Developmental Stages of the Learner
Susan B. Bastable
Gina M. Myers
CHAPTER HIGHLIGHTS
Developmental Characteristics
The Developmental Stages of Childhood
Infancy (First 12 Months of Life) and Toddlerhood (1-2 Years of Age)
Early Childhood (3-5 Years of Age)
Middle and Late Childhood (6-11 Years of Age)
Adolescence (12-19 Years of Age)
The Developmental Stages of Adulthood
Young Adulthood (20-40 Years of Age)
Middle-Aged Adulthood (41-64 Years of Age)
Older Adulthood (65 Years of Age and Older)
The Role of the Family in Patient Education
State of the Evidence
KEY TERMS
pedagogy
object permanence
causality
precausal thinking
animistic thinking
egocentric causation
syllogistic reasoning
conservation
causal thinking
propositional reasoning
egocentrism
imaginary audience
personal fable
andragogy
dialectical thinking
ageism
gerogogy
crystallized intelligence
fluid intelligence
OBJECTIVES
After completing this chapter, the reader will be able to
Identify the physical, cognitive, and psychosocial characteristics of learners that influence learning at various stages of growth and development.
Recognize the role of the nurse as educator in assessing stage-specific learner needs according to maturational levels.
Determine the role of the family in patient education.
Discuss appropriate teaching strategies effective for learners at different developmental stages.
When planning, designing, implementing, and evaluating an educational program, the nurse as educator must carefully consider the characteristics of learners with respect to their developmental stage in life. The more heterogeneous the target audience, the more complex the development of an educational program to meet the diverse needs of the population. Conversely, the more homogeneous the population of learners, the more straightforward the approach to teaching.
An individual’s developmental stage significantly influences the ability to learn. Pedagogy, andragogy, and gerogogy are three different orientations to learning in childhood, young and middle adulthood, and older adulthood, respectively. To meet the health-related educational needs of learners, a developmental approach must be used. Three major stage-range factors associated with learner readiness—physical, cognitive, and psychosocial maturation—must be taken into account at each developmental period throughout the life cycle.
For many years, developmental psychologists have explored the various patterns of behavior particular to stages of development. Educators, more than ever before, acknowledge the effects of growth and development on an individual’s willingness and ability to make use of instruction.
This chapter has specific implications for staff nurses and staff development nurse educators because of the recent mandates by The Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]). For healthcare agencies to meet Joint Commission accreditation requirements, teaching plans must address stage-specific competencies of the learner. In this chapter, the distinct life stages of learners are examined from the perspective of physical, cognitive, and psychosocial development; the role of the nurse in assessment of stage-specific learner needs; the role of the family in the teaching-learning process; and the teaching strategies specific to meeting the needs of learners at various developmental stages of life.
A deliberate attempt has been made to minimize reference to age as the criterion for categorization of learners. Research on life-span development shows that chronological age per se is not the only predictor of learning ability (Crandell, Crandell, & Vander Zanden, 2012; Santrock, 2011). At any given age, one finds a wide variation in the acquisition of abilities related to the three fundamental domains of development: physical (biological), cognitive, and psychosocial (emotional-social) maturation. Age ranges, such as those included after each developmental stage heading in this chapter, are intended to be used as merely approximate age-strata reference points or general guidelines; they do not imply that chronological ages necessarily correspond perfectly to
the various stages of development. Thus the term developmental stage is the perspective used, based on the confirmation from research that human growth and development are sequential but not always specifically age related.
the various stages of development. Thus the term developmental stage is the perspective used, based on the confirmation from research that human growth and development are sequential but not always specifically age related.
Recently, it has become clear that development is contextual. Even though the passage of time has traditionally been synonymous with chronological age, social and behavioral psychologists have begun to consider the many other changes occurring over time that affect the dynamic relationship between a human’s biological makeup and the environment. It is now understood that three important contextual influences act on and interact with the individual to produce development (Crandell et al., 2012; Santrock, 2011):
1. Normative age-graded influences are strongly related to chronological age and are similar for individuals in a particular age group, such as the biological processes of puberty and menopause, and the sociocultural processes of transitioning to different levels of formal education or to retirement.
2. Normative history-graded influences are common to people in a particular age cohort or generation because they have been uniquely exposed to similar historical circumstances, such as the Vietnam War, the age of computers, or the terrorist events of September 11, 2001.
3. Normative life events are the unusual or unique circumstances, positive or negative, that are turning points in individuals’ lives that cause them to change direction, such as a house fire, serious injury in an accident, winning the lottery, divorce, or an unexpected career opportunity.
