Assessment of Medical Fear Among Hospitalised School-Age Children Using the Child Medical Fear Scale (CMFS)

Medical fear is one of the most common and least-addressed problems of childhood hospitalisation. Children between 8 and 12 years are old enough to understand that a needle will hurt or a scan will be noisy, but not always old enough to say what frightens them — so nurses meet crying, refusal, aggression or silence without knowing the cause. Unrecognised fear makes procedures harder to perform, increases the need for restraint and reassurance, and can push children towards avoiding healthcare later in life.

This project is a descriptive cross-sectional study of medical fear among hospitalised school-age children, carried out by a group of four B.Sc Nursing students in the paediatric ward of a teaching hospital (referred to here as the study hospital). Fear is measured with the Child Medical Fear Scale (CMFS) — a self-report instrument originally developed by Broome and colleagues and revised by Mahat into a 17-item scale on which children rate how afraid they are of specific medical experiences such as injections, blood tests, ward routines and separation from parents.

Along with the overall level of fear, the study examines how CMFS scores relate to age, gender and previous hospitalisation experience, and which items are feared most. The work runs entirely on anonymised, aggregate data under the ICMR National Ethical Guidelines, with institutional ethics approval, written parental consent and child assent. It ends with practical nursing implications: procedural preparation, comfort positioning, distraction during venepuncture and child-friendly ward communication.

Nurses in a paediatric ward manage fear without measuring it. When a school-age child resists cannulation or cries before an injection, the team responds in the moment but has no record of what the child fears most, how intense the fear is, or which children are at highest risk. Visible distress appears late; by then, procedures take longer, require more staff, and leave the child less willing to cooperate the next day. Parents report that their children "dread" hospital visits, and nursing staff intuitively know this — yet the ward has no data to justify a formal preparation programme, a comfort-positioning protocol or distraction resources. There is a need for a structured, ethically sound measurement of medical fear using a validated self-report instrument, so that nursing care for hospitalised school-age children can be planned from evidence instead of impressions.

Abstract

Hospitalisation is a stressful event for a child: unfamiliar surroundings, separation from parents, painful procedures and loss of control all contribute to fear. This study measures the level and pattern of medical fear among hospitalised school-age children (8–12 years) in a paediatric ward using the Child Medical Fear Scale, and examines its association with selected variables. Data are analysed in SPSS and translated into concrete nursing implications for procedural preparation and child-friendly care.

Introduction

A school-age child admitted for dengue fever, a fracture or a planned surgery faces repeated blood sampling, intravenous cannulation, injections and examinations. Paediatric nursing textbooks treat fear as expected, but ward practice rarely measures it — nurses rely on visible distress, by which point cooperation is already lost. A short, validated self-report scale lets the child describe the fear directly, in their own rating, and gives the ward objective data to plan preparation and support.

Existing knowledge and the gap

International work with the CMFS (Broome's original scale and Mahat's revised 17-item version) consistently reports that "getting a shot" is the most feared item and that fear decreases with age. Indian paediatric nursing studies on procedural fear exist, but most focus on parents' perceptions or on a single procedure such as venepuncture. Few describe the overall fear profile of hospitalised Indian school-age children using a standardised self-report tool, and fewer still link the profile to nursing actions. This study fills that local gap: it produces a ward-level fear profile that the study hospital can act on immediately.

Proposed study

• Administer the CMFS to 60 hospitalised children aged 8–12 years who have been in the ward for at least 24 hours.
• Record socio-demographic and clinical variables (age, gender, diagnosis group, number of previous hospitalisations) on a separate anonymised sheet.
• Analyse scores in SPSS: descriptive statistics, item ranking, and association tests (chi-square, Mann-Whitney U, Spearman's correlation as applicable).
• Convert findings into a nursing-implications note and a poster for the paediatric ward.

Feasibility

• Technical: the tool is short, needs no equipment beyond printed forms, and the group already has SPSS through the Nursing Research and Statistics course.
• Financial: printing costs only; no intervention is tested, so no drug or consumable cost arises.
• Operational: the paediatric ward routinely admits school-age children, so 60 participants are reachable within 4–5 weeks of data collection.
• Ethical: the study is observational — it changes no treatment, stores no identity details, and uses consent plus assent at every step.

