Child-Reported Hospital Fears

In 4 to 6-Year-Old Children
Marja Salmela
Sanna Salanter
Eeva Aronen
The aim of this study was to describe hospital-related fears of 4 to 6-year-old children. Data were collected by interviewing 4 to 6-year-old children (N = 90) in Finland, who were chosen through purposive sampling in which volunteers were asked to take part in the study. Data were gathered by semi-structured interview, 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 categorized 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, childstaff 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, identifying, and alleviating the hospital fear of healthy or sick children.
eing admitted to the hospital
causes fear and anxiety in 4
to 6-year-old children. According to parents, 83% of
p reschool or kindergarten-aged child ren suffer from diff e rent kinds of anxiety symptoms related to hospital fear
even after a minor operation in a hospital (Rossen & McKeever, 1996).
Knowledge about preschoolers fears
in the hospital is mostly based on the
information given by parents or nurses 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, Salanter, & LeinoKilpi, 2006). Very little is known about
h o s p i t a l - related fear as said by child 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 Salanter, 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.

immaturity, young children often have

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 child re n s reactions and anxiety toward
nursing interventions (Gozal, Drenger,
Levin, Kadari, & Gozal, 2004; Kain,
Mayes, OConnor, & 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 environment, interaction between nursing
staff and the child, and nursing interventions reported by 4 to 6-year-old
c h i l d ren. Earlier studies have reported
that repeated admissions to the hospital increase childrens 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 hospital.

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

Only a few earlier studies were

found to describe the child reporting
fears related to hospital treatment. In a
Finnish study of 5 to 6-year-old children (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, Laijrvi, & stedtKurki, 1999). In a study concern i n g
children attending day surg e ry, 5 to 6year-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 & Salanter,
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 injections 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 chil269

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 ular developmental stage, such as the
fear of darkness, loud noises, unfamiliar people, and separation from parents. 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 (AlsopShields & Mohay, 2001; Brewer et al.,
2006; Romino, Keatley, Secrest, &
Good, 2005; Snyder, 2004). Because
of the rich imagination of preschoolaged children, imaginary fears and
fears caused by the lack of knowledge
are emphasized during this stage
(Deering & Cody, 2002; Flinkman &
Salanter, 2004).
It is especially important to identify
the possible fears of a child when caring for preschoolers. According to
several studies, preschoolers have
m o re hospital-related fears than older
children because of their developmental 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 childs 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 usually more cooperative and less anxious 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 undergoing 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-Hallstrm,
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 ct u red interviews supported by pict 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 million), of which 63 children were interviewed 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 purposive 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 childs typically
developing (evaluated by kindergarten and hospital personnel).
A c c o rding to the phenomenological
research tradition, any person fulfilling
the inclusion criteria is a good informant, and thus, purposive sampling was
used (Spradley. 1979).
Interviews were arranged with the
head nurses of the wards in the university hospital and with the heads of the
kindergarten classes. The first author
(M.S.) and interviewers informed the
personnel of the wards and kindergarten classes of the study. The personnel 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 permission 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 graduating nurses in their final semester.
Interviewers were trained to the special 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 ct u red interviews and were support e d

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 Kims typology
of domains or main contents for nursing (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 relationship; and d) fears resulting from nursing interventions (Burns & Grove,
2001; Morse & Richards, 2002; Polit,
Beck, & Hungler, 2004). The interview
method was flexible and child-centered; 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 pict 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 surrounded by doctors and nurses, and
d) a child sitting in a wheelchair in a
corridor in the ward. The younger the
childs age, the more his or her discussion 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 wer also observed the child and re c o rded the findings in a re s e a rch diary.
Childrens answers were sometimes
so short that without the diary, reliable
analysis would have been impossible.
However, the interviewer did not interpret the childs 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-

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

Child-Reported Hospital Fears in 4 to 6-Year-Old Children

egories included a) fears related to
being a patient, b) the developmental
stage of the child, c) unknown experiences and lack of information, d) the
physical environment, e) the social
and symbolic environment of the hospital, f) child-staff relations, and g)
nursing interventions. All expressions
of fear were categorized, including the
less than 6% of expressions that re p resented unrealistic fears or figments of
the childs imagination. For example,
in these cases, the child said he was
afraid because [the vaccine] is poison, or the needle goes through the
arm, or if [doctors] dont have
masks, they smell bad. Data were
reviewed by quantitative and qualitative methods.