Although this chapter focuses on the client as the learner throughout the life span, nurses and nurse educators can apply the stage-specific characteristics of adulthood and the associated principles of adult learning presented herein to any audience of young, middle, or older adult learners, whether the nurse is instructing the general public in the community, preparing students in a nursing education program, or teaching continuing education to staff nurses or colleagues.
DEVELOPMENTAL CHARACTERISTICS
As noted earlier, actual chronological age is only a relative indicator of someone’s physical, cognitive, and psychosocial stage of development. Unique as each individual is, however, some typical developmental trends have been identified as milestones of normal progression through the life cycle. When dealing with the teaching-learning process, it is imperative to examine the developmental phases as individuals progress from infancy to senescence so as to fully appreciate the behavioral changes that occur in the cognitive, affective, and psychomotor domains.
As influential as age can be to learning readiness, it should never be examined in isolation. Growth and development interact with experiential background, physical and emotional health status, and personal motivation, as well as numerous environmental factors such as stress, the surrounding conditions, and the available support systems, to affect a person’s ability and readiness to learn.
Musinski (1999) describes three phases of learning: dependence, independence, and interdependence. These passages of learning ability from childhood to adulthood, labeled by Covey (1990) as the “maturity continuum,” are identified as follows:
Dependence is characteristic of the infant and young child, who are totally dependent on others for direction, support, and nurturance from a physical,
emotional, and intellectual standpoint (unfortunately, some adults are considered to be stuck in this stage if they demonstrate manipulative behavior, do not listen, are insecure, or do not accept responsibility for their own actions).
Independence occurs when a child develops the ability to physically, intellectually, and emotionally care for himself or herself and make his or her own choices, including taking responsibility for learning.
Interdependence occurs when an individual has sufficiently advanced in maturity to achieve self-reliance, a sense of self-esteem, and the ability to give and receive, and when that individual demonstrates a level of respect for others. Full physical maturity does not guarantee simultaneous emotional and intellectual maturity.
If the nurse as educator is to encourage learners to take responsibility for their own health, learners must be recognized as an important source of data regarding their health status. Before any learning can occur, the nurse must assess how much knowledge the learner already possesses with respect to the topic to be taught. With the child as client, for example, new content should be introduced at appropriate stages of development and should build on the child’s previous knowledge base and experiences.
The major question underlying the planning for educational experiences is: When is the most appropriate or best time to teach the learner? The answer is when the learner is ready. The teachable moment, as defined by Havighurst (1976), is that point in time when the learner is most receptive to a teaching situation. It is important to realize that the teachable moment need not be a spontaneous and unpredictable event. That is, the nurse as educator does not always have to wait for teachable moments to occur; the teacher can actively create these opportunities by taking an interest in and attending to the needs of the learner, as well as using the present situation to heighten the learner’s awareness of the need for health behavior changes (Lawson & Flocke, 2009). When assessing readiness to learn, the nurse educator must determine not only whether an interpersonal relationship has been established, prerequisite knowledge and skills have been mastered, and the learner exhibits motivation, but also whether the plan for teaching matches the learner’s developmental level (Crandell et al., 2012; Leifer & Hartston, 2004; Polan & Taylor, 2011; Santrock, 2011).
THE DEVELOPMENTAL STAGES OF CHILDHOOD
Pedagogy is the art and science of helping children to learn (Knowles, 1990; Knowles, Holton, & Swanson, 2011). The different stages of childhood are divided according to what developmental theorists and educational psychologists define as speci fic patterns of behavior seen in particular phases of growth and development. One common attribute observed throughout all phases of childhood is that learning is subject centered. This section reviews the developmental characteristics in the four stages of childhood and the teaching strategies to be used in relation to the physical, cognitive, and psychosocial maturational levels indicative of learner readiness (Table 5-1).
Infancy (First 12 Months of Life) and Toddlerhood (1-2 Years of Age)
The field of growth and development is highly complex, and at no other time is physical, cognitive, and psychosocial maturation so changeable as during the very early years of childhood. Because of the dependency of members of this age group, the main focus of instruction for health maintenance of children is geared
toward the parents, who are considered to be the primary learners rather than the very young child (Crandell et al., 2012; Palfrey et al., 2005; Santrock, 2011). However, the older toddler should not be excluded from healthcare teaching and can participate to some extent in the education process.
toward the parents, who are considered to be the primary learners rather than the very young child (Crandell et al., 2012; Palfrey et al., 2005; Santrock, 2011). However, the older toddler should not be excluded from healthcare teaching and can participate to some extent in the education process.
