The Journal of School Nursing
2025, Vol. 41(2) 258–268
© The Author(s) 2025
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DOI: 10.1177/10598405231209897
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Abstract
During the COVID-19 pandemic, health professionals had to spend much of their time working in hospitals, which may have caused psychological distress to their children. This study was in the form of a case study pattern, one of the qualitative research methods aimed to identify the psychosocial effects of the COVID-19 pandemic on the primary school children of health professionals. Its sample consisted of health professionals (n = 60) and their children (n = 60), who were all at primary school. Data were collected from the parents using a questionnaire, and from the children by asking them to create drawings and explain them. Descriptive and content analysis were carried out. The findings were grouped under the headings of “Spatial and Social Effects on the Child’s Daily Life,” “Effects on the Child’s Emotions,” and “Effects on the Parent From the Child’s Perspective.” It is recommended that interventions to maintain the psychosocial well-being of children be planned.
KeywordsCOVID-19 pandemic, child, child’s drawings, psychosocial health
The daily lives of people changed drastically with the World Health Organization’s declaration on March 11, 2020 that the global COVID-19 outbreak had become a pandemic (WHO, 2020). Pandemics have profound physiological and psychological effects on human health (Ahorsu et al., 2020; Yakut et al., 2020). In such situations, individuals may experience fears about becoming infected and spreading the infection to family members, social isolation, and financial losses (Dubey et al., 2020; Jeong et al., 2016). Health professionals were the occupational group most affected by the course of the pandemic. Some had to self-isolate to protect their families from the virus (Nyashanu et al., 2020). In a study conducted with 989 hospital employees in Lahore, Pakistan to identify the effects of the COVID-19 pandemic on health professionals, more than half of the participants stated that they were deeply concerned about their health, while 73.5% reported their concern about their families was far greater (Talat et al., 2020).
Many health professionals had to spend time away from their families during the pandemic, and this negatively affected their children as well (Creese et al., 2021). Children who are separated from their families are at high risk for psychological disorders (Cao et al., 2020). During the pandemic, children experienced problems such as fear, anxiety, and physical and social isolation and may also have missed school for a prolonged period. It was reported at the time that clinging, inattention, and irritability were the most severe psychological conditions demonstrated by children during the pandemic (Jiao et al., 2020). In a study conducted with 359 young children aged 7–12 and 3,254 adolescents aged 13–18 in China, 91.06% reported having concerns about this pandemic; the anxiety levels of adolescents were significantly higher than those of the pre-teenage children, while having a family member or friend infected with coronavirus was also significantly associated with increases in anxiety levels (Duan et al., 2020).
While concerns have been reported about the effects of the COVID-19 pandemic on children, studies on this topic are still at an early stage (Gritti et al., 2020). Primary school children are able to understand cause-and-effect relationships regarding the concepts of illness and health, and have reached a stage of cognitive development that enables them to express their thoughts and feelings verbally and through visual representations (Hockenberry et al., 2021). Elharake et al. (2023) stated that being a family member of a healthcare worker was strongly associated with worse mental health outcomes in college students. Having a parent who is a health professional can make a child feel more safe and secure, but it can also mean parents spending time away from their children and make the parents more concerned about themselves or their children becoming infected. Identifying how the pandemic affected the children of health professionals may contribute to reducing the negative aspects of these effects and guide in the planning of appropriate interventions to help children cope with them. This study therefore aimed to identify the psychosocial effects of the COVID-19 pandemic on the primary school children of health professionals. The research questions were as follows:
(1) How do the primary school children of health professionals describe the effects of the COVID-19 pandemic on their daily life and emotions?
(2) How do the primary school children of health professionals describe the effects of the COVID-19 pandemic on their parents?
This study took the form of a case study, one of the qualitative research methods. Yıldırım and Şimşek (2011) explain case studies as follows: “The key feature of the qualitative case study is the in-depth investigation of one or more cases. In other words, factors related to a case (environment, individuals, events, processes, etc.) are investigated with a holistic approach; the focus is on how they affect the relevant case and how they are affected by it.” In addition, case studies focus on current events but do not attempt to change or control them (Yin, 1994). In this vein, the present study investigated the recent COVID-19 pandemic and its effects on the primary school children of health professionals. The study adhered to the applicable EQUATOR guidelines.
