School-age children’s perception of the hospital experience

Abstract

In order to determine the perception of hospital experiences among school-age children’s (6–12 years), a descriptive and cross-sectional study was performed in 130 children hospitalized in a pediatric hospital with different diagnoses. Data were collected using a pediatric information form, questionnaire form, scale for attitudes towards hospital and healthcare personnel, and sources of anxiety generating thoughts scale (SAGTS). Children’s expectations of the nurses were to be well treated (62%), to perform painless procedures (20%), to play games together (12%), to be capable of their job (10%), and to be cheerful (10%). Children’s expectation of the hospital facilities was the availability of playgrounds and toys (19.2%), large and single rooms (15.4%), rooms with private bathroom (9.2%), and rooms with a television and Internet access (7.7%). A statistically significant, negative, and moderate linear relationship was found between the scale for attitudes towards hospital and healthcare personnel and SAGTS (p < 0.05, r: −0.296). The present study was performed to define the children’s hospital experiences, keeping in mind that the best opinion on this matter is the child’s own opinion. The foundation of this understanding depends on admitting that the children can express their own opinions about the care they receive.

Keywords

Children’s perception pediatric nurses quality of care

Introduction

Hospitalization is an extremely stressful and traumatic experience for children as well as their parents (Ball et al., 2015). It was previously reported that some of the effects may continue for months or even for years and last longer especially in children who experience frequent and prolonged hospitalizations (Melnyk, 2000). Currently, these effects on children continue to represent a problem for the nurses and other healthcare professionals, and the importance of satisfying the children’s psychosocial needs as well as their physical requirements is particularly emphasized. Pediatric nurses have a critical role, which may lead to a positive or negative impact on the hospital experience of the children during the complete period of hospitalization (Duzkaya et al., 2014; Linder and Seitz, 2016). This is because in addition to having the required knowledge, skills, and equipment to improve the child’s health, pediatric nurses are the ones that children refer after their family to help them cope with their fears and anxiety about the disease and hospitalization (Salmela et al., 2011). One of the most important responsibilities of pediatric nurses is to work to ensure the children are provided with better and less traumatic care and play active roles in the development of policy and procedures.

Pediatric nursing care and services provided were traditionally assessed from a professional perspective. After the 1990s, patient’s perspective gained importance and began to be considered for the assessment and development of nursing care (Pelander and Leino-Kilpi, 2004). In pediatrics, on the other hand, the assessment of quality of care or any planned innovation appears to be made by the nurses or parents rather than the children themselves (Melnyk et al., 2004). However, hospital services and policies should be focused on the children and families, and the children’s opinion should be obtained and their contribution to decisions should be encouraged at each step of their care (Coyne, 2006). Also in terms of children’s rights, children have the right to express their decisions regarding the events that affect them (Pelander and Leino-Kilpi, 2004). Therefore, it is extremely important to define the meaning of such a difficult experience for children and to plan their care in this perspective.

A review of international literature on this subject shows that lots of studies have been completed. Also, many studies have reported that experiences and perspectives of hospitalized children about physical environment in hospital (Lambert et al. 2014); experiences of specialized clinic like surgery (Ford et al., 2011), pediatric emergency unit (Jensen et al., 2012), and diseases related (Ojmyr-Joelsson et al., 2011). Moreover, there is currently limited study in the national literature that evaluates the 6–12 year children’s hospital experiences with few exceptions (Duzkaya et al., 2014; Ercan, 2003). This study aimed to explore children’s experiences and perspectives of both healthcare professionals and the physical environment and factors affecting the attitude and concerns of school-age children towards hospital personnel.

Aim of the study and research questions

The aim of this study was to identify the school-age (6–12 years) children’s experiences during hospitalization.

The following research questions underpinned the study: (1) What are the school-age children’s experiences of hospital environment and nurses? (2) What do the school-age children expect from the nurses and hospital environment? (3) What are the factors affecting the attitude and concerns of school-age children towards hospital personnel?

Methods

Setting and sample

The study sample consisted of children aged between 6 years and 12 years, who were hospitalized due to different diagnoses in a university hospital in Ankara province between December 2014 and June 2015. This hospital has a 280-bed children’s facility with services to approximately 242,000 outpatients and 5000 inpatients.