TABLE 5-1 Stage-Appropriate Teaching Strategies | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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PHYSICAL, COGNITIVE, AND PSYCHOSOCIAL DEVELOPMENT
At no other time in life is physical maturation so rapid as during the period of development from infancy to toddlerhood (London, Ladewig, Ball, Bindler, & Cowen, 2011). Exploration of self and the environment becomes paramount and stimulates further physical development (Crandell et al., 2012). Patient education must focus on teaching the parents of very young children the importance of stimulation, nutrition, the practice of safety measures to prevent illness and injury, and health promotion (Polan & Taylor, 2011).
Piaget (1951, 1952, 1976)—a noted expert in defining the key milestones in the cognitive development of children—labels the stage of infancy to toddlerhood as the sensorimotor period. This period refers to the coordination and integration of motor activities with sensory perceptions. As children mature from infancy to toddlerhood, learning is enhanced through sensory experiences and through movement and manipulation of objects in the environment. Toward the end of the second year of life, the very young child begins to develop object permanence—that is, recognition that objects and events exist even when they cannot be seen, heard, or touched (Santrock, 2011). Motor activities promote toddlers’ understanding of the world and an awareness of themselves as well as others’ reactions in response to their own actions. Encouraging parents to create a safe environment can allow their child to develop with a decreased risk for injury.
The toddler has the rudimentary capacity for basic reasoning, understands object permanence, has the beginnings of memory, and begins to develop an elementary concept of causality, which refers to the ability to grasp a cause-and-effect relationship between two paired, successive events (Crandell et al., 2012). With limited ability to recall past happenings or anticipate future events, the toddler is oriented primarily to the here and now and has little tolerance for delayed gratification. The child who has lived with strict routines and plenty of structure has more of a grasp of time than the child who lives in an unstructured environment.
Children at this stage have short attention spans, are easily distracted, are egocentric in their thinking, and are not amenable to correction of their own ideas. Unquestionably, they believe their own perceptions to be reality. Asking questions is the hallmark of this age group, and curiosity abounds as they explore places and things. They can respond to simple, step-by-step commands and obey such directives as “give Grandpa a kiss” or “go get your teddy bear” (Santrock, 2011).
Language skills are acquired rapidly during this period, and parents should be encouraged to foster this aspect of development by talking with and listening to their child. As they progress through this phase, children begin to engage in fantasizing and make-believe play. Because they are unable to distinguish fact from fiction and have limited cognitive capacity for understanding cause and effect, the disruption in their routine during illness or hospitalizations, along with the need to separate from parents, are very stressful for the toddler (London et al., 2011). Routines give these children a sense of security, and they gravitate toward ritualistic ceremonial-like exercises when carrying out activities of daily living. Separation anxiety is also characteristic of this stage of development and is particularly apparent when children feel insecure in an unfamiliar environment. This anxiety is often compounded when they are subjected to medical procedures
and other healthcare interventions performed by people who are strangers to them (London et al., 2011).
and other healthcare interventions performed by people who are strangers to them (London et al., 2011).
According to Erikson (1963), the noted authority on psychosocial development, the period of infancy is one of trust versus mistrust. During this time, children must work through their first major dilemma of developing a sense of trust with their primary caretaker. As the infant matures into toddlerhood, autonomy versus shame and doubt emerges as the central issue. During this period of psychosocial growth, toddlers must learn to balance feelings of love and hate and learn to cooperate and control willful desires (Table 5-2).
Children progress sequentially through accomplishing the tasks of developing basic trust in their environment to reaching increasing levels of independence and self-assertion. Their newly discovered sense of independence often is expressed by demonstrations of negativism. Children may have difficulty in making up their minds, and, aggravated by personal and external limits, they may express their level of frustration and feelings of ambivalence in words and behaviors, such as by engaging in temper tantrums to release tensions (Falvo, 1994). With peers, play is a parallel activity, and it is not unusual for them to end up in tears because they have not yet learned about tact, fairness, or rules of sharing (Babcock & Miller, 1994; Polan & Taylor, 2011).