We determined the sample of the study using criterion sampling and convenience sampling, which are purposeful sampling methods used in qualitative research. “Criterion sampling” refers to the researcher’s determination of a sample in line with specific criteria. “Convenience sampling” refers to a sample that researchers reach easily, practically, and quickly (Yıldırım & Şimşek, 2011). The generalizability and reliability of convenience sampling are less than in other sampling methods. However, in the current study, we tried to reduce these limitations by using this method alongside criterion sampling.
The study was conducted in a university hospital with parents who were health professionals directly responsible for the treatment and care of patients. While the accessibility of the hospital was the main factor for its selection, in accordance with the use of convenience sampling, the fact that the hospital had a variety and relatively large number of health professionals was also important. After the specific hospital had been determined, two criteria were used to select the sample from this hospital:
(1) Having a child in primary school, and
(2) Volunteering to participate in the study with their child.
Ultimately, in line with both the aim and the sampling methods, the sample consisted of health professionals who worked at the university hospital, had children in primary school, and agreed to participate in the study with their children on a voluntary basis. Since the size of the sample and the experiences of the children of health professionals working in different units may have differed, all personnel who were parents of children in primary school and who could be reached were included. Initially, 65 health professionals wanted to participate in the study, but the children of 5 of them did not want to answer the questions afterward so they were excluded from the sample. Consequently, 60 health professional parents and their children participated in the study on a voluntary basis. Of the participating parents, 73.3% (n = 44) were female and 26.7% (n = 16) were male. More than half of the parents were nurses. Of the participating children, 63.3% (n = 38) were 6–8 years old, 53.3% (n = 32) were female, and 46.7% (n = 28) were male. Table 1 gives detailed information about the participants.
The study was carried out between January 10 and March 10, 2021. First, the researchers identified the health professionals in the hospital (nurses, physicians, emergency medical technicians, anesthesia technicians, and operating room technicians) who had children in primary school. Afterward, they explained the aim of the study and obtained the parents’ consent. The researchers asked the parents to fill in their part of the form, and then fill in the Child Form with their children. The researchers asked parents to have their children draw and explain the COVID-19 pandemic in accordance with a set of instructions provided. The data were then collected from the parents and the children. The fieldwork process of the study was thus completed.
In the hospital where the study was conducted, two wards and an intensive care unit were transformed into a COVID-19 care unit during the pandemic. During this process, adequate personal protective equipment (gloves, masks, and aprons) was provided to the healthcare workers. There was no change in the working hours of the personnel. However, a guesthouse was set up in order that COVID would not be transmitted to the relatives of any staff who developed COVID-19. Visits by relatives of patients were limited in all clinics, and a ban on visitation was imposed in COVID-19 unit.
Data were collected from the parents using a questionnaire, and from the children in the form of their drawings and explanations of those drawings. The data collection tool was the Parent and Child Form. The form was developed by researchers based on a literature review and after receiving expert opinion. The form was piloted among two parent– child dyads who were not part of the study.
The first part of the form was the Parent Form. This asked for information about the parents, such as gender and profession. The second part of the form was the Child Form. This consisted of questions for the child. For this section, the parents were instructed that they could directly ask the questions to their children and write down their answers, or that the children could write down their own answers if they wished. The questions in this section were about the children’s age, the things they could and could not do before and during the COVID-19 pandemic, and their positive and negative thoughts. In addition, one question showed images of six facial expressions and asked the children to mark the one that best represented their emotion during the COVID-19 pandemic (Gao et al., 2014). The third part of the form began with an instruction to parents under the heading “Instructions for Collecting Data From Your Child Through Drawing.”