Our study was based on the development theories that investigate children’s age range. Also, this age group was selected because it was anticipated that they would have the cognitive and verbal capacity to participate in the research process (Ball et al., 2015). It was the reason we determined age range as 6–12-years old school-aged children. Children who consented to participation, who had been followed up in the hospital for at least three days any disease, and who had no communication problems were included in the study. Participants were required to speak and understand Turkish and be able to respond to the study questions. Children who were unconscious, had communication problems, did not have families with them, had pain, and were staying at hospital less than three days were excluded in the study. A power analysis of the study was performed with 80% power at α = 0.05 level, and the required sample size was estimated as 130 children based on a preliminary study.

Data collection

The data were collected using a pediatric information form, a questionnaire form, the scale for attitudes towards hospital and healthcare personnel, and the sources of anxiety generating thoughts scale (SAGTS) questionnaire, and the scales were administered by researcher during face to face and carried out in patient rooms and lasted from 35 min to 50 min; all of them were conducted by the same researcher. Data were conducted at times when the children and parents were convenient and willing.

Pediatric information form

The form collected descriptive information about children such as age, gender, diagnosis, hospital admission date, experience of hospital admission, frequency of painful procedures, continuing communicating with their classmates or not, and having information about hospital and service environment. This form was filled with children’s parents.

Questionnaire form

This form was used to get information from children about their hospital experiences. This form consisted of some items such as children’s thoughts about the hospital environment and children’s expectations from the nurses and physical environment.

Scale for attitudes towards hospital and healthcare personnel

Scale for attitudes towards hospital and healthcare personnel was previously developed by Ercan (2003). This scale is used to assess children’s fears and concerns about the hospital and healthcare personnel such as “I don’t know anything that happens in hospital” and “People who are in the hospital become more anxious”. Each item is graded on a scale of 1–5. The highest and lowest possible scores are 75 and 15, respectively. High total scores indicate positive thoughts towards the healthcare personnel and the hospital, while low scores represent negative thoughts.

Sources of anxiety generating thoughts scale

This scale was developed by Gonener in 1997. This form, consisting of 20 items, was developed in order to measure the level of anxiety at the time of hospitalization among school-age children who were hospitalized for an acute illness. This form consisted of items such as “I constantly think that nurses will inject me” and “I think that I will be away from my friends”. Internal consistency (Cronbach’s α) of the scale was estimated as 0.75. In the present study, it was found to be highly reliable with Cronbach α value of 0.817.

Ethics

Written permission and ethics committee approvals to perform the study were obtained from Hacettepe University Ihsan Dogramaci Pediatric Hospital. Written informed consents were obtained from participating children as well as their parents.

Data analysis

Data were transferred and analyses were performed by IBM SPSS Statistics V 22 software. Differences between the two independent groups were assessed by the independent sample’s t-test, and differences between more than two independent groups were analyzed by one-way analysis of variance. Pearson’s correlation was used to assess the relationship between two continuous variables. Responses given to open-ended questions were listed, and similar responses were self-grouped.

Results

A majority (80%) of the participating children had no previous history of hospitalization. Among the children with a history of hospitalization, 40.4% were hospitalized six or more times. Of all children included in the study, 50.8% were previously informed about their planned hospitalization, and they were mostly informed by a doctor or their mothers. Information regarding the hospital environment was not provided to 79.2% of the children at hospital. In total, 69.2% of the children underwent painful procedures one to five times per week, and 60.8% were informed about the painful procedure. The information regarding planned painful procedure is mostly (68.6%) provided by nurses. Of all children, 70.5% cannot continue communicating with their classmates. Among those who continue communicating with their classmates, 76.3% use telephone as the tool of communication. A majority (80.8%) of the children had a break from school due to their illness and 77.1% took a sick leave for 1–2 months.

The most common aspects that distressed, worried, or scared the children at the hospital were feeling pain during medical procedures (50%) and being operated on (35.3%). When the children were asked about their opinions regarding the good things nurses do, 21.5% responded as performing painless procedures and 12.3% responded as getting good care. Children’s opinions about the bad things that nurses do included painful procedures (29.2%) and the nurses being intolerant and angry (14.6%; see supplementary material 1).

Children’s expectations from the nurses include behaving well (47.7%) and performing painless procedures (15.4%). The most frequently stated expectation of children regarding physical environment was availability of playgrounds and toys in the hospital (19.2%; see supplementary material 2).

Pearson’s correlation analysis showed a statistically significant, negative, and moderate linear relationship between the scale for attitudes towards hospital and healthcare personnel and the SAGTS (p < 0.05, r: −0.292; Table 1). Independent sample’s t-test indicated a statistically significant difference between the degree of sources of anxiety generating thoughts and the status of being informed about hospitalization beforehand (p = 0.005). The degree of sources of anxiety generating thoughts among children who were informed about their hospitalization was higher compared to the children who were not informed. Independent sample’s t-test showed a statistically significant difference between the degree of sources of anxiety generating thoughts and the status of being informed about hospitalization at the hospital (p = 0.049). The degree of sources of anxiety generating thoughts among children who were not informed about the hospital environment was higher compared to the children who were informed. Our statistical analysis determined no differences between ages.