In scope

• Hospitalised children aged 8–12 years admitted to the paediatric ward for at least 24 hours.
• Self-reported fear measured by the 17-item CMFS, administered in English or Kannada as the child prefers.
• Socio-demographic and clinical variables limited to age, gender, diagnosis group, admission type and number of previous hospitalisations.
• Descriptive and inferential analysis of anonymised, aggregate data in SPSS.

Out of scope

• Children below 8 years (the CMFS is designed for school-age children) and adolescents above 12 years.
• Critically ill children in the PICU, children too unwell to participate, and those whose parents decline consent.
• Any intervention — the study measures fear; it does not test a therapy. Preparatory programmes are proposed only as future work.
• Parents' own anxiety scores, staff perceptions and clinical outcomes such as length of stay.

Research design: descriptive cross-sectional survey, approved by the institutional ethics committee of the study hospital and the college. Population and sampling: hospitalised school-age children (8–12 years) with at least 24 hours of ward stay; consecutive (non-probability) sampling until 60 usable responses, excluding critically ill children and refusals. Instruments: (1) a socio-demographic and clinical data sheet with no names or ID numbers — each child carries a study code; (2) the CMFS, translated into Kannada and back-translated, then pilot-tested on six eligible children who are excluded from the main sample.

Analysis plan: mean, SD, median and range for total fear; item-level means ranked to find the most feared experiences; Shapiro-Wilk to check normality; chi-square or Mann-Whitney U for gender and previous-hospitalisation comparisons; Spearman's correlation for age versus fear score. Significance is read at p < 0.05. As the team will defend in the viva, cut-off categories for reporting are derived from this sample's own distribution, not borrowed from any unverified source.

The study design is best read as a pipeline from approval to ward action, drawn below as a flowchart.

flowchart TD
  A["Permission: hospital + institutional ethics committee"] --> B["CMFS translated to Kannada and back-translated"]
  B --> C["Content validation by 2 paediatric nursing experts"]
  C --> D["Pilot with 6 children (excluded from main sample)"]
  D --> E["Main sample: 60 children, 8-12 years, ward stay 24 h or more"]
  E --> F{"Consent and assent obtained?"}
  F -->|"Parent consent + child assent"| G["Administer socio-demographic sheet + CMFS"]
  F -->|"Refusal at any point"| H["Child excluded; participation recorded as declined"]
  G --> I["Score items in Excel under study code only"]
  I --> J["SPSS: descriptive statistics and item ranking"]
  J --> K["Association tests: chi-square / Mann-Whitney U / Spearman"]
  K --> L["Report + nursing-implications note + ward poster"]

The conceptual frame links who the child is to what we measure and what nursing does with it:

flowchart LR
  V["Selected variables: age, gender, previous hospitalisations, diagnosis group"] --> S["Medical fear: CMFS total and item scores"]
  S --> N["Nursing implications: procedural preparation, comfort positioning, distraction, child-friendly communication"]

Three design decisions deserve mention. First, the scale is administered as the child's own self-report — the student reads items verbatim when needed but never suggests an answer, protecting the validity of the data. Second, consent and assent are treated as a stage gate: no form is collected from a child whose parent declined or who personally declined, and refusal is simply recorded as a count. Third, all analysis happens on coded, aggregate data, so no child can be identified at any stage — in the report, in the poster, or in the viva.

• Test a preparation intervention: a pre-post study of therapeutic play, demonstrator dolls or a picture-based preparation booklet against the fear profile this study produces.
• Widen the lens to parents: measure parental state anxiety during the child's procedure and study the parent–child fear relationship.
• Compare settings: replicate in a paediatric OPD or day-care chemotherapy unit, where the feared experiences differ from an inpatient ward.
• Follow the trajectory: a short longitudinal version measuring fear at admission, mid-stay and discharge to see whether ward experience reduces or reinforces fear.
• Support system change: if the top fears are procedural (they usually are), propose a ward protocol for comfort positioning and distraction, and audit its uptake.