Nursing Education and Teaching Strategies for Adolescence
What Is Adolescence (12-19 Years of Age)
Adolescence marks the transition from childhood to adulthood. During this prolonged and very change filled time, many adolescents and their families experience much turmoil. How adolescents think about themselves and the world significantly influences many healthcare issues facing them, from anorexia to obesity. Teenage thought and behavior give insight into the etiology of some of the major health problems of this group of learners (Elkind, 1984).
Adolescents are known to be among the nation's most at-risk populations (Ares, Kuhns, Dogra, & Kar mik , 2015). Most recently, Healthy People 2020 identified “Adolescent Health” as a new topic area, with objectives focused on interventions to promote health as well as mitigate the risks associated with this population (USDHHS, 2014).
For patient education to be effective, an understanding of the characteristics of the adolescent phase of development is crucial ( Ackard & Neumark Sztainer , 2001; Ormrod, 2012). Today's adolescents comprise the generational cohort Generation Z, or Gen Z. They excel with self-directed learning and thrive on the use of technology (Shatto & Erwin, 2016).
Aspects of Development In Adolescence
Adolescents vary greatly in their biological, psychological, social, and cognitive development. From a physical maturation standpoint, they must adapt to rapid, dramatic, and significant bodily changes, which can temporarily result in clumsiness and poorly coordinated movement. Alterations in physical size, shape, and function of their bodies, along with the appearance and development of secondary sex characteristics, bring about a significant concern with their appearance and a strong desire to express sexual urges (Crandell et al., 2012; Santrock, 2017).
And, according to neuroscience research, adolescent brains are different than adult brains in the way they process information, which may explain that adolescent behaviors, such as impulsiveness, rebelliousness, lack of good judgment, and social anxiety, stem from biological reasons more than environmental influences (Packard, 2007).
Piaget (1951, 1952, 1976) termed this stage of cognitive development as the period of formal operations. Adolescents have attained a new, higher order level of reasoning superior to earlier childhood thoughts. They are capable of abstract thought and the type of complex logical thinking described as propositional reasoning, as opposed to syllogistic reasoning. Their ability to reason is both inductive and deductive, and they can hypothesize and apply the principles of logic to situations never encountered before.
Adolescents can conceptualize and internalize ideas, debate various points of view, understand cause and effect, understand complex explanations, imagine possibilities, make sense out of new data, discern relationships among objects and events, and respond appropriately to multiple-step directions (Aronowitz, 2006; Crandell et al., 2012). Formal operational thought enables adolescents to conceptualize invisible processes and make determinations about what others say and how they behave.
With this capacity, adolescents can become obsessed with what they think as well as what others are thinking, a characteristic known as adolescent egocentrism. They begin to believe that everyone is focusing on the same things they are, namely, themselves and their activities. Elkind (1984) labels this belief as the imaginary audience, a type of social thinking that has considerable influence over an adolescent's behavior.
The imaginary audience explains the pervasive self-consciousness of adolescents, who, on the one hand, may feel embarrassed because they believe everyone is looking at them and, on the other hand, desire to be looked at and thought about because this attention confirms their sense of being special and unique (Crandell et al., 2012; Oswalt, 2010; Santrock, 2017; Snowman & McCown, 2015).
Adolescents are able to understand the concept of health and illness, the multiple causes of diseases, the influence of variables on health status, and the ideas associated with health promotion and disease prevention, Parents, health-care providers, and the Internet are all potential sources of health related information for adolescents. At this developmental stage, adolescents recognize that illness and disability are processes resulting from a dysfunction or non function of a part or parts of the body and can understand the outcomes or prognosis of an illness.
They also can identify health behaviors, although they may reject practicing them or begin to engage in risk-taking behaviors because of the social pressures they receive from peers as well as their feelings of invincibility (Ormrod, 2012). Elkind (1984) labels this second type of social thinking as the personal fable. The personal fable leads adolescents to believe that they are invulnerable-other people grow old and die, but not them; Other people may not realize their personal ambitions, but they will.