Since children and researchers could not meet face-to-face due to the pandemic, the parents collected the data from the children in the form of their drawings. The instructions for the parents were created and explained to them. They included information about the appropriate space, atmosphere, materials to be used, the instructions to be given to the child, and the language to be used when asking the child to draw. Alternative explanations were also included, as well as what should be done if the child was not able to read and write, and the extent to which the parents could intervene in the process, as well as warnings about what not to do. In this context, the child was asked to divide a piece of paper into two by drawing a line in the middle. On one half of the page, the child was asked to draw their daily life before the pandemic (such as going to school, going to the park), how they felt (happy, relaxed, sad, etc.) and their parents. On the second half of the page, the child depicted their daily life during the pandemic (such as playing games at home, watching TV), how they felt (happy, relaxed, sad, etc.) and their parents. Then, the child was asked to explain the drawing verbally or in writing. If they explained the situation orally, the parent wrote this explanation down; otherwise, the child wrote this down themself.
Thus, while the form used as the data collection tool was sent to the parents in a single package, its first part collected data from the parent, while the second and third parts collected data from the child.
Approval was obtained from the Republic of Türkiye Ministry of Health to conduct this study. Written approval (KA20/377) was obtained from the University’s Non-Invasive Clinical Trials Ethics Committee. Written approval was also granted by the hospital to perform the study. Participation in the study was on a voluntary basis. The parents were informed about the aim of the study. Written informed consent was then obtained from the parents and children regarding their voluntary participation in the study. The participants’ names were not used; instead, they were identified with letter codes (for the child participants these were “C1, C2, … etc.”).
The data were subjected to descriptive and content analysis. This analysis was carried out in four stages:
(1) Determining the codes: Three researchers created a preliminary code list by taking into account the research questions and the questions and instructions in the Parent and Child Form.
(2) Coding the data: Two researchers independently analyzed the data using the preliminary code list. At this stage, each of them added new codes while marking down which codes in the preliminary code list had not been used. They then created the final code list together and recoded the data. Another researcher, who had not participated in the previous coding, subsequently reanalyzed the data independently together with two researchers. The consistency of these two separate encodings was calculated according to the Miles and Huberman formula: (P) = 82/(82 + 2) × 100 = 97.61. Therefore, the consistency between the coders was 97.61%.
(3) Finding and organizing the themes: The codes in the final code list created by the researchers were grouped and organized by theme.
(4) Obtaining the findings: The findings obtained through data analysis were presented by giving direct quotations under the themes.
The data consisted of the opinions of the health professional parents, the drawings made by their children, and the children’s explanations of these drawings. Descriptive and content analysis of the collected data was carried out. The findings obtained in this analysis are presented below under the sub-headings of “Spatial and Social Effects on the Child’s Daily Life,” “Effects on the Child’s Emotions,” and “Effects on the Parent From the Child’s Perspective.”
The children’s drawings represented a number of “empty spaces” in the section depicting their life during the pandemic. Most of the children drew parks when illustrating the pre-pandemic period (on the left side of the paper) and discussed in their explanations. Below are the examples of the drawings and explanations of the children who drew parks to depict their daily life before the pandemic (Figures 1–2).
Most of the children’s drawings of their daily life during the pandemic (on the right side of the paper), featured houses and empty playgrounds and they discussed this in their explanations. Below are examples of the drawings and explanations of houses as places related to the children’s daily life during the pandemic (Figures 3–4).
The data analysis showed that the second most frequent representation was of a school in the children’s drawings and explanations for the pre-pandemic period. Most of the children drew a school when depicting daily life before the pandemic. Below are the direct quotations from their explanations of their drawings:
Before the pandemic, we used to play in the garden with my teacher and friends (C19, aged 7)
I was very happy, my life was very fun and nice, and we went to school with my father. (C22, aged 7)
Before the pandemic, we played games and I had classes at school with my friends. Everything was great. (C33, aged 10)
Images of a hospital, a tent, an empty street, an empty balcony, and a police station were all featured as depictions of life during the pandemic. These drawings and the explanations for them are given below (Figures 5–7).
Markets, shopping malls, water parks, friends’ houses, the sea, a restaurant, and a football stadium were also found in some of the children’s drawings and explanations about their pre-pandemic lives. Below are the examples of these drawings and explanations (Figures 8–9).
According to the data analysis, one issue that stood out in the drawings and explanations of life before and during the pandemic was that the children often referred directly or indirectly to socializing and social activities. Most of the children drew themselves playing games with their friends in this context. Some children directly said “playing games” to explain them playing with friends and gave details such as “playing ball” or “jumping rope.” However, they also emphasized activities other than playing specific games with their friends, such as studying at school, going to their friends’ homes, singing with friends, and hugging them. Below is an example of a drawing and explanation about socializing with friends (Figure 10).
