The Voices of Children:
Stories About Hospitalization
Margaret E. Wilson, PhD, Mary E. Megel, PhD, Laura Enenbach, MSN,
& Kimberly L. Carlson, MSN care and occurs primarily in specialized
ABSTRACT
Introduction: The study explored children’s views of
hospitalization through their own voices.
Method: In this secondary analysis, 93 children aged 5 to 9 years
told stories about hospitalization using a set of drawings of
children in the hospital. Children were recruited in the hospital
and in the community. Themes were identified through
qualitative analysis.
Results: Children’s stories focused on being alone and feeling
scared, mad, and sad. These children wanted protection.
Children in the stories were not always facing scary events. They
were simply not at home and feeling bored, lonely, and sad. They
wanted companions. Children displayed awareness of both good
and bad outcomes. The hospital was a unique environment that
could be fun as well as threatening. Discussion: Children’s views
of hospitalization were not invariably negative. The themes of
hospitalized and neverhospitalized children were different only
in degree of detail. J Pediatr Health Care. (2010) 24, 95-102.
KEY WORDS
Child, hospitalization, qualitative
Margaret E. Wilson, Associate Professor, College of Nursing, University
of Nebraska Medical Center, Omaha, NE.
Mary E. Megel, Associate Professor, College of Nursing, University of
Nebraska Medical Center, Omaha, NE.
Laura Enenbach, Assistant Professor, Clarkson College, Omaha, NE.
Kimberly L. Carlson, Clinical Instructor, Creighton University School of
Nursing, Omaha, NE.
Presented at the 18th International Nursing Research Conference,
Sigma Theta Tau International, Vienna, Austria, July 2007.
Correspondence: Margaret E. Wilson, PhD, 985330 Nebraska Medical
Center, Omaha, NE 68198-5330; e-mail: mwilson@unmc. edu.
0891-5245/$36.00
Copyright Q 2010 by the National Association of Pediatric Nurse
Practitioners. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.pedhc.2009.02.008
Hospitalization has been referred to as a ‘‘landmark
event in a child’s life’’ (Vessey, 2003). Hospitalization of
children has become reserved for increasingly complex
www.jpedhc.org
children’s and
teaching hospitals (National Association of Children’s
Hospitals and Related Institutions [NACHRI], n.d.). Exact
numbers of children hospitalized each year in the United
States are not readily available. However, acute hospital
stays in children’s hospitals, which account for more than
40% of all inpatient stays, produce $10 billion of annual
hospital care costs for children (NACHRI).
The fact that hospitalization can be a traumatic and
stressful experience for children has been wellknown
since the mid 1960s (King & Ziegler, 1981; Thompson,
1985; Thompson, 1986; Vernon, Foley, Sipowicz, &
Schulman, 1965; Visintainer & Wolfer, 1975). A recent
search of the literature related to the psychosocial impact
of hospitalization on school-aged children revealed that
the topic has received little research effort in the past 5
years. Current research emphases seem to be the impact of
specific diseases or conditions such as traumatic injuries
(Scheeringa, Wright, Hunt, & Zeanah, 2006; Sturms et al.,
2005) and diabetes (Garrison, Katon, & Richardson, 2005)
or particular environments such as the pediatric intensive
care unit (Board, 2005). The results of this search
emphasize the importance of revisiting the topic of the
impact of hospitalization in general on children given the
current high-technological, complex nature of hospital
environments. The purpose of this descriptive qualitative
secondary data analysis was to develop an understanding
of school-aged children’s views of hospitalization.
LITERATURE REVIEW
Hospitalization as a Stressor
The hospitalization experience has changed considerably
during the past 20 years as hospital staff and
administrators have made many attempts to improve
hospital environments for children. These improvements
include lifting restrictions on visitors and visiting hours,
providing space for children to play and parents to room-
in with their hospitalized child, as well as making Child
Life staff available on inpatient units and in
outpatient/diagnostic departments. Today, children’s units
in hospitals are colorful places with active play rooms,
access to computers, movies, and games, and special
therapies such as pet and music therapy. All members of
the health care team value attending to the psychosocial as
well as physical needs of the children (Hasenfuss &
Franceschi, 2003).
