The Perception of Nurses From Children With Intellectual Disabilities Using the Drawing Method: A Qualitative Study

ABSTRACT

Aim

This study aims to explore how children with mild intellectual disabilities perceive the nursing profession through the drawing method.

Design

This qualitative descriptive study used visual data analysis and the draw‐and‐tell technique to explore children's perceptions of nursing.

Methods

Phenomenology, a qualitative research approach, was employed to analyse 66 drawings obtained through the drawing method.

Results

The analysis revealed that children with intellectual disabilities predominantly perceive nurses as female and associate them with syringes. Furthermore, 82% of the children depicted nurses with smiling facial expressions, while only 4% portrayed frightened facial expressions. Through the drawing method, nurses can gain valuable insights into effective approaches when interacting with children with special needs. Moreover, this method has the potential to mitigate fears and foster positive perceptions of nursing among children with mild intellectual disabilities.

Patient or Public Contribution

A total of 66 participants consisting of children with intellectual disabilities agreed to participate in this study. Interviews with these participants were conducted in special education centres. Their responses contributed significantly to the content of this article. It will contribute to the approach of nurses to children with special needs.

1. Introduction

Individuals with intellectual disabilities are characterised by significant differences in their personal and developmental attributes, as well as academic abilities, in comparison to their peers. These differences arise from various factors (Eldeniz‐Çetin 2017). Individuals with intellectual disabilities encounter difficulties in areas such as education, transportation, accessing health services effectively, employment and economic status (Çakirer Çalbayram et al. 2018). Among the group of individuals with special needs, children with high sensitivity, particularly those with intellectual disabilities who cannot achieve their independence, stand out. It is known that the frequency of hospitalisation due to health problems other than disabilities is six times higher among disabled children compared to healthy peer groups (Bodur and Durduran 2009). Since health problems occur more frequently, monitoring of disabled children should be continued until the age of 18. Negative attitudes of nurses towards individuals with intellectual disabilities in healthcare delivery, limited service provision or low service quality can lead to feelings of helplessness, disappointment, and humiliation for both individuals with intellectual disabilities and caregivers, thereby exacerbating health inequalities and hindering their access to social services (Yıldırım Sarı 2010; Çelik et al. 2013).

Children with intellectual disabilities are required to cope with both the challenges brought by their special conditions and inequalities in healthcare. Considering the increasing number of individuals with intellectual disabilities worldwide and in Turkey, there emerges a necessity for nurses providing healthcare services to evolve and improve. This is because nurses, being indispensable members of the healthcare system, are expected to provide higher quality and more effective care (Gül and Dinç 2018; Kritsotakis et al. 2017). Revealing the perceptions of nursing among children with mild intellectual disabilities can be crucial in enhancing the quality of service provided. The drawing method can serve as a tool in expressing the difficulties experienced by children with intellectual disabilities and uncovering their perceptions of nursing.

Research involving children emphasises recognising them as experts of their own experiences, owning their knowledge, and valuing their unique perspectives (Kilgariff et al. 2025). This aligns with qualitative research traditions aimed at democratising the process by addressing power imbalances in researcher‐participant relationships and focusing on marginalised experiences (Karnieli‐Miller et al. 2009). Participatory methods are often employed, engaging children in activities like photography or drawing, as such approaches are believed to yield richer insights compared to traditional methods like interviews or observations (Berson et al. 2019).

Children reflect their hidden feelings in their inner worlds through drawing according to their mental‐sensory‐cognitive developmental stages, expressing an experience. In other words, drawing allows children to express themselves (Berson et al. 2019; Demirel and Çifçi 2021). Especially for special children who need to express themselves or be supported, data obtained through drawing can be used by nurses for identifying children's problems, communicating at a level appropriate to their development, and adopting appropriate approaches (Demirel and Çifçi 2021). Studies using the drawing method for children to express themselves can be found in the literature (Uysal et al. 2018; Çakirer Çalbayram et al. 2018). However, there is no study in the literature that reveals the perceptions of nursing among children with intellectual disabilitieswho frequently use healthcare facilities (February 21, 2024). Recent qualitative studies have explored children's perceptions of nursing through drawings, highlighting the role of social representations, stereotypes, and professional identity construction (García‐Navarro et al. 2024). While these studies demonstrate the value of drawing‐based methods in understanding children's views of nursing, research focusing specifically on children with intellectual disabilities remains scarce. Therefore, the present study addresses an important gap in the literature by examining this population. Although existing studies have examined children's perceptions of nurses in various international contexts, research focusing on children with intellectual disabilities from a cross‐cultural and inclusive healthcare perspective remains limited.