Table 1.

Descriptive statistics for the scale for attitudes towards hospital and healthcare personnel and SAGTS.

	N	Mean	Standard deviation
Scale for attitudes towards hospital and healthcare personnel	130	50.28	6.842
SAGTS	130	58.37	10.014

SAGTS: sources of anxiety generating thoughts scale.

Discussion

In Turkey, children’s experiences, perceptions, and expectations of hospitalization and health professionals are not sufficiently evaluated. Thus, the present study is important as it is unique to investigate the children’s opinions of healthcare personnel and hospital environment, beyond the traditional understanding of nursing care.

Informing the child in an age-appropriate manner is essential for the child to contribute to his or her own care and become a decision maker (Coyne et al., 2014). For this reason, children being hospitalized should be informed about the illness and the hospital environment, and they should become familiar with the hospital facilities to overcome their fear and concerns. Previous studies demonstrated that information provided in this regard by the pediatric nurses, and inclusion of the children to their own care, reduced the fear and anxiety of children from surgery and painful procedures and increased their self-confidence (Coyne et al., 2014; Pelander and Leino-Kilpi, 2010; Salmela et al., 2011). The present study showed that the degree of sources of anxiety generating thoughts among children who were not informed about the hospital environment was significantly higher compared to the children who were informed. However, the degree of sources of anxiety generating thoughts among children who were informed about their hospitalization beforehand (50.8%) was significantly higher compared to the children who were not informed (Table 1). Based on our observations, the reason for this finding can be explained by the fact that the children included in the study population were informed shortly and in a hurry, and such explanations were not satisfactory for children to understand the procedures and overcome their concerns.

Additionally, it was noted that the majority of the children (60.8%) in this study were not informed about the planned painful procedures. Thus it is necessary to inform the children about planned procedures in order to reduce their fears and ensure they feel safe (Pelander and Leino-Kilpi, 2004; Salmela et al., 2011). Studies showed that explaining the procedures to the children and preparing them for the procedure reduced their anxiety, accelerated their healing, and decreased emotional disturbances such as separation anxiety and insomnia (Forsner et al., 2005; Justus et al., 2006). Children included in this study also defined the negative hospital experiences as the procedures that are painful and being taken into a surgery (see supplementary material 1). Therefore, pediatric nurses should plan any interventions in cooperation with the children’s family, in order to prepare the children for and facilitate their adaptation to painful procedures.

Academic failure, taking a break from school, and losing loved ones such as peers due to hospitalization are among the problems faced by the children (Linder and Seitz, 2016). In this study, 80.8% of the children took a break from school due to their illness, and 70.5% did not continue communicating with their classmates. Moreover, children stated that one of the worst experiences of hospitalization was being unable to see their friends (see supplementary material 1). Pelander and Leino-Kilpi (2010) evaluated the positive and negative experiences of hospitalization among children aged 7–11 years and reported that the inability to continue school and be with their group of friends were among the negative experiences stated by the children (Pelander and Leino-Kilpi, 2010). Similarly, in his study evaluating the obstacles resulting from hospitalization in school-age children aged between 7 years and 12 years, Linder and Seitz (2016) reported that the children defined being isolated from their group of friends and taking a break from school as the most important obstacles (Linder and Seitz, 2016). In this context, it is extremely important to ensure that children continue communicating with their schoolmates and friends during hospitalization in order to avoid the development of feelings such as loneliness and isolation. Particularly during prolonged hospitalizations, it should be a possibility to supply the children with a mobile phone, Internet, and other new social media networks, so that they are in continuous communication with their friends (Pelander and Leino-Kilpi, 2010). In addition, hospital schools and interventions that support the children’s development and education should be planned to ensure their school education continues during hospitalization and thus avoid the negative impact of absence from the school (Melnyk et al., 2004).

