This study was supported by the Finnish Cultural Foundation.
Coping strategies for hospital-related fears in pre-school-aged children
Version of Record online: 26 JAN 2010
© 2010 The Authors. Journal compilation © 2010 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
Journal of Paediatrics and Child Health
Volume 46, Issue 3, pages 108–114, March 2010
How to Cite
Salmela, M., Salanterä, S., Ruotsalainen, T. and Aronen, E. T. (2010), Coping strategies for hospital-related fears in pre-school-aged children. Journal of Paediatrics and Child Health, 46: 108–114. doi: 10.1111/j.1440-1754.2009.01647.x
- Issue online: 17 MAR 2010
- Version of Record online: 26 JAN 2010
- Accepted for publication 29 June 2009.
- coping strategies/methods;
- hospital related fears;
- pre-school-aged children;
- qualitative research
Aim: The aim of this study was to describe the child-reported coping strategies for hospital-related fears in 4–6-year-old children.
Method: The data were collected by semi-structured interviews of 4–6-year-old volunteering children (n= 82) in Finland. Thirty-four children were interviewed in hospital, and 48 in kindergarten. The children were chosen through a purposive sampling method, in which volunteers were asked to take part in the study. The data were analysed with quantitative and qualitative methods.
Results: The most frequent child-reported coping strategies were: the presence of parents and other family members (81/517, 15.7%), the help of the hospital personnel (58/517, 11.2%), positive images and humour (57/517, 11%), play (57/517, 11%) and the child's own safety toy (45/517, 8.7%). The children interviewed in hospital mentioned significantly more often play (P= 0.000) as their coping strategy than children interviewed in a kindergarten. Children interviewed in kindergarten expressed significantly more often the presence of parents (P= 0.032) and the help of the doctor (P= 0.012) as their coping strategy than the children interviewed in the hospital.
Conclusions: The results showed that children have many coping strategies, especially ones in which the children themselves play an active role. Besides, the traditional methods for alleviating fear, children need possibilities to use coping methods in which they have an active role giving them a feeling of some control over the hospital environment and medical procedures.
There are no previous research data on the coping strategies, which pre-school-aged children use to deal with fears related to hospitals and medical procedures, as reported by the children themselves. However, this subject is important because pre-school-aged children may experience several hospital-related fears,1,2 and interventions designed to help the children to cope with their fears are not only likely to decrease their stress at the time of hospitalisation, but are also likely to influence their development3 and well-being later in life.4–7
According to information obtained from the parents and the hospital personnel, the presence of supportive parents during the child's hospitalisation,1,8–10 during painful procedures11,12 and during the day surgery process13 helped children to cope with separation anxiety. Sibling relationships also helped to alleviate the fear caused by separation.8 In the absence of parents, children resort to the nursing staff.12,14,15 When the nursing staff gave honest information and discussed the hospital experience with the children and the children were given time and the chance to participate in decisions, all helped them to cope with their fears of surgery and general anaesthesia.4,16–19 Moreover, methods such as behavioural modelling and reinforcement procedures for ‘bravery training’, including parent training,20,21 music and art therapy,14,22–24 and therapeutic play17,25–28 have been found to alleviate children's fears of medical procedures.
The aim of this study was to describe the amount and quality of child-reported coping strategies for hospital-related fears in 4–6-year-old children. We also wanted to determine whether the children being treated in hospital expressed more or different coping methods, compared with the children who were interviewed at kindergarten. The coping strategies can be problem-oriented (the child tries to eliminate the fear by seeking information, solving problems or asking adults for help), emotion-oriented (the child handles the fear in order to attain balance), and function-oriented (the child tackles the fear by withdrawal, aggressive behaviour, hyperactivity or playing).29–31 In our study, coping strategies are defined as the child's active attempts at cognitive, emotional and functional actions to master her/his hospital-related fears.
- 1Pre-school-aged children report many coping strategies, especially strategies in which the children themselves play an active role.