Drawing can be beneficial not only for nurses and other healthcare professionals but also for children with special needs. These benefits are as follows: (i) Nurses can obtain information on how to approach children with special needs, which can reduce the child's stress, accelerate the healing process, and shorten hospital stays (Çakirer Çalbayram et al. 2018). The comments obtained from the analysis of drawings may increase nurses' awareness of their roles and responsibilities and support them in approaching this sensitive group more empathetically. Due to being an easy and straightforward method for children to express their feelings, stronger bonds can be formed between the child and the nurse. (ii) Drawing may be effective in reducing fears related to the perception of nurses among children with intellectual disabilities and transforming perceptions of nursing positively. (iii) Additionally, it can be used to identify the expectations, perceptions, fears, and anxieties of children with intellectual disabilities regarding nurses and other healthcare professionals and hospitalisation and treatment. Therefore, the difficulties experienced by individuals with intellectual disabilities in accessing healthcare services may be minimised. (iv) The findings to be obtained using the drawing method may contribute to the planning of hospital nursing services for children with intellectual disabilities and their families. (v) It can guide nursing education institutions to include the difficulties experienced by children with intellectual disabilities and their families in their curricula. (vi) Nurses working in any setting can use the drawing method alongside verbal methods, considering the special circumstances and developmental levels of children. From a theoretical perspective, this study is informed by Social Representations Theory, which explains how individuals construct shared meanings about social objects and professional roles through everyday experiences, communication and cultural narratives. Children's perceptions of nursing are shaped not only by direct healthcare encounters but also by broader social and media representations of the profession. Recent international studies have increasingly used children's drawings to explore such social representations of nursing and healthcare professionals (e.g., García‐Navarro et al. 2024; Chang et al. 2022; Kim 2023). Positioning the present study within this framework allows for an interpretation of children's drawings as socially and culturally situated expressions rather than individual psychological diagnoses.

This study aims to explore the perceptions of children with mild intellectual disabilities regarding the nursing profession using the drawing method. The guiding research questions for this study are as follows:

1. What are the perceptions of children with intellectual disabilities towards nursing?

2. What are the variables that influence the perceptions of children with intellectual disabilities towards nursing?

2. Methods

2.1. Study Design

This study employed a qualitative descriptive research design using visual data analysis through the draw‐and‐tell technique. Qualitative descriptive designs aim to provide a comprehensive summary of participants' experiences and perceptions using low‐inference interpretation. In this study, children's drawings and accompanying verbal explanations were analysed descriptively to explore perceptions of nursing without applying formal phenomenological or psychotherapeutic analytic procedures. In this study, the phenomenon under investigation was the perception of nurses among children with special needs, examined through the method of drawing. Although some analytical aspects of drawing interpretation may appear similar to projective approaches, the present study does not aim to conduct projective or diagnostic psychological analysis. Instead, drawings were treated as visual and experiential expressions through which children communicate their perceptions of nursing. Interpretations were grounded primarily in the children's own verbal explanations accompanying their drawings, thereby focusing on meaning‐making processes rather than psychological inference or diagnosis. This clarification situates the study firmly within a visual phenomenological framework.

2.2. Place and Time of the Study

The study was conducted in three (3) special education and rehabilitation centres serving in Kastamonu City Center between December 11, 2023 and March 1, 2024. A psychologist, physiotherapist, physical education teacher, special educator (Child Development, Classroom and Preschool Teacher branches), and nurse work in the institution. Although there is no requirement for nurses in private institutions, there are nurses in the two institutions where the study was conducted.

2.3. Population and Sample

The population of the study consisted of children aged 6–12 years diagnosed with mild intellectual disabilities attending three special education and rehabilitation centres in Kastamonu city center for educational purposes. The inclusion criterion of mild intellectual disability was determined based on school records and confirmation by special education teachers, ensuring that all participants met the study requirements. The age range of 6–12 years was selected because children in this developmental period generally possess the cognitive, linguistic, and symbolic abilities required to understand and represent social roles, such as healthcare professionals, through drawings. Previous research indicates that children within this age range can meaningfully express perceptions and experiences related to professional concepts using visual and verbal methods. The sample for the study comprised children who voluntarily agreed to participate, with consent obtained from their families. Data were collected from 74 children. Eight drawings were excluded because they did not meet the predefined inclusion criteria. Specifically, exclusions included drawings that did not depict the concept of a nurse, drawings consisting of unrelated objects, or instances in which the child declined to engage with the drawing task. Exclusion decisions were made through consensus between two evaluators following independent review. Coding and thematic analysis were conducted on the final dataset consisting of 66 drawings and their accompanying verbal explanations.

2.4. Inclusion Criteria

The study included children with mild intellectual disabilities, aged 6–12 years, who were enrolled in special education centres. This age group was chosen because children with mild intellectual disabilities within this range typically have the ability to draw human figures and include details in their drawings, such as the sun, trees, and flowers. Participation in the study was voluntary, and children were included if their families did not include nurses and if they did not have any conditions that would impede their ability to draw. Exclusion criteria comprised children outside of special education institutions, those diagnosed with moderate to severe disabilities, those with impairments that hinder drawing (such as inability to use their hands), and those who declined to participate.

2.5. Data Collection Instruments

The data were obtained using the ‘Nurses from the Perspective of Children with Intellectual disabilities Data Collection Form’ prepared by the researchers, the ‘Nurse Facial Expression Form’, and the ‘Draw and Tell Method’. Children were provided with a white A4 paper and coloured pencils to create their drawings. Coloured pencils were preferred for drawing to allow for clearer depiction of discontinuity and continuity in the drawings and to determine clarity in colour preferences. Forms were completed before the drawing activity. Data obtained from the questionnaire were used to contextualise the visual data and to support the interpretation of children's drawings and verbal explanations. Questionnaire responses were not analysed independently but were integrated into the qualitative analysis to enhance interpretive transparency.

