling of safety. In addition to pain
medication, the child needs support
f rom parents and staff, information,
and guidance. There are also methods
suitable for the child’s developmental
stage that the children can use to alle-
viate pain and fear. These methods
(such as diff e rent types of relaxation)
affect the child’s emotions and cogni-
tion, allowing the child be an active
participant in his or her own care
(Salanterä, 1999). The presence of a
p a rent and the fact that the child does
not have to be alone in a hospital
d e c reases his or her hospital fear.
Hospital fear will also decrease if the
physical environment of the hospital is
made entertaining and safe. Be-
coming familiar with the instruments
and machines of the hospital also
d e c reases the child’s fear of the phys-
ical environment of the hospital.
Knowledge evokes security and confi-
dence in preschoolers and decreases
unnecessary hospital fear.
Being admitted to a hospital is an
event that may increase the fears of a
4 to 6-year-old child. Children who
have personal experience of being
admitted to a hospital describe more
fears than healthy children in kinder-
garten. There is no single method to
remove all hospital fears, but a pre re q-
uisite for eliminating fear is the staff’s
a w a reness of the issues that may
cause children fear, and staff’s willing-
ness to prevent and recognize possible
fears help and support the child in cop-
ing. The fears of the child can also be
p revented and alleviated by giving the
parents information on the child’s hos-
pital fears and on the meaning of sep-
aration from parents to the child.
Guiding the parents to support their
child is also important. Parental aware-
ness and participation in their child’s
hospitalization is essential for eff e c t i v e
coping. It would be desirable that a
children’s hospital would be a place
that promotes the healing of the child
and his or her feeling of safety, not a
place that increases fear.
This article describes the amount
and content of hospital fears reported
by 4 to 6-year-old children them-
selves. The information is useful when
trying to understand children’s experi-
ences of fear and anxiety in a hospital,
during certain nursing processes, at
the doctor’s or dentist’s office, and in
child health clinics. The inform a t i o n
can also be useful in preventing, iden-
tifying, and alleviating the hospital fear
of healthy or sick children. More
re s e a rch is needed on the situations
and contexts that give rise to chil-
d re n ’s hospital fears and the conse-
276
quences of these fears to small chil-
d ren. Research is also needed on the
coping skills that children use when
they try to cope with their fears, the
content of these skills, and how nurs-
ing staff can support the coping of the
child.
References
Alsop-Shields, L., & Mohay, H. (2001). John
Bowlby and James Robertson: Theorists,
scientists and crusaders for improve-
ments in the care of children in hospital.
Journal of Advanced Nursing, 35(1), 50-
58.
B evan, J., Johnston, C., Haig, M.J.,
Tousignant, G., Lucy, S., Kirnon, V., et
al. (1990). Preoperative parental anxiety
predicts behav i o u ral and emotional
responses to induction of anaesthesia
in children. Canadian Journal of
Anaesthesia, 37(2), 177-182.
B r ewe r, S., Glenditsch, S., Syblik, C.,
Tietjens, M., & Vacik, H. (2006).
Pe d i a t ric anxiety: Child life intervention
in day surgery. Journal of Pediatric
Nursing, 21(1), 13-22.
Bricher, G. (1999). Children and qualitative
research methods: A review of literature
related to interv i ew and interpretive
processes. Nursing Research, 6(4), 65-
77.
Burns, N., & Grove, S. (2001). The practice of
nursing research: Conduct, critique, and
utilization (4th ed.). Philadelphia: W.B.
Saunders.
Carney, T., Murphy, S., McClure, J., Bishop,
E., Kerr, C., Parker, J., et al. (2003).
Children’s views of hospitalization: An
exploratory study of data collection.
Journal of Child Health Care, 7(1), 27-
40.
Cohen, M.Z., & Knafl, K.A. (1993). Evaluating
qualitative research. In P. Munhall & C.
Boyd (Eds.), Nursing research. A quali -
tative perspective (2nd ed.) (pp. 476-
92). N ew Yo rk : National League for
Nursing.
C oy n e, I. (1998). Researching children:
Some methodological and ethical con-
sidera t i o n s. Journal of Clinical Nursing,
7(5), 409-416.
Coyne, I. (2006). Consultation with children in
hospital: Children, parents´ and nurses´
p e r s p e c t i ve s. Journal of Clinical
Nursing, 15(1), 61-71.