- 2The children interviewed in hospital mentioned significantly more often both play and positive images and humour as their coping strategy than children interviewed in kindergarten.
- 3Children interviewed in kindergarten expressed significantly more often than hospitalised children the presence of parents and other family members, as well as the help of the doctor as their coping strategy.
A qualitative study was conducted in 2004–2006. The data was collected using a semi-structured interview that was supported by pictures, and analysed by inductive content analysis. The sample consisted of voluntary participants: 82 4–6-year-old children, living in the metropolitan area of Finland (population about 1.5 million).
A purposive sampling method was used. A purposive sample consists of information-rich cases that manifest the phenomenon of interest.32,33 The criteria for participation in the study were: age 4–6 years, the child's ability to communicate in Finnish, and the child's normal developmental stage (evaluated by kindergarten and hospital personnel). The nursing staff gave all the parents whose 4–6-year-old child was on the ward or in the kindergarten during the period of the study, an information letter of the study with a request for written permission to interview their child. All those children were interviewed whose parents gave written permission – and the child verbal consent – to participate in the study.
The interviews were carried out by 19 trained interviewers who were graduating nurses in their final semester. One of the authors (M.S.) supervised and standardised the interview process by training the interviewers in the ethics and the trustworthiness of interviewing children, by requiring pilot interviews, and by listening to the recordings of the interviews.
The data were gathered by a semi-structured child interview, which was supported by pictures. The topics and issues to be covered were specified in advance as the themes of the interview, but the interviewer decided the sequence and wording of the questions in the course of the interview.32 The research themes were formulated on the basis of earlier studies of coping.29–31 The themes were: (i) the problem-oriented coping strategies, (ii) the emotion-oriented coping strategies, and (iii) the function-oriented strategies for coping with hospital-related fears in pre-school-aged children. The topics of the pictures consisted of children in the hospital environment. The pictures helped the children to become interested in and concentrate on the conversation, connect their own experiences to the topic and express their thoughts.34–37
The interviews were tape-recorded and transcribed. The length of the transcribed interviews ranged from 1 to 13 pages, and the interviews lasted from 15 min to 1 h.
All interview data were analysed by inductive content analysis (by one of the authors: M.S.). Inductive content analysis involves identifying, coding, categorising, and classifying the primary patterns in the data. Each category was named using content-characteristic words, subcategories with similar coping strategies were grouped together as categories, and categories were classified into 14 main categories.32,33,38 The data were entered onto a SPSS database and subjected to frequency distributions, and chi-square analysis. To test the inter-rater reliability of the content analysis 10% (n= 9) of the interviews were analysed by both M.S. and S.S. (one of the authors) and Cohen's Kappa values were calculated.39 The kappa value was 95%.
The hospital district's ethics committee and the City Social Services Department both granted their approval for the study. Interviews proceeded on the child's terms and the parents could follow the interview if they wished. The participants' identity was protected and the information given by the child was processed confidentially.33,40
Thirty-four children were interviewed in hospital in two paediatric surgical wards. These children were admitted to hospital because of a short-term illness or a single operation. Forty-eight children were interviewed in six kindergartens. The data included 43 girls and 39 boys. Twenty-five of the children were 4 years old, 20 were 5 years old, and 37 were 6 years old.
The number of coping strategies
The data included a total of 517 expressions of coping (Table 1). The children expressed 75 different types of coping strategies. The number of child-reported coping strategies among children interviewed in kindergartens ranged from one to 12, and in hospital from one to 23. Altogether 22/82, 27% children expressed 1–3 coping strategies, 28/82, 34% expressed 4–6 strategies, 18/82, 22% expressed 7–9 strategies, and 14/82, 17% expressed more than nine coping strategies related to hospital fears (Table 1).
|The number of coping strategies||Hospital||Kindergarten||Total|
The contents of the coping strategies
Most of the children expressed the presence of parents (57/82, 70%) as their coping strategy. The next larges categories consisted of the child's own toy, the care of the nurse, play and the presence of grandparents or other adults important to the child.