One result of the analysis of children’s drawings and explanations for pre-pandemic daily life was that most of the children emphasized activities with their parents. These activities included going to and from school together, going to a concert, the theater, a park, as well as going jogging, and going out in general. They also mentioned activities like cycling outside, horse riding, and going to the market. Below are examples of relevant drawings and explanations (Figures 11–12).
Regarding socializing during the pandemic, some children stated that they had online lessons, kept a distance when meeting friends, made phone calls, and dreamed of being able to play with their friends at home. Regarding the lack of socializing, some children stated that they played computer games at home, watched TV, and read books. Below are examples from the children’s drawings and explanations (Figures 13–14).
In the same vein, the children answered the question of how they would describe the COVID-19 pandemic by explaining the loss of parts of their usual routine, as expressed in their drawings. Most of the children discussed this issue. The losses in usual routines, from the most to the least common, were as follows: Not being able to go to a mall, park, cinema, or theater, not being able to take swimming, gymnastics, or basketball courses, not being able to play with friends, not going to school, and not being able to ride a bicycle. Below are some direct quotations from the children’s explanations:
I had a very good life before the pandemic, I used to go to the movies … During the pandemic, I could not go at all. (C28, Aged 7)
COVID-19 took away my friends and my swimming. (C29, Aged 10)
I can’t go to school, I’ve been away from my friends at school and in the apartment. (C43, Aged 8)
However, five children made positive statements about the pandemic, and said that the situation could be an advantage in terms of school holidays and spending more time with parents. Below is an example of this:
It’s good that school is on holiday. Mom and dad are at home on weekends. (C22, Aged 6)
In the present study, the analysis of the data obtained from the children through the drawings and the explanations of drawings yielded findings about how the children felt before and during the pandemic. The emotions expressed by the children in the drawings and explanations for the prepandemic period, from the most expressed to the least, were happy, jolly, free, relaxed, and strong. Below is a drawing that expresses such emotions (Figure 15).
The analysis of the drawings and descriptions of their lives during the pandemic showed that the emotions expressed by the children varied. According to the data analysis, the emotions from the most expressed to the least expressed were constricted, unhappy, bored, missing friends, school, teacher, cousins, sad, lonely, victimized, angry, threatened by the virus, and crazy. Below are the direct quotations by the children who expressed such emotions (Figure 16):
I’m tired of wearing masks. I miss my school, my friends and my teacher. I can’t go out whenever I want. (C10, Aged 9)
While describing the COVID-19 pandemic, children used expressions similar to the emotions revealed by analyzing the drawings and explanations. Thus, most children described the pandemic with emotions. Children’s emotions varied, and they reported that they experienced negative emotions more intensely. These emotions were feelings of frustration, longing, anxiety, and anger. Below are the direct quotations from children:
Before the pandemic, I could go out without a mask at any time and any day I wanted. In the pandemic, I can get out for a limited time. I used to visit, hug and kiss my relatives whenever I wanted. But I can’t anymore. (C3, aged 10)
I miss my friends so much because of COVID-19. (C27, aged 8)
It’s frustrating, I’m really annoyed. (C30, aged 9)
The children’s choices of facial expressions for the emotions they experienced due to the COVID-19 pandemic supported the findings of the data analysis. These choices also supported the emotions identified by the analysis of the drawings and explanations. As seen in Table 2, 36.7% of the children chose the “angry” face, 30% chose the “sad” face, and 18.3% chose the “natural” face.
The analysis of the data obtained from the children through their drawings and the explanations of these also focused on how they viewed the effect of the COVID-19 pandemic on their parents, revealing that the children mostly saw these effects through the prism of their relationships and the activities they did with their parents. The analysis of the drawings and explanations for the pre-pandemic period showed that the children were happy, they hugged their parents, spent time out on the balcony as a family, and had a regular schedule. Below is an example of this (Figure 17).
