Yearbook on Journal of the Japan Society of Nursing Research 2014

Factors Affecting Nursing Students’ Hesitation to become Involved with Children in aChild Nursing Practicum
Hitomi Ojiro1), Hiromi Naragino2)
Key Words :hesitation
child nursing practicumchildnursing students
interpersonal relationship

ABSTRACT
We conducted a qualitative inductive study to clarify the factors affecting nursing students’ hesitation tointeract with children in a child nursing practicum. A semi-structured interview was conducted with nine
nursing students who completed a child nursing practicum. The data obtained were analyzed using the KJ
technique. Five categories of factors were identified; “the psychological burden caused by the presence ofthe parents,” “the attitude of dislike displayed by the child,” “the child’s reactions that make the participant
feel rejected,” “anticipatory anxiety,” and “situation resulting in a feeling of fear,” Nursing students were
hesitant to interact with children whose attitudes and responses they considered difficult to deal with,and the students were affected by the responses of children as the children’s moods changed. In addition,
nursing students envisioned the children’s attitudes and responses that they felt would be difficult to deal
with, which led to anticipated apprehension. Overemphasis on the parents’ relationship with their child also
led to psychological strain for the nursing students. Being nursing students, they worried about how theywould be assessed and were daunted by the medical personnel and instructors present.

I. Introduction

skills develop along with physical growth and development 8).
During later childhood and adolescence, the development ofphysical functions is accompanied by the development ofcognition and language skills; this is the beginning of identity establishment. Thus, children undergo various stagesof development. It is difficult to form relationships with andattempt to understand and share the thoughts and feelingsof children who are in an immature state of development.
For nurses to be capable of understanding children, interact
with them, and form relationships, nursing students need tofoster those skills, which should begin while they are still in
nursing school.
Since the curriculum revisions in 1997, a reduced amountof time has been allocated to clinical child nursing practicum.
In addition, because of the shortened length of hospital stays
for children, the period during which a nursing student isin charge of a child is shorter, and in some cases, a nursing
student is in charge of multiple children. Nursing students
are in a situation where, within a short time, they have tounderstand children, form relationships, and graduate toclinical nursing practice. However, current nursing students
have shown changes in their academic skills, way of thinking,and basic attitude in daily life, as well as a lack of communication skills 9-11). Even if nursing students gain a theoreticalunderstanding of children’s conditions, it is difficult for themto make use of the knowledge when deciding how to deal withchildren in a practical setting 12).
Researchers have informed nursing students about pediatric nursing. In many cases, even when nursing students
were enthusiastic about visiting children’s hospital rooms,
they were embarrassed to talk with the children, to hold theirhands, or to embrace them. Therefore, pediatric nursing students face various difficulties when dealing with children
during clinical training. We investigated the factors that leadto nursing students’ confusion, reluctance to relate to children, and difficulty in establishing relationships. We proposethat clarifying the factors causing nursing students’ hesitanceto relate to children may help improve child nursing education, including lectures and practicum.
Therefore, we examined influencing factors from the perspective of nursing students, such as issues pertaining to theinvolvement with children during practical clinical trainingthat nursing students find difficult, and which makes themDue to advances in medical care and improvements ofthe standard of living, disease structures have changed. In
addition, a declining birthrate and an aging population areaccompanied by a need for improvements in public healthand medical services. Consequently, there is a strong need
to upgrade and expand nursing services and to improve thequalification of nursing staff. Under such circumstances, there
is a gap between the skills of nursing students at the timeof the completion of their basic nursing education and theskills that are required of nurses in clinical settings, which
may cause nurses to leave their profession. Therefore, thecurriculum in basic nursing education has been revised to
improve practical clinical skills at the time of graduation 1-3). In
addition, it is considered necessary that basic nursing education be reorganized as a four-year college course in order toreally achieve an improvement in the quality of nursing care.
An amendment of the Act on Public Health Nurses, Midwives
and Nurses came into effect from April 2010.
In pediatric nursing, high-level skills are needed, including
relating with children and understanding the particularitiesof each child’s stage of development, as well as developing human relationships, comprehending the child’s needs,
and providing assistance in a way that enhances the child’s
strength. However, because of the declining birthrate, many
pediatric clinics and pediatric wards have become unprofitable and have closed, or have been merged and mixed withwards designed for adults; children’s length of hospital stay
has also been shortened 4-7). Therefore, the practice of childnursing practicum has been constrained to a limited hospitalenvironment. Children are in a state of growth and development. Through the development of sensory functions duringchildhood and infancy, along with the development of motor
functions such as those of the hands and legs, children become
familiar with the outside world, which they explore actively.
In addition, they express their thoughts by laughing, crying,or by using their hands and fingers. Cognition and language
1) Aino University
2) Osaka Prefecture University