March/April 2010 95
 At the same time that positive changes have been
madein modern hospital environments,the complexity of
care within the hospital has increased. Many minor
illnesses and surgeries for which children were once
hospitalized now take place in the outpatient setting.
Inpatient admissions currently are reserved for children
experiencing severe or chronic illnesses and often involve
procedures and repeated hospitalizations, which may
increase anxiety and create lasting effects on children and
their development (Grey, 1993; McClowry, 1991;
Melnyk, 2000).
Several researchers have identified stressful
experiences for children in the hospital. Any painful
procedure, particularly those involving needles or
‘‘shots,’’ is almost universally regarded as a negative
experience by children (Bossert, 1994; Coyne, 2006;
Forsner, Jansson, & Sørlie, 2005; Lindeke, Nakai, &
Johnson, 2006; Melnyk, 2000; Wollin et al., 2004). Other
stressors involve being sick, not knowing what to expect
in the hospital (Carney etal.,2003), having activity
restrictions and decreased independence, missing school,
and being separated from family and friends (Bossert;
Coyne; Lindeke et al.).
Melnyk (2000) reviewed studies documenting
outcomes of hospitalization for young children. These
outcomes continued after hospitalization and included
regression, separation anxiety, sleep disturbances, and
emotions such as sadness and apathy. Behaviors such as
hyperactivity and aggression were noted in some children.
Sadly, some of these outcomes can persist for months or
years, particularly in children with repeated or lengthy
hospital stays.
These adverse effects of hospitalization continue to
challenge the skills of nurses and other health care
providers. Vessey (2003) calls for us to revisit the topic of
children’s responses to hospitalization: ‘‘Nursing must
reexamine what we know or, more precisely, what we
think we know’’’ (p. 192) in order to effectively meet the
needs of hospitalized children.
Techniques to Elicit Children’s Thoughts and
Feelings
Curtin (2001) outlined several techniques that can be used
to elicit children’s views, which include drawing,
Volume 24 Number 2
storytelling, acting, writing in a diary, explaining a
videotape or movie, participating in a focus group, and
talking through a doll or toy telephone. Interviews have
been used to ask direct questions to determine coping
strategies of children having surgery (LaMontagne, 2000),
determine children’s descriptions of hospitalization and
their recommendations for change (Lindeke et al., 2006),
and examine children’s opinions of the quality of nursing
care received (Pelander, Leino-Kilpi, & Katajisto, 2007).
Less
96 directive techniques (e.g., drawing and storytelling)
may be particularly useful in eliciting a child’s feelings
because these methods are non-threatening and allow the
child to express perceptions that they may not be
‘‘consciously aware of or able to express verbally’’
(Bellack & Fleming, 1996 , p. 10). Carney et al. (2003)
tested four methods to elicit children’s views of
hospitalization. While they obtained the most concrete
information from a structured questionnaire, the visual
structured questionnaire (five drawings of hospital events)
was most effective in eliciting feelings about the hospital
experience.
Projective techniques such as storytelling have been
used since the 1940s to obtain information that might be
difficult to obtain through standard interviewing (Poster,
1989). Stories provide effective and safe opportunities for
children to explore frightening situations (Hudson,
Leeper, Strickland, & Jessee, 1987). With
thisprojectivetechnique,the
researcherpresentsanonspecific stimulus (picture) to the
subject and asks for a story to be told about it. The child
can have multiple responses to the picture, none of which
need to be the ‘‘right’’ answer. Results of projective
techniques are assumed to provide insight into the child’s
inner emotions, perceptions, and fears (Bellack &
Fleming, 1996).
The revised Barton Hospital Picture Test (BHPT) is one
example of a projective technique that uses storytelling to
generate text that is then scored for stress levels. The
validation, scoring, and psychometric properties of this
instrument are described elsewhere (see Wilson et al.,
2007). The BHPT, a thematic apperceptive test, consists
of eight drawings of specific hospital situations
(admission to hospital, separation from parents, being
examined by doctor, being alone in hospital room,
receiving oral medication, receiving an injection, being in
the operating room, and being in the playroom).