TABLE 5-2 Erikson’s Eight Stages of Psychosocial Development | |||||||||||||||||||||||||||||||||
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TEACHING STRATEGIES
Patient education for infancy through toddlerhood need not be illness related. Usually less time is devoted to teaching parents about illness care, and considerably more time is spent teaching aspects of normal development, safety, health promotion, and disease prevention. When the child is ill or injured, the first priority for teaching interventions would be to assess the parents’ and child’s anxiety levels and to help them cope
with their feelings of stress related to uncertainty and guilt about the cause of the illness or injury. Anxiety on the part of the child and parents can adversely affect their readiness to learn.
with their feelings of stress related to uncertainty and guilt about the cause of the illness or injury. Anxiety on the part of the child and parents can adversely affect their readiness to learn.
Although teaching activities primarily are directed to the main caregiver(s), children at this developmental stage in life have a great capacity for learning. Toddlers are capable of some degree of understanding procedures and interventions that they may experience. Because of the young child’s natural tendency to be intimidated by unfamiliar people, it is imperative that a primary nurse is assigned and time is taken to establish a relationship with the child and parents. This approach not only provides consistency in the teaching-learning process but also helps to reduce the child’s fear of strangers. Parents should be present whenever possible during formal and informal teaching and learning activities to allay stress, which could be compounded by separation anxiety (London et al., 2011).
Ideally, health teaching should take place in an environment familiar to the child, such as the home or daycare center. When the child is hospitalized, the environment selected for teaching and learning sessions should be as safe and secure as possible, such as the child’s bed or the playroom, to increase the child’s sense of feeling protected.
Movement is an important mechanism by which toddlers communicate. Immobility resulting from illness, hospital confinement, or disability tends to increase children’s anxiety by restricting activity. Nursing interventions that promote children’s use of gross motor abilities and that stimulate their visual, auditory, and tactile senses should be chosen whenever possible.
Developing rapport with children through simple teaching helps to elicit their cooperation and active involvement. The approach to children should be warm, honest, calm, accepting, and matter-of-fact. A smile, a warm tone of voice, a gesture of encouragement, or a word of praise goes a long way in attracting children’s attention and helping them adjust to new circumstances. Fundamental to the child’s response is how the parents respond to healthcare personnel and medical interventions.
The following teaching strategies are suggested to convey information to members of this age group. These strategies feed into children’s natural tendency for play and their need for active participation and sensory experiences.
For Short-Term Learning
Read simple stories from books with lots of pictures.
Use dolls and puppets to act out feelings and behaviors.
Use simple audiotapes with music and videotapes with cartoon characters.
Role-play to bring the child’s imagination closer to reality.
Give simple, concrete, nonthreatening explanations to accompany visual and tactile experiences.
Perform procedures on a teddy bear or doll first to help the child anticipate what an experience will be like.
Allow the child something to do—squeeze your hand, hold a Band-Aid, sing a song, cry if it hurts—to channel his or her response to an unpleasant experience.
Keep teaching sessions brief (no longer than about 5 minutes each) because of the child’s short attention span.
Cluster teaching sessions close together so that children can remember what they learned from one instructional encounter to another.
Avoid analogies and explain things in straightforward and simple terms because children take their world literally and concretely.
Individualize the pace of teaching according to the child’s responses and level of attention.
For Long-Term Learning
Focus on rituals, imitation, and repetition of information in the form of words and actions to hold the child’s attention. For example, practice washing hands before and after eating and toileting.
Use reinforcement as an opportunity for children to achieve permanence of learning through practice.
Employ the teaching methods of gaming and modeling as a means by which children can learn about the world and test their ideas over time.
Encourage parents to act as role models, because their values and beliefs serve to reinforce healthy behaviors and significantly influence the child’s development of attitudes and behaviors.
Early Childhood (3-5 Years of Age)
Children in the preschool years continue with development of skills learned in the earlier years of growth. Their sense of identity becomes clearer, and their world expands to encompass involvement with others external to the family unit. Children in this developmental category acquire new behaviors that give them more independence from their parents and allow them to care for themselves more autonomously. Learning during this time period occurs through interactions with others and through mimicking or modeling the behaviors of playmates and adults (Crandell et al., 2012; Santrock, 2011).
PHYSICAL, COGNITIVE, AND PSYCHOSOCIAL DEVELOPMENT
The physical maturation during early childhood is an extension of the child’s prior growth. Fine and gross motor skills become increasingly more refined and coordinated so that children are able to carry out activities of daily living with greater independence (Crandell et al., 2012; Santrock, 2011). Although their efforts are more coordinated, supervision of activities is still required because they lack judgment in carrying out the skills they have developed.
The early childhood stage of cognitive development is labeled by Piaget (1951, 1952, 1976) as the preoperational period. This stage, which emphasizes the child’s inability to think things through logically without acting the situation out, is the transitional period when the child starts to use symbols (letters and numbers) to represent something (Crandell et al., 2012; Santrock, 2011; Snowman, McCown, & Biehler, 2012).
