Chapter 5 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 conservation dialectical thinking object permanence causal thinking ageism causality propositional reasoning gerogogy precausal thinking egocentrism crystallized intelligence animistic thinking imaginary audience fluid intelligence egocentric causation personal fable syllogistic reasoning andragogy

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OBJECTIVES

After completing this chapter, the reader will be able to 1. Identify the physical, cognitive, and psychosocial characteristics of learners that influence learning at various stages of growth and development. 2. Recognize the role of the nurse as educator in assessing stage-specific learner needs according to maturational levels. 3. Determine the role of the family in patient education. 4. Discuss appropriate teaching strategies effective for learners at different developmental stages.

hen planning, designing, implement- cognitive, and psychosocial development. Also, ing, and evaluating an educational this chapter emphasizes the role of the nurse program, the nurse as educator must in assessment of stage-specific learner needs, Wcarefully consider the characteristics of learn- the role of the family in the teaching–learning ers with respect to their developmental stage process, and the teaching strategies specific to in life. The more heterogeneous the target au- meeting the needs of learners at various devel- dience, the more complex the development of opmental stages of life. an educational program to meet the diverse A deliberate attempt has been made to min- needs of the population. Conversely, the more imize reference to age as the criterion for cat- homogeneous the population of learners, the egorization of learners. Research on life-span more straightforward the approach to teaching. development shows that chronological age per An individual’s developmental stage signifi- se is not the only predictor of learning ability cantly influences the ability to learn. Pedagogy, (Crandell, Crandell, & Vander Zanden, 2012; andragogy, and gerogogy are three different ori- Santrock, 2017). At any given age, one finds a wide entations to learning in childhood, young and variation in the acquisition of abilities related to middle adulthood, and older adulthood, respec- the three fundamental domains of development: tively. To meet the health-related educational physical (biological), cognitive, and psychosocial needs of learners, a developmental approach (emotional–social) maturation. Age ranges, such must be used. Three major stage-range factors as those included after each developmental stage associated with learner readiness—physical, heading in this chapter, are intended to be used as cognitive, and psychosocial maturation—must merely approximate age-strata reference points or be considered at each developmental period general guidelines; they do not imply that chrono- throughout the life cycle. logical ages necessarily correspond perfectly to For many years, developmental psychologists the various stages of development (Newman & have explored the various patterns of behavior Newman, 2015). Thus, the term developmental characteristic of specific stages of development. stage is the perspective used, based on the con- Educators, more than ever before, acknowledge firmation from research that human growth and the effects of growth and development on an development are sequential but not always spe- individual’s willingness and ability to make use cifically age related (Kail & Cavanaugh, 2015). of instruction. This chapter has specific impli- Recently, it has become clear that develop- cations for nurses educating patients, staff, and ment is contextual. Even though the passage of students as teaching plans must address stage- time has traditionally been synonymous with specific competencies of the learner. In this chap- chronological age, social and behavioral psy- ter, therefore, the distinct life stages of learners chologists have begun to consider the many are examined from the perspective of physical, other changes occurring over time that affect

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the dynamic relationship between a human’s bi- cognitive, and psychosocial stage of development. ological makeup and the environment. It is now Unique as every individual is in the world, how- understood that three important contextual in- ever, some typical developmental trends have fluences act on and interact with the individual been identified as milestones of normal progres- to produce development (Crandell et al., 2012; sion through the life cycle. When dealing with Santrock, 2017): the teaching–learning process, it is imperative to examine the developmental phases as individuals 1. Normative age-graded influences are strongly related to chronological age progress from infancy to senescence to fully ap- and are similar for individuals in a preciate the behavioral changes that occur in the specific age group, such as the biolog- cognitive, affective, and psychomotor domains. ical processes of puberty and meno- As influential as age can be to learning read- pause and the sociocultural processes iness, it should never be examined in isolation. of transitioning to different levels of Growth and development interact with experiential background, physical and emotional formal education or to retirement. health status, and personal motivation, as well as 2. Normative history-graded influences are common to people in a certain numerous environmental factors such as stress, age cohort or generation because the surrounding conditions, and the available they have been uniquely exposed support systems, to affect a person’s ability and to similar historical circumstances, readiness to learn. such as the Vietnam War, the age of Musinski (1999) describes three phases of computers, or the terrorist events of learning: dependence, independence, and inter- September 11, 2001. dependence. These passages of learning ability 3. Normative life events are the unusual from childhood to adulthood, labeled by Covey or unique circumstances, positive or (1990) as the “maturity continuum,” are identi- negative, that are turning points in fied as follows. individuals’ lives that cause them to ■■ change direction, such as a house fire, Dependence is characteristic of the infant serious injury in an accident, win- and young child, who are totally dependent on others for direction, support, and ning the lottery, divorce, or an un- nurturance from a physical, emotional, and expected career opportunity. intellectual standpoint (unfortunately, some Although this chapter focuses on the patient adults are considered stuck in this stage if as the learner throughout the life span, nurses they demonstrate manipulative behavior, and nurse educators can apply the stage-specific do not listen, are insecure, or do not accept characteristics of adulthood and the associated responsibility for their own actions). principles of adult learning presented herein to ■■ Independence occurs when a child develops any audience of young, middle, or older adult the ability to physically, intellectually, and learners, whether the nurse is instructing the emotionally care for himself or herself and public in the community, preparing students in make his or her own choices, including a nursing education program, or providing con- taking responsibility for learning. tinuing education to staff nurses or colleagues. ■■ Interdependence occurs when an individual has sufficiently advanced in maturity to achieve self-reliance, a sense of self-esteem, ▸▸ Developmental and the ability to give and receive, and Characteristics when that individual demonstrates a level of respect for others. Full physical matu- As noted earlier, actual chronological age is rity does not guarantee simultaneous emo- only a relative indicator of someone’s physical, tional and intellectual maturity.

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If the nurse as educator is to encourage learn- define as specific patterns of behavior seen in ers to take responsibility for their own health, definitive phases of growth and development. learners must be recognized as an important One common attribute observed throughout all source of data regarding their health status. Be- phases of childhood is that learning is subject fore any learning can occur, the nurse must as- centered. This section reviews the developmen- sess how much knowledge the learner already tal characteristics in the four stages of child- possesses with respect to the topic to be taught. hood and the teaching strategies to be used in With the child as client, for example, new con- relation to the physical, cognitive, and psycho- tent should be introduced at appropriate stages social maturational levels indicative of learner of development and should build on the child’s readiness (Table 5-1). previous knowledge base and experiences. The major question underlying the planning for educational experiences is: When Infancy (First 12 Months of Life) is the most appropriate or best time to teach the learner? The answer is when the learner is ready. and Toddlerhood (1–2 Years The teachable moment, as defined by Havighurst of Age) (1976), is that point in time when the learner is The field of growth and development is highly most receptive to a teaching situation. It is im- complex, and at no other time is physical, cog- portant to realize that the teachable moment need nitive, and psychosocial maturation so change- not be a spontaneous and unpredictable event. able as during the very early years of childhood. That is, the nurse as educator does not always Because of the dependency of members of this have to wait for teachable moments to occur; the age group, the focus of instruction for health teacher can actively create these opportunities by maintenance of children is geared toward the taking an interest in and attending to the needs parents, who are considered the primary learn- of the learner, as well as using the present situ- ers rather than the very young child (Callans, ation to heighten the learner’s awareness of the Bleiler, Flanagan, & Carroll, 2016; Crandell et al., need for health behavior changes (Hinkle, 2014; 2012; Santrock, 2017). However, the older tod- Lawson & Flocke, 2009). When assessing readi- dler should not be excluded from healthcare ness to learn, the nurse educator must determine teaching and can participate to some extent in not only whether an interpersonal relationship the education process. has been established, prerequisite knowledge and skills have been mastered, and the learner exhibits motivation, but also whether the plan Physical, Cognitive, and for teaching matches the learner’s developmental level (Crandell et al., 2012; Leifer & Hartston, Psychosocial Development 2013; Polan & Taylor, 2015; Santrock, 2017). At no other time in life is physical maturation so rapid as during the period of development from infancy to toddlerhood (London et al., ▸ 2017). Exploration of self and the environment ▸ The Developmental becomes paramount and stimulates further phys- Stages of Childhood ical development (Crandell et al., 2012; Kail & Cavanaugh, 2015). Patient education must focus Pedagogy is the art and science of helping chil- on teaching the parents of very young children dren to learn (Knowles, 1990; Knowles, Holton, the importance of stimulation, nutrition, the & Swanson, 2015). The different stages of child- practice of safety measures to prevent illness hood are divided according to what develop- and injury, and health promotion (Polan & mental theorists and educational psychologists Taylor, 2015).

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TABLE 5-1 Stage-Appropriate Teaching Strategies

Learner General Characteristics Teaching Strategies Nursing Interventions

Infancy–Toddlerhood

Approximate age: Dependent on environment Orient teaching to caregiver Welcome active involvement Birth–2 years Needs security Use repetition and imitation of Forge alliances Cognitive stage: Explores self and environment information Encourage physical closeness Sensorimotor Natural curiosity Stimulate all senses Provide detailed information Psychosocial stage: Provide physical safety and emotional Answer questions and Trust vs. mistrust security concerns (Birth–12 mo) Allow play and manipulation of objects Ask for information on child’s Autonomy vs. shame and strengths/limitations and likes/ doubt (1–2 yr) dislikes

Early Childhood The Developmental StagesofChildhood The Developmental Approximate age: Egocentric Use warm, calm approach Welcome active involvement 3–5 years Thinking precausal, concrete, literal Build trust Forge alliances Cognitive stage: Believes illness self-caused and Use repetition of information Encourage physical closeness Preoperational punitive Allow manipulation of objects and Provide detailed information Psychosocial stage: Limited sense of time equipment Answer questions and Initiative vs. guilt Fears bodily injury Give care with explanation concerns Cannot generalize Reassure not to blame self Ask for information on child’s Animistic thinking (objects possess Explain procedures simply and briefly strengths/limitations and likes/ life or human characteristics) Provide safe, secure environment dislikes Centration (focus is on one Use positive reinforcement characteristic of an object) Encourage questions to reveal Separation anxiety perceptions/feelings Motivated by curiosity Use simple drawings and stories Active imagination, prone to fears Use play therapy, with dolls and puppets Play is his/her work Stimulate senses: Visual, auditory, tactile, 173

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TABLE 5-1 Stage-Appropriate Teaching Strategies (continued)

Learner General Characteristics Teaching Strategies Nursing Interventions Chapter 5Developmental Stagesof theLearner

Middle And Late Childhood

Approximate age: More realistic and objective Encourage independence and active Welcome active involvement 6–11 years Understands cause and effect participation Forge alliances Cognitive stage: Deductive/inductive reasoning Be honest, allay fears Encourage physical closeness Concrete operations Wants concrete information Use logical explanation Provide detailed information Psychosocial stage: Able to compare objects and events Allow time to ask questions Answer questions and Industry vs. inferiority Variable rates of physical growth Use analogies to make invisible processes concerns Reasons syllogistically real Ask for information on child’s Understands seriousness and Establish role models strengths/limitations and likes/ consequences of actions Relate care to other children’s dislikes Subject-centered focus experiences; compare procedures Immediate orientation Use subject-centered focus Use play therapy Provide group activities Use diagrams, models, pictures, digital media, printed materials, and computer, tablet, or smartphone applications as adjuncts to various teaching methods 24/08/17 6:46 PM 9781284127461_CH05.indd 175

Adolescence

Approximate age: Abstract, hypothetical thinking Establish trust, authenticity Explore emotional and 12–19 years Can build on past learning Know their agenda financial support Cognitive stage: Reasons by logic and understands Address fears/concerns about outcomes Determine goals and Formal operations scientific principles of illness expectations Psychosocial stage: Future orientation Identify control focus Assess stress levels Identity vs. role confusion Motivated by desire for social Include in plan of care Respect values and norms acceptance Use peers for support and influence Determine role responsibilities Peer group important Negotiate changes and relationships Intense personal preoccupation, Focus on details Engage in 1:1 teaching without appearance extremely important Make information meaningful to life parents present, but with (imaginary audience) Ensure confidentiality and privacy adolescent’s permission inform Feels invulnerable, invincible/ Arrange peer group sessions in person family of content covered immune to natural laws (personal or virtually (e.g., blogs, social networking, fable) podcasts, online videos) Use audiovisuals, role play, contracts,

reading materials StagesofChildhood The Developmental Provide for experimentation and flexibility

Young Adulthood

Approximate age: Autonomous Use problem-centered focus Explore emotional, financial, 20–40 years Self-directed Draw on meaningful experiences and physical support system Cognitive stage: Uses personal experiences to Focus on immediacy of application Assess motivational level for Formal operations enhance or interfere with learning Encourage active participation involvement Psychosocial stage: Intrinsic motivation Allow to set own pace, be self-directed Identify potential obstacles Intimacy vs. isolation Able to analyze critically Organize material and stressors Makes decisions about personal, Recognize social role occupational, and social roles Apply new knowledge through role Competency-based learner playing and hands-on practice 175

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Learner General Characteristics Teaching Strategies Nursing Interventions Chapter 5Developmental Stagesof theLearner

Middle-Aged Adulthood

Approximate age: Sense of self well developed Focus on maintaining independence and Explore emotional, financial, 41–64 years Concerned with physical changes reestablishing normal life patterns and physical support system Cognitive stage: At peak in career Assess positive and negative past Assess motivational level for Formal operations Explores alternative lifestyles experiences with learning involvement Psychosocial stage: Reflects on contributions to family Assess potential sources of stress caused Identify potential obstacles Generativity vs. self- and society by midlife crisis issues and stressors absorption and stagnation Reexamines goals and values Provide information to coincide with life Questions achievements and successes concerns and problems Has confidence in abilities Desires to modify unsatisfactory aspects of life

Older Adulthood

Approximate age: Cognitive changes Use concrete examples Involve principal caregivers 65 years and over Decreased ability to think abstractly, Build on past life experiences Encourage participation Cognitive stage: process information Make information relevant and meaningful Provide resources for support Formal operations Decreased short-term memory Present one concept at a time (respite care) Psychosocial stage: Increased reaction time Allow time for processing/response (slow Assess coping mechanisms Ego integrity vs. despair Increased test anxiety pace) Provide written instructions for Stimulus persistence (afterimage) Use repetition and reinforcement of reinforcement Focuses on past life experiences information Provide anticipatory problem Avoid written exams solving (what happens if . . .) Use verbal exchange and coaching Establish retrieval plan (use one or several clues) Encourage active involvement Keep explanations brief Use analogies to illustrate abstract 24/08/17 6:46 PM information 9781284127461_CH05.indd 177

Sensory/motor deficits Speak slowly, distinctly Auditory changes Use low-pitched tones Hearing loss, especially high-pitched Avoid shouting tones, consonants (S, Z, T, F, and G), Use visual aids to supplement verbal and rapid speech instruction Visual changes Avoid glares, use soft white light Farsighted (needs glasses to read) Provide sufficient light Lenses become opaque (glare Use white backgrounds and black print problem) Use large letters and well-spaced print Smaller pupil size (decreased visual Avoid color coding with pastel blues, adaptation to darkness) greens, purples, and yellows Decreased peripheral perception Increase safety precautions/provide safe Yellowing of lenses (distorts environment low-tone colors: blue, green, violet) Ensure accessibility and fit of prostheses Distorted depth perception (i.e., glasses, hearing aid) Fatigue/decreased energy levels Keep sessions short Pathophysiology (chronic illness) Provide for frequent rest periods Allow for extra time to perform Establish realistic short-term goals StagesofChildhood The Developmental