Ta ble 1.
Hospital-Related Fears Reported by 4 to 6-Year-Old Children (N = 90)
Single Expressions
of Fear
Objects of Fear

Pain

51

57

Staying in hospital

23

26

Being admitted to hospital

17

19

Symptoms of the disease

15

17

Bodily injuri e s

10

11

Being left alone

19

21

Ethical Considerations

Imagination

13

14

The hospitals ethics committee

and the City Social Services
Department both granted their
a p p roval for the study. All participating parents received written inform ation on the study before being asked
to consent. After receiving written
consent from the parent or guardian,
the autonomy of the child was
respected by giving him or her oral
information on the study and asking
for oral consent to participate.
Interviews proceeded on the childs
terms, and all children received a
small re w a rd (such as a sticker) after
the interview. Parents could take part
in the interview if they wished. Each
participants identity was protected so
that individuals could not be recognized in the study. Children were
assigned code numbers identifying
their gender, age, and place of interview (kindergarten or hospital), and
they were not requested to identify
themselves by names on the tape. The
information given by the child was
processed in confidentiality, which
was protected by coding all data and
keeping all documentation in a safe
location (Burns & Grove, 2001;
Munhall, 1999).

Loss of autonomy

10

11

Unfamiliar people

10

Other fears caused by the developmental stage

10

Results
Results are presented here re g a rding the amount and types of fears that
4 to 6-year-old children have about
the hospital. Diff e rences that exist in
e x p ressions of fears in children who
a re in the hospital at the time of the
interview and those who are in kindergarten are described, and girls and
boys expressions of fear are comp a red.

Fears of Being a Patient

Becoming ill
Fears Caused by the Developmental Stage of the Child

Fears Caused by Unfamiliar Environment or Lack of Information

Lack of information

18

20

New and unknown experiences

15

17

Instruments and equipment

19

21

Facilities of the hospital

11

12

10

20

22

Exercise of power by adults

16

18

Doctors

13

14

Nurses

10

11

Shots

45

50

Sample-taking and tests

29

32

Other nursing interventions

29

32

Operation

12

13

Medication

12

13

Physical Environment

Noises and smells of the hospital

Social and Symbolic Environment
S e p a ration from the family
Other fears caused by the social and symbolic environment
Child-Staff Relations

Nursing Interventions

Hospital-Related Fears of a
4 to 6-Year-Old Child.
In this study, the children expressed
29 diff e rent types of fears related to
the hospital. Data included a total of
441 expressions of fear. The amount
of child-reported fears ranged from no
fears to 22 fears (mean = 4.9). There

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

were 8 children (9%) who expressed

no hospital-related fears at all, 34
(38%) who expressed 1 to 3 fears, 20
(22%) who expressed 4 to 6 fears, and
28 (31%) who expressed more than 7
hospital-related fears.
Most fears were categorized in the
category of nursing interventions (see
Table 1). Half of the children re p o rt e d
271

Table 2.
The Amount of Hospital-Related Fears
Amount
of Fears

Children in
Kindergarten

Children in
Hospital

Total

13

1 to 3 fears

28

44

22

34

38

4 to 6 fears

12

19

30

20

22

More than 7 fears

15

24

13

48

28

31

Total

63

100

27

100

90

100

they were afraid of shots, and 29 mentioned tests, sample-taking or examinations, and other nursing interv e ntions. 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 childs own imagination (n =
13). This category also included child 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 nment 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 nment 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, separation from family, being alone, and
instruments. About 20% of the child 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