Children in the preschool years begin to develop the capacity to recall past experiences and anticipate future events. They can classify objects into groups and categories but have only a vague understanding of their relationships. The young child continues to be egocentric and is essentially unaware of others’ thoughts or the existence of others’ points of view. Thinking remains literal and concrete—they believe what is seen and heard Precausal thinking allows young children to understand that people can make things happen, but they are unaware of causation as the result of invisible physical and mechanical forces. They often believe that they can influence natural phenomena, and their beliefs reflect animistic thinking—the tendency to endow inanimate objects with life and consciousness (Pidgeon, 1977; Santrock, 2011).
Preschool children are very curious, can think intuitively, and pose questions about almost anything. They want to know the reasons, cause, and purpose for everything (the why), but are unconcerned at this point with the process (the how). Fantasy and reality are not well differentiated. Children in this cognitive stage mix fact and fiction, tend to generalize, think magically, develop imaginary playmates, and believe they can control events with their thoughts. At the same time, they do possess self-awareness and realize that they are vulnerable to outside influences (Crandell et al., 2012; Santrock, 2011).
The young child also continues to have a limited sense of time. For children of this age,
being made to wait 15 minutes before they can do something can feel like an eternity. They do, however, understand the timing of familiar events in their daily lives, such as when breakfast or dinner is eaten and when they can play or watch their favorite television program. As they begin to understand and appreciate the world around them, their attention span (ability to focus) begins to lengthen such that they can usually remain quiet long enough to listen to a song or hear a short story read (Santrock, 2011).
being made to wait 15 minutes before they can do something can feel like an eternity. They do, however, understand the timing of familiar events in their daily lives, such as when breakfast or dinner is eaten and when they can play or watch their favorite television program. As they begin to understand and appreciate the world around them, their attention span (ability to focus) begins to lengthen such that they can usually remain quiet long enough to listen to a song or hear a short story read (Santrock, 2011).
In the preschool stage, children begin to develop sexual identity and curiosity, an interest that may cause considerable discomfort for their parents. Cognitive understanding of their bodies related to structure, function, health, and illness becomes more specific and differentiated. They can name external body parts but have only an ill-defined concept of the size and shape of internal organs and the function of body parts (Kotchabhakdi, 1985).
Explanations of the purpose and reasons for a procedure remain beyond the young child’s level of reasoning, so any explanations must be kept very simple and matter-of-fact (Pidgeon, 1985). Children at this stage have a fear of body mutilation and pain, which not only stems from their lack of understanding of the body but also is compounded by their active imagination. Their ideas regarding illness also are primitive with respect to cause and effect; illness and hospitalization are seen as a punishment for something they did wrong, either through omission or commission (London et al., 2011). Children’s attribution of the cause of illness to the consequences of their own transgressions is known as egocentric causation (Polan & Taylor, 2011; Richmond & Kotelchuck, 1984).
Erikson (1963) has labeled the psychosocial maturation level in early childhood as the period of initiative versus guilt. Children take on tasks for the sake of being involved and on the move (Table 5-2). Excess energy and a desire to dominate may lead to frustration and anger on their part. They show evidence of expanding imagination and creativity, are impulsive in their actions, and are curious about almost everything they see and do. Their growing imagination can lead to many fears—of separation, disapproval, pain, punishment, and aggression from others. Loss of body integrity is the preschool child’s greatest threat, which significantly affects his or her willingness to interact with healthcare personnel (Poster, 1983; Vulcan, 1984).
In this phase of development, children begin interacting with playmates rather than just playing alongside one another. Appropriate social behaviors demand that they learn to wait for others, give others a turn, and recognize the needs of others. Play in the mind of a child is equivalent to the work performed by adults. Play can be as equally productive as adult work and is a means for self-education of the physical and social world (Whitener, Cox, & Maglich, 1998). It helps the child act out feelings and experiences so as to master fears, develop role skills, and express joys, sorrows, and hostilities. Through play, children in the preschool years also begin to share ideas and imitate parents of the same sex. Role playing is typical of this age as the child attempts to learn the responsibilities of family members and others in society (Santrock, 2011).