Psychosocial changes Give time to reminisce Decreased risk taking Identify and present pertinent material Selective learning Use informal teaching sessions Intimidated by formal learning Demonstrate relevance of information to daily life Assess resources Make learning positive Identify past positive experiences Integrate new behaviors with formerly established ones 177 24/08/17 6:46 PM 178 Chapter 5 Developmental Stages of the Learner

Piaget (1951, 1952, 1976)—a noted expert to foster this aspect of development by talking in defining the key milestones in the cogni- with and listening to their child. As they progress tive development of children—labels the stage through this phase, children begin to engage in of infancy to toddlerhood as the sensorimotor fantasizing and make-believe play. Because they period. This period refers to the coordination are unable to distinguish fact from fiction and and integration of motor activities with sensory have limited cognitive capacity for understand- perceptions. As children mature from infancy ing cause and effect, the disruption in their rou- to toddlerhood, learning is enhanced through tine during illness or hospitalizations, along with sensory experiences and through movement the need to separate from parents, is very stress- and manipulation of objects in the environ- ful for the toddler (London et al., 2017). Rou- ment. Toward the end of the second year of life, tines give these children a sense of security, and the very young child begins to develop object they gravitate toward ritualistic ceremonial-like permanence—that is, recognition that objects exercises when carrying out activities of daily and events exist even when they cannot be seen, living. Separation anxiety is also characteris- heard, or touched (Santrock, 2017). Motor ac- tic of this stage of development and is particu- tivities promote toddlers’ understanding of the larly apparent when children feel insecure in an world and an awareness of themselves as well unfamiliar environment. This anxiety is often as others’ reactions in response to their own ac- compounded when they are subjected to med- tions. Encouraging parents to create a safe envi- ical procedures and other healthcare interven- ronment can allow their child to develop with a tions performed by people who are strangers to decreased risk for injury. them (London et al., 2017). The toddler has the rudimentary capacity According to Erikson (1963), the noted au- for basic reasoning, understands object perma- thority on psychosocial development, the pe- nence, has the beginnings of memory, and begins riod of infancy is one of trust versus mistrust. to develop an elementary concept of causality, During this time, children must work through which refers to the ability to grasp a cause-and- their first major dilemma of developing a sense effect relationship between two paired, succes- of trust with their primary caretaker. As the in- sive events (Crandell et al., 2012). With limited fant matures into toddlerhood, autonomy versus ability to recall past happenings or anticipate shame and doubt emerges as the central issue. future events, the toddler is oriented primarily During this period of psychosocial growth, tod- to the here and now and has little tolerance for dlers must learn to balance feelings of love and delayed gratification. The child who has lived hate and learn to cooperate and control willful with strict routines and plenty of structure has desires (Table 5-2). more of a grasp of time than the child who lives Children progress sequentially through ac- in an unstructured environment. complishing the tasks of developing basic trust Children at this stage have short attention in their environment to reaching increasing lev- spans, are easily distracted, are egocentric in els of independence and self-assertion. Their their thinking, and are not amenable to correc- newly discovered sense of independence often tion of their own ideas. Unquestionably, they is expressed by demonstrations of negativism. believe their own perceptions to be reality. Asking Children may have difficulty in making up their questions is the hallmark of this age group, and cu- minds, and, aggravated by personal and exter- riosity abounds as they explore places and things. nal limits, they may express their level of frus- They can respond to simple, step-by-step com- tration and feelings of ambivalence in words mands and obey such directives as “give Grandpa a and behaviors, such as by engaging in tem- kiss” or “go get your teddy bear” (Santrock, 2017). per tantrums to release tensions (Falvo, 2011). Language skills are acquired rapidly during With peers, play is a parallel activity, and it is this period, and parents should be encouraged not unusual for them to end up in tears because

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TABLE 5-2 Erikson’s Nine Stages of Psychosocial Development

Developmental Stages Psychosocial Stages Strengths

Infancy Trust versus mistrust Hope

Toddlerhood Autonomy versus shame and Will doubt

Early childhood Initiative versus guilt Purpose

Middle and late childhood Industry versus inferiority Competence

Adolescence Identity versus role confusion Fidelity

Young adulthood Intimacy versus isolation Love

Middle-aged adulthood Generativity versus self- Care absorption and stagnation

Older adulthood Ego integrity versus despair Wisdom

Very old age (late 80s and beyond) Hope and faith versus despair Wisdom and transcendence

Data from Ahroni, J. H. (1996). Strategies for teaching elders from a human development perspective. Diabetes Educator, 22(1), 47–52; Crandell, T. L., Crandell, C. H., & Vander Zanden, J. W. (2012). Human development (10th ed.). New York, NY: McGraw-Hill.

they have not yet learned about tact, fairness, the child and parents can adversely affect their or rules of sharing (Miller & Stoeckel, 2016; Po- readiness to learn. See Chapter 4 on factors in- lan & Taylor, 2015). fluencing readiness to learn. Although teaching activities primarily are directed to the main caregiver(s), children at this Teaching Strategies developmental stage in life have a great capacity Patient education for infancy through toddler- for learning. Toddlers are capable of some degree hood need not be illness related. Usually less of understanding procedures and interventions time is devoted to teaching parents about ill- that they may experience. Because of the young ness care, and considerably more time is spent child’s natural tendency to be intimidated by un- teaching aspects of normal development, safety, familiar people, it is imperative that a primary health promotion, and disease prevention. When nurse is assigned and time is taken to establish the child becomes ill or injured, the first prior- a relationship with the child and parents. This ity for teaching interventions would be to as- approach not only provides consistency in the sess the parents’ and child’s anxiety levels and teaching–learning process but also helps to re- to help them cope with their feelings of stress duce the child’s fear of strangers. Parents should related to uncertainty and guilt about the cause be present whenever possible during formal and of the illness or injury. Anxiety on the part of informal teaching and learning activities to allay

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stress, which could be compounded by separa- ■■ Perform procedures on a teddy bear or doll tion anxiety (London et al., 2017). first to help the child anticipate what an Ideally, health teaching should take place in experience will be like. an environment familiar to the child, such as the ■■ Allow the child something to do—squeeze home or daycare center. When the child is hos- your hand, hold a Band-Aid, sing a song, cry pitalized, the environment selected for teaching if it hurts—to channel his or her response and learning sessions should be as safe and secure to an unpleasant experience. as possible, such as the child’s bed or the playroom, ■■ Keep teaching sessions brief (no longer to increase the child’s sense of feeling protected. than about 5 minutes each) because of the Movement is an important mechanism by child’s short attention span. which toddlers communicate. Immobility re- ■■ Cluster teaching sessions close together sulting from illness, hospital confinement, or so that children can remember what they disability tends to increase children’s anxiety by learned from one instructional encounter restricting activity. Nursing interventions that to another. promote children’s use of gross motor abilities ■■ Avoid analogies and explain things in straight- and that stimulate their visual, auditory, and tac- forward and simple terms because children tile senses should be chosen whenever possible. take their world literally and concretely. Developing rapport with children through ■■ Individualize the pace of teaching according simple teaching helps to elicit their cooperation to the child’s responses and level of attention. and active involvement. The approach to children should be warm, honest, calm, accepting, For Long-Term Learning and matter of fact. A smile, a warm tone of voice, ■■ Focus on rituals, imitation, and repetition a gesture of encouragement, or a word of praise of information in the form of words and goes a long way in attracting children’s attention actions to hold the child’s attention. For and helping them adjust to new circumstances. example, practice washing hands before Fundamental to the child’s response is how the and after eating and toileting. parents respond to healthcare personnel and ■■ Use reinforcement as an opportunity for medical interventions. children to achieve permanence of learning The following teaching strategies are sug- through practice. gested to convey information to members of ■■ Employ the teaching methods of gaming this age group. These strategies feed into chil- and modeling as a means by which children dren’s natural tendency for play and their need can learn about the world and test their for active participation and sensory experiences. ideas over time. ■■ Encourage parents to act as role models, be- For Short-Term Learning cause their values and beliefs serve to re- ■■ Read simple stories from books with lots inforce healthy behaviors and significantly of pictures. influence the child’s development of atti- ■■ Use dolls and puppets to act out feelings tudes and behaviors. and behaviors. ■■ Use simple audiotapes with music and Early Childhood videotapes with cartoon characters. ■■ Role play to bring the child’s imagination (3–5 Years of Age) closer to reality. Children in the preschool years continue with ■■ Give simple, concrete, nonthreatening ex- development of skills learned in the earlier planations to accompany visual and tactile years of growth. Their sense of identity becomes experiences. clearer, and their world expands to encompass

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involvement with others external to the family mechanical forces. They often believe that they unit. Children in this developmental category can influence natural phenomena, and their be- acquire new behaviors that give them more in- liefs reflect animistic thinking—the tendency to dependence from their parents and allow them endow inanimate objects with life and conscious- to care for themselves more autonomously. ness (Pidgeon, 1977; Santrock, 2017). Learning during this developmental period Preschool children are very curious, can occurs through interactions with others and think intuitively, and pose questions about al- through mimicking or modeling the behaviors most anything. They want to know the reasons, of playmates and adults (Crandell et al., 2012; cause, and purpose for everything (the why), but Santrock, 2017). are unconcerned at this point with the process (the how). Fantasy and reality are not well dif- Physical, Cognitive, and ferentiated. Children in this cognitive stage mix fact and fiction, tend to generalize, think Psychosocial Development magically, develop imaginary playmates, and The physical maturation during early childhood believe they can control events with their is an extension of the child’s prior growth. Fine thoughts. At the same time, they do possess and gross motor skills become increasingly more self-awareness and realize that they are vul- refined and coordinated so that children can nerable to outside influences (Crandell et al., carry out activities of daily living with greater 2012; Santrock, 2017). independence (Crandell et al., 2012; Kail & The young child also continues to have a lim- Cavanaugh, 2015; Santrock, 2017). Although ited sense of time. For children of this age, being their efforts are more coordinated, supervi- made to wait 15 minutes before they can do some- sion of activities is still required because they thing can feel like an eternity. They do, however, lack judgment in carrying out the skills they understand the timing of familiar events in their have developed. daily lives, such as when breakfast or dinner is The early childhood stage of cognitive de- eaten and when they can play or watch their fa- velopment is labeled by Piaget (1951, 1952, 1976) vorite television program. As they begin to un- as the preoperational period. This stage, which derstand and appreciate the world around them, emphasizes the child’s inability to think things their attention span (ability to focus) begins to through logically without acting out the situa- lengthen such that they can usually remain quiet tion, is the transitional period when the child long enough to listen to a song or hear a short starts to use symbols (letters and numbers) to story read (Santrock, 2017). represent something (Crandell et al., 2012; San- In the preschool stage, children begin to trock, 2017; Snowman & McCown, 2015). develop sexual identity and curiosity, an inter- Children in the preschool years begin to de- est that may cause considerable discomfort for velop the capacity to recall past experiences and their parents. Cognitive understanding of their anticipate future events. They can classify ob- bodies related to structure, function, health, jects into groups and categories but have only and illness becomes more specific and differ- a vague understanding of their relationships. entiated. They can name external body parts The young child continues to be egocentric and but have only an ill-defined concept of the lo- is essentially unaware of others’ thoughts or the cation of internal organs and the specific func- existence of others’ points of view. Thinking re- tion of body parts (Raven, 2016). mains literal and concrete—they believe what Explanations of the purpose and reasons is seen and heard. Precausal thinking allows for a procedure remain beyond the young child’s young children to understand that people can level of reasoning, so any explanations must be make things happen, but they are unaware of kept very simple and matter of fact (Pidgeon, causation as the result of invisible physical and 1985). Children at this stage have a fear of body

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mutilation and pain, which not only stems from Teaching Strategies their lack of understanding of the body but also The nurse’s interactions with preschool children is compounded by their active imagination. and their parents are often sporadic, usually oc- Their ideas regarding illness also are primi- curring during occasional well-child visits to the tive with respect to cause and effect; illness and pediatrician’s office or when minor medical prob- hospitalization are thought to be a punishment lems arise. During these interactions, the nurse for something they did wrong, either through omission or commission (London et al., 2017). should take every opportunity to teach parents Children’s attribution of the cause of illness to about health promotion and disease prevention the consequences of their own transgressions measures, to provide guidance regarding normal is known as egocentric causation (Polan & growth and development, and to offer instruc- Taylor, 2015; Richmond & Kotelchuck, 1984). tion about medical recommendations related to Erikson (1963) has labeled the psychosocial illness or disability. Parents can be a great asset maturation level in early childhood as the period to the nurse in working with children in this de- of initiative versus guilt. Children take on tasks velopmental phase, and they should be included for the sake of being involved and on the move in all aspects of the educational plan and the ac- (Table 5-2). Excess energy and a desire to dom- tual teaching experience. Parents can serve as the inate may lead to frustration and anger on their primary resource to answer questions about chil- part. They show evidence of expanding imagi- dren’s disabilities, their idiosyncrasies, and their nation and creativity, are impulsive in their ac- favorite toys—all of which may affect their abil- tions, and are curious about almost everything ity to learn (Bedells & Bevan, 2016; Hussey & they see and do. Their growing imagination can Hirsh, 1983). lead to many fears—of separation, disapproval, Children’s fear of pain and bodily harm is pain, punishment, and aggression from others. uppermost in their minds, whether they are well Loss of body integrity is the preschool child’s or ill. Because young children have fantasies and greatest threat, which significantly affects his or active imaginations, it is most important for the her willingness to interact with healthcare per- nurse to reassure them and allow them to express sonnel (Poster, 1983; Vulcan, 1984). their fears openly (Heiney, 1991). Nurses need In this phase of development, children be- to choose their words carefully when describing gin interacting with playmates rather than just procedures and interventions and keep expla- playing alongside one another. Appropriate so- nations simple (Miller & Stoeckel, 2016). Pre- cial behaviors demand that they learn to wait school children are familiar with many words, for others, give others a turn, and recognize but using terms such as cut and knife is fright- the needs of others. Play in the mind of a child ening to them. Instead, nurses should use less is equivalent to the work performed by adults. threatening words such as fix, sew, and cover up Play can be as equally productive as adult work the hole. Band-Aids is a much more understand- and is a means for self-education about the phys- able term than dressings, and bandages are of- ical and social world (Ormrod, 2012). It helps ten thought by children to have magical healing the child act out feelings and experiences to mas- powers (Miller & Stoeckel, 2016). ter fears, develop role skills, and express joys, Although still dependent on family, the sorrows, and hostilities. Through play, children young child has begun to have increasing con- in the preschool years also begin to share ideas tact with the outside world and is usually able to and imitate parents of the same sex. Role play- interact more comfortably with others. Never- ing is typical of this age as the child attempts theless, significant adults in a child’s life should to learn the responsibilities of family members be included as participants during teaching ses- and others in society (Santrock, 2017). sions. They can provide support to the child,