Another significant developmental characteristic of school-age children is the increase in the importance of the concept of privacy. Privacy can be ignored in hospitalized children due to the factors such as inappropriate physical conditions, high number of patients, and false attitudes of healthcare personnel, for that matter (Lerwick, 2013). In this study, children stated the lack of privacy in the hospital environment as one of the worst experiences they had in the hospital (see supplementary material 1). The reason of this finding can be that single rooms of study hospital are usually used for isolations. According to Lambert et al. (2014), the benefits of residing in a single room, as expressed by child participants, where parents being able to stay are increased comfort, privacy, and dignity. Also, Pelander (2004) reported that the principal of privacy should be among the standards required to increase the quality of care provided by pediatric nurses and privacy should be ensured by the nurses (Pelander and Leino-Kilpi, 2004). For this purpose, healthcare professionals should evaluate the children’s perspective and take measures to make the provided care focus on the child.

Corsano et al. (2012) demonstrated that a harmonic and conflict-free close relationship developed between the nurses and children, who were aged between 6 years and 15 years and being monitored at the pediatric hematology and oncology services, increased their coping abilities with the painful and distressing procedures that they experience during hospitalization (Corsano et al., 2012). This study showed that the sources of anxiety generating thoughts decreased as the children’s positive attitude towards the hospital and healthcare personnel increased (Table 1). In this regard, the children’s expectations of nurses should be known in order to identify the factors that result in an overall negative hospital experience and eventually to develop the care provided to the children. This study also showed that the most common expectations of children from nurses were to be well treated, to perform painless procedures, and to play games with them (see supplementary material 2). Pelander and Leino-Kilpi (2010) stated that the school-age children describe the nurses who are kind, friendly, who play games with them, and who develop close relationships as the best nurses (Pelander and Leino-Kilpi, 2010). Similar studies also showed that the school-age children expect the nurses to be nice, humane, to have humor, to provide information, to have sufficient skills, and to perform procedures in a painless way (Brady, 2009; Linder and Seitz, 2016; Marcinowicz et al., 2016; Schmidt et al., 2007). Based on the literature and our findings, the quality of care provided to children and positive attitude of the children towards the nurses can be improved by training the nurses to avoid negative manners and insufficient skills that may have a negative impact on the children’s development and experience of hospitalization, as well as learning and applying psychosocial behavior approaches such as playing games, humor, and distraction, which may reduce the child’s stress and have a positive influence.

In the present study, the best hospital experiences of children were associated with playing with toys in their rooms, availability of television and Internet, and being visited by a clown (see supplementary material 1). Also, an assessment of the children’s expectations about the physical environment in this study showed similar findings to the literature (see supplementary material 2). Similar to Lambert el al.’s (2014) study, children in our study wanted to cheerful, warm, colorful, and comfortable hospital environment. In line with the studies investigating how a hospital environment should be from the children’s perspective, the most common expectations included colorful hospital rooms, corridors, and nurse uniforms; larger rooms and comfortable beds; availability of more toys and game opportunities; availability of common spaces to spend time with friends; and hospital environment reflecting a home environment (Coad and Coad, 2008; Duzkaya et al., 2014; Linder and Seitz, 2016; Schalkers et al., 2015). In other words, the previous studies demonstrated that the best hospital experiences among children were mostly those associated with activities, particularly entertaining activities and presence of objects (Ford et al., 2011; Marcinowicz et al., 2016; Salmela et al., 2011). Thus, it is extremely important to provide the children with spaces they can spend comfortable time.

Limitations

This study has some limitations. First, the sample represented a range of children with different ages and diseases but did not include special experiences such as cancer, acute care, and surgery. Further research is required for children who have specific diseases and hospital experiences. Statistical analysis determined no differences between ages, so it is suggested that future studies should be done with a large sample size. Also, further research is required how characteristic of nurses and hospital environment effect on children’s further life.

Conclusions

The present study contributes to the literature on the children’s experiences, as it is the first study in Turkey investigating the children’s experiences of hospitalization and opinions about the healthcare personnel and hospital environment. This study demonstrated that providing information, preparing the child for painful procedures, keeping the child’s family close, ensuring privacy according to age and developmental status, and maintaining communication with friends who are a reflection of school life are important aspects in order to improve pediatric nursing care. Moreover, this study showed that the sources of anxiety-generating opinions decrease as the children develop a positive attitude towards the hospital and healthcare personnel, and the expectations of children from nurses include being well-treated, cheerful, close, and perform procedures in a painless manner, have the right skills for their job, and play games with them. The results and our research findings regarding the hospitalization experience of children might help develop nursing guidelines for the care and treatment of hospitalized children.

Footnotes

Acknowledgements

The author is grateful to the children participating in this study. The authors thank the parents who participated in the study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported/funded by Hacettepe University Scientific Research Projects Coordination Unit (project number: THD 2015 5112).

Supplemental material

The online data supplements are available at .

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