Corresponding author. Tel.: +81 744 22 3051; Fax: +81 744 22 7555.
E-mail address: ojiro@naramed-u.ac.jp (H. Ojiro)

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Yearbook on Journal of the Japan Society of Nursing Research 2014

4. Data analysis method

hesitant to interact with children.
II. Research objectives

All the data collected during the interviews were transcribed into written records, encoded, and analyzed using
the KJ method. In this study, we aimed to identify influencing
factors that affect nursing students’ hesitation in relating tochildren during pediatric nursing practicum. In addition, toensure that the meaning of the contents verbally mentionedby the participants could be used without being truncated,
the KJ method technique described in the analyses was considered appropriate for inferring the ideas conveyed by thedata. Further, to increase the reliability and validity of the data
analysis, the study was repeated by researchers specializingin pediatric nursing.

The purpose of this study was to identify factors that lead tonursing students’ hesitation to interact with children during
practical clinical training in pediatric nursing.
III. Definition and use of terms
1. Hesitation

The word “hesitation” means “wasting time and being
unable to make a decision” or “faltering” 13). In this study, “hesitant” refers specifically to the reluctance to relate to children,
inability to make any judgment or decision with regard to
relating to children, or inability to act with regard to relating to children. Thus, “hesitating to relate to children,” means“being uncertain, unable, or unwilling to relate to a child”.

V. Ethical considerations

This study was approved by the Institutional Ethics Review
Board of Shiga University of Medical Science (approval
number 18-106). A call for cooperation in this study was sent
in a written document addressed to nursing colleges in the
Kinki region, and to which the researchers were not affiliated.
In nursing colleges that gave their consent to cooperate, acall for participation in the study was sent to nursing students, through an referrer. The researchers directly requested
participation from students who showed willingness to participate in the study, and provided verbal and written explanations regarding the following issues, after which consent was
obtained with the students’ signatures.
The study participants kept their own free will regarding
the research objectives and methods, and had the right torefuse or withdraw their participation. Participants were notrequired to discuss subjects that may be painful, or that they
were unwilling to discuss. The participants were not forced
to answer questions that they found difficult to answer. Discontinuing the interview or refusing to discuss difficult subjects would not result in any disadvantage for the participant.
The researchers would not report to the referrer whether theparticipant agreed to participate in the study or not. Participation or non-participation in the study would not affect theirperformance grades for the pediatric nursing practicum. Anonymity and protection of privacy were strictly observed. Aftercompletion of the study, the data were erased and all written
records and documents destroyed. The results of this study
were intended to be presented at nursing-related academic
meetings.

IV. Research methods
1. Participants

The participants consisted of nine nursing students fromtwo nursing colleges, who had completed their practical clinical training in pediatric nursing, who had not been enrolled inclinical training in multiple facilities such as nursery schools
in the Kinki region, and who had clinical training in a childnursing practicum, only in pediatric wards.
2. Study design

A qualitative inductive research approach was used in thisstudy.
3. Survey method

1) Interviewing procedure

Dates and places that were convenient for the participants
were determined; verbal and written explanations pertaining to the research purposes, methods, necessary duration of
the study, and ethical considerations were provided; and theparticipants who gave their consent were requested to signa consent form. A semi-structured interview was conductedwith the nursing students who understood the purpose of thestudy and who agreed to be interviewed by the researchers.

VI. Results2) Interview contents

The mean age of the study participants was 23 years. Theinterview period ranged from the day of the completion of
their practical clinical training in pediatric nursing up to 5
months afterward. The mean duration of the interviews was
71 min.
The participants were assigned to be in charge of 11 children (referred to, below, as “children”), most of whom were
infants. Among the children, nine were accompanied by achaperone and two were in the acute phase of their disease(Table 1).
The data comprised 425 meaning items, 5 categories, and16 sub-categories. The categories are displayed with the following sign: [ ]; the sub-categories are displayed with the following sign:{}; and the interview contents that represented

The contents of the interview examined the following threepoints:(1) the participants’ thoughts about children,(2) what embarrasses the participants regarding relationships with children, and(3) what worries the participants when they are in contact
with children.
3) Data collection period