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substitute as the teacher if their child is reluctant ■■ Use storybooks to emphasize the humanity to interact with the nurse, and reinforce teach- of healthcare personnel; to depict relation- ing at a later point in time. The primary care- ships between the child, parents, and others; takers, usually the mother and father, are the and to help the child identify with certain recipients of most of the nurse’s teaching efforts. situations. They are the learners who will assist the child in achieving desired health outcomes (Callans For Long-Term Learning et al., 2016; Kaakinen, Gedaly-Duff, Coehlo, & ■■ Enlist the help of parents, who can play a Hanson, 2010; Whitener, Cox, & Maglich, 1998). vital role in modeling a variety of healthy The following specific teaching strategies habits, such as practicing safety measures are recommended. and eating a balanced diet; offer them access to support and follow-up as the For Short-Term Learning need arises. ■ ■■ Provide physical and visual stimuli because ■ Reinforce positive health behaviors and the language ability is still limited, both for acquisition of specific skills. expressing ideas and for comprehending verbal instructions. Middle and Late Childhood ■■ Keep teaching sessions short (no more than 15 minutes) and scheduled sequentially at (6–11 Years of Age) close intervals so that information is not In middle and late childhood, children have forgotten. progressed in their physical, cognitive, and psy- ■■ Relate information needs to activities and ex- chosocial skills to the point where most begin periences familiar to the child. For example, formal training in structured school systems. ask the child to pretend to blow out candles They approach learning with enthusiastic an- on a birthday cake to practice deep breathing. ticipation, and their minds are open to new ■■ Encourage the child to participate in and varied ideas. selecting between a limited number of Children at this developmental level are mo- teaching–learning options, such as play- tivated to learn because of their natural curios- ing with dolls or reading a story, which ity and their desire to understand more about promotes active involvement and helps themselves, their bodies, their world, and the in- to establish nurse–client rapport. fluence that different things in the world have ■■ Arrange small-group sessions with peers to on them (Whitener et al., 1998). This stage is a make teaching less threatening and more fun. period of great change for them, when attitudes, ■■ Give praise and approval, through both values, and perceptions of themselves, their so- verbal expressions and nonverbal gestures, ciety, and the world are shaped and expanded. which are real motivators for learning. Visions of their own environment and the cul- ■■ Give tangible rewards, such as badges or tures of others take on more depth and breadth small toys, immediately following a suc- (Santrock, 2017). cessful learning experience to encourage the mastery of cognitive and psychomotor skills. Physical, Cognitive, and ■■ Allow the child to manipulate equipment and play with replicas or dolls to learn about Psychosocial Development body parts. Special kidney dolls, ostomy The gross- and fine-motor abilities of school- dolls with stomas, or orthopedic dolls with aged children become increasingly more coordi- splints and tractions provide opportunities nated so that they have the ability to control their for hands-on experience. movements with much greater dexterity than ever

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before. Involvement in all kinds of curricular and and use sarcasm as well as to employ well- extracurricular activities helps them to fine tune developed language skills for telling jokes, con- their psychomotor skills. Physical growth during veying complex stories, and communicating this phase is highly variable, with the rate of de- increasingly more sophisticated thoughts (Snow- velopment differing from child to child. Toward man & McCown, 2015). the end of this developmental period, girls more Nevertheless, thinking remains quite lit- than boys on average begin to experience prepu- eral, with only a vague understanding of abstrac- bescent bodily changes and tend to exceed the tions. Early in this phase, children are reluctant boys in physical maturation. Growth charts, which to exchange magical thinking for reality think- monitor the rate of growth, are a more sensitive ing. They cling to cherished beliefs, such as the indicator of health or disability than actual size existence of Santa Claus or the tooth fairy, for (Crandell et al., 2012; Santrock, 2017). the fun and excitement that the fantasy pro- Piaget (1951, 1952, 1976) labeled the cogni- vides them, even when they have information tive development in middle and late childhood that proves contrary to their beliefs. as the period of concrete operations. During this Children passing through elementary and time, logical, rational thought processes and the middle schools have developed the ability to ability to reason inductively and deductively concentrate for extended periods, can toler- develop. Children in this stage can think more ate delayed gratification, are responsible for objectively, are willing to listen to others, and independently carrying out activities of daily selectively use questioning to find answers to living, have a good understanding of the en- the unknown. At this stage, they begin to use vironment around them, and can generalize syllogistic reasoning—that is, they can con- from experience (Crandell et al., 2012). They sider two premises and draw a logical conclusion understand time, can predict time intervals, from them (Bara, Bucciarelli, & Johnson-Laird, are oriented to the past and present, have some 1995; Elkind, 1984; Steegen & De Neys, 2012). grasp and interest in the future, and have a For example, they comprehend that mammals vague appreciation for how immediate actions are warm blooded and whales are mammals, so can have implications over the course of time whales must be warm blooded. (Kail & Cavanaugh, 2015). Special interests in Also, children in this age group are intel- topics of their choice begin to emerge, and they lectually able to understand cause and effect in can pursue subjects and activities with devotion a concrete way. Concepts such as conservation, to increase their talents in selected areas. which is the ability to recognize that the prop- Children at this cognitive stage can make de- erties of an object stay the same even though cisions and act in accordance with how events are its appearance and position may change, are interpreted, but they understand only to a limited beginning to be mastered. For example, they extent the seriousness or consequences of their realize that a certain quantity of liquid is the choices. Children in the early period of this de- same amount whether it is poured into a tall, velopmental phase know the functions and names thin glass or into a short, squat one (Snowman of many common body parts, whereas older chil- & McCown, 2015). Fiction and fantasy are sepa- dren have a more specific knowledge of anatomy rate from fact and reality. The skills of memory, and can differentiate between external and in- decision making, insight, and problem solving ternal organs with a beginning understanding are all more fully developed (Protheroe, 2007). of their complex functions (Raven, 2016). Children in this developmental phase can As part of the shift from precausal think- engage in systematic thought through inductive ing to causal thinking, the child begins to in- reasoning. They have the ability to classify objects corporate the idea that illness is related to cause and systems, express concrete ideas about rela- and effect and can recognize that germs create tionships and people, and carry out mathemat- disease. Illness is thought of in terms of social ical operations. Also, they begin to understand consequences and role alterations, such as the

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realization that they will miss school and out- them from one another (Table 5-2). They be- side activities, people will feel sorry for them, gin to establish their self-concept as members and they will be unable to maintain their usual of a social group larger than their own nuclear routines (Banks, 1990; Koopman, Baars, Chap- family and start to compare their own family’s lin, & Zwinderman, 2004). values with those of the outside world. Marin (2010) found that concepts of ill- The school environment for children of this ness in children vary depending on socioeco- age facilitates their development of a sense of nomic status (SES) and ethnicity, although she responsibility and reliability. With less depen- found no differences in their thinking based on dency on family, they extend their intimacy to gender. Children from lower SES levels and mi- include special friends and social groups (New- nority backgrounds had a less sophisticated un- man & Newman, 2015; Santrock, 2017). Rela- derstanding of the causes of illness compared tionships with peers and adults external to the with those children from higher SES levels and home environment become important influ- those belonging to the majority population. ences in their development of self-esteem and She suggested that this may be a result of edu- their susceptibility to social forces outside the cational, cultural, and language differences and family unit. School-aged children fear failure that healthcare professionals should consider a and being left out of groups. They worry about child’s ethnicity and SES when communicating their inabilities and become self-critical as they symptoms and causes of illness based on cul- compare their own accomplishments to those tural health beliefs and practices. of their peers. They also fear illness and dis- Also, research indicates that systematic dif- ability that could significantly disrupt their ac- ferences exist in children’s reasoning skills with ademic progress, interfere with social contacts, respect to understanding body functioning and decrease their independence, and result in loss the cause of illness resulting from their expe- of control over body functioning. riences with illness. Children suffering from chronic diseases have been found to have more sophisticated conceptualization of illness causal- Teaching Strategies ity and body functioning than do their healthy It is important to follow sound educational prin- peers. Piaget (1976) postulated that experience ciples with the child and family, such as iden- with a phenomenon catalyzes a better under- tifying individual learning styles, determining standing of it. readiness to learn, and accommodating special Conversely, the stress and anxiety result- learning needs and abilities to achieve positive ing from having to live with a chronic illness health outcomes. Given their increased ability or disability can interfere with a child’s general to comprehend information and their desire for cognitive performance. Chronically ill children active involvement and control of their lives, it is have a less refined understanding of the physi- very important to include school-aged children cal world than healthy children do, and the for- in patient education efforts as these “hands-on” mer often are unable to generalize what they experiences are important sources of learning learned about a specific illness to a broader un- (Hayes, 2015). The nurse in the role as educa- derstanding of illness causality (Perrin, Sayer, tor should explain illness, treatment plans, and & Willett, 1991). Thus, illness may act as an in- procedures in simple, logical terms in accor- trusive factor in overall cognitive development dance with the child’s level of understanding (Bell, Bayliss, Glauert, Harrison, & Ohan, 2016). and reasoning. Although children at this stage Erikson (1963) characterized school-aged of development can think logically, their abil- children’s psychosocial stage of life as industry ity to engage in abstract thought remains lim- versus inferiority. During this period, children ited. Therefore, teaching should be presented begin to gain an awareness of their unique tal- in concrete terms with step-by-step instruc- ents and the special qualities that distinguish tions (Pidgeon, 1985; Whitener et al., 1998). It

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is imperative that the nurse observe children’s children. The school nurse can play a vital role reactions and listen to their verbal feedback to in providing education to the school-aged child confirm that information shared has not been to meet these goals (American Academy of Pedi- misinterpreted or confused. atrics Council on School Health, 2016). In sup- To the extent feasible, parents should be port of this teaching–learning process, Healthy informed of what their child is being taught. People 2020 has introduced the topic area “Early Teaching parents directly is encouraged so that and Middle Childhood,” which recommends they may be involved in fostering their child’s providing formal health education in the school independence, providing emotional support setting (USDHHS, 2014). The school nurse is and physical assistance, and giving guidance re- afforded the opportunity to educate children garding the correct techniques or regimens in not only in a group when teaching a class but self-care management. Siblings and peers also also on a one-to-one basis when encountering should be considered as sources of support. In an individual child in the office for a certain attempting to master self-care skills, children problem or need. thrive on praise from others who are important The specific conditions that may come to in their lives as rewards for their accomplish- the attention of the nurse in caring for children ments and successes (Hussey & Hirsh, 1983; at this phase of development include problems Santrock, 2017). such as behavioral disorders, hyperactivity, learn- Education for health promotion and health ing disorders, obesity, diabetes, asthma, and en- maintenance is most likely to occur in the school uresis. Extensive teaching may be needed to help system through the school nurse, but the par- children and parents understand a condition ents as well as the nurse outside the school particularly related to them and learn how to setting should be told which content is being overcome or deal with it (Edelman et al., 2013). addressed. Information then can be reinforced The need to sustain or bolster their self- and expanded when in contact with the child in image, self-concept, and self-esteem requires other care settings. Numerous opportunities for that children be invited to participate, to the nurses to teach the individual child or groups extent possible, in planning for and carrying of children about health promotion and disease out learning activities (Snowman & McCown, and injury prevention are available in schools, 2015). For young children receiving an x-ray or physicians’ offices, community centers, outpa- other imaging procedure, for example, it would tient clinics, or hospitals. Health education for be beneficial to have them initially simulate the children of this age can be very fragmented be- experience by positioning a doll or stuffed ani- cause of the many encounters they have with mal under the machine as the technician explains nurses in a variety of settings (Edelman, Mandle, the procedure. This strategy allows them to par- & Kudzma, 2013). ticipate and can decrease their fear. Because of The school nurse is in an excellent posi- children’s fears of falling behind in school, be- tion to coordinate the efforts of all other pro- ing separated from peer groups, and being left viders to avoid duplication of teaching content out of social activities, teaching must be geared or the giving of conflicting information as well toward fostering normal development despite as to provide reinforcement of learning. Accord- any limitations that may be imposed by illness or ing to Healthy People 2020 (U.S. Department of disability (Falvo, 2011; Leifer & Hartston, 2013). Health and Human Services [USDHHS], 2014), Children in middle and late childhood are health promotion regarding healthy eating and used to the structured, direct, and formal learn- weight status, exercise, sleep, and prevention of ing in the school environment; consequently, injuries, as well as avoidance of tobacco, alcohol, they are receptive to a similar teaching–learning and drug use, are just a few examples of objec- approach when hospitalized or confined at tives intended to improve the health of American home. The following teaching strategies are

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suggested when caring for children in this de- a means of interpreting the results of nurs- velopmental stage of life (Edleman et al., 2013; ing interventions specific to the child’s own Falvo, 2011; Hayes, 2015; Leifer & Hartston, condition. 2013; Snowman & McCown, 2015). ■■ Provide time for clarification, validation, and reinforcement of what is being learned. For Short-Term Learning ■■ Select individual instructional techniques ■■ Allow school-aged children to take re- that provide opportunity for privacy—an sponsibility for their own health care be- increasingly important concern for this cause they are not only willing but also group of learners, who often feel quite self- capable of manipulating equipment with conscious and modest when learning about accuracy. Because of their adeptness in re- bodily functions. lation to manual dexterity, mathematical ■■ Employ group teaching sessions with oth- operations, and logical thought processes, ers of similar age and with similar problems they can be taught, for example, to apply or needs to help children avoid feelings of their own splint or use an asthma inhaler isolation and to assist them in identifying as prescribed. with their own peers. ■■ Teaching sessions can be extended to last ■■ Prepare children for procedures and in- up to 30 minutes each because the increased terventions well in advance to allow them cognitive abilities of school-aged children time to cope with their feelings and fears, to make possible the attention to and the re- anticipate events, and to understand what tention of information. However, lessons the purpose of each procedure is, how it should be spread apart to allow for com- relates to their condition, and how much prehension of large amounts of content time it will take. and to provide opportunity for the practice ■■ Encourage participation in planning for of newly acquired skills between sessions. procedures and events because active in- ■■ Use diagrams, models, pictures, digital me- volvement helps the child to assimilate in- dia, printed materials, and computer, tab- formation more readily. let or smartphone applications as adjuncts ■■ Provide much-needed nurturance and sup- to various teaching methods because the port, always keeping in mind that young increased facility these children have with children are not just small adults. Praise language (both spoken and written) and and rewards help motivate and reinforce mathematical concepts allows them to learning. work with more complex instructional tools. For Long-Term Learning ■■ Choose audiovisual and printed materials ■ that show peers undergoing similar proce- ■ Help school-aged children acquire skills dures or facing similar situations. that they can use to assume self-care re- ■■ Clarify any scientific terminology and med- sponsibility for carrying out therapeutic ical jargon used. treatment regimens on an ongoing basis ■■ Use analogies as an effective means of pro- with minimal assistance. ■ viding information in meaningful terms, ■ Assist them in learning to maintain their such as “Having a chest x-ray is like having own well-being and prevent illnesses from your picture taken” or “White blood cells occurring. are like police cells that can attack and de- Research suggests that lifelong health stroy infection.” attitudes and behaviors begin in the early child- ■■ Use one-to-one teaching sessions as a hood phase of development and remain intra- method to individualize learning rele- personally consistent throughout the stage of vant to the child’s own experiences and as middle to late childhood (USDHHS, 2014).