2.6. Data Collection Process

Participants were recruited through three special education and rehabilitation centres after obtaining institutional permission. Information about the study was first shared with the parents, and children whose families provided written consent were invited to participate. Children were informed in age‐appropriate language that participation was voluntary and that they could withdraw from the study at any time without any negative consequences. After providing information about the study to the children and their families and obtaining their consent, the ‘Nurses from the Perspective of Children with Intellectual Disabilities Data Collection Form’ was filled out by the researcher through face‐to‐face interviews with the children. Subsequently, the researcher distributed A4‐sized drawing papers (21.0 × 29.7 cm) and sets of 12 coloured pencils to the children, and they were asked to draw a picture representing what the term ‘nurse’ meant to them using the materials provided. Prior to the activity, no explanation was given to the children about the concept, and no intervention was made during the activity. There was no time limit set for the drawing activity. The drawing session took place in a quiet room within the educational centre that was familiar to the child. No teachers or institutional staff members were present during the drawing activity or the individual interviews in order to minimise any perception of obligation and to ensure the child's comfort and privacy. During the drawing activity, the researcher took notes on the figures drawn by the children. After all the children completed their drawings, individual interviews were conducted with them, asking them to explain their drawings. Data collection was conducted by the first author, who has an academic background in nursing and qualitative research methods and experience working with children. In addition to formal training in drawing analysis, the researcher had prior experience in qualitative data collection, including child‐centred interview techniques. The researcher had no prior relationship with the participants or their families before the study.

2.7. Ethical Considerations

Parents and children were provided with both verbal and written information about the purpose and characteristics of the research, emphasising voluntary participation, data confidentiality, and anonymity. The study was conducted in accordance with the principles of the Helsinki Declaration and was approved by the Social and Human Sciences Ethics Committee (Decision No: 26, Meeting Date: 08 November 2023). Written permission was obtained from the three special education and rehabilitation institutions where the research was conducted. Permission was also obtained from children and their families for the publication of children's drawings within the scope of informed consent. Written informed consent was obtained from parents or legal guardians prior to data collection. In addition, verbal assent was obtained from children using age‐appropriate language, emphasising that participation was voluntary. Consent and assent were treated as ongoing processes throughout the study. Children were reminded that they could pause or stop the drawing activity or interviews at any time without any consequences, and this was respected during the entire research process.

2.8. Data Analysis

The data obtained from the study were analysed using a combination of descriptive statistical methods and qualitative thematic analysis. In addition, the draw‐and‐tell technique was employed, in which researchers engaged in individual conversations with each child regarding their drawing. Children's verbal explanations and descriptions were audio‐recorded, transcribed verbatim, and analysed alongside the visual data to support interpretation. The draw‐and‐tell technique is widely used in research involving children, as it facilitates clarification of the meanings underlying visual representations (Sewell 2011). The draw‐and‐tell procedure was developed based on established literature and expert consultation to ensure age‐appropriate and ethically sound implementation. Although no formal pilot testing was conducted, the procedure followed widely used approaches in qualitative research with children and was reviewed by researchers experienced in child‐centred qualitative methods prior to data collection.

An inductive analytical approach was adopted. Initial codes were generated directly from both the drawings and the children's verbal explanations. These codes were subsequently grouped into broader categories and themes through iterative comparison. Visual and verbal data were analysed together to avoid isolated or decontextualized interpretation of drawings. All analyses were conducted manually without the use of qualitative data analysis software.

The drawings were interpreted by a researcher who is a professor in child development and who had received formal training in picture analysis, including Picture Analysis Practitioner Training, Objective and Projective Evaluation Tests, Child Perception Test, Thematic Perception Test and Visual Perception Test Practitioner Training. To enhance analytical rigour, a second academic with expertise in qualitative research and child development independently reviewed and coded the drawings. Discrepancies were discussed until consensus was reached.

During the analysis, the following criteria were considered:

• Human figure characteristics (e.g., presence or absence of body parts);

• Colours used in the drawings;

• Size and spatial placement of figures on the paper;

• Children's own verbal explanations, which provided contextual meaning for ambiguous or incomplete visual elements.

By integrating visual data with children's verbal narratives and employing analyst triangulation, the study aimed to ensure a comprehensive and credible understanding of how children with mild intellectual disabilities perceive nurses. Children's verbal explanations accompanying the drawings were transcribed verbatim and coded together with visual elements. An inductive thematic analysis approach was employed, allowing codes and themes to emerge directly from the data rather than being predetermined. Initial open codes were generated separately for visual and verbal data and then integrated during theme development.

Examples of initial codes included ‘nurse as injection,’ ‘smiling nurse’, ‘fear related to syringe’ and ‘absence of self‐representation’. These codes were subsequently grouped into broader categories such as ‘technical tasks associated with nursing’, ‘emotional expressions toward nurses’ and ‘children's positioning in relation to the nurse figure’. Themes were refined through iterative comparison across drawings and verbal narratives.