Data collection lasted from April to August 2007.
10

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Yearbook on Journal of the Japan Society of Nursing Research 2014

Table 1. Background of the Child
ID
1
2
3
4
5
6
7
8
9

developmental stage
childhood stage
childhood stage
childhood stage
childhood stage
babyhood stage
childhood stage
childhood stage
childhood stage
babyhood stage
childhood stage
adolescence

1) {Excessive awareness of the parents}

periodThe nursing students who had already established a relationship with the child, and cherished the child, considered
the parents who constantly accompanied the child “impossible to ignore” and, therefore, found that the presence of theparents negatively affected their ability to interact with thechild. In addition, they felt difficulty relating with the children because of the parents’ “stern facial expression” and“nervous” appearance, as well as the parents’ attitude of “notsaying what they actually thought.” In addition, “being withthe mother was a source of tension,” and “once the motherwas present, the child became defensive”; as a result, nursing
students had an excessive awareness of the children’s parents,
which made them feel a psychological burden when relating
to the children. Furthermore, the nursing students also interacted with the children while being attentive to parents who
were “tired from accompanying their child,” “worried about
the child’s siblings,” and “worried about their child’s recovery
from the disease.” In addition, conflicts also occurred, during
which the nursing students considered that, despite theirplans, they were unable to relate sufficiently (to the child),
and that “they would have been able to relate much better if
the parents had not been present.” Moreover, they mentionedthat if the parents had not been there, they “would have beenable to relate more intimately” with the children, and thatan awareness of the parents’ presence, as well as “worrying
about the mother,” made them experience difficulty relating
to the children.

convalescent stage
chronic stage
chronic stage
convalescent stage
chronic stage
chronic stage
chronic stage
chronic stage
acute stage
acute stage
acute stage

Table 2. Factors affecting nursing students' hesitation to
become involved with children in a child nursing
practicum
categories
sub-categories
The psychological burden Excessive awareness of the parents
caused by the presence of Confusion when relating to the parents
the parents
Strain felt as a result of the parent’s gaze
Feeling of alienation from the child andthe parents
The attitude of displayed Antisocial children
by the childChildren whose ages are not familiar to
the nursing studentsChildren with mood swings
Children in painful situations
The child’s reactions that Children resistant to assistancemake the participant feel Children who experience difficulty formrejected
ing attachments to other peopleChildren who are not receptive to nursing students’ ideas and feelings
Children who cuddle up to their parents
and healthcare professionals
Anticipatory anxiety
Anxiety caused by imagining the children’s negative attitudes
Worrying about interacting with unknown
childrenSituation rcsulting in a The gaze of healthcare professionals,
feeling of fear
which was felt as evaluative
Sense of emptiness associated with afeeling of difficulty in relating

2) {Confusion when relating to the parents}

Nursing students perceived that when children wereaccompanied by their parents, a “two-against-one relationship” was built between the child and the parent on one
side, and the nursing students on the other side. In addition,
the idea that “the nurse’s efforts would be worthless unlessassistance was provided to take care of the parents as well as
the child” was a heavy psychological burden for the nursing
students, who were consequently anxious about “whether
they would be able to maintain a good relationship with theparents.”

the categories are displayed with the following sign: “ ”. Whenever something interfered with the context, or whenever theinterview contents were difficult to understand, the contexts
before and after the content mentioned verbally by the participant were supplemented with words in parentheses ( ).
The five categories consisted of [the psychological burdencaused by the presence of the parents], [the attitude of dislike
displayed by the child], [the child’s reactions that make theparticipant feel rejected], [anticipatory anxiety], and [situation resulting in a feeling of fear] (Table 2).

3) {Strain felt as a result of the parent’s gaze}

Regarding parents who were worried about their child’s
medical condition, nursing students performed nursing carewhile being attentive to “what the parents thought about thedisease.” In addition, because parents assist their children in
their daily lives, they felt they had a better understanding thannursing students about the child’s medical condition; therefore, because “they had already had multiple experiences ofwhat I (the nursing student) was thinking (regarding nursingcare),” “I respected the parents’ feelings and lost confidence inmyself as I was engaged in doing my work as a nurse.” Nursing
students thought that “it would not be good to talk to children
in an overly familiar manner,” and interacted with the children
while worrying about the gaze of the parents.