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The development of cognitive understanding Today’s adolescents comprise the generational of health and illness has been shown to follow cohort Generation Z, or Gen Z. They excel with a systematic progression parallel to the stage of self-directed learning and thrive on the use of general cognitive development (Koopman et al., technology (Shatto & Erwin, 2016). 2004). As the child matures, beliefs about health and illness become less concrete and more ab- Physical, Cognitive, and stract, less egocentric, and increasingly differ- entiated and consistent. Psychosocial Development Motivation, self-esteem, and positive self- Adolescents vary greatly in their biological, psy- perception are personal characteristics that in- chological, social, and cognitive development. fluence health behavior. Research has shown From a physical maturation standpoint, they that the higher the grade level of the child, must adapt to rapid, dramatic, and significant the greater the understanding of illness and bodily changes, which can temporarily result in an awareness of body cues. Thus, children clumsiness and poorly coordinated movement. become more actively involved in their own Alterations in physical size, shape, and function health care as they progress developmentally of their bodies, along with the appearance and (Farrand & Cox, 1993; Whitener et al., 1998). development of secondary sex characteristics, Teaching should be directed at assisting them bring about a significant preoccupation with their to incorporate positive health actions into appearance and a strong desire to express sex- their daily lives. Because of the importance of ual urges (Crandell et al., 2012; Santrock, 2017). peer influence, group activities are an effec- And, according to neuroscience research, ado- tive method of teaching health behaviors, at- lescent brains are different than adult brains in titudes, and values. the way they process information, which may explain that adolescent behaviors, such as im- pulsiveness, rebelliousness, lack of good judg- Adolescence (12–19 Years of Age) ment, and social anxiety, stem from biological Adolescence marks the transition from child- reasons more than environmental influences hood to adulthood. During this prolonged and (Packard, 2007). very change-filled time, many adolescents and Piaget (1951, 1952, 1976) termed this stage their families experience much turmoil. How ad- of cognitive development as the period of for- olescents think about themselves and the world mal operations. Adolescents have attained a new, significantly influences many healthcare issues higher order level of reasoning superior to ear- facing them, from anorexia to obesity. Teenage lier childhood thoughts. They are capable of ab- thought and behavior give insight into the eti- stract thought and the type of complex logical ology of some of the major health problems of thinking described as propositional reason- this group of learners (Elkind, 1984). Adoles- ing, as opposed to syllogistic reasoning. Their cents are known to be among the nation’s most ability to reason is both inductive and deductive, at-risk populations (Ares, Kuhns, Dogra, & Kar- and they can hypothesize and apply the prin- mik, 2015). Most recently, Healthy People 2020 ciples of logic to situations never encountered identified “Adolescent Health” as a new topic before. Adolescents can conceptualize and inter- area, with objectives focused on interventions to nalize ideas, debate various points of view, un- promote health as well as mitigate the risks as- derstand cause and effect, comprehend complex sociated with this population (USDHHS, 2014). explanations, imagine possibilities, make sense For patient education to be effective, an out of new data, discern relationships among understanding of the characteristics of the ad- objects and events, and respond appropriately olescent phase of development is crucial (Ack- to multiple-step directions (Aronowitz, 2006; ard & Neumark-Sztainer, 2001; Ormrod, 2012). Crandell et al., 2012).

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Formal operational thought enables ado- it also leads teenagers to believe they are cloaked lescents to conceptualize invisible processes and in an invisible shield that will protect them from make determinations about what others say and bodily harm despite any risks to which they may how they behave. With this capacity, teenagers subject themselves (Alberts, Elkind, & Ginsberg, can become obsessed with what they think as 2007; Jack, 1989; Oswalt, 2010). They can un- well as what others are thinking, a characteris- derstand implications of future outcomes, but tic known as adolescent egocentrism. They be- their immediate concern is with the present. gin to believe that everyone is focusing on the Recent research, however, reveals that ado- same things they are—namely, themselves and lescents 15 years of age and older are not as sus- their activities. Elkind (1984) labels this belief ceptible to the personal fable as once thought as the imaginary audience, a type of social (Cauffman & Steinberg, 2000). Although chil- thinking that has considerable influence over dren in the mid- to late-adolescent period appear an adolescent’s behavior. The imaginary audi- to be aware of the risks they take, it is import- ence explains the pervasive self-consciousness ant, nevertheless, to recognize that this popu- of adolescents, who, on the one hand, may feel lation continues to need support and guidance embarrassed because they believe everyone is (Brown, Teufel, & Birch, 2007). looking at them and, on the other hand, desire Erikson (1968) has identified the psychoso- to be looked at and thought about because this cial dilemma adolescents face as one of identity attention confirms their sense of being special versus role confusion. Children in this age group and unique (Crandell et al., 2012; Oswalt, 2010; indulge in comparing their self-image with an Santrock, 2017; Snowman & McCown, 2015). ideal image (Table 5-2). Adolescents find them- Adolescents are able to understand the con- selves in a struggle to establish their own iden- cept of health and illness, the multiple causes tity, match their skills with career choices, and of diseases, the influence of variables on health determine their self. They work to emancipate status, and the ideas associated with health pro- themselves from their parents, seeking indepen- motion and disease prevention. Parents, health- dence and autonomy so that they can emerge as care providers, and the Internet are all potential more distinct individual personalities. sources of health-related information for ado- Teenagers have a strong need for belonging lescents. At this developmental stage, adoles- to a group, friendship, peer acceptance, and peer cents recognize that illness and disability are support. They tend to rebel against any actions processes resulting from a dysfunction or non- or recommendations by adults whom they con- function of a part or parts of the body and can sider authoritarian. Their concern over personal comprehend the outcomes or prognosis of an appearance and their need to look and act like illness. They also can identify health behaviors, their peers drive them to conform to the dress although they may reject practicing them or be- and behavior of this age group, which is usually gin to engage in risk-taking behaviors because contradictory, nonconformist, and in opposi- of the social pressures they receive from peers tion to the models, codes, and values of their as well as their feelings of invincibility (Ormrod, parents’ generation. Conflict, toleration, stereo- 2012). Elkind (1984) labels this second type of typing, or alienation often characterizes the rela- social thinking as the personal fable. The per- tionship between adolescents and their parents sonal fable leads adolescents to believe that they and other authority figures (Hines & Paulson, are invulnerable—other people grow old and 2006). Adolescents seek to develop new and die, but not them; other people may not realize trusting relationships outside the home but re- their personal ambitions, but they will. main vulnerable to the opinions of those whom This personal fable has value in that it al- they emulate (Santrock, 2017). lows individuals to carry on with their lives even Adolescents demand personal space, con- in the face of all kinds of dangers. Unfortunately, trol, privacy, and confidentiality. To them, illness,

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injury, disability, and hospitalization mean de- largely ignored by the healthcare system glob- pendency, loss of identity, a change in body image ally (Patton et al., 2016). Thus, the educational and functioning, bodily embarrassment, confine- needs of adolescents are broad and varied. The ment, separation from peers, and possible death. potential topics for teaching are numerous, rang- The provision of knowledge alone is, therefore, ing from sexual adjustment, contraception, and not sufficient for this population. Because of venereal disease to accident prevention, nutri- the many issues apparent during the adolescent tion, substance abuse, and mental health. period, the need for coping skills is profound Healthy teens have difficulty imagining and can influence the successful completion themselves as sick or injured. Those with an of this stage of development (Grey, Kanner, & illness or disability often comply poorly with Lacey, 1999; Hoffman, 2016; Williams & medical regimens and continue to indulge in McGillicuddy-De Lisi, 1999; Zimmer-Gembeck & risk-taking behaviors. Because of their preoc- Skinner, 2008). Some developmentalists are ex- cupation with body image and functioning and tending the uppermost age range of the ado- the perceived importance of peer acceptance and lescent period to 24 years of age because it has support, they view health recommendations as been determined that many young people in a threat to their autonomy and sense of control. this stage do not meet the typical psychosocial Probably the greatest challenge to the nurse milestones until well into their second decade responsible for teaching the adolescent, whether of life (Newman & Newman, 2015). healthy or ill, is to be able to develop a mutually respectful, trusting relationship (Brown et al., 2007). Adolescents, because of their Teaching Strategies well-developed cognitive and language abili- Although most individuals at this phase of de- ties, can participate fully in all aspects of learn- velopment remain relatively healthy, an esti- ing, but they need privacy, understanding, an mated 20% of U.S. teenagers have at least one honest and straightforward approach, and un- serious health problem, such as asthma, learn- qualified acceptance in the face of their fears of ing disabilities, eating disorders (e.g., obesity, embarrassment, losing independence, identity, anorexia, or bulimia), diabetes, a range of dis- and self-control (Ackard & Neumark-Sztainer, abilities resulting from injury, or psychological 2001). The American Academy of Pediatrics problems resulting from depression or phys- Committee on Adolescence (2016) cites avail- ical and/or emotional maltreatment. In addi- ability, visibility, quality, confidentiality, afford- tion, adolescents are considered at high risk for ability, flexibility, and coordination as important teen pregnancy, the effects of poverty, drug or factors in providing education effectively to the alcohol abuse, and sexually transmitted diseases adolescent population. such as venereal disease and AIDS. The three The existence of an imaginary audience leading causes of death in this age group are ac- and personal fable can contribute to the exacer- cidents, homicide, and suicide (Kochanek, Xu, bation of existing problems or cause new ones. Murphy, Minino, & Kung, 2011; London et al., Adolescents with disfiguring disabilities, who as 2017). More than 50% of all adolescent deaths young children exhibited a great deal of spirit are a result of accidents, and most of these inci- and strength, may now show signs of depression dents involve motor vehicles (Santrock, 2017). and lack of will. For the first time, they look at Despite these potential threats to their themselves from the standpoint of others and well-being, adolescents use medical services the reinterpret behavior once seen as friendly as ac- least frequently of all age groups. Compounding tually condescending. Teenagers may fail to use this problem is the realization that adolescent contraceptives because the personal fable tells health has not been a priority in the past and them that other people will get pregnant or get the health issues of this population have been venereal disease, but not them. Teenagers with

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chronic illnesses may stop taking prescribed ■■ Share decision making whenever possible, medications because they feel they can manage because control is an important issue for without them to prove to others that they are adolescents. well and free of medical constraints; other peo- ■■ Include adolescents in formulating teaching ple with similar diseases need to follow thera- plans related to teaching strategies, expected peutic regimens, but not them. outcomes, and determining what needs to Adolescents’ language skills and ability to be learned and how it can best be achieved conceptualize and think abstractly give the nurse to meet their needs for autonomy. as educator a wide range of teaching methods ■■ Suggest options so that they feel they have and instructional tools from which to choose a choice about courses of action. (Brown et al., 2007). The following teaching strat- ■■ Give a rationale for all that is said and done egies are suggested when caring for adolescents. to help adolescents feel a sense of control. ■■ Approach them with respect, tact, open- For Short-Term Learning ness, and flexibility to elicit their attention ■■ Use one-to-one instruction to ensure con- and encourage their responsiveness to fidentiality of sensitive information. teaching–learning situations. ■■ Choose peer-group discussion sessions as ■■ Expect negative responses, which are com- an effective approach to deal with health mon when their self-image and self-integrity topics such as smoking, alcohol and drug are threatened. use, safety measures, obesity, and teenage ■■ Avoid confrontation and acting like an sexuality. Adolescents benefit from being authority figure. Instead of directly contra- exposed to others who have the same con- dicting adolescents’ opinions and beliefs, cerns or who have successfully dealt with acknowledge their thoughts and then ca- problems like theirs. sually suggest an alternative viewpoint or ■■ Use face-to-face or computer group discus- choices, such as “Yes, I can see your point, sion, role playing, and gaming as methods but what about the possibility of . . .?” to clarify values and solve problems, which feed into the teenager’s need to belong and For Long-Term Learning to be actively involved. Getting groups of ■■ Accept adolescents’ personal fable and peers together in person or virtually (e.g., imaginary audience as valid, rather than blogs, social networking, podcasts, online challenging their feelings of uniqueness videos) can be very effective in helping and invincibility. teens confront health challenges and ■■ Acknowledge that their feelings are very learn how to significantly change behavior real because denying them their opinions (Snowman & McCown, 2015). simply will not work. ■ ■ Employ adjunct instructional tools, such ■■ Allow them the opportunity to test their own as complex models, diagrams, and specific, convictions. Let them know, for example, detailed written materials, which can be used that although some other special people competently by many adolescents. Using may get away without taking medication, technology is a comfortable approach to others cannot. Suggest, if medically feasible, learning for adolescents, who generally have setting up a trial period with medications facility with technological equipment after scheduled further apart or in lowered dos- years of academic and personal experience ages to determine how they can manage. with telecommunications in the home and at school. Although much of patient education ■■ Clarify any scientific terminology and should be done directly with adolescents to re- medical jargon used. spect their right to individuality, privacy, and

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confidentiality, teaching effectiveness may be to being an independent, self-directed enhanced by including their families to some human being. extent (Brown et al., 2007). The nurse as edu- 2. He or she accumulates a growing cator can give guidance and support to families, reservoir of previous experience that helping them to better understand adolescent be- serves as a rich resource for learning. havior (Hines & Paulson, 2006). Parents should 3. Readiness to learn becomes increas- be taught how to set realistic limits and at the ingly oriented to the developmental same time foster the adolescent’s sense of inde- tasks of social roles. pendence. Through prior assessment of poten- 4. Adults are best motivated to learn tial sources of stress, teaching both the parents when a need arises in their life situ- and the adolescent (as well as siblings) can be en- ation that will help them satisfy their hanced. Because of ambivalence the adolescent desire for information. feels while in this transition stage from child- 5. Adults learn for personal fulfillment hood to adulthood, healthcare teaching, to be such as self-esteem or an improved effective, must consider the learning needs of quality of life. the adolescent as well as the parents (Ackard & Neumark-Sztainer, 2001; Falvo, 2011). A limitation of Knowles’s assumptions about child versus adult learners is that they are derived from studies conducted on healthy people. Ill- ▸▸ The Developmental ness and injury, however, have the potential to significantly change the cognitive and psycho- Stages of Adulthood logical processes used for learning (Best, 2001). The period of adulthood constitutes three Andragogy , the term used by Knowles (1990) major developmental stages—the young adult to describe his theory of adult learning, is the stage, the middle-aged adult stage, and the older art and science of teaching adults. Education adult stage (Table 5-1). Although adulthood, like within this framework is more learner cen- childhood, can be divided into various devel- tered and less teacher centered; that is, instead opmental phases, the focus for learning is quite of one party imparting knowledge to another, different. Whereas a child’s readiness to learn de- the power relationship between the educator pends on physical, cognitive, and psychosocial and the adult learner is much more horizontal development, adults have essentially reached the (Curran, 2014). The concept of andragogy has peak of their physical and cognitive capacities. served for years as a useful framework in guid- The emphasis for adult learning revolves ing instruction for patient teaching and for con- around differentiation of life tasks and social tinuing education of staff. Recently, based on roles with respect to employment, family, and emerging research and theory from a variety of other activities beyond the responsibilities of disciplines, Knowles and colleagues (2015) dis- home and career (Boyd, Gleit, Graham, & Whit- cussed new perspectives on andragogy that have man, 1998). In contrast to childhood learning, refined and strengthened the core adult learn- which is subject centered, adult learning is prob- ing principles that Knowles originally proposed. lem centered. The prime motivator to learn in The following basic assumptions about adulthood is being able to apply knowledge and Knowles’s framework have major implications skills for the solution of immediate problems. for planning, implementing, and evaluating Unlike children, who enjoy learning for the sake teaching programs for adults as the individ- of gaining an understanding of themselves and ual matures: the world, adults must clearly perceive the rel- 1. The adult’s self-concept moves from evancy of acquiring new behaviors or chang- one of being a dependent personality ing old ones for them to be willing and eager to

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learn. In the beginning of any teaching–learning further learning. Adults already have a rich re- encounter, therefore, adults want to know how source of stored information on which to build they will benefit from their efforts at learning a further understanding of relationships be- (Knowles et al., 2015). tween ideas and concepts (Conlan, Grabowski, In contrast to the child learner, who is de- & Smith, 2015). Compared to children, adults pendent on authority figures for learning, the grasp relationships more quickly, but they do not adult is much more self-directed and indepen- tolerate learning isolated facts as well. Table 5-3 dent in seeking information. For adults, past ex- highlights the main differences between teach- periences are internalized and form the basis for ing children and teaching adults.