Children’s input was used in the development of the
picture set.
METHODS
Design
This study is a qualitative descriptive (Sandelowski, 2000)
secondary analysis of the stories told by 93 children in
response to BHPT pictures during an instrumentation
study (Wilson et al., 2007). Qualitative description
involves the presentation of recurring ‘‘facts’’ in the data
at a low level of abstraction. However, all analysis
involves some interpretation (Sandelowski). In secondary
analysis, data generated for one set of questions are used
to answer other questions (Coyer & Gallo, 2005).
Secondary analysis is a strategy for increasing the
usefulness of collected data, thereby saving time, money,
and participant burden (Hinds, Vogel, & Clarke-Steffen,
1997; Polit & Beck, 2008).
The original BHPT analysis (Wilson et al., 2007) did
not use a qualitative approach but used a predetermined
Journal of Pediatric Health Care
coding system (no stress, anxiety-fear, anxietydefense, researcher moved to the next picture. If the child did not
dependency, or aggression) to derive a score. The talk about feelings in the story, the interviewer then asked,
qualitative analysis reported in this article is a secondary ‘‘What do you think?’’ ‘‘How do you think the child
analysis and not part of the instrumentation study. feels?’’ After the last story, each child was asked three
questions regarding his or her own view of hospitalization.
Study Participants and Settings These questions were: ‘‘What is the best thing about being
The children who participated in the original study in the hospital?’’ ‘‘What is the worst thing about being in
(Wilson et al., 2007) were selected using quota sampling the hospital?’’ and ‘‘If you had one wish that could come
to achieve 9 to 10 children at each year of age from 5 to 9 true, how would you change the hospital to make it a nicer
years both in the hospital (n = 48) and residing in the place for children?’’ All interviewers were experienced
community (n = 45). Five-year-old children are old pediatric nurses who were trained to collect data via team
enough to respond to the pictures with stories. Children meetings and review of practice interviews. Review of
older than 9 years are more likely to tell stories they transcribed story sets was used to ensure consistency in
believe the researchers want to hear. The hospitalized data collection.
children were recruited from one children’s hospital and
one university health science center in the Midwest. The Data Analysis
community children were recruited from both rural and
urban settings in the Midwest. In the original study, a
group of children from the community was included to test
discriminant validity. We used the data from the
community children in this secondary analysis because the
published research on children and hospitalization has
only included hospitalized or about-to-be hospitalized
children. This data set offered the unique opportunity to
examine the views of hospitalization from never-
hospitalized children. The children were predominantly
White (88%) and from middle-class to upper-class
backgrounds. Slightly more girls (58%) than boys (42%)
participated. Approximately half of the hospitalized
children had chronic illnesses; the others were
hospitalized with acute illnesses or trauma. Inclusion
criteria in addition to age group were the ability to
understand and speak English and being developmentally
appropriate for age. Approval for the study was obtained
from the institutional review boards of the University of
Nebraska Medical Center and Children’s Hospital in
Omaha, Nebraska.

Procedures
Following informed consent from a parent and when
obtaining assent from the child, the children were
informed that their stories would be audiotaped.
Interviews were conducted in hospital rooms and in
children’s homes. Parents sometimes were present but
were asked not to interrupt the data collection with
questions or comments. The length of the interviews
varied widely depending on the age and verbosity of the
child. The researcher showed each BHPT picture to the
child, provided a brief introduction to the picture, and
invited the child to tell a story about the picture to the
researcher. For example, the researcher would say, ‘‘This
is a picture of a boy and his mother going to the hospital.
Tell me a story about this picture.’’ The child was
encouraged to respond, but suggestive or leading
comments were avoided. If the child failed to respond, he
or she was asked, ‘‘What is happening in this picture?’’ If
the child did not respond after two or three probes, the
www.jpedhc.org March/April 2010 97
Each child’s stories were transcribed verbatim. For
purposes of this secondary analysis, all codes from the
original study were removed. Data were analyzed using
conventional content analysis (Hsieh & Shannon, 2005).