In the drawings and explanations of life during the pandemic, the children stated that their parents were unhappy, could not hug them, and were always in the hospital. Also, some children stated that their parent was constantly cleaning the home, making them study, only talking to the child on the phone or at a physical distance, was constantly tired and that they went out on the balcony less often. Below are examples of the children’s drawings and explanations (Figure 18):
I couldn’t hug my mother when she came home, I couldn’t jump into her lap. (C25, Aged 6)
Being always at home, watching cartoons together, going to the market together, helping each other, and playing games together at home were stated as positive effects of the pandemic.
In their drawings, the children emphasized the physical spaces that featured in their daily life both before and during the pandemic. They often depicted playing areas and schools for the pre-pandemic period, and the family home for the pandemic period. They expressed happiness at being able to spend time with friends and family members in these spaces before the pandemic. During the pandemic, some of the emphasis shifted to drawings of empty parks/streets, hospitals, and police stations. This suggests how their daily life had been interrupted, and may also indicate a longing to be able to freely spend time again in parks and in the street.
A meta-analysis of 15 studies examined the psychosocial and behavioral impact of lockdown and quarantine measures for the COVID-19 pandemic on children and adolescents and found that the behavior/psychological state of 79.4% of the children was negatively affected by the pandemic and quarantine, that at least 22.5% of children had a significant fear of COVID-19, and that 35.2% of the children experienced boredom (Panda et al., 2021). The study by Usta and Gökcan (2020) reported that the changes that children experienced the most during the pandemic were related to social isolation. The study by Aksu (2021) reported that the children mostly depicted streets and parks as spaces indicating their longing to be able to spend time outside, and that drawing rooms demonstrated boredom. According to “Ecological Theory,” a child’s microsystem consists of daily, continuous, and close relationships. Peer groups and school are important for school-age children and being able to attend school and engage in various forms of play are tools for socializing and learning them (Törüner & Büyükgönenç, 2017).
In the present study, half of the children drew themselves playing games with friends when thinking about the prepandemic period. Being able to play is vital for a child’s optimal growth and development and helps them develop to abilities to observe, understand, and learn about the world (Törüner & Büyükgönenç, 2017). In the present study, in addition to playing, the children’s drawings and explanations emphasized other activities with their friends (such as studying together, going to friends’ houses, and hugging their friends) and activities with their parents (such as going to and from school, going to a concert, the theater, or the park). Participation in group activities with peers, as well as in activities with their parents, is important for school-aged children (Hockenberry, 2020). In the study by Caldwell et al. (2021) conducted with young people in grades 3–12 (n = 279) and their parents (n = 699), the young people reported feeling bored, relaxed, depressed, safe, and worried, while 63% of them reported that they felt they were missing out on important life events. Gupta and Jawanda (2020) described negative daily changes due to the pandemic, including a lack of outdoor physical activities, disconnection from schools, and social isolation. As a result of schools being closed, the participants most frequently shared that they missed their friends and social interactions, in-person learning, and extra-curricular activities.
In the present study, the drawings and explanations of the social aspects of life during the pandemic often depicted online classes, keeping at a distance from friends, watching TV, playing computer games, and dreaming of playing with friends at home. In general, the children emphasized how their ability to socialize had been limited as a result of the pandemic. The majority of the children discussed changes and losses in their usual routines and the feeling of longing for things to be different. In a similar vein, the study by Üstündağ (2021), which investigated the effect of pandemic on children’s daily life and habits, reported that the children missed going to school instead of distance learning, spending their day with friends, maintaining their routine and previous habits, playing sports, and attending extracurricular activities.
In the study, children’s drawings and explanations expressed that they felt happy, joyful, and free in the pre-pandemic period and that they felt constricted, unhappy, and bored during the pandemic, and longed to be with their friends, cousins, and at school with their teachers. A similar study by Aydın (2021) with 876 participants, including children in grades 1–8 and their parents, found that while the anxiety and anger of children increased significantly, their happiness decreased significantly during the pandemic. One study evaluated the drawings of the 7–11-year-old children (n = 17) of nurses working in a pandemic hospital through their answers to open-ended questions about their perceptions of COVID-19 pandemic (Tiryaki et al., 2021). It found that the children depicted both positive emotions, such as excitement and happiness, and negative emotions such as sadness, anger, and fear, in their drawings, while some (n = 6) thought that people would be healthy if they complied with precautions. A similar study obtained similar results in drawings of 55 children (aged 4–14) from 17 countries, reflecting their perceptions of COVID-19 (Foster Club, 2020). It was also shown that the children had higher levels of anxiety and depression after the pandemic. Targeted early prevention and intervention services are needed to support children experiencing emotional problems and their access to health services.