TABLE 5-3 Process Elements of Andragogy

Pedagogical Element Approach Andragogical Approach

1. Preparing Learners Minimal Provide information Prepare for participation Help develop realistic expectations Begin thinking about content

2. Climate Authority oriented Relaxed, trusting Formal Mutually respectful Competitive Informal, warm Collaborative, supportive Openness and authenticity Humanness

3. Planning By instructor Mechanism for mutual planning by learners and facilitator

4. Diagnosis of Needs By instructor By mutual assessment

5. Setting of Objectives By instructor By mutual negotiation

6. Designing Learning Logic of subject Sequenced by readiness Plans matter Problem units Content units

7. Learning Activities Transmittal Experiential techniques (inquiry) techniques

8. Evaluation By instructor Mutual rediagnosis of needs Mutual measurement of program

Reproduced with permission from Knowles, M. S., Holton, E. F., & Swanson, R. A. (2015). The adult learner: The definitive classic in adult education and human resource development (8th ed.). London: Routledge: Taylor and Francis Group. Copyright © 2015 by Routledge.

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Because adults already have established clear and identifiable objectives. ideas, values, and attitudes, they also tend to Continuing education for them is be more resistant to change. In addition, adults episodic and occurs as a recurring must overcome obstacles to learning very differ- pattern throughout their lives as they ent from those faced by children. For example, realize the need for or an interest they have the burden of family, work, and social in expanding their knowledge and responsibilities, which can diminish their time, skills. Adults attend night courses energy, and concentration for learning. Also, or professional workshops to build their need for self-direction may present prob- their expertise in a specific subject lems because various stages of illness, as well as or for advancement in their profes- the healthcare setting in which they may find sional or personal lives. themselves, can force dependency. Anxiety, too, 2. Activity-oriented learners select ed- may negatively affect their motivation and abil- ucational activities primarily to meet ity to learn, especially if the content is perceived social needs. The learning of content as difficult (Kinkead, Miller, & Hammett, 2016). is secondary to their need for human Furthermore, some adults may feel too old or contact. Although they may choose too out of touch with the formal learning of the to participate in support groups, school years to learn new things. If past experi- special-interest groups, or self-help ences with learning were not positive, they may groups, or attend academic classes also shy away from assuming the role of learner because of an interest in a topic be- for fear of the risk of failure (Boyd et al., 1998). ing offered, they join essentially out Although nurse educators can consider of their desire to be around others adult learners as autonomous, self-directed, and and converse with people in similar independent, these individuals often want circumstances—retirement, parent- and need structure, clear and concise specifics, ing, divorce, or widowhood. Their and direct guidance. As such, Taylor, Marienau, drive is to alleviate social isolation and Fiddler (2000) label adults as “paradoxi- or loneliness. cal” learners. 3. Learning-oriented learners view Only recently has it been recognized that themselves as perpetual students learning is a lifelong process that begins at birth who seek knowledge for knowl- and does not cease until the end of life. Growth edge’s sake. They are active learn- and development are a process of becoming, and ers throughout their lives and tend learning is inextricably a part of that process. As to join groups, classes, or organiza- a person matures, learning is a significant and tions with the anticipation that the continuous task to maintain and enhance one- experience will be educational and self (Knowles, 1990; Knowles et al., 2015). Social personally rewarding. scientists now recognize that adulthood “is not a single monolithic stage sandwiched between ado- In most cases, all three types of learners ini- lescence and old age” (Crandell et al., 2012, p. 403). tiate the learning experience for themselves. In A variety of reasons explain why adults planning educational activities for adults, it is pursue learning throughout their lives. Basi- important to determine their motives for want- cally, three categories describe the general ori- ing to be involved. That is, it is advantageous for entation of adults toward continuing education the nurse educator to understand the purpose (Knowles et al., 2015; Miller & Stoeckel, 2016): and expectations of the individuals who participate in continuing education programs. Armed 1. Goal-oriented learners engage in ed- with that knowledge, the nurse educator can ucational endeavors to accomplish best serve learners in the role of facilitator for

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referral or resource information, thereby em- the formal operations stage of cognitive devel- bracing the adults’ state of independence and opment (Piaget, 1951, 1952, 1976). These ex- interdependence (Musinski, 1999). periences add to their perceptions, allow them Obviously, there are many differences be- to generalize to new situations, and improve tween child and adult learners (Table 5-1 and their abilities to critically analyze, solve prob- Table 5-3). As the following discussion clearly lems, and make decisions about their personal, reveals, there also are differences in the char- occupational, and social roles. Their interests acteristics of adult learners within the three de- for learning are oriented toward those experi- velopmental stages of adulthood. ences that are relevant for immediate application to problems and tasks in their daily lives. Young adults are motivated to learn about the Young Adulthood possible implications of various lifestyle choices (20–40 Years of Age) (Crandell et al., 2012). Erikson (1963) describes the young adult’s The transition from adolescence to becoming a stage of psychosocial development as the period young adult has been termed emerging adulthood. of intimacy versus isolation. During this time, Early adulthood is composed of the cohort cur- individuals work to establish trusting, satisfy- rently between 20 and 34 years of age, who being, and permanent relationships with others long to the millennial generation, as well as the (Table 5-2). They strive to make commitments cohort currently aged 35 to 40, who are known to others in their personal, occupational, and as Generation X. Both generations exhibit their social lives. As part of this effort, they seek to own characteristic traits and present different maintain the independence and self-sufficiency challenges to the nurse educator (Fishman, 2016). they worked to obtain in adolescence. These two age cohorts encompass approximately Young adults face many challenges as they 140 million Americans and are more ethnically take steps to control their lives. Many of the diverse than ever (Crandell et al., 2012; Fry, 2016). events they experience are happy and growth Young adulthood is a time for establishing promoting from an emotional and social per- long-term, intimate relationships with other peo- spective, but they also can prove disappointing ple, choosing a lifestyle and adjusting to it, de- and psychologically draining. The new experi- ciding on an occupation, and managing a home ences and multiple decisions young adults must and family. These decisions lead to changes in make regarding choices for a career, marriage, the lives of young adults that can be a potential parenthood, and higher education can be quite source of stress for them. It is a time when inti- stressful. Young adults realize that the avenues macy and courtship are pursued and spousal and/ they pursue will affect their lives for years to or parental roles are developed (Santrock, 2017). come (Santrock, 2017).

Physical, Cognitive, and Teaching Strategies Psychosocial Development Based on the paucity of literature on health During this period, physical abilities for most teaching of individuals who belong specifi- young adults are at their peak, and the body is at cally to this age cohort, young adulthood is the its optimal functioning capacity (Crandell et al., life-span period that has received the least atten- 2012). The cognitive capacity of young adults is tion by nurse educators. At this developmental fully developed, but with maturation, they con- stage, prior to the emergence of the chronic dis- tinue to accumulate new knowledge and skills eases that characterize the middle-age and older from an expanding reservoir of formal and in- years, young adults are generally very healthy formal experiences. Young adults continue in and tend to have limited exposure to health

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professionals. Their contact with the health- promotion, more money, or more time to pursue care system is usually for preemployment, col- outside activities (Crandell et al., 2012; Miller lege, or presport physicals; for a minor episodic & Stoeckel, 2016). complaint; or for pregnancy and contraceptive When young adults are faced with acute or care (Orshan, 2008). At the same time, young chronic illnesses or disabilities, many of which adulthood is a crucial period for the establish- may significantly alter their lifestyles, they are ment of behaviors that help individuals to lead stimulated to learn to maintain their indepen- healthy lives, both physically and emotionally. dence and return to normal life patterns. It is Many of the choices young adults make, if not likely they will view an illness or disability as a positive ones, will be difficult to modify later. serious setback to achieving their immediate or As Havighurst (1976) points out, this stage is future life goals. full of “teachable moment” opportunities and Because adults typically desire active participa- healthcare providers must take advantage of ev- tion in the educational process, whenever possible ery opportunity to promote healthy behaviors it is important for the nurse as educator to allow with this population (Hinkle, 2014). them the opportunity for mutual collaboration in Health promotion is the most neglected as- health education decision making. They should pect of healthcare teaching at this stage of life. be encouraged, as Knowles (1990) suggested, to Yet, many of the health issues related to risk select what to learn (objectives), how they want factors and stress management are important material to be presented (teaching methods and to deal with to help young adults establish pos- tools), and which indicators will be used to de- itive health practices for preventing problems termine the achievement of learning goals (eval- with illness in the future. The major factors uation). Also, it must be remembered that adults that need to be addressed in this age group are bring to the teaching–learning situation a variety healthy eating habits, regular exercise, and avoid- of experiences that can serve as the foundation ing drug abuse. Such behaviors will reduce the on which to build new learning. Consequently, incidence of high blood pressure, elevated cho- it is important to draw on their personal expe- lesterol, obesity, smoking, and overuse of alco- riences to make learning relevant, useful, and hol and drugs (Santrock, 2017). motivating. Young adults tend to be reluctant to The nurse as educator must find a way of expend the resources of time, money, and energy reaching and communicating with this audi- to learn new information, skills, and attitudes if ence about health promotion and disease pre- they do not see the content of instruction as rel- vention measures. Readiness to learn does not evant to their current lives or anticipated prob- always require the nurse educator to wait for it lems (Collins, 2004; Knowles et al., 2015). to develop. Rather, such readiness can be ac- Teaching strategies must be directed at en- tively fostered through experiences the nurse couraging young adults to seek information that creates. Knowledge of the individual’s lifestyle expands their knowledge base, helps them con- can provide cues to concentrate on when de- trol their lives, and bolsters their self-esteem. termining specific aspects of education for the Whether they are well or ill, young adults need young adult. For example, if the individual is to know about the opportunities available to planning marriage, then establishing healthy learning. Making them aware of health issues relationships, family planning, contraception, and learning opportunities can occur in a vari- and parenthood are potential topics to address ety of settings, such as physicians’ offices, stu- during teaching (Orshan, 2008). The motiva- dent health services, health fairs, community and tion for adults to learn comes in response to outpatient clinics, or hospitals. In all cases, these internal drives, such as need for self-esteem, educational opportunities must be convenient a better quality of life, or job satisfaction, and and accessible to them in terms of their lifestyle in response to external motivators, such as job with respect to work and family responsibilities.

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Relevant, applicable, and practical information is the average life expectancy has increased by what adults desire and value—they want to know 30 years (Crandell et al., 2012; Santrock, 2017). “what’s in it for me,” according to Collins (2004). Thus, the concept of what has been thought Because they tend to be very self-directed of as middle age is being nudged upward. As in their approach to learning, young adults do more people live longer, middle age is now com- well with written patient education materials and ing later in life than ever before. Adults are no audiovisual tools, including computer-assisted longer considered to be “over the hill” when instruction, that allow them to self-pace their they celebrate their 40th birthday. Middle age learning independently. Group discussion is for many healthy adults is starting later and last- an attractive method for teaching and learning ing longer. Remember, chronological age is one because it provides young adults with the op- factor, but biological, psychological, and social portunity to interact with others of similar age age also must be considered (Newman & New- and in similar situations, such as in parenting man, 2015; Santrock, 2017). groups, prenatal classes, exercise classes, or mar- During middle age, many individuals are ital adjustment sessions. Although assessment highly accomplished in their careers, their sense prior to teaching helps to determine the level of who they are is well developed, their children at which to begin teaching, no matter what the are grown, and they have time to share their tal- content, the enduring axiom is to make learning ents, serve as mentors for others and pursue new easy and relevant. To facilitate learning, present or latent interests. This stage is a time for them concepts logically from simple to complex and to reflect on the contributions they have made establish conceptual relationships through spe- to family and society, relish in their achieve- cific application of information (Collins, 2004; ments, and reexamine their goals and values Musinski, 1999). (Newman & Newman, 2015).

Physical, Cognitive, and Middle-Aged Adulthood Psychosocial Development (41–64 Years of Age) During this stage of maturation, physiologi- Just as adolescence is the link between childhood cal changes begin to take place. Skin and mus- and adulthood, so midlife is the transition pe- cle tone decreases, metabolism slows down, riod between young adulthood and older adult- body weight tends to increase, endurance and hood. Middle-aged Americans make up about energy levels lessen, hormonal changes bring one fourth of the population, and this current about a variety of symptoms, and hearing and cohort has typically been labeled the baby-boom visual acuity start to diminish. All these physical generation. Although middle-aged adulthood changes and others affect middle-aged adults’ self- was once one of the most neglected age peri- image, ability to learn, and motivation for learn- ods, baby boomers, who now make up this co- ing about health promotion, disease prevention, hort, are receiving increasingly more attention and maintenance of health (Crandell et al., 2012). from developmental psychologists and health- The ability to learn from a cognitive stand- care providers. This emphasis is occurring not point remains at a steady state for middle-aged only because they constitute the largest cohort adults as they continue in what Piaget (1951, of any current generation but also because cur- 1952, 1976) labeled the formal operations stage rent middle-aged adults are the best educated, of cognitive development. He maintained that most affluent generation in history, and they have cognitive development stopped with this fourth the potential to enjoy a healthier life than ever stage (meaning the ability to perform abstract before because of medical discoveries that can thinking). However, over the years the critics of stave off the aging process. In just one century, Piaget’s theory have begun to assert the existence

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of postformal operations. That is, adult thought served as mentors. During this time, individu- processes go beyond logical problem solving to als often become oriented away from self and include what is known as dialectical thinking. family and toward the larger community. New This type of thinking is defined as the ability to social interests and leisure activities are pursued search for complex and changing understand- as they find more free time from family respon- ings to find a variety of solutions to any given sit- sibilities and career demands. As they move to- uation or problem. In other words, middle-aged ward their retirement years, individuals begin to adults see the bigger picture (Crandell et al., 2012). plan for what they want to do after culminating For many adults, the accumulation of their career. This transition sparks their interest life experiences and their proven record of in learning about financial planning, alternative accomplishments often allow them to come lifestyles, and ways to remain healthy as they to the teaching–learning situation with confi- approach the later years (Crandell et al., 2012). dence in their abilities as learners. However, if their past experiences with learning were minimal or not positive, their motivation likely will Teaching Strategies not be at a high enough level to easily facilitate Depending on individual situations, middle- learning. Physical changes, especially with re- aged adults may be facing either a more relaxed spect to hearing and vision, may impede learn- lifestyle or an increase in stress level because of ing as well (Santrock, 2017). midlife crisis issues such as menopause, obvious Erikson (1963) labels this psychosocial stage physical changes in their bodies, responsibility of adulthood as generativity versus self-absorption for their own parents’ declining health status, or and stagnation. Midlife marks a point at which concern about how finite their life really is. They adults realize that half of their potential life has may have regrets and feel they did not achieve been spent. This realization may cause them to the goals or live up to the values they had set question their level of achievement and suc- for themselves in young adulthood or the excess. Middle-aged adults, in fact, may choose pectations others had of them as young adults. to modify aspects of their lives that they per- Santrock (2017) cites research indicating that ceive as unsatisfactory or adopt a new lifestyle this stage in life is not so much seen as a crisis as a solution to dissatisfaction. but rather as a period of midlife consciousness. Developing concern for the lives of their When teaching members of this age group, grown children, recognizing the physical changes the nurse must be aware of their potential sources in themselves, dealing with the new role of be- of stress, the health risk factors associated with ing a grandparent, and taking responsibility for this stage of life, and the concerns typical of mid- their own parents whose health may be fail- life. Misconceptions regarding physical changes ing are all factors that may cause adults in this such as menopause are common. Stress may in- cohort to become aware of their own mortal- terfere with middle-aged adults’ ability to learn ity (Table 5-2). During this time, middle-aged or may be a motivational force for learning adults may either feel greater motivation to fol- (Merriam & Bierema, 2014). Those who have low health recommendations more closely or— lived healthy and productive lives are often mo- just the opposite—may deny illnesses or abandon tivated to contact health professionals to ensure healthy practices altogether (Falvo, 2011). maintenance of their healthy status. Such con- The later years of middle adulthood are the tacts represent an opportune time for the nurse phase in which productivity and contributions educator to reach out to assist these middle-aged to society are valued. They offer an opportunity adults in coping with stress and maintaining to feel a real sense of accomplishment from hav- optimal health status. Many need and want in- ing cared for others—children, spouse, friends, formation related to chronic illnesses that can parents, and colleagues for whom adults have arise at this phase of life (Orshan, 2008).