All analyses were conducted manually without the use of qualitative data analysis software.

2.9. Validity and Reliability

In contrast to quantitative research, validity and reliability in qualitative research can be classified into persuasiveness, transferability, and confirmability (Lincoln and Guba 1985). To ensure persuasiveness, experts with experience in qualitative research were asked to examine the study. After in‐depth examination and analysis of the drawings, they were presented to an expert proficient in picture analysis for validation. For transferability, which can also be referred to as external validity, the obtained data were supported by similar studies and theoretical knowledge. Confirmability was ensured by storing the data for future reference or examination if needed.

Yıldırım and Şimşek (2013) stated that reliability studies related to time and observation can be conducted to ensure the reliability of qualitative data. Time‐related reliability involves measuring the same phenomenon in the same way at different times, while observation‐related reliability refers to measuring a phenomenon in the same way by multiple researchers. In this study, two picture analyst academics examined and coded the pictures. The coding was repeated 2 weeks later to ensure reliability. Miles and Huberman's (2019) reliability formula, which is based on intercoder reliability, was used (Reliability = Agreement/Agreement + Disagreement). As a result of the calculations, the intercoder reliability was found to be 92% (75/75 + 15). An intercoder reliability above 70% is considered reliable (Miles and Huberman 2019).

2.9.1. Researcher Reflexivity and Trustworthiness

The research team consisted of academics with backgrounds in nursing, child development, and qualitative research methods. One researcher, who conducted the primary interpretation of the drawings, is a professor in child development and has formal training in picture analysis, including objective and projective evaluation techniques. All researchers had prior experience in qualitative research with children and had no prior relationship with the participants.

Throughout the research process, reflexivity was maintained by acknowledging the researchers' professional backgrounds and potential interpretive perspectives. To minimise subjective bias, interpretations of the drawings were grounded primarily in children's own verbal explanations and were discussed among the research team.

Credibility was enhanced through analyst triangulation. Drawings and accompanying verbal data were independently reviewed and coded by two researchers, and discrepancies were resolved through discussion until consensus was reached. Transferability was supported by providing detailed descriptions of the research context, participant characteristics, data collection procedures and analytical steps, allowing readers to assess the applicability of the findings to other settings. Confirmability was ensured by maintaining an audit trail, including original drawings, transcripts of children's explanations, coding sheets, and researcher notes, which were preserved for potential external review.

3. Findings

The findings are presented under key thematic areas to provide a focused and coherent overview of children's perceptions of nurses. Detailed illustrative examples are used selectively to support each theme, while interpretive and theoretical considerations are addressed in the Section 4. The examination of the demographic data of the research sample revealed that 52% of the participants are female and 48% are male. The most populous age group (64%) was 9–11 year‐olds. It was also noted that 95% of the children did not have a chronic illness, and 53% had no history of hospitalisation. Regarding the mothers' educational level, the majority were middle school graduates (both 41%), while the percentage of illiterate mothers and university graduates were the same at 2%. Furthermore, 85% of the mothers were reported as not working. Regarding the fathers' educational level, the highest proportion (43.9%) was graduates of middle school, while the lowest proportion (1.5%) was reported as illiterate. It can be said that the majority of the participants' family income level was moderate (73%). When asked which facial expression best reflects a nurse, the participants overwhelmingly (83%) chose the smiling face, while the least selected option was the scared expression (5%) (Table 1).

TABLE 1.

Descriptive characteristics of participants.

		N	%
Gender	Female	34	52
	Male	32	48
Age	6–8	18	27
	9–11	42	64
	12	6	9
Presence of chronic diseases	Yes	3	5
	No	63	95
Hospitalisation history	Yes	31	47
	No	435	53
Mother's level of education	Illiterate	2	3
	Primary school	15	22.7
	Middle school	27	41
	High school	20	30.3
	Bachelor's degree	2	3
Mother's employment status	Employed	10	15
	Unemployed	56	85
Father's level of education	Illiterate	1	1.5
	Primary school	19	28
	Middle school	29	43.9
	High school	15	22.7
	Bachelor's degree	2	3
Income level	Good	10	15
	Moderate	48	73
	Low	8	12
Which facial expression do the participants associate nurses with?	Smiling	55	83
	Angry	4	6
	Sad	4	6
	Scared	3	5
Total		66	100

When Figure 1 was examined, it was observed that a large portion of the children paired the nurse with the syringe, and in some drawings, children only drew the syringe without the nurse figure. In drawings featuring the syringe (51%), this figure appears larger than all other figures. Apart from the syringe, children generally associated a nurse with patient bed (13.5%), intravenous (IV) drip set (10.5%), hospital building (10.5%), stethoscope (5%), medication (5%), blood pressure cuff (3%) and white coat (1.5%) (Table 2). Children typically draw on past experiences when creating drawings (Yavuzer 1992). According to information obtained from teachers and children's descriptions of their drawings, a significant portion of the children who particularly drew patient beds (7 out of 9 children) had previously been hospitalised for treatment. During interviews with the children following the drawings, it was generally stated that nurses administer injections, draw blood, insert IV drips and administer medication. These responses are supportive of the children's drawings.