1. [The psychological burden caused by the presence of theparents]

This category showed that a considerable feeling of pressure on the nursing student’s psychological state was causedby the presence of the child’s parents. This category was composed of four subcategories: {excessive awareness of the parents}, {confusion when relating to the parents}, {strain felt asa result of the parent’s gaze}, and {feeling of alienation fromthe child and the parents}.

4) {Feeling of alienation from the child and the parents}

Regarding parents who established a parent-child relationship, nursing students who already had experience in raising11

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Yearbook on Journal of the Japan Society of Nursing Research 2014

children felt that they were “absolutely unlikely to win overthe mother’s” and felt “reluctant to interfere in the relationship between the mother and the child.” In addition, “the two(the parent and the child) have their own space and their own
world,” and when the nursing student was interacting withthe mother and child together, he/she “felt as though I did notbelong to the group,” or “felt as though I was visiting a friend’shome”; therefore, the student felt anxious when “a parent waspresent beside the child,” and “when I got involved in the intimate relationship between the parent and the child.” In addition, I thought that “since (the child) was living away from themother, (the child) might want to interact with the motherat the time of her hospital visits,” and that when the care of
the child was left to the parent, “the (parent-child) relationship may become intimate” and “the bond with the parent”
would be strengthened. Since “I had no self-confidence inrelating with children,” “I refrained from being involved withchildren and their parents”. Moreover, I considered that “mypresence (the nursing student) interfered with the relationship between the two (the parent and the child).”

during which the development of language function is in progress), at “ages that (the nursing students) had not yet encountered,” or at “ages with which (the nursing students) were notsufficiently familiar.” In addition, as they actually interactedwith the children, it was difficult for nurses to deal with children who pointed to various objects with their fingers while
talking, but who could not be understood no matter how manytimes they repeated themselves. Furthermore, for nursing students, adolescents who did not talk much about their thoughts
and feelings were considered “self-centered” and “difficult tounderstand”; therefore, they (nursing students) were hesitant
to interact with adolescents.
Nursing students who have little experience in working
with children “get nervous at the mere idea of dealing withchildren,” and are “unable to speak to children.” In addition,
nursing students are conscious of the fact that “they (nursing
students) are unaccustomed to children” and that “they do nothave the confidence to be attractive to children,” and therefore
lost self-confidence when they were in front of children.
3) {Children with mood swings}

2. [The attitude of dislike displayed by the child]Nursing students were deterred by children who weregoing through a life stage where exploratory behaviors wereactive, who moved actively, whose “feelings moved on rapidly
from one thing to another,” and whose “(playing) cycle was
fast.” Nursing students were confused by the changes in children’s moods as the children’s “feelings were different fromday to day” and because “even though the nursing students
sympathized with children on a subject, the children reverted
to their original emotional states the next day”; therefore, thenursing students experienced difficulty understanding children’s feelings.

This category referred to the condition of children considered by nursing students as difficult to deal with, and wascomposed of four subcategories: {antisocial children}, {children whose ages are not familiar to the nursing students},{children with mood swings}, and {children in painful situations}.
1) {Antisocial children}

For nursing students who were not accustomed to children’s “stern facial expression,” “crying,” “shyness,” “tension,”“fear,” and unresponsiveness” at the time of the first encounter, they did not know how to relate to the children, andtherefore they were reluctant to interact with the children.
Furthermore, they felt anxious that they were being rejectedby the children, because the latter “might be scared of them(nursing students).” In addition, when the children were “ina bad mood,” the nursing students attempted to relate to thechildren, using various approaches to improve their moods;
however, when the children’s moods did not improve, thenursing students were confused. Furthermore, when children showed a “poor response” or an “absence of change in
response (positive reactions),” despite having changed theapproach many times, or when children “do not talk much,”nursing students lost self-confidence in establishing relationships; “they (nursing students) thought that their feelings
were not conveyed to the pediatric patients (children),” andfelt that it was impossible to form relationships with the children. In addition, they (nursing students) were discouraged,
thought that “nothing would change, even if they (nursing
students) were absent,” thought that the children were notwilling to accept them, and lost their self-confidence in relating with children.