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Adult learners need to be reassured or com- Most older people have at least one chronic plimented on their learning competencies. Rein- condition, and many, especially in the later years, forcement for learning is internalized and serves have multiple conditions. On average, they are to reward them for their efforts. Teaching strat- hospitalized longer than persons in other age egies for learning are similar in type to teach- categories and require more teaching overall to ing methods and instrumental tools used for broaden their knowledge of self-care. In addi- the young adult learner, but the content is dif- tion, it is approximated by the USDHHS that as ferent to coincide with the concerns and prob- of 2016, the educational profile of older Ameri- lems specific to this group of learners. cans is as follows: 54% of Hispanics, 77% of Black Americans, 80% of those of Asian descent, and 90% of Caucasians older than 65 years of age Older Adulthood have a high school education; this percentage is 84% for the aggregate. These numbers have (65 Years of Age and Older) increased significantly since 1970, when only The percentage of middle-aged adults in the 28% of older adults had a high school diploma. United States has tripled since 1900, and in However, currently, only 28% of them have a 2011, the first wave of baby boomers turned 65 college degree at the bachelor’s level or higher years of age. Older persons constitute approxi- (USDHHS, 2016). Lower educational levels in mately 15% of the U.S. population now, but by some ethnic groups, sensory impairments, the 2030, the number of those older than age 65 disuse of literacy skills once learned, and cog- will increase to 21%, or approximately 74 mil- nitive changes in the population of older adults lion Americans. Those aged 85 and older make may contribute to their decreased ability to read up the fastest-growing segment of the popu- and comprehend written materials (Best, 2001). lation in the country today, and that segment For these reasons, their patient education is expected to more than triple by 2060, ris- needs are generally greater and more complex ing to approximately 20 million (Federal In- than those for persons in any of the other de- teragency Forum on Aging-Related Statistics, velopmental stages. Numerous studies have 2016). With more than 45% of the 2010 fed- documented that older adults can benefit from eral budget allocated for Medicare, Medicaid, health education programs. Their compliance, and Social Security, a considerable portion of if they are given specific health directions, can this country’s fiscal resources is used for pro- be quite high. Given the considerable health- grams that support those 65 years and older care expenditures for older people, education (Crandell et al., 2012). programs to improve their health status and re- Some developmentalists have in recent years duce morbidity would be a cost-effective mea- begun to categorize older adults into distinct di- sure (Behm et al., 2014; Best, 2001; Mauk, 2014; visions based on different age ranges. For ex- Robnett & Chop, 2015). ample, Santrock (2017) identifies three groups Because American society values physical of older adults: the young-old (65–74 years of strength, beauty, social networking, produc- age), the old-old (75–84 years of age), and the tivity, and integrity of body and mind, people oldest-old (85 years and older). Newman and fear the natural losses that accompany the ag- Newman (2015) have identified the last stages ing process. Growing older is a normal event, of aging into two categories: later adulthood yet the inevitable continuation of human de- (60–75 years) and elderhood (75 years until velopment that results in biological, psycho- death). These new distinctions acknowledge a logical, and social changes with the passage shift in health and productivity levels of peo- of time is a reminder of mortality. Nurses and ple in the later years according to biological nurse educators must recognize that a signifi- and social trends. cant number of older persons respond to these

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changes by viewing them as challenges rather create obstacles to learning unless nurses under- than defeats. Many aspects of older adulthood stand them and can adapt appropriate teaching can be pleasurable, such as becoming a grand- interventions to meet the older person’s needs. parent and experiencing retirement that gives The following discussion of physical, cognitive, one time to pursue lifelong interests, as well as and psychosocial maturation is based on find- freedom to explore new avenues of endeavor ings reported by numerous authors (Ahroni, (Santrock, 2017). 1996; Best, 2001; Crandell et al., 2012; Gavan, Ageism describes prejudice against the 2003; Hinkle, 2014; Mauk, 2014; Santrock, 2017; older adult. This discrimination based on age, Weinrich & Boyd, 1992). which exists in most segments of American society, perpetuates the negative stereotype Physical, Cognitive, and of aging as a period of decline (Gavan, 2003; Miller & Stoeckel, 2016). Ageism, in many re- Psychosocial Development spects, can be compared to the discriminatory With advancing age, so many physical changes attitudes of racism and sexism (Crandell et al., occur that it becomes difficult to establish nor- 2012). This bias interferes with interactions be- mal boundaries. As a person grows older, nat- tween the older adult and younger age groups ural physiological changes in all systems of the and must be counteracted because it “prevents body are universal, progressive, decremental, older people from living lives as actively and and intrinsic. Alterations in physiological func- happily as they might” (Ahroni, 1996, p. 48). tioning can lead secondarily to changes in learn- Given that the aging process is universal, even- ing ability. The senses of sight, hearing, touch, tually everyone is potentially subject to this taste, and smell are usually the first areas of de- type of prejudice. New research that focuses on creased functioning noticed by adults (Miller healthy development and positive lifestyle ad- & Stoeckel, 2016). aptations, rather than on illnesses and impair- The sensory perceptive abilities that relate ments in the older adult, can serve to reverse most closely to learning capacity are visual and the stereotypical images of aging. Education auditory changes. Hearing loss, which is very to inform people of the significant variations common beginning in the late 40s and 50s, in- that occur in the way that individuals age and cludes diminished ability to discriminate high- education to help the older adult learn to cope pitched, high-frequency sounds. Visual changes with irreversible losses can combat the preju- such as cataracts, macular degeneration, re- dice of ageism as well (Crandell et al., 2012). duced pupil size, decline in depth perception, The teaching of older persons, known as and presbyopia may prevent older persons from gerogogy, is different from teaching younger being able to see small print, read words printed adults (andragogy) and children (pedagogy). For on glossy paper, or drive a car. Yellowing of the teaching to be effective, gerogogy must accom- ocular lens can produce color distortions and modate the normal physical, cognitive, and psy- diminished color perceptions. chosocial changes that occur during this phase Other physiological changes affect organ of growth and development (Best, 2001; Miller functioning and result in decreased cardiac & Stoeckel, 2016). Until recently, little had been output, lung performance, and metabolic rate; written about the special learning needs of older these changes reduce energy levels and lessen adults that acknowledged the physiological and the ability to cope with stress. Nerve conduction psychological aging changes that affect their velocity also is thought to decline by as much ability to learn. as 15%, influencing reflex times and muscle re- Age changes, which begin in young and sponse rates. The interrelatedness of each body middle adulthood, progress significantly at this system has a total negative cumulative effect on older adult stage of life. These changes often individuals as they grow older.

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Aging affects the mind as well as the body. remains strong, such as the ability Cognitive ability changes with age as perma- to clearly and accurately remember nent cellular alterations invariably occur in something from their youth. the brain itself, resulting in an actual loss of 4. Increased test anxiety. People in the neurons, which have no regenerative powers. older adult years are especially anx- Physiological research has demonstrated that ious about making mistakes when per- people have two kinds of intellectual ability— forming; when they do make an error, crystallized and fluid intelligence. Crystal- they become easily frustrated. Because lized intelligence is the intelligence absorbed of their anxiety, they may take an in- over a lifetime, such as vocabulary, general in- ordinate amount of time to respond formation, understanding social interactions, to questions, particularly on tests that arithmetic reasoning, and ability to evaluate are written rather than verbal. experiences. This kind of intelligence increases 5. Altered time perception. For older with experience as people age. However, it is persons, life becomes more finite and important to understand that crystallized in- compressed. Issues of the here and telligence can be impaired by disease states, now tend to be more important, such as the dementia seen in Alzheimer’s dis- and some adhere to the philosophy, ease. Fluid intelligence is the capacity to per- “I’ll worry about that tomorrow.” This ceive relationships, to reason, and to perform way of thinking can be detrimental abstract thinking. This kind of intelligence de- when applied to health issues because clines as degenerative changes occur. it serves as a vehicle for denial or The decrease in fluid intelligence results in delay in taking appropriate action. the following specific changes: Despite the changes in cognition caused by 1. Slower processing and reaction time. aging, most research supports the premise that Older persons need more time to the ability of older adults to learn and remem- process and react to information, es- ber is virtually as good as ever if special care is pecially as measured in terms of rela- taken to slow the pace of presenting information, tionships between actions and results. to ensure relevance of material, and to give ap- Figure 5-1 However, if the factor of speed is re- propriate feedback when teaching ( ). moved from intelligence tests, for Erikson (1963) labels the major psycho- example, older people can perform social developmental task at this stage in life as well as younger people. In per- as ego integrity versus despair. This phase of formance of activities of daily living older adulthood includes dealing with the re- when speed is not a factor, older ality of aging, the acceptance of the inevitabil- adults can demonstrate their true ity that all persons die, the reconciling of past abilities to function well and inde- failures with present and future concerns, and pendently (Kray & Lindenberger, 2000). developing a sense of growth and purpose for 2. Persistence of stimulus (afterimage). those years remaining (Table 5-2). The most Older adults can confuse a previous common psychosocial tasks of aging involve symbol or word with a new word or changes in lifestyle and social status based on symbol just introduced. the following circumstances. 3. Decreased short-term memory. Older ■■ Retirement adults sometimes have difficulty re- ■■ Illness or death of spouse, relatives, and membering events or conversations friends that occurred just hours or days before. ■■ The moving away of children, grandchil- However, long-term memory often dren, and friends

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Learning Influences in the Maximizing Learning in the Older Adult Older Adult

– Sensory perceptions (hearing, – Personalized goals seeing, touching) – Cueing – Energy level – Positive reinforcement – Memory Older Adult – Pacing with rest periods – Affect – Rehearsing – Risk-taking ability – Time for questions – Response time – Relaxed environment – Cultural background – Flexibility – Disability – Provide purpose of teaching – Stress – Establish rapport – Health literacy level – Material easy to read

FIGURE 5-1 Learning in the older adult. Data from Mauk, K. L. (2014). Gerontological nursing: Competencies for care (3rd ed.). Burlington, MA: Jones & Bartlett Learning; Rendon, D. C., Davis, D. K., Gioiella, E. C., & Tranzillo, M. J. (1986). The right to know, the right to be taught. Journal of Gerontological Nursing, 12(12), 36.

■■ Relocation to an unfamiliar environment vary from less frequent to no more frequent such as an extended-care facility or senior than the incidence rate found in middle adult- residential living center hood. This situation arises because older adults overall have fewer economic hardships and in- After Erikson’s death in 1994, a ninth creased religiosity. However, depressive symp- stage of psychosocial development, hope and toms do increase in the oldest-old and are thought faith versus despair was published by his wife to be associated with more physical disability, in the book The Life Cycle Completed (Erikson more cognitive impairment, and lower socio- & Erikson, 1998). This new final stage was de- economic status. veloped from notes that Erikson left behind, For those who experience major depres- along with the conversations he had with his sion (the “common cold” of mental disorders), wife. It addresses those individuals reaching the most likely predictors are a previous history their late 80s and older, identifying that aging of depression, lack of perceived social support, individuals need to accept greater assistance as poor health, disability, and losing members of their bodies age. The goal is to find a renewed the established social network (Santrock, 2017). awareness of self in accordance with this need These losses, which signify a threat to one’s own for additional care while eventually achieving autonomy, independence, and decision making, a new sense of wisdom that is less materialis- result in isolation, financial insecurity, dimin- tic and moves the individual beyond physical ished coping mechanisms, and a decreased sense limits (Crandell et al., 2012; Erikson & Erikson, of identity, personal value, and societal worth. 1998). Although this additional stage has been With aging, some individuals, particularly the published for some time, it has not been incor- oldest-old, begin to question their perception porated into the literature discussing Erikson’s of a meaningful life—that is, the potential for stages of development. However, Brown and further enjoyment, pleasure, and satisfaction. Lowis (2003) conducted a study that did provide Depressive symptoms in the oldest-old, espe- some evidence of a distinct differentiation be- cially men, are thought to be associated with tween stages eight and nine in aging individuals. more physical disability, more cognitive impair- Depression, grief, loneliness, and isolation, ment, and lower socioeconomic status (Federal once thought to be common traits among older Interagency Forum on Aging-Related Statistics, adults, have now been found by researchers to 2016; Santrock, 2017).

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Separate from biological aging but closely gained over the years. Negative coping related are the many sociocultural factors that mechanisms indicate an individual’s affect how older adults see themselves as com- focus on losses and show that his petent individuals (Crandell et al., 2012; Leifer or her thinking is immersed in the & Hartston, 2013; Newman & Newman, 2015; past. The emphasis in teaching is on Santrock, 2017). The following traits regarding exploring alternatives, determining personal goals in life and the values associated realistic goals, and supporting large with them are significantly related to motiva- and small accomplishments. tion and learning: 5. Meaning of life. For well-adapted older persons, having realistic goals 1. Independence. The ability to provide for their own needs is the most allows them the opportunity to enjoy important aim of most older per- the smaller pleasures in life, whereas sons, regardless of their state of less well-adapted individuals may be health. Independence gives them frustrated and dissatisfied with per- a sense of self-respect, pride, and sonal inadequacies. Health teaching self-functioning so as not to be a must be directed at ways older adults burden to others. Health teaching can maintain optimal health so that is the tool to help them maintain or they can derive pleasure from their regain independence. leisure years. 2. Social acceptability. Winning approval from others is a common goal of many older adults. It is derived from health, Teaching Strategies a sense of vigor, and feeling and think- Learning in older adults can be affected by such ing young. Despite declining phys- sociological, psychological, and cognitive factors ical attributes, the older adult often as retirement, economics, mental status, and in- has residual fitness and functioning formation processing abilities (Crandell et al., potentials. Health teaching can help 2012; Miller & Stoeckel, 2016; Santrock, 2017). to channel these potentials. Understanding older persons’ developmental 3. Adequacy of personal resources. tasks allows nurses to alter how they approach Resources, both external and internal, both well and ill individuals in terms of coun- are important considerations when seling, teaching, and establishing a therapeu- assessing the older adult’s current tic relationship. Nurses must be aware of the health and wellness status. Life pat- possibility that older patients may delay medi- terns, which include habits, physical cal attention. Decreased cognitive functioning, and mental strengths, and economic sensory deficits, lower energy levels, and other situation, should be assessed to de- factors may prevent early disease detection and termine how to incorporate teaching intervention. A decline in psychomotor per- to complement existing regimens formance affects older adults’ reflex responses and resources (financial and support and their ability to handle stress. Coping with system) with new required behaviors. simple tasks becomes more difficult. Chronic 4. Coping mechanisms. The ability to illnesses, depression, and literacy levels, partic- cope with change during the aging ularly among the oldest-old, have implications process is indicative of the person’s with respect to how they care for themselves readiness for health teaching. Pos- (eating, dressing, and taking medications) as itive coping mechanisms allow for well as the extent to which they understand the self-change as older persons draw nature of their illnesses (Best, 2001; Katz, 1997; on life experiences and knowledge Mauk, 2014; Phillips, 1999).