TEACHING STRATEGIES
The nurse’s interactions with preschool children and their parents are often sporadic, usually occurring during occasional well-child visits to the pediatrician’s office or when minor medical problems arise. During these interactions, the nurse should take every opportunity to teach parents about health promotion and disease prevention measures, to provide guidance regarding normal growth and development, and to offer instruction about medical recommendations related to illness or disability. Parents can be
a great asset to the nurse in working with children in this developmental phase, and they should be included in all aspects of the educational plan and the actual teaching experience. Parents can serve as the primary resource to answer questions about children’s disabilities, their idiosyncrasies, and their favorite toys—all of which may affect their ability to learn (Hussey & Hirsh, 1983; Ryberg & Merrifield, 1984; Woodring, 2000).
a great asset to the nurse in working with children in this developmental phase, and they should be included in all aspects of the educational plan and the actual teaching experience. Parents can serve as the primary resource to answer questions about children’s disabilities, their idiosyncrasies, and their favorite toys—all of which may affect their ability to learn (Hussey & Hirsh, 1983; Ryberg & Merrifield, 1984; Woodring, 2000).
Children’s fear of pain and bodily harm is uppermost in their minds, whether they are well or ill. Because young children have fantasies and active imaginations, it is most important for the nurse to reassure them and allow them to express their fears openly (Heiney, 1991). Nurses need to choose their words carefully when describing procedures and interventions. Preschool children are familiar with many words, but using terms such as cut and knife is frightening to them. Instead, nurses should use less threatening words such as fix, sew, and cover up the hole. Band-Aids is a much more understandable term than dressings, and bandages are often thought by children to have magical healing powers (Babcock & Miller, 1994).
Although still dependent on family, the young child has begun to have increasing contact with the outside world and is usually able to interact more comfortably with others. Nevertheless, signi ficant adults in a child’s life should be included as participants during teaching sessions. They can provide support to the child, substitute as the teacher if their child is reluctant to interact with the nurse, and reinforce teaching at a later point in time. The primary caretakers, usually the mother and father, are the recipients of the majority of the nurse’s teaching efforts. They are the learners who will assist the child in achieving desired health outcomes (Kaakinen, Gedaly-Duff, Coehlo, & Hanson, 2010; Whitener et al., 1998).
The following specific teaching strategies are recommended:
For Short-Term Learning
Provide physical and visual stimuli because language ability is still limited, both for expressing ideas and for comprehending verbal instructions.
Keep teaching sessions short (no more than 15 minutes) and scheduled sequentially at close intervals so that information is not forgotten.
Relate information needs to activities and experiences familiar to the child. For example, ask the child to pretend to blow out candles on a birthday cake to practice deep breathing.
Encourage the child to participate in selecting between a limited number of teaching-learning options, such as playing with dolls or reading a story, which promotes active involvement and helps to establish nurse-client rapport.
Arrange small-group sessions with peers as a way to make teaching less threatening and more fun.
Give praise and approval, through both verbal expressions and nonverbal gestures, which are real motivators for learning.
Give tangible rewards, such as badges or small toys, immediately following a successful learning experience as reinforcers in the mastery of cognitive and psychomotor skills.
Allow the child to manipulate equipment and play with replicas or dolls to learn about body parts. Special kidney dolls, ostomy dolls with stomas, or orthopedic dolls with splints and tractions provide opportunities for hands-on experience.
Use storybooks to emphasize the humanity of healthcare personnel; to depict relationships between the child, parents, and others; and to assist with helping the child identify with particular situations.
For Long-Term Learning
Enlist the help of parents, who can play a vital role in modeling a variety of healthy habits, such as practicing safety measures and eating a balanced diet; offer them access to support and follow-up as the need arises.
Reinforce positive health behaviors and the acquisition of specific skills.
Middle and Late Childhood (6-11 Years of Age)
In middle and late childhood, children have progressed in their physical, cognitive, and psychosocial skills to the point where most begin formal training in structured school systems. They approach learning with enthusiastic anticipation, and their minds are open to new and varied ideas.
Children at this developmental level are motivated to learn because of their natural curiosity and their desire to understand more about themselves, their bodies, their world, and the influence that different things in the world have on them (Whitener et al., 1998). This stage is a period of great change for them, when attitudes, values, and perceptions of themselves, their society, and the world are shaped and expanded. Visions of their own environment and the cultures of others take on more depth and breadth (Santrock, 2011).
PHYSICAL, COGNITIVE, AND PSYCHOSOCIAL DEVELOPMENT
The gross- and fine-motor abilities of school-aged children become increasingly more coordinated so that they are able to control their movements with much greater dexterity than ever before. Involvement in all kinds of curricular and extracurricular activities helps them to fine-tune their psychomotor skills. Physical growth during this phase is highly variable, with the rate of development differing from child to child. Toward the end of this developmental period, girls more so than boys on the average begin to experience prepubescent bodily changes and tend to exceed the boys in physical maturation. Growth charts, which monitor the rate of growth, are a more sensitive indicator of health or disability than actual size (Crandell et al., 2012; Santrock, 2011).