Deering, C., & Cody, D. (2002). Commu-
nicating effectively with children and
adolescents. American Journal of
Nursing, 102(3), 34-41.
Docherty, S., & Sandelowski, M. (1999).
Focus on qualitative methods: I n t e r-
viewing children. Research in Nursing &
Health, 22(2), 177-185.
D overborg, E., & Pramling, S. (2000). Att
förstå barns tankar. Metodik för barnin -
tervjuer (3rd ed.). Stockholm, Sweden,
Liber AB.
Driessnack, M. (2006). Draw-and-tell conve r-
sations with children about fear.
Qualitative Health Research, 16( 1 0 ) ,
1414-1436.
Eder, D., & Fingerson, L. (2002). Interviewing
children and adolescents. In J. Gubrium
PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5
& I. Holstein (Eds.), Handbook of inter -
viewing research: Context & method. (p.
181). Thousand Oaks, CA: Sage
Publications.
Faux, S.A., Walsh, M., & Deatrick, J. (1988).
Intensive interviewing with children and
a d o l e s c e n t s. We s t e rn Journal of
Nursing Research, 10(2), 180-194.
Flinkman, T., & Salanterä, S. (2004). The
fears of a preschool child at day sur-
gery. (Finnish, English abstra c t )
Hoitotiede, 16(3), 121-131.
Gazal, G., & Mackie, I. (2007). Distress relat-
ed to dental ex t raction for children under
general anaesthesia and their parents.
European Journal of Paediatric
D e n t i s t ry, 8(1), 7-12.
Gozal, D., Drenger, B., Levin, P., Kadari, A., &
Gozal, Y. (2004). A pediatric
sedation/anesthesia program with dedi-
cated care by anesthesiologists and
nurses for procedures outside the oper-
ating room. Journal of Pediatri c s,
145(1), 47-52.
Gullone, E. (2000). The development of nor-
mal fear: A century of research. Clinical
Psychology Review, 20(4), 429.
Ivanoff, P., Laijärvi, H., & Åstedt-Kurki, P.
(1999). Pre-school children’s ex p e ri-
ence of hospital fear (Finnish, English
abstract). Hoitotiede, 11(5), 272-281.
Jost, K. (1996). Nursing standards for child
development. The American Journal of
M a t e rnal/Child Nursing, 21(2), 67-71.
Kain, Z., Mayes, L., O´Connor, T., & Cicchetti,
D. (1996). Preoperative anxiety in chil-
dren: Predictors and outcomes.
Archives of Pediatric and Adolescent
Medicine, 150(12), 1238-1245.
Kettwich, S., Sibbitt, W., Brandt, J., Johnson,
C., Wong, C., & Bankhurst, A. (2007).
Needle phobia and stress-reducing
medical devices in pediatric and adult
c h e m o t h e ra py patients. Journal of
Pe d i a t ric Oncology Nursing, 24(1), 20-
28.
Kim, H. (2000). The nature of theoretical
thinking in nu r s i n g. New Yo rk : Springer
Publishing Company.
Kim, H., & Kollak, I. (1999). Nursing theories:
Conceptual and philosophical founda -
tions. New York: S p ringer Publishing
Company.
Koenig, K., Chesla, C., & Kennedy, C. (2003).
Parents’ perspectives of asthma crisis
hospital management in infants and tod-
dlers: An interpretive view through the
lens of attachment theory. J o u rnal of
Pe d i a t ric Nursing, 18(4), 233-243.
Kristensson-Hallström, I., Elander, G., &
Malmfors, G. (1997). Increased parental
participation in a paediatric surgical
day-care unit. Journal of Clinical
Nursing, 6(4), 297-302.
Lahikainen, A., Kra av, I., Kirmanen, T., &
Taimalu, M. (2006). Child-parent agr e e-
ment in the assessment of young chil-
dren’s fears: A comparative perspective.
J o u rnal of Cross-Cultural Psychology,
37(1), 100-119.
LeRoy, S., Elixson, M., O´Brien, P., Tong, E.,
Turpin, S., & Uzark, K. (2003).
continued on page 303
 Hospital Fears
continued from page 276
Recommendations for preparing children
and adolescents for invasive cardiac pro-
cedures. Circulation, 108(20), 2550-
2564.