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In working with older adults, reminiscing is amount of contacts older adults have with a beneficial approach to use to establish a thera- significant others remains constant over peutic relationship. Memories can be quite pow- time. Successful aging depends on an ex- erful. Talking with older persons about their tended family support network. experiences—marriage, children, grandchildren, Crandell et al. (2012) also point out that jobs, community involvement, and the like—can American culture is preoccupied with youthful- be very stimulating. Furthermore, their answers ness and has distorted notions about late adult will give the nurse insight into their humanness, hood that perpetuate negative views of this their abilities, and their concerns. generation. There is no typical older adult—not Too many times nurses and other health all individuals in this age group are unhealthy, professionals believe the adage, “You can’t teach unhappy, fearful, institutionalized, or disengaged; an old dog new tricks.” Gavan (2003) warns that dwell on their own mortality; or find themselves it is easy to fall into the habit of believing the in financial straits. Stereotypes can have a very myths associated with the intelligence, person- powerful impact on older adults in both a pos- ality traits, motivation, and social relations of itive and negative way, affecting their physical older adults. She outlined the following prev- and cognitive functioning. Positive stereotypes alent myths that must be dispelled to prevent can bring out the best in a person, whereas neg- harmful outcomes in the older adult when these ative ones can lead to fulfillment of a pessimis- myths are assumed to be true: tic state (Bennett & Gaines, 2010). Myth No. 1: Senility. Intelligence test scores Nurse educators may not even be aware of indicate that many older adults maintain their stereotypical attitudes toward older adults. their cognitive functioning well into their 80s Furthermore, healthcare providers make assump- and 90s. Mental decline is not always caused tions about older clients that cause them to over- by the aging process itself but rather by disease look problems that could be treatable (Gavan, processes, medication interactions, sensory 2003). To check their assumptions, nurses can deficits, dehydration, and malnutrition. think about the last time they gave instructions to an older patient and ask themselves the fol- Myth No. 2: Rigid Personalities. Personality lowing questions. traits, such as agreeableness, satisfaction, and extraversion, remain stable throughout ■■ Did I talk to the family and ignore the pa- the older adult years. Although diversity tient when I described some aspect of care in personality traits among individuals in or discharge planning? the older population exists as it does in all ■■ Did I tell the older person not to worry other stages of life, labeling older adults when he or she asked a question? Did I say, as cranky, stubborn, and inflexible does a “Just leave everything up to us”? disservice to them. ■■ Did I eliminate information that I normally Myth No. 3: Loneliness. As mentioned earlier, would have given to a younger patient? ■ the belief that older adults are more fre- ■ Did I attribute a decline in cognitive func- quently vulnerable to depression, isolation, tioning to the aging process without and feelings of being lonely has not been considering common underlying causes upheld by research, which indicates that their in mental deterioration, such as effects of satisfaction with life continues at a steady medication interactions, fluid imbalances, level throughout the period of adulthood. poor nutrition, or sensory impairments? Myth No. 4: Abandonment. It is untrue All health professionals must remember that older adults are abandoned by their that older people can learn, but their abilities children, siblings, or good friends. The and needs differ from those of younger persons.

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The process of teaching and learning is much limited, it may be beneficial to schedule addi- more rewarding and successful for both the tional time, if possible, to allow for a more re- nurse and the patient if it is tailored to fit the laxed environment. Individual and situational older adult’s physical, cognitive, motivational, variables such as motivation, life experiences, and social differences. educational background, socioeconomic sta- Because changes during aging vary con- tus, health or illness status, and motor, cogni- siderably from one individual to another, it is tive, and language skills may all influence the essential to assess each learner’s physical, cog- ability of the older adult to learn. nitive, and psychosocial functioning levels be- A recent report found that 59% of those fore developing and implementing any teaching persons older than age 65 are engaged in plan (Miller & Stoeckel, 2016). Keep in mind some type of computer use (Smith, 2014). Thus, that older adults have an overall lower educa- although many older adults routinely use com- tional level of formal schooling than does the puters, a good number do not. Assuming the remainder of the population. Also, they were client has the computer skills necessary to look raised in an era when consumerism and health up healthcare information or engage in self- education were practically nonexistent. As a re- education can derail learning. As the popula- sult, older people may feel uncomfortable in the tion continues to age, computer use will be more teaching–learning situation and may be reluc- prevalent and preferred by clients who have been tant to ask questions. comfortable using technology to increase their As the older population becomes more knowledge (Mauk, 2014). However, despite the educated and in tune with consumer activism cognitive comfort some aging clients have with in the health field, these individuals will likely technology, the nurse may need to suggest adap- have an increased desire to actively participate tive devices for the computer to accommodate in decision making and demand more detailed the physical changes of aging. and sophisticated information. Nurse educa- Some of the more common aging changes tors must take steps to support older clients in that affect learning and the teaching strategies making decisions affecting their health (Mauk, specific to meeting the needs of the older adult 2014). This increased participation by clients are summarized in Table 5-1. When teaching can assist in managing chronic diseases, pro- older persons, abiding by the following spe- moting quality and safety in healthcare organi- cific tips can create an environment for learning zations, and ensuring effective redesign of care that considers major changes in their physical, and treatment-related processes (Longtin et al., cognitive, and psychosocial functioning (Best, 2010). Further, the involvement of clients in de- 2001; Crandell et al., 2012; Doak, Doak, & Root, ciding the course of their own care is supported 1996; Katz, 1997; Phillips, 1999; Robnett & Chop, by Healthy People 2020 (USDHHS, 2014). 2015; Ruholl, 2003; Santrock, 2017; Weinrich & Health education for older persons should Boyd, 1992): be directed at promoting their involvement and changing their attitudes toward learning Physical Needs (Ahroni, 1996; Weinrich & Boyd, 1992). A cli- 1. To compensate for visual changes, mate of mutual respect in which they are made teaching should be done in an envi- to feel important for what they once were as ronment that is brightly lit but with- well as for what they are today should be cul- out glare. Visual aids should include tivated. Interaction needs to be supportive, large print, well-spaced letters, and not judgmental. the use of primary colors. The edu- Interventions work best when they take cator should wear bright colors and place in a casual, informal atmosphere. In a visible name tag. Use white or off- the primary care setting, where time is often white, flat matte paper and black print

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for posters, diagrams, and other writ- determine whether you are speaking ten materials. too softly, too fast, or not distinctly Because of older persons’ diffi- enough. When addressing a group, culty in discriminating certain shades microphones are useful aids. of color, avoid blue, blue–green, and Be alert to nonverbal cues from violet hues. Keep in mind that tasks that the audience. Participants who are require recognizing different shades having difficulty with hearing your of color, such as test strips measur- message may try to compensate by ing the presence of sugar in the urine, leaning forward, turning the good may present learning difficulties for ear to the speaker, or cupping their older patients. Color distortions can hands to their ears. Ask older per- have an especially devastating effect sons to repeat verbal instructions to on learning if, for example, the type of be sure they heard and interpreted pills are referred to by color in guiding correctly the entire message. patients to take medications as pre- 3. To compensate for musculoskeletal scribed. Green, blue, and yellow pills problems, decreased efficiency of the may all appear gray to older persons. cardiovascular system, and reduced Additional accommodations kidney function, keep sessions short, should be made to meet older adults’ schedule frequent breaks to allow for physical needs, such as arranging seats use of bathroom facilities, and allow so that the learner is reasonably close time for stretching to relieve painful, to the instructor and to any visual stiff joints and to stimulate circula- aids that may be used. For patients tion. Provide pain medication and who wear glasses, be sure they are encourage the learner to follow his or readily accessible, lenses are clean, her usual pain management routine. and frames are properly fitted. Also, provide comfortable seating. 2. To compensate for hearing losses, 4. To compensate for any decline in cen- eliminate extraneous noise, avoid cov- tral nervous system functioning and ering your mouth when speaking, decreased metabolic rates, set aside directly face the learner, and speak more time for the giving and receiv- slowly. These techniques assist the ing of information and for the prac- learner who may be seeking visual tice of psychomotor skills. Also, do confirmation of what is being said. not assume that older persons have Low-pitched voices are heard best, the psychomotor skills necessary to but be careful not to drop your voice handle technological equipment for at the end of words or phrases. Do self-paced learning, such as comput- not shout, because it distorts sounds ers and mouse, ear buds instead of and the decibel level is usually not a headsets, MP3 players, and DVD problem for individuals with hearing players. In addition, they may have impairments. The intensity of sound difficulty with independently apply- seems to be less important than the ing prostheses or changing dress- pitch and rate of auditory stimuli. ings because of decreased strength Word speed should not exceed and coordination. Be careful not to 140 words spoken per minute. If the misinterpret the loss of energy and learner uses hearing aids, be sure he motor skills as a lack of motivation. or she has working batteries. Ask 5. To compensate for the impact of hear- for feedback from the learner to ing and visual changes on computer

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use, be sure that the speakers on the and react to information and to see computer are working well and use relationships between concepts. Re- headphones to block background search has shown that older adults noise. The computer screen should can learn anything if new informa- be clean and free of glare, offer good tion is tied to familiar concepts drawn resolution, and provide large-enough from relevant past experiences. print. Further, clients with arthritis When teaching, nurses should may need to learn alternative ways avoid presenting long lists by divid- to use the mouse (Mauk, 2014). ing a series of directions for action Table 5-4 outlines specific strate- into short, discrete, step-by-step mes- gies that can assist older adults to sages and then waiting for a response overcome problems associated with after each one. For instance, to give computer use. directions about following different menus depending on exercise levels, Cognitive Needs they can use an active voice to per- 1. To compensate for a decrease in fluid sonalize the message. For example, intelligence, provide older persons instead of saying, “Use menu A if with more opportunities to process not active; use menu B if somewhat

TABLE 5-4 Problems That Can Be Overcome by Older Adults Using Computers

Age Change Effect on ComputerU se Possible Solutions

Hearing Sound from computer may not be Use earphones to enhance hearing and heard eliminate background noise. Speak slowly and clearly.

Vision Vision declines, need for bifocal Adjust monitor’s tilt to eliminate glare. glasses, viewing monitor may be Change size of font to 14. difficult, problems with glaucoma and Make sure contrast is clear. light/colors Change the screen resolution to promote color perception.

Motor May affect use of keyboard or control Highlight area and press Enter. control of mouse, may not be able to hold Avoid double clicking. tremors the mouse and consistently click correct mouse buttons

Arthritis May not be able to hold the mouse Highlight area and press Enter. and consistently click correct mouse Teach how to use options on keyboard. buttons

Attention Problems with inability to focus and Priming—introduce concept early on. span making correct inferences Repetition is key to retention. Use cheat sheets.

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active; use menu C if very active,” they learned it. Confirm patients’ level should say, “You should use menu A of knowledge before beginning to if you are not active.” Then wait for teach. Basic information should be the learner’s response, which might understood before progressing to be, “That’s what I should eat if I’m more complex information. not very active?” The nurse educa- 4. Convincing older persons of the use- tor can follow up with the response, fulness of what the educator is teach- “That’s right. And if you are some- ing is only half the battle in getting what active, you should . . .” them motivated. Nurse educators may Older persons also tend to confuse also have to convince patients that previous words and symbols with a the information or technique they are new word or symbol being introduced. teaching is correct. Anything that is Again, nurse educators can wait entirely strange or that upsets estab- for a response before introducing lished habits is likely to be far more a new concept or word definition. difficult for older adults to learn. For decreased short-term memory, Information that confirms existing coaching and repetition are very beliefs (cognitive schema) is better useful strategies that assist with remembered than that which con- recall. Memory also can be enhanced tradicts these beliefs. Patients with by involving the learner in devising chronic illnesses frequently have es- ways to remember how or when to tablished schemas about their medical perform a procedure. Because many conditions that they have embraced older adults experience test anxiety, for years. try to explain procedures simply and As perception slows, the older thoroughly, reassure them, and, if person’s mind has more trouble ac- possible, give verbal rather than commodating to new ways than does written tests. the mind of a younger person. Find 2. Be aware of the effects of medica- out about older persons’ health hab- tions and energy levels on concentra- its and beliefs before trying to change tion, alertness, and coordination. Try their ways or teach something new. to schedule teaching sessions before For example, many older adults were or well after medications are taken taught as children that pain is a sign and when the person is rested. For that something is wrong and they example, the patient who has just should always stop whatever they returned from physical therapy or a are doing if it causes pain. Educa- diagnostic procedure will likely be tors need to identify this belief be- too fatigued to attend to learning. fore trying to teach them that they 3. Be certain to ask what an individual sometimes need to move through already knows about a healthcare their pain to avoid stiffness and joint issue or technique before explaining contractures. it. Repetition for reinforcement of 5. Arrange for brief teaching sessions learning is one thing; repeating in- because a shortened attention span formation already known may seem (attentional narrowing) requires patronizing. Nurse educators should scheduling a series of sessions to pro- never assume that because someone vide sufficient time for learning. In has been exposed to information addition, if the material is relevant before that the individual, in fact, and focused on the here and now,

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older persons are more likely to be Figure 5-2 presents strategies to meet the attentive to the information being cognitive needs of older adults. presented. If procedures or treat- ments are perceived as stressful or Psychosocial Needs emotionally threatening, attentional 1. Assess family relationships to de- narrowing occurs. termine how dependent the older 6. Recognize that the process of con- person is on other members for ceptualizing and the ability to think financial and emotional support. In abstractly become more difficult turn, nurse educators can explore with aging. Conclude each teach- the level of involvement by family ing session with a summary of the members in reinforcing the lessons information presented and allow for they are teaching and in giving a question-and-answer period to assistance with self-care measures. correct any misconceptions. Do family members help the older

Elements of Nursing Strategies to Learning Process Facilitate Learning

Environmental Apprehending: Manipulation, Registering Rest Periods, Stimuli, Relaxation Techniques, Attending, Reduced Stimulus Perceiving Overload LEARNING LEARNING Pacing, Acquiring: Reduce Task Relevance Complexity, and Coding Organize, Personalized Learner Goals

Storage: Primary Repetition, to Rehearsing Secondary Overlearning Memory REMEMBERING REMEMBERING Retrieval Associative Recall and Cues Transfer

FIGURE 5-2 A basic gerontological teaching–learning model for nursing. Reproduced from Rendon, D. C., Davis, D. K., Gioiella, E. C., & Tranzillo, M. J. (1986). The right to know, the right to be taught. Journal of Gerontological Nursing, 12(12), 36. Reproduced with permission of SLACK Incorporated.