FIGURE 1.

Child drawings associated with syringe.

TABLE 2.

Distribution of figures depicted in association with nurses.

Figures depicted in association with nurses	N	%
Syringe	34	51
Patient bed	9	13.5
IV drip	7	10.5
Hospital	7	10.5
Medication	3	5
Stethoscope	3	5
Blood pressure monitor	2	3
White coat	1	1.5
Total	66	100

Children generally preferred to draw nurses with a smiling face (73%), while some (27%) chose to represent nurses without indicating any facial expression by drawing a straight line for a mouth or even without drawing a face at all (Table 3). A smiling face represents trust and friendliness in children's drawings. It is observed that children predominantly chose the smiling face symbol not only when drawing the figure itself but also in their preferences for facial expressions representing nurses.

TABLE 3.

The distribution of participants according to the depiction of the facial expressions of nurses.

Nurses' facial expressions depicted by the participants	N	%
Smiling face	46	73
Neutral face	17	27
Total	63	100

Although children may express anxiety or fear related to the elements they associate with nurses, they often do not attribute this anxiety to the nurse themselves. For example, in some instances, children drew nurses with wings (R29), or some added toys, flowers (R6), or heart figures next to them. In their descriptions of the drawings, they provided answers such as ‘the nurse played with me’, ‘she gave me toys’ or ‘she smiled at me’. However, in some drawings, it is possible to see figures with expressionless faces or without facial features such as eyes, mouth or nose being drawn for the nurses. The absence of eyes in the drawing may be interpreted as a reluctance to engage in communication, while the absence of a nose may reflect the child's expressed feelings during the draw‐and‐tell interview, rather than indicating a specific psychological condition. In one example (P54), the lack of any facial features on the nurse's face may suggest the child's avoidance of interacting with the nurse and an attempt to ignore her, reflecting the child's sense of insecurity. Similarly, in another example (P64), where the figures consist only of heads and bodies, each represented in a different colour, and no facial features are drawn to describe the figures, this ambiguity may indicate that the child's mind is unclear about nursing images, and the absence of hands and arms suggests that there is no clear indication of any contact or past life experience. Additionally, the absence of feet in the drawings may suggest uncertainty in the child's representation of interpersonal interaction, as supported by the contextual interpretation of the drawing. The direction of the figures' feet in the drawings also indicates the direction of communication. Figures whose feet face each other represent being in communication. The absence of feet in the drawing can also be interpreted as a sign of this uncertainty. When demographic data about the child who drew this picture is examined, the absence of a chronic illness and hospitalisation history supports this finding (Figure 2).

FIGURE 2.

Pictures of children associated with facial expressions of nurses.

The majority of the children did not include themselves in the picture next to the nurse figure; however, it is observed that some children did include themselves in the drawing (Table 4). Among these children, 12 (70.5%) depicted themselves with a smiling face, 3 (17.5%) with a fearful expression, and 2 (12%) portrayed themselves as sad.

TABLE 4.

Distribution of participants' own facial expressions as depicted by themselves.

Participants' own facial expressions as depicted by themselves	n	%
Smiling face	12	70.5
Scared face	3	17.5
Sad face	2	12
Total	17	100

Children also supported their emotions with the colours they used in their drawings. For example, in one drawing (P57), the child depicted himself as sad while lying in a hospital bed, choosing the purple colour that reflects his anxiety and sorrow. The medical treatment could be considered as a procedure that should cause concern for him. In the same example, the child depicted his father as sad and pessimistic, representing his wish for his father to prevent this procedure with the colour black, which symbolises sadness and despair. He depicted his mother as waiting sadly and helplessly, choosing the colour blue to represent her calmness. This example can be considered as a beautiful illustration of children expressing their emotions through drawings. Furthermore, the child's decision to depict the nurse by only drawing one arm in the same picture supports the findings in the previous table. In another example (P46), the child depicted her fear by painting herself clearly while obscuring the nurse figure with red, indicating their closed‐off communication. Similarly, by placing herself at one end of the paper and the nurse figure at the other end, the child expressed lack of communication (Figure 3).

FIGURE 3.

Pictures related to participants' own facial expressions.

The use of paper revealed various symbolic meanings in the positioning of the depicted figure. The spatial placement of figures on the paper was examined as a descriptive visual characteristic. While some interpretative frameworks in the literature associate spatial positioning with temporal or relational meanings, in the present study, placement was considered contextually and descriptively rather than as an indicator of specific psychological or temporal states. Figure placement on the upper or lower parts of the paper was described as a visual feature of the drawings. Interpretations were made cautiously and supported by children's verbal explanations, rather than being treated as symbolic or therapeutic indicators (Tezelli 2020). The majority of children (62%) preferred to draw their images in the centre of the given space (Table 5). For instance, in one example (P53), the child drew nurse figures throughout the paper while depicting himself inside a car. The figures standing on and in front of the car are indicated to be nurses holding needles, implying the child's desire to escape and his inability to do so. By positioning these drawings in the centre, the child referred to a recent hospital experience. Subsequently, drawings where the nurse figure was mostly (25%) depicted on the left side of the paper were observed. Drawings on the left side symbolise the past in human life, indicating the children's past hospitalisation or treatment experiences.