Researchers deliberately avoided using the five category
labels from the original study. First, transcripts were read
in their entirety. Each transcript was then coded line by
line in words close to the child’s own words (e.g.,
‘‘scared’’ or ‘‘lonely’’). After all story sets were coded in
this manner, codes were sorted and grouped into more
abstract themes or categories. For example, codes such as
‘‘making new friends, going to the playroom, playing with
hospital equipment’’ were eventually grouped into a
theme called Hospitals as Unique Environments.
Discussion among the researchers ensued until all
researchers were satisfied that all themes had been
developed that the data supported. All themes were
supported by data from many children’s story sets, and all
themes contained data from both hospitalized and non-
hospitalized children. The research team (all pediatric
nurses and two with experience in qualitative research)
returned to the stories again and again to confirm that
themes were present consistently in the story sets and
included codes from hospitalized and non-hospitalized
story sets. Because the data were collected using a
projective technique, member checks (returning to
FIGURE. Experience of hospitalization.
children who were interviewed to verify findings) were
not considered appropriate. Finally, a diagram of the
themes and their relationships was developed and revised
until the researchers agreed that the data were
satisfactorily and thoroughly explained (Figure). All data
analysis was conducted in team meetings.
98
RESULTS
The primary theme identified in this analysis was being
alone. When children were alone, they were uncertain
about what would happen to them; they were afraid of
known scary things; and they were not at home.
Uncertainty and known scary things led to feelings of
being scared, mad, and sad. Children wanted protection.
Children reacted to not being at home by feeling bored,
lonely, and sad. They wanted companions. Additional less
extensive themes included being aware of the possibility
for good or bad outcomes and viewing hospitals as unique
environments.
Being Alone
Children’s stories often focused on being alone and the
consequences of being alone. When children were alone,
they could be uncertain about what was going to happen
or they might predict something negative (scary, painful)
that could happen based on past experience. The
emotional response to being alone in these two
circumstances was scared, mad, and sad. Children wanted
protection in these situations. Protection did not prevent
scary events like shots from happening but rather provided
comfort. Children told many stories about being lonely.
For example: ‘‘She was very lonely and her father came
to visit her.
Volume 24 Number 2
After a while her father just left and she was very lonely
and she didn’t want to be lonely.’’ ‘‘She’s mad that her
parents aren’t there
Journal of Pediatric Health Care
and that she’s aloneChildren’s stories until their mom sad wanted
too.’’ comesand the companions. They doctor
often focused on said,

The following children’s stories re-being ‘‘Your mom’s wanted parents, not here, we

alone and the flect feeling friends, siblings, have to give you
scaredconsequences your shot right and even staff for
now.’’ The other
of and uncertain about play, talk, and
being alone. When girl says, ‘‘I’m not getting my companionship.
both known and unknown shot, not until my
mom gets here!’’
events.children were If they were scared or something then the nurses could
Stories often ex- alone, they could pressed tell them stories so that they wouldn’t be that scared
fears or con- anymore.
be uncertain about Children in the stories were not always facing scary
cerns about needles events when they were alone. They were simply not at
home or in another familiar environment. The emotional
evenwhenthe draw-what was going to
response to being alone and not at home was bored,
ing that elicited thehappen or lonely, and sad. Children in the stories who were bored,
they story did not contain might predict lonely, or sad wanted companions. They wanted parents,
or suggest needles. friends, siblings, and even staff for play, talk, and
companionship:
Other fears weresomething negative
She wanted her friends around her. She doesn’t want
less specific and re-(scary, painful) that to be lonely. She wants kids to surround all over her.
flected uncertainty Once my dog was alone in a hospital room and she
could happen about what might happen. whined and whined and whined and whined and whined.