Primary school children understand concepts such as time, space, and distance and can establish cause–effect relationships by thinking logically (Hockenberry, 2020). Thus, they are aware of the causal relationship between disease and health (Ball et al., 2015). In addition, children at this age have high separation anxiety (Törüner & Büyükgönenç, 2017). Children of health care professionals being taken care of by their grandparents or relatives are subjected to separation anxiety and excessive worrying (Mahajan et al., 2020). In the present study, some of the children stated that they could not spend time with their parents like before, could not hug them, were spending time away from them, or could only talk to them on the phone. Similarly, other studies have reported that anxiety and fear in children increased with the pandemic (Jiao et al., 2020; Tiryaki et al., 2021; Vigo et al., 2020).
Following rules, experiencing success, and meeting the expectations of society in general, their peers, and their families are important for children of this age (Hockenberry, 2020). Considering the characteristics of their developmental stage, the children involved in the present study may have been revealing the effects of the pandemic on themselves when they stated that their parents were sad and unhappy because they were apart and could not spend time together.
The study was limited to parents who volunteered, who were health professionals of the hospital selected using the convenience sampling method, and their children. In addition, due to the pandemic conditions, data were collected from parents and children using a form rather than through face-to-face interviews and observations.
Our study examined the psychosocial effects of the COVID-19 pandemic on the primary school children of health professionals. It was found that the children’s drawings emphasized that these children had to spend time away from their parents, that their daily routines had been disrupted, and that their lives had been negatively affected by the pandemic.
Primary school children of health professionals have unique psychosocial needs and experiences related to the COVID-19 pandemic. School nurses can be crucial in supporting these children and addressing their specific concerns. Children of health professionals experience higher levels of stress and anxiety due to concerns about the increased workload, risks their parents face, and disrupted family and daily routines. School nurses should be prepared to identify signs of anxiety and stress in these children and to provide a safe space for children to discuss changes in their family dynamics and offer emotional support. Also, they should maintain open lines of communication with health professional parents to understand their specific concerns and needs regarding their children’s well-being. Therefore, they could encourage resilience-building activities and coping strategies tailored to these children’s unique needs. This might include relaxation techniques and stress management strategies.
The authors would like to thank the study participants. The authors would like to express their gratitude to the mothers and infants who participated in the study.
Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ayşe Ay https://orcid.org/0000-0002-1574-4673
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Azize Karahan, PhD, RN, is a Professor at Başkent University Health Sciences Faculty, Department of Nursing, Ankara, Turkey.
Nida Temiz, PhD, is a Associate professor at Başkent University Education Faculty, Primary Teaching Programme, Ankara, Turkey.
Ziyafet Uğurlu, PhD, RN, is a Associate professor at Başkent University Health Sciences Faculty, Department of Nursing, Ankara, Turkey.
Berrak Fulser, Msc, RN, is a Lecturer at Acıbadem University Health Sciences Faculty, Department of Nursing.
Aysel Abbasoğlu, Msc, RN, is a Lecturer at Başkent University Health Sciences Faculty, Department of Nursing.
Ayşe Ay, PhD, RN, is a Assistant professor at Başkent University Health Sciences Faculty, Department of Nursing, Ankara, Turkey.
Nalan Özhan Elbaş, PhD, RN, is a Professor at Başkent University Health Sciences Faculty, Department of Nursing, Ankara, Turkey.
1 Department of Nursing, Başkent University Health Sciences Faculty, Ankara, Turkey
2 Primary Teaching Programme, Başkent University Education Faculty, Ankara, Turkey
3 Department of Nursing, Acıbadem University Health Sciences Faculty, Istanbul, Turkey
Corresponding Author:Ayşe Ay, Department of Nursing, Başkent University Health Sciences Faculty, Ankara, Turkey.Email: ayse0526@gmail.com