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person to function independently, Self-paced instructional tools may be very or do they foster dependency? With appropriate, but it is important to know the permission of the patient, include client’s previous learning techniques, mental family members in teaching sessions and physical abilities, and comfort levels with and enlist their support. certain approaches before assigning any such 2. Determine availability of resources. tools. Many older adults grew up in a time A lack of resources can sabotage when technology was very different than it is any teaching plan, especially if the today, and those who have always learned by recommendations include expecting reading and discussion may not like electronic older adults to carry out something devices. Introducing new teaching methods they cannot afford or lack the means and tools, such as the use of computer and to do, such as buying or renting interactive video formats, without adequate equipment, having transportation instructions on how to operate these techni- to get to therapy or teaching ses- cal devices, may inhibit learning by increas- sions, purchasing medications, and ing anxiety and frustration levels and may the like. adversely affect self-esteem. 3. Encourage active involvement of Games, role play, demonstration, and re- older adults to improve their self- turn demonstration can be used to rehearse esteem and to stimulate them both problem-solving and psychomotor skills if these mentally and socially. Teaching methods, and the tools used to complement must be directed at helping them them, are designed appropriately to accommo- find meaningful ways to use talents date the various developmental characteristics acquired over their lifetime. Estab- of this age group. For example, speed or com- lishing a rapport based on trust can petition should not be factors in the games cho- provide them contact with others sen, and plenty of time should be reserved for to bolster their sense of self-worth. return demonstrations. These teaching methods 4. Identify coping mechanisms. No stimulate learning and can offer active learn- other time in the life cycle carries ing opportunities to put knowledge into prac- with it the number of developmen- tice. Written materials, if appropriate in terms tal tasks associated with adaptation to of literacy level and visual impairments in the loss of roles, social and family con- older adult, are excellent adjuncts to augment, tacts, and physical and cognitive ca- supplement, and reinforce verbal instructions. pacities that this time does. Teaching must include offering constructive methods of coping. ▸▸ The Role of the Family The older person’s ability to learn may be in Patient Education affected by the methods and materials chosen for teaching. One-to-one instruction provides a The role of the family is considered one of the nonthreatening environment for older adults in key variables influencing positive patient care which to meet their individual needs and goals. outcomes. The primary motives in patient edu- This teaching approach helps them to compen- cation for involving family members in the care sate for their special deficits and promotes their delivery and decision-making process are to de- active participation in learning. Group teaching crease the stress of hospitalization, reduce costs also can be a beneficial approach for fostering of care, increase satisfaction with care, reduce social skills and maintaining contact with oth- hospital readmissions, and effectively prepare ers through shared experiences. the patient for self-care management outside

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the healthcare setting. Family caregivers pro- In patient education, the nurse may be vide critical emotional, physical, and social tempted to teach as many family members as support to the patient (Gavan, 2003; James & possible. Realistically, it is difficult to coordi- Hughes, 2016; Reeber, 1992; Reinhard, Levine, nate the instruction of so many different peo- & Samis, 2012). ple. The more individuals involved, the greater Future projections indicate that the num- the potential for misunderstanding of instruc- ber of Americans who need long-term services tion. The family must make the deliberate deci- and supports (LTSS) in the home will continue sion as to who is the most appropriate person to to grow at a significant rate, more than doubling take the primary responsibility as the caregiver. from 12 million today to 27 million by 2050. The nurse educator must determine how According to federal statistics, 20% of individ- caregivers feel about the role of providing sup- uals over 65 years of age need assistance from portive care and about learning the necessary an informal caregiver with at least one activity information. They must also explore caregiver of daily living, such as medication administra- learning style preferences, cognitive abilities, fears tion, and for those over 85 years of age, this per- and concerns, and current knowledge of the sit- centage increases to 41%. Based on 2013 data, it uation. The family and the nurse may perceive is estimated that the approximate value of ser- the patient problem differently (Mauk, 2014). vices provided to adults by family caregivers is Such difference must be identified so that ef- $470 billion annually (James & Hughes, 2016). fective teaching can be provided. The caregiver The role of family caregivers is central to needs similar information to what the patient the quality of care for older adults in the com- is given to provide support, feedback, and re- munity. Although the physical, emotional, inforcement of self-care consistent with pre- and financial toll on caregivers can be great scribed regimens of care. In some situations, a (James & Hughes, 2016), including the family secondary caregiver is identified and also must members in the teaching–learning process helps be considered when teaching. to ensure that the situation is a win-win scenario Sometimes the family members need more for both the clients and the nurse educators. Fam- information than the patient to compensate for ily role enhancement and increased knowledge any sensory deficits or cognitive limitations the on the part of the family have positive benefits patient may have. Anticipatory teaching with for the learners as well as the teachers. Patients family caregivers can reduce their anxiety, un- derive increased satisfaction and greater inde- certainty, and lack of confidence. What the fam- pendence in self-care, and nurses experience ily is to do is important, but what the family is to increased job satisfaction and personal gratifi- expect also is essential information to be shared cation in helping patients to reach their poten- during the teaching–learning process (Haggard, tial and achieve successful outcomes (Barnes, 1989). The greatest challenge for caregivers is to 1995; Gavan, 2003). develop confidence in their ability to do what Numerous nursing, life-span development, is right for the patient. Education is the means and educational psychology theories provide the to help them confront this challenge (Reinhard conceptual frameworks for understanding the et al., 2012). dynamics and importance of family relationships The family can be the educator’s great- as influential in achieving teaching–learning out- est ally in preparing the patient for discharge comes. Although a great deal of attention has and in helping the patient to become indepen- been given to the ways in which young and ad- dent in self-care. The patient’s family is per- olescent families function, unfortunately min- haps the single most significant determinant imal attention has been paid to the dynamics of of the success or failure of the education plan the complex interactions that characterize the and achievement of successful aging (Capezuti, aging family (Gavan, 2003). 2014; Gavan, 2003; Haggard, 1989). Rankin and

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Stallings’s 2001 model for patient and family up-to-date information on performance stan- education serves as a foundation for assessing dards and guidelines for a program of health- the family profile to determine the family mem- care activities for children. However, updated bers’ understanding of the actual or potential information in the healthcare literature on the health problem(s), the resources available to application of new approaches to foster child them, their ways of functioning, and their ed- health is sorely needed. ucational backgrounds, lifestyles, and beliefs. To bolster general understanding of the Education is truly the most powerful tool physical, cognitive, and psychosocial (emo- nurse educators possess to ensure optimal care tional) traits of human development across and the transfer of power to the patient–family the life span, plenty of excellent resources, dyad. It is imperative that attention be focused well grounded by research evidence, exist in on both the assumed and the expected respon- the fields of psychology in general and edu- sibilities of family caregivers. The role of the cational psychology, in particular. However, family has been stressed in each developmen- much of the educational psychology litera- tal section in this chapter. Table 5-1 outlines ture focuses extensively on the application of appropriate interventions for the family at dif- teaching and learning principles only to pre- ferent stages in the life cycle. school and K–12 classrooms. Understandably, life-span developmental scientists do not specifically consider health education of well indi- ▸▸ State of the Evidence viduals with respect to disease prevention, risk reduction, and health promotion efforts or to In an extensive review of the literature, a signif- health promotion, maintenance, and rehabil- icant number of studies, from both primary and itation measures for persons who are acutely secondary sources, that were carried out by nurses and chronically ill. The application and trans- and other healthcare professionals were found lation of developmental characteristics to the to support the application of teaching and learn- teaching and learning aspects of healthcare ing principles to the education of middle-aged delivery are the responsibility of nurses and and older adult clients in various healthcare set- other healthcare providers. Much more inves- tings. However, current nursing and healthcare tigation is needed to demonstrate how to effec- research focusing specifically on patient educa- tively teach clients at different developmental tion approaches applicable to the age cohorts of stages based on their learning needs, learning children, adolescents, and the young adult pop- styles, and readiness to learn, thereby ensur- ulation, as well as instructional needs of family ing achievement of the most positive client- members as caregivers, is lacking. centered outcomes possible. For example, the article by Richmond and Malcolm Knowles’s original 1973 the- Kotelchuck (1984), written more than 3 decades ory about adult learning and his subsequent ago, remains an excellent and thorough exam- modifications and clarifications of his theory ination of health maintenance in children, in- (Knowles, 1990; Knowles et al., 2015) seem cluding children’s cognitive understanding of to be well accepted and have stood the test of health and disease, their psychological control time. Piaget’s theory on cognitive development over health, parental and media influences on also has been accepted and extensively applied health behaviors, the impact of school health over the years, but recent critics of Piaget have education, and the role of health professionals challenged the assumptions underlying his the- in the management of childhood illness and ory with respect to the last stage of develop- health services for children. Currently, the Na- ment (formal operations). Today, psychologists tional Resource Center for Health and Safety in speculate that a fifth and qualitatively higher Child Care and Early Education (2017) publishes level of thinking follows adolescence, a stage

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postulated as the postformal operations period (2016), highlight the different experiences, val- of adulthood. Vygotsky’s sociocultural theory ues, beliefs, and needs of learners from varied adds another dimension to understanding cog- generational backgrounds. nitive development that was not addressed by Although there has been an upsurge of in- Piaget (Crandell et al., 2012; Santrock, 2017). terest in educational strategies and techniques A contemporary interpretation of Vygotsky’s for teaching and learning as they apply to cer- theory to the classroom is the current inter- tain population groups in the broad health- est in collaborative group learning with peers care arena, much more research needs to be (McLeod, 2007). done regarding the creative leadership role Erickson’s theory of the eight stages of of the nurse educator functioning as facilita- psychosocial development, whereby individu- tor rather than teacher of patients and family als face unique stage-related tasks (crises that members (at all stages of development) and must be resolved to reduce one’s vulnerability of nursing students and staff (Donner, Levo- and enhance one’s potential), is still recognized nian, & Slutsky, 2005). Research has only be- as elucidating the unique turning points in life gun to scratch the surface of how teaching and that require successful completion for healthy, learning are affected by situational variables, normal development to occur. Although Er- such as chronic illness, acute illness, disability, ickson’s theory continues to be widely applied or wellness; by personality traits, such as mo- to the field of life-span development, the exis- tivation and learning styles; by temperament tence of a ninth stage of development, hope and responses, such as anxiety and attention span; faith versus despair, has received relatively lit- and by sociocultural influences, such as gender, tle attention in the literature. More research is economic status, and educational background. needed to confirm the existence of this final stage Another area requiring further explora- of psychosocial development, which addresses tion is the role of family and other support the unique tasks of the oldest-old (Erikson & systems on the success of educational endeav- Erikson, 1998). ors to help Americans of all ages maintain and Recently, increased attention has been paid improve their health status. Much more ev- to the appropriateness of teaching methods and idence from research needs to be conducted instructional materials (especially as they relate on family structure and the many changing to multimedia technology) for college-aged stu- relationships in society that promote or hin- dents and adult learners to meet their expecta- der teaching and learning of clients in various tions for lifelong learning. Given the fact that the healthcare settings. population is steadily aging, nurses are caring The national initiatives of Healthy Peo- for an increasingly older audience of learners. ple 2020, as well as pending policy goals at Many of today’s nursing students are somewhat local and state levels, will not be realized unless older than the traditional college-aged students, a better understanding is gained of the impact and nursing staff are adult continuing-education of physical, cognitive, psychological/emotional, learners. It is gratifying to witness the acknowl- and sociocultural changes that occur across edgment of these population changes through the life course that can serve as a guideline for an emphasis on studying generational differ- teaching and learning in nursing and health- ences in learner preferences, modes of infor- care practice. mation processing, and memory and recall with respect to the impact of standard versus newer technological methods and tools for the effec- ▸▸ Summary tive delivery of instruction. The literature, such as the articles written by Billings and Kowalski For nurses, it is important to understand the (2004), Fishman (2016), and Shatto and Erwin specific and varied tasks associated with each

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developmental stage to individualize the ap- facilitator of the learning process. In conjunc- proach to education in meeting the needs and tion with these adult learners, nurse educators desires of clients and their families. Assessment can establish objectives and learner-centered ap- of physical, cognitive, and psychosocial matura- proaches that challenge the educator’s creativ- tion within each developmental period is cru- ity to foster self-direction, motivation, interest, cial in determining the appropriate strategies and active participation for independence and to facilitate the teaching–learning process. The interdependence in learning. younger learner is, in many ways, very different from the adult learner. Issues of dependency, extent of participation, rate of and capacity for Review Questions learning, and situational and emotional obsta- 1. What are the seven stages of development? cles to learning vary significantly across the var- 2. Define pedagogy, andragogy, and ious phases of development. gerogogy. Readiness to learn in children is very sub- 3. Who is the expert in cognitive develop- ject centered and highly influenced by their ment? What are the terms or labels used physical, cognitive, and psychosocial matu- by this expert to identify the key cognitive ration. By comparison, motivation to learn milestones? in adults is very problem centered and more 4. Who is the expert in psychosocial de- oriented to psychosocial tasks related to roles velopment? What are the terms or labels and expectations of work, family, and commu- used by this expert to identify the key nity activities. psychosocial milestones? For client education to be effective, the nurse 5. What are the salient or prominent char- in the role of educator must create an environ- acteristics at each stage of development ment conducive to learning by presenting infor- that influence the ability to learn? mation at the learner’s level, inviting participation 6. What are three main teaching strategies and feedback, and identifying whether paren- for each stage of development? tal, family, and/or peer involvement is appropri- 7. How do people you know in each stage ate or necessary. Nurses are the main source of of development compare with what you health information. In concert with the client, have learned about physical, cognitive, they must facilitate the teaching–learning pro- and psychosocial characteristics at the cess by determining what needs to be taught, various developmental stages? when to teach, how to teach, and who should 8. What is the role of the family in the be the focus of teaching based on the develop- teaching and learning process in each mental stage of the learner. stage of development? When nursing students and staff are the 9. How does the role of the nurse vary when audience of learners, the educator also is re- teaching individuals at different stages of sponsible for assuming the leadership role as development?

Case Study

Your local primary care network is developing a new program that focuses on a family-centered approach to diabetes management. Expected patient outcomes of the program are to reduce hospitalizations and days off from work or school. Your role as a nursing consultant to this program is to help the team develop a comprehensive, family-oriented educational program that covers important diabetes topics

(continues)

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Case Study (continued)

such as pathophysiology, nutrition, and exercise. Maurice, a member of the team, suggests, “Let’s do our teaching with all the family members together in a group.” Lina, another team member, states, “We should separate the family members into similar age groups for the teaching—that way, we can better keep their interest.” You suggest that the team integrate Maurice’s and Lina’s suggestions and plan a total of five teaching sessions, with four of the sessions grouping participants according to developmental stages and the final session grouping families together. Participants range from 6 to 75 years of age. 1. Describe how you will determine the different age range groupings of the participants for the first four sessions. Explain the different age ranges, cognitive and psychosocial stages, and general characteristics of each group. 2. Choose two different developmental stage groupings and give examples of teaching strategies you will use with each group for the specific teaching sessions. Explain why you chose these strategies for the individuals with diabetes and their families. 3. What are some advantages to grouping participants by developmental stages? What are some disadvantages?

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