TABLE 5.

Distribution of the participants regarding the positioning of the nurse figure on the paper.

The positioning of the nurse figure on the paper	n	%
Centred	39	62
On the left	16	25
On the top	3	5
On the bottom	3	5
On the right	2	3
Total	63	100

As seen in P45, drawings on the left side of the paper are also noticeably clustered in a very small and limited area. It can be said that the child's past experiences with hospitals or nurses may have been unsettling or distressing (Figure 4). Subsequently, drawings positioned on the top (5%), bottom (5%), and right side (3%) of the paper are encountered. Figures depicted above or below the paper are generally singular, and there is often no reference to the child themselves or to an event. The syringe figure below the paper may indicate a lack of confidence stemming from fear, while the drawing on top of the paper could represent the nurse imagined by the child. This assumption is based on the choice of yellow colour for the nurse's uniform, which symbolises energy and warmth. In this case, the nurse constructed in the child's imagination could be interpreted as one who provides warmth and strength.

FIGURE 4.

Participants' drawings regarding the positioning of the nurse figure on the paper.

The images related to the drawing size of the nurse figure by the participants vary. A large portion of the children in the study (48%) drew the nurse figure in normal proportions. Some children (38%) drew smaller figures, and these drawings were often positioned not at the centre but towards the bottom or left side of the paper (Table 6). Small figures in the drawings may be associated with feelings expressed by the children during the draw‐and‐tell process, rather than representing fixed psychological traits. Drawing limited images in a specific area of the paper is also interpreted as a sign of insecurity and fear. The size, position, and colour choice of the figure in the example P67 support this information. Children who used large figures in their drawings (14%) were fewer in number. Variations in figure size were described as part of the visual characteristics of the drawings and were discussed in relation to children's accompanying verbal narratives, without attributing symbolic or psychotherapeutic meanings. In the example P29, the figure with wings added occupies the entire page, supported by heart and smiling face symbols. The child expressed that the nurse sister gave him chocolate, which supports the identification he has built with admiration. In P67, the drawing is both very small and coloured in purple. These two choices represent the fear and insecurity the child feels towards the concept of a nurse (Figure 5).

TABLE 6.

Participants' distribution based on the size of the nurse figure in their drawings.

Size of the nurse figure in the drawings	n	%
Normal	30	48
Small	24	38
Big	9	14
Total	63	100

FIGURE 5.

The pictures by the participants related to the size of the nurse figure.

When Table 7 is analysed, the majority of the children drew the nurse as a female figure. 84% were drawn as women and 16% as men.

TABLE 7.

The distribution of drawings related to the gender of the nurse figure.

Gender of the nurse	N	%
Female	53	84
Male	10	16
Total	63	100

When interpreting the children's drawings, the meaning of colours was examined, and it was observed that the colour red, which was most preferred by the children (30%), was associated with anxiety and anger (Table 8). Children predominantly chose the colour red not only for the nurse figure but also for other figures such as syringes, IV sets, or medications that could cause anxiety in themselves. The colour blue, on the other hand, represents peace and tranquillity. Upon examining the drawings where blue colour was chosen, it can be said that nurses were depicted with a smiling face, and the environment was calmer. Black colour symbolises pessimism and introversion. As seen in P1, a child completely drew the nurse in black. The most noticeable feature in the drawing is the nurse's eyes. Drawing only eyes or large eyes in drawings represents the child's feeling of being watched or being very curious. In this example, the child may be thinking that the nurse is watching him. During the interview, the child stated that the nurse had blue eyes. Therefore, the focus should primarily be on the colour black chosen when drawing the nurse.

TABLE 8.

Distribution of colours preferred by participants in representing the nurse figure.

Preferred colours for representing the nurse figure	N	%
Red	19	30
Blue	13	21
Black	11	17.5
Mixed colours	11	17.5
Purple	4	6
Brown	3	5
Green	1	1.5
Orange	1	1.5
Total	63	100

In another example (P43), the child chose the colour purple associated with sadness, fear, and gloom. In the drawing, the nurse is smiling, but the child's expression is striking because it is a distant human form without a clear body or feet drawing. Here, the child omitted the body parts that enable standing without drawing the body and feet, reflecting how negatively her self‐confidence was affected. Moreover, the serum given to the child is not on her arm but above her head. The drawing of the head in children's drawings also expresses dissatisfaction with the child's cognitive problems or the compatibility of her head with her body (large/small). Considering that the children in the study group show atypical developmental characteristics, it can be said that there is a reference to cognition or intelligence. In another example (P26), dark tones of colours were predominantly chosen, reflecting the child's restlessness. In the last example (P39), the child chose multiple colours when drawing the nurse. Additionally, the child expressed his perfectionist side by adding eyelashes, buttons to the uniform, and a licence plate to the ambulance (Figure 6).

FIGURE 6.

Colours preferred by participants in representing the nurse figure.