Mahajan, L., Wyllie, R., Steffen, R., Kay, M.,
Kitaoka, G., Dettorre, J., et al. (1998).
The effects of a psychological prepara-
tion program on anxiety in children and
adolescents undergoing gastrointestinal
endoscopy. Journal of Pediatric
Gastroenterology & Nutrition, 27(2), 161-
165.
Majstorovic, M., & Veerkamp, J. (2004).
Relationship between needle phobia and
dental anxiety. J o u rnal of Dentistry for
Children, 71(3), 201-205.
Majstorovic, M., & Veerkamp, J. (2005).
Developmental changes in dental anxi-
ety in a normative population of Dutch
children. European Journal of Paediatric
Dentistry, 6(1), 30-34.
Morse, J., & Richards, L. (2002). README first
for a user´s guide to qualitative methods.
New Delhi: Sage Publications.
Munhall, P. (1999). Ethical considerations in
qualitative research. In P. Munhall,
Nursing research. A qualitative perspec -
tive (pp. 395-408). New Yo rk : National
League for Nursing.
Nicastro, E., & Whetsell, M. (1999). Children´s
fears. Journal of Pediatric Nursing, 14(6),
392-401.
Nordfeldt, S.,& Ludvigsson, J. (2005). Fear
and other disturbances of severe hy p o-
glycaemia in children and adolescents
with type 1 diabetes mellitus. J o u rnal of
Pediatric Endocrinology,18(1), 83-91.
Pelander, T., & Leino-Kilpi, H. (2004). Quality of
p e d i a t ric nursing care: Children´s ex p e c-
tations. Issues in Comprehensive
Pediatric Nursing, 27(3), 139-351.
Pelander, T., Nuutila, L., Salanterä, S., &
Leino-Kilpi, H. (2006). Children as info rm-
ants: A review of Finnish academic the-
ses in nursing science (Finnish, English
abstract). Hoitotiede, 18(4), 162-174.
Polit, D., Beck, C., & Hungler, B. (2004).
Essentials of nursing research: Methods,
appraisal, and utilization (5th ed.).
Philadelphia: Lippincott.
PEDIATRIC NURSING/September-October 2009/Vol. 35/No. 5
Rennick, J., Johnston, C., Dougherty, G., Platt,
R., & Ritchie, J. (2002). Children´s psy-
chological response after critical illness
and exposure to invasive technology.
J o u rnal of Developmental & Behavioral
Pediatrics, 23(3), 133-144.
Romino, S., Keatley, V., Secrest, J., & Good, K.
(2005). Home study program. Parental
presence during anesthesia induction in
children. AORN Journal, 81(4), 780-792.
Rossen, B., & McKeever, P. (1996).The behav-
ior of preschoolers during and after bri ef
surgical hospitalizations. Issues in
Comprehensive Pediatric Nursing, 19(2),
121-133.
Salanterä, S. (1999). C a ring for children in
pain – Nursing knowledge, activities and
outcomes. Annales Universitatis
Turkuensis, Sarja D 345, Painosalama
Oy, Turku.
Snyder, B. (2004). Preventing treatment inter-
ference: Nurses´ and parents´ interve n-
tion strategies. Pe d i a t ric Nursing, 30(1),
31-40.
Spradley J. (1979). The ethnographic inter -
view. New York: Harcourt Brace
Jovanovich College Publisher.
Styles, M., & Ari z p e, E. (2001). “A gorilla with
grandpa´s eyes:” How children interpret
visual texts. A case study of Anthony
Browne´s “Zoo.” Children’s Literature in
Education, 32(4), 261-281.
Walworth, D. (2005). Procedural-support
music therapy in the healthcare setting: A
cost-effectiveness analysis. Journal of
Pediatric Nursing, 20(4), 276-284.
Young, K. (2005). Pediatric procedural pain.
Annals of Emergency Medicine, 45(2),
160-171.
Zoppi, K., & Epstein, R. (2002). Interviewing in
medical settings. In J. G u b rium, & J.
Holstein (Eds.), Handbook of interview -
ing research: Context & method ( p. 355).
Thousand Oaks, CA: Sage Publications.
Additional Reading
Sieben-Hein, D., & Steinmiller, E. (2005).
Wo rking with complex care patients.
J o u rnal of Pediatric Nursing, 20(5), 389-
395.
303
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