4) {Children in painful situations}Because children move from their homes to be admitted
to hospital, they live in an environment and according to alifestyle that is unfamiliar to them, leading them to “have astrong desire to be discharged from the hospital” and “bein a bad mood.” Nursing students who saw such children inbad moods felt that “the duration of hospital stay was longand that the children’s stress was considerable.” When dealing with children who were under stress and in a bad mood,nursing students tried to play with them to improve theirmood; however, the children’s feelings remained unchanged,
and consequently, the nursing students were confused about
how to proceed. In addition, when dealing with children suffering from physical pain, the nursing students “cuddled thechildren, depending on their bad mood.” Even then, nurses felt
anxious as they dealt with the children, while “making sure
not to aggravate their (the children’s) conditions”; they were
confused about when they should be involved.
3. [The child’s reactions that make the participant feel
rejected]

2) {Children whose ages are not familiar to the nursing
students}

This category represents the reactions of children by whom
the nursing students felt rejected, and is composed of four
subcategories: {children resistant to assistance}, {Children
who experience difficulty forming attachments to otherpeople}, {children who are not receptive to nursing students’ideas and feelings}, and{Children who cuddle up to their

Nursing students who wanted to access the children’s emotions through conversation felt reluctant to interact with children who were in their infancy and early childhood (periods
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parents and healthcare professionals}

conditions of anxiety, concern, and nervousness before andwhile dealing with the children. This category is composed oftwo subcategories, namely {anxiety caused by imagining thechildren’s negative attitudes} and {worrying about interactingwith unknown children}

1) {Children resistant to assistance}

Nursing students who were concerned about their nursing
skills for children and who wanted to undergo practical clinical training struggled regarding how to provide assistance tochildren who were “uncooperative” and who showed “rejection” and “unwillingness.” In addition, because the nursing
students “had never been encouraged by children to provide
assistance,” they lost confidence in their own ability to assist
the children.

1) {Anxiety caused by imagining the children’s negative
attitudes}

Nursing students felt anxiety with regard to dealing withchildren, namely about what they (nursing students) would
do if the children ever “refused” them or “cried” because ofthem. For nursing students who had previous experiences ofbeing subjected to negative attitudes by children, such an anxiety also occurred when they were approaching the children.

2) {Children who experience difficulty forming attachments
to other people}

2) {Worrying about interacting with unknown children}

Nursing students lost their self-confidence in relating tochildren who are anxious or apprehensive at the sight of anursing student With adolescents, for whom the interactions
consisted mainly of conversation, rather than assistance withdaily life, nursing students were faced with blunt answers
or “non-continuation of conversations” and were therefore burdened with painful feelings, even at the mere ideaof approaching such children. Furthermore, when children
rejected nursing students physically and said that they “hated”
them, nursing students who were incapable of interpretingsuch children’s behaviors and words were discouraged; asa result, such nursing students resisted a relationship withchildren and no longer thought about children’s feelings.

Before interacting with children, nursing students withlittle experience in dealing with children had feelings of uncertainty about “how to talk with them,” “how to call them,” and“how to play with them.” Furthermore, they felt anxious about
how to converse with the children and “whether it would bepossible to communicate” with children. In addition, when it
was impossible to interpret the meaning of children’s reactions, the nursing students felt anxious about how to deal withthe children; “they did not know how to relate to children”
and “with adolescents, conversation alone was not effective.”
The nursing students were unable to imagine “how children
were, at ages that they had never dealt with,” had no idea “howto interact with small children,” and therefore, were embarrassed to relate to children. In addition, when the child was ofthe opposite sex, the nursing student had no idea about “whatthe child would be interested in.”3) {Children who are not receptive to nursing students’ ideas
and feelings}

While dealing with children who were subjected to treatment that included taking a rest, nursing students dealt
with them by convincing them to rest; however, the children“played actively” without listening to what the nursing students said, and the more the students tried to interact withthe children, the more the children had fun and “deliberately
moved around actively.” Nursing students had difficulty dealing with these children as healthcare professionals.

5. [Situation resulting in a feeling of fear]

This category represents the feelings associated with thepractical clinical training in pediatric nursing from the perspective of nursing students with little experience in nursing
care and in relating with children. This category is composedof two subcategories, namely, {the gaze of healthcare professionals, which was felt as evaluative}, and the {sense of emptiness associated with a feeling of difficulty in relating}.

4) {Children who cuddle up to their parents and healthcare
professionals}

With children who ignored the nursing students andinstead “handed their (toys) to their mothers,” nursing students experienced the painful feeling that the children refused
to deal with them. In addition, while dealing with children
who “did not talk to me (the nursing student) directly, butinstead answered me (the nursing student) through themother,” or children who “clung to their mothers,” nursing
students felt a distance between them and the children. In
addition, when children did not accept the nursing students’assistance, but rather accepted assistance from only (qualified) nurses and teachers, the nursing students felt unable toestablish a relationship with children and lost their self-confidence in providing assistance as nursing care professionals
in pediatric nursing.