Piaget (1951, 1952, 1976) labeled the cognitive development in middle and late childhood as the period of concrete operations. During this time, logical, rational thought processes and the ability to reason inductively and deductively develop. Children in this stage are able to think more objectively, are willing to listen to others, and selectively use questioning to find answers to the unknown. At this stage, they begin to use syllogistic reasoning—that is, they can consider two premises and draw a logical conclusion from them (Elkind, 1984; Steegen & De Neys, 2012). For example, they comprehend that mammals are warm-blooded and whales are mammals, so whales must be warm-blooded.
Also, children in this age group are intellectually able to understand cause and effect in a concrete way. Concepts such as conservation, which is the ability to recognize that the properties of an object stay the same even though its appearance and position may change, are beginning to be mastered. For example, they realize that a certain quantity of liquid is the same amount whether it is poured into a tall, thin glass or into a short, squat one (Snowman et al., 2012). Fiction and fantasy are separate from fact and reality. The skills of memory, decision making, insight, and problem solving are all more fully developed (Protheroe, 2007).
Children in this developmental phase are capable of engaging in systematic thought through inductive reasoning. They are able to classify objects and systems, express concrete ideas about relationships and people, and carry out mathematical operations. Also, they begin to understand and use sarcasm as well as to employ well-developed language skills for telling jokes, conveying complex
stories, and communicating increasingly more sophisticated thoughts (Snowman et al., 2012).
stories, and communicating increasingly more sophisticated thoughts (Snowman et al., 2012).
Nevertheless, thinking remains quite literal, with only a vague understanding of abstractions. Early on in this phase, children are reluctant to do away with magical thinking in exchange for reality thinking. They cling to cherished beliefs, such as the existence of Santa Claus or the tooth fairy, for the fun and excitement that the fantasy provides them, even when they have information that proves contrary to their beliefs.
Children passing through elementary and middle schools have developed the ability to concentrate for extended periods, can tolerate delayed gratification, are responsible for independently carrying out activities of daily living, have a good understanding of the environment as a whole, and can generalize from experience (Crandell et al., 2012). They understand time, can predict time intervals, are oriented to the past and present, have some grasp and interest in the future, and have a vague appreciation for how immediate actions can have implications over the course of time. Special interests in topics of their choice begin to emerge, and they can pursue subjects and activities with devotion to increase their talents in particular areas.
Children at this cognitive stage can make decisions and act in accordance with how events are interpreted, but they understand only to a limited extent the seriousness or consequences of their choices. Children in the early period of this developmental phase know the functions and names of many common body parts, whereas older children have a more specific knowledge of anatomy and can differentiate between external and internal organs with a beginning understanding of their complex functions (Kotchabhakdi, 1985).
As part of the shift from precausal thinking to causal thinking, the child begins to incorporate the idea that illness is related to cause and effect and can recognize that germs create disease. Illness is thought of in terms of social consequences and role alterations, such as the realization that they will miss school and outside activities, people will feel sorry for them, and they will be unable to maintain their usual routines (Banks, 1990; Koopman, Baars, Chaplin, & Zwinderman, 2004).
Research indicates, however, that systematic differences exist in children’s reasoning skills with respect to understanding body functioning and the cause of illness as a result of their experiences with illness. Children suffering from chronic diseases have been found to have more sophisticated conceptualization of illness causality and body functioning than do their healthy peers. Piaget (1976) postulated that experience with a phenomenon catalyzes a better understanding of it.
Conversely, the stress and anxiety resulting from having to live with a chronic illness or disability can interfere with a child’s general cognitive performance. Chronically ill children have a less refined understanding of the physical world than healthy children do, and the former often are unable to generalize what they learned about a specific illness to a broader understanding of illness causality (Perrin, Sayer, & Willett, 1991). Thus illness may act as an intrusive factor in overall cognitive development (Palfrey et al., 2005).
Erikson (1963) characterized school-aged children’s psychosocial stage of life as industry versus inferiority. During this period, children begin to gain an awareness of their unique talents and the special qualities that distinguish them from one another (Table 5-2). They begin to establish their self-concept as members of a social group larger than their own nuclear family and start to compare their own family’s values with those of the outside world.