When the coping strategies were categorised according to their contents into 14 categories, the largest category was the presence of parents or other family members. The coping strategies in which the children described how the fear was alleviated by the proximity of supporting family members were placed in this category. The second largest category was resorting to the help of the hospital personnel. The next largest categories were positive images and humour, for example, thinking about and expecting nice, happy things, along with play, into which both the child's free play, and for example, watching television were placed. The coping strategies concerning the child's own safety toy were placed in a category of their own (Table 2).
|Coping strategy||The number of expressions n||Total (%)|
|The presence of parents and other family members||81 (15.7%)|
|Presence of parents||54|
|Presence of grandparents or other family members||16|
|Petting, sitting in lap||8|
|The help of the hospital personnel||58 (11.2%)|
|Looking at the doctor||1|
|Positive images and humour||57 (11%)|
|Thinking of something nice||12|
|Waiting to get home||11|
|Waiting to get better||10|
|Waiting for the parents to come for a visit||7|
|Changing the frightening matter into something nice||4|
|Thinking of what to do once back home||1|
|Watching television, games||9|
|Games, computer games||8|
|Hobby crafts, drawing||8|
|Visiting the play room||7|
|The child's own safety toy||45 (8.7%)|
|Child's own toy||28|
|Bedtime toy or other safety object||10|
|Hugging one's own toy or otherwise holding it||7|
|The action that rejects fear||34 (6.6%)|
|Closing one's eyes||6|
|Resting and calming down||33 (6.3%)|
|Lying down, resting||9|
|The alleviation of pain and the symptoms of the disease||32 (6.2%)|
|Staying still, immobility||7|
|Expressing the pain||3|
|Controlling one's own body to alleviate the pain||3|
|Active problem solving||29 (5.6%)|
|Following the instructions||5|
|Finding out things||5|
|Facing up to the frightening situation||3|
|Possibility to participate||2|
|Keeping eyes open||1|
|Preparing oneself for the situation||1|
|Expressing fear and asking for help||28 (5.4%)|
|Telling adults about the fear||8|
|Asking for help from adults||2|
|The acceptance of fear||22 (4.3%)|
|Getting used to the situation||5|
|Accepting the fear||3|
|Thinking about the frightening situation||3|
|Accepting the facts||2|
|Thoughts that reject fear||20 (3.9%)|
|Refusing to think about the frightening matter||8|
|Denying the fear||6|
|Transferring the fear to other children||1|
|Material objects that create pleasure||11 (2.1%)|
|Getting a reward||4|
|Beautiful things in the surroundings||2|
|Meeting friends and siblings||10 (1.9%)|
|Meeting a friend||4|
|Meeting a sibling||3|
|Meeting a new friend||2|
|Thinking about a friend||1|
Approximately 30 comments were placed in the category for action that rejects fear, which reflected the children's own efforts to resist the fear-inducing event or to escape the situation. The children mentioned rest and calming down, along with the alleviating of pain and expressing fear and the symptoms of the disease as almost equally significant strategies for coping. The latter category included both the nursing offered by the hospital personnel and the children's own actions to alleviate the pain and the symptoms. The children reported that they can also manage hospital fears by being courageous and active themselves, and by trying to familiarises themselves with the event that causes fear. Expressions reflecting these kinds of coping strategies were placed in the category of problem solving. Expressing fear and asking for help are also children's ways of managing fear.
Coping strategies in which the children said they managed their fear, for example, by comforting themselves or by getting used to the situation were placed in the category of acceptance of fear. In the category of thoughts rejecting fear were placed the expressions that described the children's own efforts to reject fear through thinking. The smallest categories describing coping strategies were formed of two categories: the category of material objects that create pleasure, and the category of meeting friends and siblings.
The mean of the number of coping strategies expressed by girls was 6 and by boys 7. Boys expressed statistically significantly more often playing and games (χ2-test, P= 0.074), and girls the help of the doctor (P= 0.011).