1) {The gaze of healthcare professionals, which was felt as
evaluative}

When nursing students saw nurses and teachers as evaluators, being viewed by nurses and teachers made students
feel as though the professionals were “watching” or “listening to” the nursing students’ ways of relating with children.
Nursing students were “nervous” when they related with children; they considered that “when healthcare professionals
were present nearby, interacting with children was difficult”;
this made them feel that relating with children was unnatural. Conversely, they considered that, in the absence of other
healthcare professionals, they were “capable of calling andtalking with children without worrying about anything.”

4. [Anticipatory anxiety]This category represents nursing students’ psychological13
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parents as well as the child.
In addition, the nursing students they felt that they went
through clinical training [in a state of fear]. The nursing students took care of children while feeling a considerable pressure from {the gaze of healthcare professionals, which was
felt as evaluative}. They did not have self-confidence in taking
care of children, and were anxious while doing so. They werealso aware of the environment surrounding the children, the[presence of the parent], [the attitude of dislike displayed by
the child], and the {sense of emptiness associated with a feeling of difficulty relating}; as a result, they hesitated to takecare of the children.

2) {Sense of emptiness associated with a feeling of difficulty
in relating}Nursing students felt anxious at the idea of interacting witha child alone, because it involved dealing “with the child on a
one-on-one basis in a private room.” In addition, when a nursing student was playing with a child and the conversation or
the game was interrupted, the nursing student felt anxious
for being in a room alone with the child and felt embarrassed
at the idea of “what to do to spend time if the talk did notresume or continue.” Further, when a nursing student entered
the same room where a child was playing, the nursing student
refrained from interacting with the child when the latter wasconcentrating on the game that he or she was playing.

VII. Discussion

6. Structure of influencing factors that make nursing students
hesitant to take care of children during clinical training inchild nursing practicum (Figure 1)

This study investigated the factors that affected nursing
students’ hesitation in taking care of children. In this section,
we will discuss the following: [1] children with rapid moodswings whom the student nurses felt manipulated by, [2] theexcessive awareness of the presence of the parent, and [3]the perspective of being a nurse as well as being a nursing
student.

The factors influence nursing students’ hesitation in
taking care of children during clinical training in child nursing practicum consisted of the following: regarding childrenthat the nursing students were going to take care of for the
first time, the students imagined [the child’s antipathic attitude] and [the child’s responses, which made the students
feel rejected], thereby developing an [anticipation of anxiety]in the students, which made them hesitant to taking care of
the child. In addition, in taking care of children, nursing students were embarrassed by [children’s antipathic attitude]
and [children’s responses, which made the nursing students
feel rejected]; next, the students developed an [anticipationof anxiety] with regard to taking care of children, making it
increasingly difficult for them to take care of the children.
The students felt a [psychological burden] regarding thepresence of the parents who knew the child’s condition, andwho had an established relationship with the child. Nursing
students felt the presence of the parents as a distinct pressure
and realized the need to have a good relationship with the

1. Children with rapid mood swings who the student nurses
felt manipulated byChildren in the course of language development and therefore incapable of verbal communication expressed their
feelings straightforwardly to nursing students, who wereincapable of understanding the children’s feelings, and were
confused; therefore, it was difficult for them to interact withchildren. Nursing students attempted to understand children’s feelings through verbal communication, and therefore,
when taking care of children incapable of communicating verbally, nursing students cannot understand the children; whenchildren’s emotions become intense, such as crying, nursing
students are confused and do not know how to deal with thechildren.

[ Anticipatory anxiety ]{ Anxiety caused by imagining the children’s negative attitudes } { Worrying about interacting with unknown children }[ The attitude of dislike displayed by
the child ][ The child’s reactions that make theparticipant feel rejected ]{ Excessive awareness of the parents }

{ Antisocial children }{ Children resistant to assistance }{ Confusion when relating to the{ Children whose ages are notparents }{ Strain felt as a result of the parent’s
gaze }       {Feeling of alienation from the childand the parents }familiar to the nursing students }{ Children with mood swings }{ Children in painful situations }[ The psychological burden causedby the presence of the parents ]{Children who experience difficulty forming
attachments to other people}{ Children who are not receptive to nursing
students’ ideas and feelings }{Children who cuddle up to their parents andhealthcare professionals}[ Situation resulting in a feeling of fear ]{ The gaze of healthcare professionals, which was felt as evaluative }
{ Sense of emptiness associated with a feeling of difficulty in relating }     related factor