The girl [in the picture] is bored. She wants something to
Past experi-based on past ence with do.
hospitali-experience. They’re probably feeling better because there’s
zation appeared to make another person inhisroom andthey can talkto each other.
fears more
specific, but children who had never been hospitalized Awareness of Good and Bad Outcomes
also voiced ideas about what happens in hospitals: In their stories, children also displayed awareness of both
Thisgirl isvery scaredbecause shedoesn’tknow what good and bad outcomes from being in the hospital. Good
they’re going to do and she doesn’t have her parents with outcomes included going home, feeling well, and being
her and she thinks they’re going to give her a shot or helped. Bad outcomes were death, not being helped, and
something. staying a long time in the hospital. Awareness of bad
Thereweretwolittlegirlsonlevel9 andthey werevery outcomes was not limited to children with chronic or
scared. They made friends, but they were both sort of catastrophic illness, nor was it limited to children who had
frightenedabouteachotherbecausetheywerebothalittle been hospitalized:
bit mad at each other for doing things and fighting, The children feel good about being in the hospital
causing contention. because they want to get better.
He probably feels scared because he might get his Elizabeth broke her arm and had a very big cast. And
tonsils tooken out. her mom and dad are staying there, staring at her
because they thought she might die.
Whenchildren in the storieswere facing scaryevents, Maybe she’ll get better from the medicine and maybe
they sought protection from parents and nurses. The she’s scared that it might not help her.
majority of stories about seeking protection involved She’sthinkingwhattheoperation’sgonnabelikeand if
wanting parents present, but seeking protection from she’s gonna make it through the operation.
nurses appeared in enough stories to constitute a theme:
Thegirlsdidn’t Hospitals as Unique Environments
Stories included descriptions of the hospital as a unique
Children in the and they got
want it [a shot],
environment that could sometimes be fun as well as
stories who were real sad. They wanted to threatening. The hospital environment provided new
wait bored, lonely, or experiences to explore, to learn, and to enjoy. The hospital
www.jpedhc.org March/April 2010 99
may be a venue for making new friends and trying new
games or toys. Children found some hospital routines odd
rather than threatening:
He feels good ’cause you get to control the bed.
He’s going to pee in a cup ’cause he doesn’t feel well.
After the girl was done operating, she got to go to the
playroom and there was lots of other kids there and she
made some new friends.
Comparison of Hospitalized and Neverhospitalized
Children
Only one difference was noted between the stories related
by the hospitalized children and those who were never
hospitalized. Children who had hospital experience
‘‘knew the drill’’: They used more medical or hospital
terminology, and stories often appeared to contain
personal experiences. Examples of ‘‘knowing the drill’’
follow:
Everybody kept coming in and asking the same
questions over and over and over and over and over and
over again.
There’sglovesbecausetheydon’twanttotouchblood.
This is about a girl who got her central line. She went
to sleep and the doctor was trying to make her to sleep.
Then she waked up and she went back upstairs to go to
her room.
However, the themes as displayed in the Figure and
previously described were present in both groups of
children.
DISCUSSION
Children’s stories reflected fear of being alone in the
hospital, fear of known experiences, and feeling
threatened by uncertain possibilities. These fears have
long been expressed by hospitalized children in this age
group. Children respond to these fears by requesting to
have parents nearby, having familiar objects with them in
the hospital, or asking to go home (Coyne, 2006; Forsner
et al., 2005; Runeson, Hallstro¨m, Elander, & Hermere´n,
2002). In addition to parents, children expect nurses to
provide care and support (Bull & Gillies, 2007; Forsner et
al.; Pelander & Leino-Kilpi, 2004).
Children in an earlier study with the BHPT also described
parents and nurses as safety figures (Wilson & Miller,
1998).
Some children’s stories in our study described being
bored in the hospital environment when alone; the
children in the stories needed adults or other children for
play activities (Pelander & Leino-Kilpi, 2004; Runeson et
al., 2002), talk, and companionship. Play and being in the
playroom often were mentioned as ‘‘the best thing’’ about
being in the hospital as recounted by children in this study
and by other researchers (Lindeke et al., 2006). Eiser and
Patterson (1984) interviewed non-hospitalized children
100
about their perceptions of the hospital and found that
children Getting better,
expected to have so-
playing with others, cial
interactions with
other children whenand enjoying being
hospitalized. A mi- in the playroom, as nority
expected to well as learning and be bored.
Boredom was a theme in this mastering hospital
study when the child equipment, were wanted
companion- mentioned ship. The trend in modern
pediatric frequently by the hospitals to have
children in this only private rooms, study.
while appealing to parents
and to ado-
lescent patients, may require more attention to the
socialization needs of school-aged children.