Differences in coping strategies between children interviewed at kindergarten and at hospital
Children in kindergarten (n= 48) expressed a total of 320 coping strategies, with the number of expressed ways of coping ranging from 1 to 12. The mean number of coping strategies expressed by children in kindergarten was 6.7. Children in hospital (n= 34) expressed 197 ways of coping. The number of strategies ranged from 1 to 23, with a mean of 5.8.
The children interviewed in hospital mentioned statistically significantly more often play (P= 0.000), their own safety toy (P= 0.044) and thoughts rejecting fear (P= 0.052) as their coping strategy than children interviewed in kindergarten (Table 2). Children interviewed in kindergarten expressed statistically significantly more often than hospitalised children the presence of parents (P= 0.032) and the help of the doctor (P= 0.012) as their strategy for coping. Children interviewed in hospital mentioned somewhat more often than children in kindergarten, positive images and humour as their coping strategy (Table 3).
|Categories of coping||Children in hospital (n= 34)||Children in kinder-garten (n= 48)||Chi-square-value||P-value|
|The presence of parents and other family members||22 (65%)||36 (75%)||8.788||0.032|
|The help of the nurse||13 (38%)||17 (35%)||1.280||0.734|
|The help of the doctor||2 (6%)||16 (33%)||8.868||0.012|
|Positive images and humour||18 (53%)||16 (33%)||9.006||0.109|
|The child's own safety toy||19 (56%)||15 (31%)||8.096||0.044|
|Play||20 (59%)||7 (15%)||20.163||0.000|
|The action that rejects fear||12 (35%)||12 (25%)||5.867||0.209|
|Rest and calming down||13 (38%)||10 (21%)||4.128||0.248|
|Expressing fear and asking for help||12 (35%)||10 (21%)||3.993||0.262|
|The alleviation of pain and the symptoms of the disease||10 (29%)||10 (21%)||1.903||0.754|
|Active problem solving||9 (26%)||11 (23%)||1.578||0.813|
|The acceptance of fear||9 (26%)||8 (17%)||3.301||0.192|
|Thoughts that reject fear||9 (26%)||5 (10%)||7.710||0.052|
|Material objects that create pleasure||6 (18%)||5 (10%)||0.896||0.334|
|Meeting friends and siblings||6 (18%)||4 (8%)||1.612||0.204|
The present study described the ways in which pre-school-aged children cope with their fears related to hospitalisation and medical procedures as reported by the children themselves. The results offer new information on the coping strategies that matter most to children themselves. In addition to the support of adults, free play, watching television, various games and hobby crafts, and the child's own safety toy are all essential strategies for coping among pre-school-aged children in hospital. Equally important are the creation of positive images, maintaining them, and humour.
The results showed that children have many coping strategies, especially strategies in which the children themselves play an active role. Of all the 517 coping strategies expressed by the children, in only 150/517, 29% the children played a passive role (the presence of family members, the help of the hospital personnel, and material objects). In the other 367/517, 71% expressions describing coping, the children themselves played an active role. Similar findings were not evident in earlier studies concerning children's coping with hospital-related fear. This may reflect the fact that in the earlier studies the children themselves were not asked about their coping strategies.9–13
According to our study, the number and content of coping strategies used by healthy children and children in hospital differed. Children interviewed in kindergarten expressed more coping strategies than sick children. It is possible that admittance to hospital and the sickness caused stress and decreased children's coping strategy reporting. On the other hand, in hospital the children may have learnt which coping strategies helped them and which did not and they reported only the effective ones. Healthy children said more often than hospitalised children that they cope with their fear with the help of their parents and the hospital personnel. Instead, the hospitalised children relied often to the coping strategies with their own active role.