Figure 1. Structure of influencing factors that make nursing students hesitant to take care ofchildren during clinical training in child nursing practicum

14
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In addition, nursing students perceived children’s words tobe directed against them and were subject to the children’s
moods, which fluctuated intensely with time. As a result, thenursing student’s interest and feelings for children diminishedgradually, and ultimately, they felt that they did not want totake care of children. The facial expression, words, gestures,and behavior displayed by the children to the nursing students
tended to be perceived by the latter as the children’s feelings
towards them. Children have intense emotional variations
depending on whether they are moody as a result of their
physical condition, or because of hospitalization and separation from their parents. In addition, the presence of unfamiliar
people, as well as that of unfamiliar objects and events, causes
anxiety, which leads to negative responses such as rejection 14).
The nursing students were unable to fully understand themeaning of the reactions displayed by the children, resulting
in them having negative feelings towards children.
Furthermore, probably because children were difficult tounderstand, or because the nursing students had no selfconfidence in relating with children, the students imagined
children’s negative feelings toward them; this, together withthe attitude of dislike displayed and directed by children
against nursing students, resulted in an anticipatory anxiety
with regard to taking care of children.
Previous reports have shown that, during clinical training
in various specialties, nursing students were anxious thatpatients might have unfavorable feelings toward them; thestudents depended on verbal communication while building
relationships with the children and responded to the words
said by the children, but were unable to interpret the latter’s
feelings 15). When taking care of children who are still developing language, an attempt to communicate through verbal
communication does not deepen the understanding of children. Because they lacked a deep understanding of children,
the nursing students were swayed by children’s words andbehavior, leading them to hesitate when interacting withchildren. In addition, although nursing students learn aboutchildren’s characteristics during lectures and attend clinicaltraining in pediatric nursing, more time may be needed toconnect the ideas about children’s characteristics learned inclass with the interpretation of children’s actual words andbehavior, as well as the understanding of children. Furthermore, students are confused by children’s crying and negative
words and behavior, and might lose the ability to stay calm
and interpret children’s behavior.
To understand children, nursing students need to acquire
the ability to interpret children’s words and behavior.

and the parent. In addition, they felt the strong bond between
the parent and the child, and felt hesitant to come between
the parent and the child. Currently, nursing students havelittle experience in daily tasks related to child-rearing, suchas changing diapers 16-17); thus, nursing students’ fear was dueto their lack of experience in parenting and being in contact
with children. As nursing students go through clinical training under such psychological conditions, having the parent insight led nursing students to feel the presence of the parent
excessively.
In addition, nursing students worried about how they wereperceived by the parents, and the possibility of building a
relationship with the parents placed pressure on the nursing students because of the parents’ personalities and feelings; this led to hesitation towards interacting with children.
Furthermore, by relating to the parents a number of times, ,the nursing students realized that the parents were anxious
about the children’s illnesses and were concerned about thefamily. By being excessively aware of parents in such an unstable psychological state, nursing students were confused andwondered how to relate to the parents. In addition, interactingwith children in the presence of the parents was perceived by
the nursing students as pressurizing and led them to hesitate
approaching the children.
The parents, who knew about the course of various typesof nursing care received by the children, were perceived bynursing students as people who evaluated their performancein nursing care. Because nursing students with poor nursing
experience lacked self-confidence in their own performancein nursing care, they perceived the parents as nursing evaluators, and as a result, taking care of children caused them anxiety. Despite their lack of experience as nursing care providers,nursing students doubted whether it was good to deal withthe children of parents who were highly concerned with theirchild’s health. Furthermore, nursing students felt that taking
care of children, despite their poor experience in nursing care,led them to sympathize with the children and their parents.
Parents start to trust nursing students for the first time on
the basis of the students’ behavior during the practice of nursing assistance 18). Building up a relationship of trust with themother is important. When nursing students gain confidence
in the field of children’s nursing care, parents will also start torelate to the nursing students 19). The nursing students’ way oftaking care of the child is a major factor in building a relationship of trust with the parents 18).
3. Perspective of being a nurse at the same time as being anursing student