Children did not invariably find the experience of
hospitalization as negative and stressful. The children’s
stories also reflected the possibility of good outcomes
while in the hospital. Getting better, playing with others,
and enjoying being in the playroom, as well as learning
and mastering hospital equipment, were mentioned
frequently by the children in this study. Observations by
Runeson and colleagues (2002) of hospitalized children
during non-threatening situations revealed the children
playing as actively as was appropriate to their physical
conditions and asking questions to learn about their
environment. Making new friends emerged in our
children’s stories; these children as well as those in other
studies noted that having ‘‘pals’’ (Pelander & Leino-Kilpi,
2004, p. 146) and more play equipment would make the
hospital a better place for children (Lindeke et al., 2006).
While the purpose of this secondary analysis was not
further instrument development, we did examine the
themes for consistency with the coding categories used in
scoring the BHPT (Wilson et al., 2007). The themes of the
secondary analysis fit within that coding structure without
contradiction. Because we deliberately did not use the
coding structure of the BHPT when conducting the
secondary analysis, the resulting themes have different
names.
Volume 24 Number 2
Although measures of child anxiety or child stress
clearly differentiate between hospitalized children and
children who have not been hospitalized (Clatworthy,
Simon, & Tiedeman, 1999; Wilson et al., 2007), the
aspects of the hospitalization experience that are
significant to children appear to be the same across
groups. The only difference between groups in this study
was the degree to which the children integrated the
vocabulary of the hospital into their stories. This article is
Journal of Pediatric Health Care
the first report of children’s views of hospitalization in
which hospitalized and never-hospitalized children are
included and compared.
The themes we developed as a result of the stories told
by the children in this study are remarkably similar to
themes identified in two recent studies: Dreissnack (2006)
examined well children’s fears and Coyne (2006) studied
fears and concerns related to hospitalization of British
children. Using draw-andtell conversations with well
children, Dreissnack elicited insights about the fears of
children aged 7 and 8 years. Themes that emerged
included feeling alone or isolated, as if nobody was
available for help; being surprised and frightened by
things they did not predict; feeling helpless, as if there was
nothing they could do to escape or resolve their situations;
and ‘‘just waiting’’ and anticipating that something scary
would happen (p. 1426). Coyne conducted interviews with
hospitalized children aged 7 to 14 years and identified four
categories of concerns and fears: separation from family
and friends, being in an unfamiliar environment, fears
related to ‘‘receiving investigations and treatments,’’ and
loss of selfdetermination (p. 328).

Limitations
The children who were the participants in this study were
largely White, English speaking, and middle class,
reflecting the community in which the study was
conducted. The themes described in this study may not
reflect the views of hospitalization of poor, ethnically
diverse children. We also did not include any children
with developmental delays. More research can verify the
validity of our findings in other populations. Because this
was secondary analysis, no additional data collection was
conducted to further explore themes identified in this
analysis. The descriptions of the hospital experience can
be further developed and raised to a higher level of
abstraction in future research.

Conclusions and Implications

The general areas of fear identified by our study as well as
by Dreissnack (2006) and Coyne (2006) appear universal
among school-aged children, regardless of whether they
are currently or were ever hospitalized, their medical
diagnoses, or their gender. Previous research about
children’s views of hospitalization has

www.jpedhc.org March/April 2010 101

been conducted with hospitalized children. This study is
uniqueinthe inclusion ofchildreninthecommunity and the
finding that their views of hospitalization match those of
hospitalized children except for detail. Further research is
needed to substantiate these results and test interventions
that would be appropriate for hospitalized children or in
the preparation of children for hospitalization. Children’s
stories about illness or hospitalization may provide clues
to interventions the children would find most helpful. For
example, assessment of the hospitalized children for fear
or boredom when parents or other support persons are not
available could identify children who might benefit from
additional Child Life intervention, visits from volunteers,
or provision of age-appropriate diversionary activities.
Our description provides insights to areas of teaching and
preparation to address what may be universal fears in this
age group.
Pediatricprovidersmayusetheseresultstoplancareand
prepare children for hospitalization.
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