Another striking observation is that children use caps in their nurse figures, and some children (7 children) add the Red Cross symbol to the cap (Figure 7). In our country, the use of caps by nurses was abolished in 2004 on the grounds that ‘the cap restricts the movements of nurses, contributes to the transmission of microorganisms, and does not provide any positive contribution to nursing symbolically’. Moreover, although the symbol representing our country's healthcare system is the Red Crescent, the use of the Red Cross in the drawings can be attributed to the cartoons the children have watched. This finding also indicates that children's mental images of nurses are influenced not only by their direct life experiences but also by the media.

FIGURE 7.

One image where the participant used a cap in the nurse figure.

Interpretations related to figures, colours, and spatial placement are presented as descriptive and contextual observations based on the draw‐and‐tell process and should not be considered clinical or diagnostic conclusions.

Consistent with a descriptive phenomenological approach, the analysis focused on describing visual features and children's expressed meanings rather than attributing symbolic, temporal, or psychotherapeutic interpretations to the drawings.

4. Discussion

This study contributes to the growing international literature on children's perceptions of nursing by interpreting the findings within the framework of Social Representations Theory. This perspective allows children's drawings to be understood as socially and culturally situated representations shaped by healthcare experiences, media portrayals, and dominant professional images. Children with intellectual disabilities frequently encounter challenges when expressing their emotions. It is essential for nurses who work with these children to recognise their unique differences from adults and employ communication strategies tailored to their developmental stage to ensure effective care and treatment. Drawing pictures, known as an accessible and enjoyable technique, is thought to aid in understanding the perceptions, expectations, fears, and anxieties of children with intellectual disabilities regarding nurses, hospitals, and treatment. However, due to the absence of literature specifically examining the perception of nurses among children with special needs, the findings have been compared and discussed in light of similar research results from different sample groups.

Upon analysing children's drawings, it becomes evident that a significant number of them correlate nurses with syringes, with some drawings exclusively depicting syringes without including a nurse figure. Notably, in drawings featuring the syringe figure, it tends to be depicted larger than other elements, which could indicate heightened anxiety and aggression possibly stemming from perfectionist family expectations (Çankırılı 2011; Farokhi and Hashemi 2011; Yavuzer 1992). Furthermore, a closer examination reveals that the syringe is frequently depicted in red, suggesting that anxiety levels may be amplified for the aforementioned reasons. The colour red in children's drawings is commonly linked with illness, intense anxiety, danger, and anger (Paktuna Keskin 2012). In a study by Yılmaz and Esenay (2020) focusing on primary school children's perceptions of nursing, technical tasks such as ‘administering injections’ emerged prominently among the views of healthy children regarding nursing. Similarly, in research by Düzkaya et al. (2014) involving hospitalised children, ‘administering injections’ ranked as the foremost responsibility of nurses, with a rate of 75.2%. These findings underscore that administering injections is a central association children make with nurses, whether they are hospitalised or in good health. These findings align with previous research examining children's drawings of nurses, which emphasises the influence of social representations and stereotypical images of the nursing profession (García‐Navarro et al. 2024). Similar to our findings, children tend to associate nursing with gendered roles and specific medical tasks, suggesting that both personal healthcare experiences and broader social narratives shape their perceptions.

A smiling face represents trust and warmth in children's drawings. It is observed that children overwhelmingly choose the symbol of a smiling face (73%) not only when depicting figures but also when expressing their preferences for facial expressions representing nurses. In a study by Çakirer Çalbayram et al. (2018) investigating perceptions of nursing through drawings of 22 six‐year‐old children with chronic and acute illnesses, children generally described nurses as friendly. Similarly, Uysal et al. (2018) had hospitalised children draw pictures to determine their perceptions of nurses, finding that 66.3% of the children depicted them positively. Considering the fact that the nursing profession, which is an integral part of healthcare services today, is becoming increasingly qualified and professional, the quality of communication they establish with children could be a significant reason why children depict nurses with smiling faces.

In the drawings, most of the children (62%) preferred to draw in the centre of the space given to them. The figure being depicted in the centre represents the present moment (Tezelli 2020). Considering the special circumstances of the children in the sample, it can be said that they benefit from healthcare services more frequently compared to typically developing children. Since these children require treatment and monitoring more often, it is expected that they would depict the nurse figure in the centre to reflect the present moment.

The nursing profession is predominantly female compared to the male population. Although this ratio is gradually balancing out in recent times, it is still noticeable that the number of female nurses remains higher. In this study, 84% of the children depicted the nurse as female. Similarly, in a study conducted by Uysal et al. (2018), which examined the perception of nurses among hospitalised children using the drawing method, it was found that 85.5% of the children depicted the nurse as female.