(62%) participated in the study. The

total number of individual, hospitalrelated fears expressed by girls was
151, while boys expressed 290 individual 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 significant more fears toward the re l ations between the child and the staff
(Mann-Whitney U = 739.500, p =
0.017). There was no significant difference in the number of fears
between diff e rent age groups of child 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%) 5year 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 child ren who were interviewed in kindergarten expressed more than 7 fears.
The number of hospital-re l a t e d
fears expressed by children in the hospital varied from 1 to 14 fears. Among
these children, 22% mentioned 1 to 3

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 hospital was 6.48. When examining the percentage distribution of fears, children
in the hospital expressed substantially
more fears than children in kindergarten (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 children 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 kindergarten 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 children in the hospital using the Pearson
Chi-Square test, statistically significant 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 nursing interventions ( [1] = 6.805, p =
0.009), and operations ( [1] = 5.293,
p = 0.021) (see Table 3).
When examining childrens fears
according to the categories based on
the typology of nursing domains, there
were also statistically significant differences 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 (MannWhitney 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 (MannWhitney 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 earlier 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 interviewed in the hospital, little more than

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

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
(n = 63)

Hospital
(n = 27)

Chi-Square Tests
(d f 1)

Value

Pain

32

51

19

70

2.95

0.086

Staying in hospital

16

25

26

0.003

0.958

Being admitted to hospital

10

11

41

12.02

0.001

Symptoms of the disease

14

22

0.857

0.355

Bodily injuries

14

2.14

0.143

Becoming ill

0.034

0.854

Fears of Being a Patient

Fears Caused by the Developmental Stage of the Child

Being left alone

11

17

30

1.69

0.195

Imagination

14

15

0.00

0.948

Loss of autonomy

10

15

0.53

0.464

Unfamiliar people

10

11

0.053

0.818

Other fears caused by the developmental stage

19

0.121

0.087

Lack of information

12

19

22

0.12

0.730

New and unknown experiences

10

16

19

0.095

0.758

12

19

26

0.54

464

Facilities of the hospital

13

11

0.044

0.833

Noises and smells of the hospital

15

0.99

0.319

10

16

33

2.24

0.135

0.43

0.510

Exercise of power by adults

13

30

3.70

0.054

Doctors

10

26

4.11

0.043

Nurses

19

2.14

0.143

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

26

5.29

0.021

Medication

10

22

2.64

0.104

Fears Caused by Unfamiliar Environment or Lack of Information

Physical Environment
I n s t ruments and equipment

Social and Symbolic Environment

Separation from the family
Other fears caused by the social and symbolic environment
Child-Staff Relations

Nursing Interventions

a half (52%) expressed 1 to 6 hospitalrelated fears, and 48% more than 7

fears. All children who were interviewed in the hospital expressed at
least one fear related to the hospital.
According to this study, fears
expressed most often by 4 to 6-yearold children were caused by the practice 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 disease. The third largest category consisted of fears related to the develop-

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

mental stage of the child (14%). In this

category, children most often mentioned the fear of being left alone in the
hospital. More than 20% of preschoolers 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
273

Ta ble 4.
The Expressions of Fears Expressed by Children in Kinderg a rten and in Hospital
Expressions of Fear

U-Test (Exact Sig. 1-tailed)

Kindergarten
n

Hospital
n

Fears of being a patient

76

46

586.500

0.007

Fears caused by the developmental stage of child

36

24

652.500

0.028

Fears caused by unknown environment or lack of information

22

11

810.00

0.359

Physical environment

25

14

749.00

0.136

Social and symbolic environment

12

778.00

0.254

Child-staff relation

19

20

614.00

0.008

Nursing interventions

76

51

584.500

0.007

Categories of Fear

Figure 1.
Hospital-Related Fears Reported by 4 to 6-Year-Old Children

e n v i ronment of the hospital, and childstaff relations (see Figure 1).