The school environment, in particular, facilitates children of this age in gaining a sense of responsibility and reliability. With less dependency on family, they extend their intimacy to include special friends and social groups (Santrock, 2011). Relationships with peers and adults external to the home environment become important influences
in their development of self-esteem and their susceptibility to social forces outside the family unit. School-aged children fear failure and being left out of groups. They worry about their inabilities and become self-critical as they compare their own accomplishments to those of their peers. They also fear illness and disability that could significantly disrupt their academic progress, interfere with social contacts, decrease their independence, and result in loss of control over body functioning.
in their development of self-esteem and their susceptibility to social forces outside the family unit. School-aged children fear failure and being left out of groups. They worry about their inabilities and become self-critical as they compare their own accomplishments to those of their peers. They also fear illness and disability that could significantly disrupt their academic progress, interfere with social contacts, decrease their independence, and result in loss of control over body functioning.
TEACHING STRATEGIES
Woodring (2000) emphasizes the importance of following sound educational principles with the child and family, such as identifying individual learning styles, determining readiness to learn, and accommodating particular learning needs and abilities to achieve positive health outcomes. Given their increased ability to comprehend information and their desire for active involvement and control of their lives, it is very important to include school-aged children in patient education efforts. The nurse in the role as educator should explain illness, treatment plans, and procedures in simple, logical terms in accordance with the child’s level of understanding and reasoning. Although children at this stage of development are able to think logically, their ability to engage in abstract thought remains limited. Therefore, teaching should be presented in concrete terms with step-by-step instructions (Pidgeon, 1985; Whitener et al., 1998). It is imperative that the nurse observe children’s reactions and listen to their verbal feedback to confirm that information shared has not been misinterpreted or confused.
To the extent feasible, parents should be informed of what their child is being taught. Teaching parents directly is encouraged so that they may be involved in fostering their child’s independence, providing emotional support and physical assistance, and giving guidance regarding the correct techniques or regimens in self-care management. Siblings and peers should also be considered as sources of support. In attempting to master self-care skills, children thrive on praise from others who are important in their lives as rewards for their accomplishments and successes (Hussey & Hirsh, 1983; Santrock, 2011).
Education for health promotion and health maintenance is most likely to occur in the school system through the school nurse, but the parents as well as the nurse outside the school setting should be told which content is being addressed. Information then can be reinforced and expanded when in contact with the child in other care settings. Numerous opportunities for nurses to teach the individual child or groups of children about health promotion and disease and injury prevention are available in schools, physicians’ offices, community centers, outpatient clinics, or hospitals. Health education for children of this age can be very fragmented because of the many encounters they have with nurses in a variety of settings.
The school nurse, in particular, is in an excellent position to coordinate the efforts of all other providers so as to avoid duplication of teaching content or the giving of conflicting information as well as to provide reinforcement of learning. According to Healthy People 2020 (U.S. Department of Health and Human Services, 2012), health promotion regarding healthy eating and weight status, exercise, sleep, and prevention of injuries, as well as avoidance of tobacco, alcohol, and drug use, are just a few examples of objectives intended to improve the health of American children. The school nurse can play a vital role in providing education to the school-aged child to meet these goals (Leifer & Hartston, 2004). In support of this teaching-learning process, Healthy People 2020 has introduced the topic area “Early and Middle Childhood,” which recommends providing formal health education in the school setting (U.S. Department of Health and Human Services, 2012). The school nurse has the opportunity to educate children not only in a group when teaching a class, but also on a one-to-one basis when
encountering an individual child in the office for a particular problem or need.
encountering an individual child in the office for a particular problem or need.
The specific conditions that may come to the attention of the nurse in caring for children at this phase of development include problems such as behavioral disorders, hyperactivity, learning disorders, obesity, diabetes, asthma, and enuresis. Extensive teaching may be needed to help children and parents understand a particular condition and learn how to overcome or deal with it.
The need to sustain or bolster their self-image, self-concept, and self-esteem requires that children be invited to participate, to the extent possible, in planning for and carrying out learning activities (Snowman et al., 2012). For young children receiving an X-ray or other imaging procedure, for example, it would be beneficial to have them initially simulate the experience by positioning a doll or stuffed animal under the machine as the technician explains the procedure. This strategy allows them to participate and can decrease their fear. Because of children’s fears of falling behind in school, being separated from peer groups, and being left out of social activities, teaching must be geared toward fostering normal development despite any limitations that may be imposed by illness or disability (Falvo, 1994; Leifer & Hartston, 2004).
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