The results confirm earlier findings of the significance of the presence of parents in the coping of the children.1,8 Resorting to the nurse,12 receiving information,4,16 play25,28 and positive visual images14 have previously been shown to alleviate the fear of young children. Moreover, expressing fear, rejecting and denying it are known to alleviate fears and pain in children.41 Several coping strategies, for example, playing and crying, may probably act both as an expression of fear and a coping strategy, a fact that has also been noted previously.42
This study differs from earlier studies because of the aim, the informants and the data collection method. Earlier studies, in which the data have mainly been collected by observing the children or interviewing adults, have focused on the coping of children, for example, through the day surgery process, painful procedures or the hospital experience of children in general. In this study, we wanted to look more deeply at the child's own expressions about coping with hospital-related fears. It can be assumed that the children described the methods that are most effective for them. We interviewed both children in hospital and in kindergartens, so it was possible to describe the differences between these children in the results. Our results emphasised the importance of the active part played by the child in coping, as well as the fact that essential coping strategies are those which are part of the child's normal activities and familiar to them from their everyday life.
Limitations of the study
In the present study, volunteers were recruited for the study, which limits generalisation of the results to the general population of 4–6-year-old children. Differences in the children's personality and developmental stage might have decreased the reliability of the results. However, thanks to the pictures used, it was easy for the children to identify their coping strategies and discuss their own thoughts, emotions and actions.
The use of several interviewers at the data collection stage may decrease the trustworthiness and reliability of the results, as well as the different circumstances of each interview, and the possible contribution of parents and nurses to the interview. However, the trustworthiness of the data collection was assured by training the interviewers in interviewing children, by requiring pilot interviews and by giving systematic instructions about the interview process in advance through lectures and individual instruction (M.S.). All the interviews were based on standardised themes, and were supported by the interview guide, which ensured that the same basic line of inquiry were pursued with each child.32 Before analysing the data the researcher (M.S.) listened to the recordings and checked that the transcripts had been made reliably, reading the transcribed material several times in order to become immersed in the data.33,43 The inter-rater reliability of the content analysis was found to be good, 95%.39
In this study, one of the aims was to give the pre-school-aged children themselves the opportunity to discuss their coping strategies. Neither the earlier hospital experiences of the children nor the socio-economic background of their families was controlled, which again may limit the extrapolation of the results. However, the participants represented common Finnish children, interviewed in public kindergartens and in a university hospital. In Finland all children have the right to attend a public day nursery by law.44 Kindergartens were located in low, high, and middle socio-economic districts of the city and the families' income levels, as well as the parents' educational background fluctuated from high to low levels.
The phenomenon of coping with hospital-related fear was examined from the perspective of both children interviewed in hospital and kindergarten, in order to determine whether there were differences in coping strategies between the two groups. All the children interviewed in kindergarten had experiences of health care services at least through well baby clinic visits with shots and health inspections, and their images of coping with hospital-related fears were based on these and possibly other doctor visit experiences. According to the qualitative research tradition, the informants always find their experience real, regardless of the basis of the experience.45
Conclusions and clinical implications
In this study, the children mentioned a great variety of coping strategies. Adults should encourage and support children to use these strategies when the children confront hospitalisation and/or medical procedures. It would also be of great importance to know which methods are important to each individual child. When the child is listened to, she/he is given the opportunity to report her/his own ways of coping in the stressful situation, and thus she/he can be given the most appropriate support. Qualitative research studies have demonstrated that very young children can provide important insights into their health experiences, so their views can and ought to be taken seriously.46,47 It might be useful to create a questionnaire or a list of coping methods for the parents and the child, and with its help find out the most effective way to support the child.
Children have been found to benefit from the teaching of cognitive-behavioural coping skills. Parents also need guidance in supporting the child's coping skills.20 Whether children should be taught several different coping methods or only a few should be studied. Our results suggest that children already have many coping mechanisms in which they play an active role, and that these mechanisms should be first evaluated and then supported.
The results show that besides the traditional strategies for alleviating fear, the children need methods that they can use when they need them, that have an effect on their emotions and cognitions, and are suitable for their developmental stage. It is important for the children that they can use coping strategies that give them an active role. These methods alleviate the fear of the children, give them a feeling of control over the nursing situation, and the opportunity to participate in their own treatment.48
This study was supported by the Finnish Cultural Foundation.
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