2. Excessive awareness of the presence of parents

For nursing students, it is during practical clinical training in child nursing practicum that they get their very firstexperience in the actual practice of pediatric nursing. For
nursing students, clinical training in child nursing practicum
is an “unknown world,” which they go through with anxiety.
Clinical training in child nursing practicum is as short as twounits, and it is within that brief period that one has to build up
a relationship with children, which will allow for conducting
nursing care on the children. In addition, nursing students
went through clinical training while wondering how to initiate communication with nurses for the first time. While insuch a clinical training environment, relating with children
and their parents leads nursing students to be nervous. Whilein such a clinical training environment, relating with children

The presence of parents was also a factor with a major
impact on nursing students.
When a nursing student initially takes a child in theircharge, the parent who is present beside the child is perceived as someone who is familiar to the child, who knows
the child in detail, who has an established relationship withthe child, and most significantly, a person who has alreadyhad experience with raising children. Nursing students areexcessively aware of such parents, and are made more awareof their own lack of experience in raising children, as wellas their lack of contact with children; as a result, students
think they “cannot win-over the parents,” and are reluctant
to include themselves in the relationship between the child
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Yearbook on Journal of the Japan Society of Nursing Research 2014

and their parents is believed to lead to continuous anxiety innursing students.
Regarding the children who accepted being taken care of,as well as their parents, nursing students felt sympathy when
conducting nursing care, despite being students with little
nursing experience. With regard to children, nursing students
think that the burden on children due to nursing assistance
was minimal. However, nursing students felt fear even before
taking care of children, as they think of their own strengthand lack of self-confidence in conducting nursing assistance.
While taking care of children, nursing students felt anxious
about aggravating the children’s conditions.
In addition, clinical instructors and teachers, who practicechild nursing practicums in clinical settings, have experiencein pediatric nursing. For nursing students, the presence ofsuch medical professionals while they were taking care of thechildren made them feel as though they were undergoing anevaluation. The nursing students’ lack of self-confidence intaking care of children led them to feel nervous and frightened
while taking care of children in front of these professionals.

environments during nursing students’ clinical training period,or during a clinical training period in pediatric nursing. The
involvement of nursing students with children during clinical training in child nursing practicum was different among
nursing students, depending on the presence or absence ofexperience in conducting nursing assistance with children,and depending on the level of medical professionals’ involvement with the nursing students. The effect of the timing of theclinical training, as well as the effect of the clinical training
environment, require further investigation.
Acknowledgments

I would like to thank all nursing students from nursing colleges, who understood the purposes of this study and who
collaborated in the interviews. In addition, this study waspartially based on a presentation given at the 18th Annual
Meeting of the Japan Society of Child Health Nursing, withrevisions and corrections.
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In this study, which aimed at identifying the factors that
influence nursing students’ hesitation in taking care of children, an interview survey was conducted on nine nursing students who were studying at nursing colleges and who had
already completed their clinical training in pediatric nursing.
The resulting data were analyzed by adopting the techniqueused in the KJ method, and the following results were found.

1. Regarding factors influencing the reluctance felt by nursing
students with regard to taking care of children, the following
five categories were extracted: [psychological burden due
to the presence of the parents], [the attitude of dislike
displayed by the child], [the child’s reaction, which makes
the participant feel rejected], [anticipatory anxiety], and[situations resulting in fear].

2. The children-related factors influencing nursing students’hesitation were [the attitude of dislike displayed by children]and that which they directed against the nursing students,
as well as [the reactions displayed by children in response
to care, which made the nursing students feel rejected]. In
addition, as the nursing students imagined [the attitudeof dislike displayed by the children] and [the children’s
reactions, which made the nursing students feel rejected],
they displayed an [anticipatory anxiety].
3. Another influencing factor, which led nursing students
to hesitate to take care of children, was the [psychologicalburden caused by the nursing students’ excessive awarenessof the presence of the parents].

4. Other influencing factors that led nursing students tohesitate to take care of children were the fact that nursing
students, who were learners, were too concerned about
their own evaluation, as well as the presence of medical
professionals, which led to [situations resulting in fear].
IX. Limitations of this study and future challenges

This study did not consider the clinical training
16

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Yearbook on Journal of the Japan Society of Nursing Research 2014
Experiences with Children and Their Recognition of Children:
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Mothers in the Clinical Teaching of Pediatric Nursing—The
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How instruction should be given to the nurse students. The
Japanese Red Cross Junior College of Akita, 5, 73-78.

17This paper was published at “the Japan Society of Nursing Research” Vol.33 No.2 in 2010.