Children's colour preferences in drawings are often a reflection of their subconscious; however, sometimes they may be related to momentary choices or the meaning attributed to a colour or the connection they establish with it. In this study, it was observed that the most preferred colour by children was red (30%). The colour red is associated with anxiety and anger. Children predominantly chose the colour red when colouring not only the nurse figure but also figures like syringes, serum sets, or medicines that could cause anxiety. Additionally, 62% of the children placed the nurse in the centre of the paper in their drawings. The fact that the figure in the centre of the paper is a nurse suggests recent hospital experience. The process of illness is a stressful and anxiety‐inducing experience for children and their parents (Konuk Şener and Karaca 2017). In the literature, it is reported that children may exhibit aggression behaviours such as anxiety, fear, stress, regression, unhappiness, apathy, hyperactivity and sleep disturbances associated with hospitalisation (Açıkgöz et al. 2019; Başbakkal et al. 2010; Melnyk 2000; Öztürk Şahin and Topan 2019). As nurses are healthcare professionals working in hospital environments, it is common for professions and objects that remind them of hospitals to be depicted in red. It is important to emphasise that interpretations related to colours, figure size, and spatial placement are presented as contextual and descriptive observations rather than diagnostic indicators. While previous literature suggests that visual elements in children's drawings may be associated with emotional experiences, these associations should be interpreted cautiously and within the context of children's verbal narratives and lived experiences. Interpreted within the framework of Social Representations Theory, the findings suggest that children's drawings reflect socially shared images of nursing that transcend individual experiences. The frequent depiction of nurses as female and associated with injections mirrors dominant international representations of nursing roles reported in recent literature. These representations appear to be shaped by healthcare encounters as well as broader cultural and media influences, supporting the relevance of an international perspective when interpreting children's perceptions of nursing.

4.1. Implications for Practice and Research

The findings of this study provide insight into how children with mild intellectual disabilities perceive nurses. The drawings reflect children's thoughts, emotions, and potential concerns regarding healthcare experiences, including common fears such as injections. These findings do not imply that nurses should implement the drawing method as a routine assessment tool, as this may not be feasible or appropriate in clinical settings.

Instead, the study highlights the importance of understanding children's experiences and perceptions. Nurses can use this knowledge to facilitate transitions in healthcare, anticipate potential anxieties, and provide tailored communication strategies. For example, if a child is likely to fear injections, nurses can proactively provide reassurance or clarify when procedures involving needles will not occur.

These findings emphasise that listening to and observing children's perspectives—through drawings in a research context—can inform practical approaches to improving paediatric care, without imposing additional responsibilities such as interpreting drawings in routine practice.

4.2. Study Strengths and Limitations

This study is one of the few that investigates how children with intellectual disabilities perceive nurses within health services in Turkey, and it is the first known study to employ the drawing method for this purpose. It contributes to the existing body of knowledge by highlighting how drawing enables children to express their views in healthcare settings, where their voices are not always sufficiently considered.

Nevertheless, this study has several limitations. First, it was conducted in a single province in Turkey, which limits the transferability of the findings to other regions and cultural contexts. Second, the sample consisted only of children with mild intellectual disabilities. Therefore, the results cannot be generalised to children with moderate or severe levels of disability, who may hold different perceptions and face distinct challenges. Third, the drawing method, while valuable for capturing children's perspectives, is interpretative by nature and does not establish causality between experiences and perceptions. Finally, relying solely on drawings may not fully reflect the complexity of children's understandings; integrating interviews, focus groups, or observational data could strengthen future studies and provide a more comprehensive view. Although children with mild intellectual disabilities have the capacity to actively contribute to research processes, the present study adopted a researcher‐guided approach due to ethical considerations and the structured nature of data collection within special education centres. Parents or guardians were not involved in the study design phase; however, their role was limited to providing informed consent and supporting their child's voluntary participation. Future studies may benefit from adopting more participatory and inclusive designs by involving.

5. Conclusion and Recommendations

It has been identified that children with intellectual disabilities predominantly perceive nurses as female and often associate them with syringes. In fact, 82% of the children depicted nurses with a smiling expression. Given that children frequently encounter difficulty in articulating their emotions, nurses who work with such children must recognise their distinctiveness from adults and employ communication strategies tailored to their developmental stage. Utilising drawing as a simple and enjoyable technique can offer valuable insights into children's expectations of nurses and other healthcare providers, as well as their apprehensions regarding hospitals and medical procedures. When children feel understood, their trust grows, alleviating their anxieties and expediting the healing process. Through the medium of drawing, nurses can glean vital information, particularly on how to interact with children with intellectual disabilities, thereby mitigating their stress and facilitating their adjustment. It is advisable to undertake qualitative studies to deepen our understanding of how children perceive nurses and to pinpoint effective behavioural interventions. Because children with intellectual disabilities have complex care burdens, psychosocial risk factors, frequent health service use or need multiple service providers, the child and family in this group need proactive care coordination that should be provided by the nurse. Therefore, it is recommended that nurses take part in the team in special care centres. In addition, this study shed light on how nurses, who frequently encounter children with intellectual disabilities in many places where nursing services are provided such as hospitals, rehabilitation centres, home health services, school health, special clinics and polyclinics, community health and public health services, are perceived in the world of children.

Author Contributions

Mahinur Durmus: writing – original draft, methodology, investigation, data curation. Havva Kaçan: writing – review and editing, writing – original draft, supervision, formal analysis, data curation. Mehmet Kanak: supervision, methodology, formal analysis, data curation, conceptualization.

Funding

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.