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Article Excerpt
Being admitted to the hospital causes fear and anxiety in 4 to 6-year-old children. According to parents, 83% of preschool or kindergarten-aged children suffer from different 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 procedure or situation in nursing care (Brewer, Glenditsch, Syblic, Tietjens, & Vacik, 2006; Coyne, 1998; Mahajan et al., 1998; Pelander, Nuutila, Salantera, & Leino-Kilpi, 2006). Very little is known about hospital-related fear as said by children themselves. Because of their immaturity, young children often have been underestimated as reporters of their own well being or considered as unreliable informants (Coyne, 1998, 2006). However, preschoolers want and are able to express and discuss their own experiences. The best way to get information about children's fears to is to ask them. It is difficult to understand children's experiences without including their self-report (Coyne, 1998; Lahikainen, Kraav, Kirmanen, & Taimalu, 2006; Pelander et al., 2006; Pelander & Leino-Kilpi, 2004).
Although several studies describe preschool or kindergarten-aged children'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 environment, interaction between nursing staff and the child, and nursing interventions reported by 4 to 6-year-old children. Earlier studies have reported that repeated admissions to the hospital increase children's anxiety (Brewer et al., 2006). However, there is no information on whether the hospital fears of healthy preschoolers differ from the fears of children of the same age who are being treated in the hospital.
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 reported 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 free choice (Ivanoff, Laijarvi, & Astedt-Kurki, 1999). In a study concerning children attending day surgery, 5 to 6-year-old children (N = 25) reported 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 & Salantera, 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 from parents, unfamiliar people, difficulties in breathing, blood samples, being held still, nursing procedures, and unfamiliarity with the norms of accepted behavior cause fear in children (Gozal et al., 2004; Gullone, 2000; Jost, 1996; Koenig, Chesla, & Kennedy, 2003; LeRoy et al. 2003; Nicastro & Whetsell, 1999; Snyder, 2004).
In the hospital, a preschooler can also have typical fears of that particular developmental stage, such as the fear of darkness, loud noises, unfamiliar people, and separation from parents. Preschoolers are also afraid of failure, 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 & Salantera, 2004).
It is especially important to identify the possible fears of a child when caring for preschoolers. According to several studies, preschoolers have more hospital-related fears than older children because of their developmental stage (Bevan et al., 1990; Gazal & Mackie, 2007; Gozal et al., 2004; Majstorovic & Veerkamp, 2004, 2005; Rennick, Johnston, Dougherty, 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 (Brewer 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 are 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 return home sooner (Walworth, 2005). For children undergoing surgery, the operation can be performed more quickly, smoothly, and with fewer personnel, making it easier for the child and parents (Kain et al., 1996; Kristensson-Hallstrom, Elander, & Malmfors, 1997).
The first aim of this study was to describe hospital-related fears of 4 to 6-year-old children using semi-structured interviews supported by pictures. A second aim was to determine if children who were hospitalized had more fears, or different 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 expressed by the children themselves. The research 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 children were chosen through purposive sampling, in which volunteers were asked to take part in the study. The criteria for participation in the study were age (4 to 6 years), the child's ability to communicate in Finnish, and the child's typically developing (evaluated by kindergarten and hospital personnel). According 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...
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