It is difficult to compare results conc e rning the number of child-reported
hospital fears with earlier studies
because only very little similar information on preschoolers is available. In
Ivanoffs (1999) study, nine 5 to 6year-old children were interviewed
about their hospital fears. According to
Ivanoffs 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

body, pain, restriction of self-determ ination, and submission. Similar fears

also occurred in this study; however,
except for pain, children expressed
m o re fears related to nursing interv e ntions, such as the fear of shots, sampletaking, and tests, and only seldom
(10% to 16% of children) expressed
other main fears in Ivanoffs study. In
the qualitative study by Flinkman and
Salanter (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

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 findings 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 hospit a l - related fears. In the data, there
were 17 fears that had also been mentioned 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 unfamiliar 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 hospitalized children than in their peers,
which may suggest that being treated
in the hospital increases the number of

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

Child-Reported Hospital Fears in 4 to 6-Year-Old Children

h o s p i t a l - related fears in 4 to 6-yearold children. Children who were in the
hospital reported fear of being admitted 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 systematic framework that can be used to
examine elements in the fields of nursing. 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 developmental 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 nment of the hospital (for example, the
fear of rules and regulations) were
mentioned by one child only. Earlier
studies on the hospital fears of child ren using the domains of nursing for
categorization were not available. The
categorization used in this study
p roved to be functional. It was possible 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 nursing, these results can be used when
p reventing, identifying, and relieving
the fears of hospitalized preschoolers.
Only a few methods of data collection 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 studies have used draw-and-tell conversations (Driessnack, 2006), childrens
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 themselves, which is why data were collected by semi-stru c t u red interviews supported by pictures. Because of its flexibility, the semi-stru c t u red interv i e w

was suitable for 4 to 6-year-old child ren. During the interv i e w, it was possible to take into account the childs
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 answering yes, no, or I dont 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 hospital-related fears. The pictures served
as a stimulating basis for the interview,
and helped the child become intere s ted in and concentrate on the conversation, 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 collection 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 child ren because of the data collection
method.
Differences in the childrens personality and developmental stage
might decrease the trustworthiness of
the results. The childrens ability to
concentrate and their interest in the
subject varied as well as their individ-

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

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 interviewers 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 wers to the special characteristics of
interviewing children, requiring pilot
interviews, and instructing the process
of the interview in advance in a systematic way (by first author M.S.). All
interviewers had studied the nursing
care of children and re s e a rch methods, a fact that increases the trustworthiness of the results. They had studied the developmental stage of a 4 to
6-year-old child, especially the childs
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
childs answer (Burns & Grove, 2001;
Cohen & Knafl, 1993). Tru s tworthiness 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 nurses contributed to the interview.
One aim of this study was to give
the preschoolers themselves the
opportunity to discuss their hospitalrelated fears. Neither the earlier hospital 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 hospital. 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

childs 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 childs developmental
stage that the children can use to alleviate pain and fear. These methods
(such as diff e rent types of relaxation)
affect the childs emotions and cognition, allowing the child be an active
participant in his or her own care
(Salanter, 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. Becoming familiar with the instruments
and machines of the hospital also
d e c reases the childs fear of the physical environment of the hospital.
Knowledge evokes security and confidence 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 kindergarten. There is no single method to
remove all hospital fears, but a pre re quisite for eliminating fear is the staffs
a w a reness of the issues that may
cause children fear, and staffs willingness to prevent and recognize possible
fears help and support the child in coping. The fears of the child can also be
p revented and alleviated by giving the
parents information on the childs hospital fears and on the meaning of separation from parents to the child.
Guiding the parents to support their
child is also important. Parental awareness and participation in their childs
hospitalization is essential for eff e c t i v e
coping. It would be desirable that a
childrens 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 themselves. The information is useful when
trying to understand childrens experiences of fear and anxiety in a hospital,
during certain nursing processes, at
the doctors or dentists office, and in
child health clinics. The inform a t i o n
can also be useful in preventing, identifying, 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 child re n s hospital fears and the conse276

quences of these fears to small child 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 nursing staff can support the coping of the
child.
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Additional Reading
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