This personal fable has value in that it allows individuals to carry on with their lives even in the face of all kinds of dangers. Unfortunately. it also leads teenagers to believe they are cloaked in an invisible shield that will protect them from bodily harm despite any risks to which they may subject themselves (Alberts, Elkind, & Ginsberg, 2007; Jack, 1989; Oswalt, 2010). They can understand implications of future outcomes, but their immediate concern is with the present.
Recent research, however, reveals that adolescents 15 years of age and older are not as susceptible to the personal fable as once thought (Cauffman & Steinberg, 2000). Although children in the mid- to late-adolescent period appear to be aware of the risks they take, it is important, however, to recognize that this population continues to need support and guidance (Brown, Teufel, & Birch, 2007).
Erikson (1968) has identified the psychosocial dilemma adolescents face as one of identity versus role confusion. Children in this age group indulge in comparing their self image with an ideal image. Adolescents find themselves in a struggle to establish their own identity, match their skills with career choices, and determine their self. They work to emancipate themselves from their parents, seeking independence and autonomy so that they can emerge as more distinct individual personalities.
Teenagers have a strong need for belonging to a group, friendship, peer acceptance, and peer support. They tend to rebel against any actions or recommendations by adults whom they consider authoritarian. Their concern over personal appearance and their need to look and act like their peers drive them to conform to the dress and behavior of this age group, which is usually contradictory, nonconformist, and in opposition to the models, codes, and values of their parents 'generation.
Conflict, tolerance, stereotyping, or alienation often characterizes the relationship between adolescents and their parents and other authority figures (Hines & Paulson, 2006). Adolescents seek to develop new and trusting relationships outside the home but remain vulnerable to the opinions of those whom they emulate (Santrock, 2017).
Adolescents demand personal space, control, privacy, and confidentiality. To them, illness, injury, disability, and hospitalization mean dependency, loss of identity, a change in body image and functioning, bodily embarrassment, confinement, separation from peers, and possible death. The provision of knowledge alone is, therefore, not sufficient for this population.
Because of the many issues apparent during the adolescent period, the need for coping skills is profound and can influence the successful completion of this stage of development (Grey, Kanner, & Lacey, 1999; Hoffman, 2016; Williams & McGillicuddy-De Lisi, 1999; Zimmer- Gembeck & Skinner, 2008). Some developmentalists are extending the uppermost age range of the adolescent period to 24 years of age because it has been determined that many young people in this stage do not meet the typical psychosocial milestones until well into their second decade of life (Newman & Newman, 2015 ).
Adolescent and Teaching Strategies In Nursing Education
Although most individuals at this phase of development remain relatively healthy, an estimated 20% of US adolescents have at least one serious health problem, such as asthma, learning disabilities, eating disorders (eg, obesity, anorexia, or bulimia), diabetes, a range of disabilities resulting from injury, or psychological problems resulting from depression or physical and/or emotional maltreatment.
In addition, adolescents are considered at high risk for teen pregnancy, the effects of poverty, drug or alcohol abuse, and sexually transmitted diseases such as venereal disease and AIDS. The three leading causes of death in this age group are accidents, homicide, and suicide (Kochanek, Xu, Murphy, Minino, & Kung, 2011; London et al., 2017). More than 50% of all adolescent deaths are a result of accidents, and most of these incidents involve motor vehicles (Santrock, 2017).
Despite these potential threats to their well-being, adolescents use medical services the least frequently of all age groups. Compounding this problem is the realization that adolescent health has not been a priority in the past and the health issues of this population have been largely ignored by the healthcare system globally (Patton et al., 2016). Thus, the educational needs of adolescents are broad and varied.
The potential topics for teaching are numerous, ranging from sexual adjustment, contraception, and venereal disease to accident prevention, nutrition, substance abuse, and mental health.Healthy teens have difficulty imagining themselves as sick or injured. Those with an illness or disability often comply poorly with medical regimens and continue to indulge in risk taking behaviors.
Because of their concern with body image and functioning and the perceived importance of peer acceptance and support, they view health recommendations as a threat to their autonomy and sense of control.Probably the greatest challenge to the nurse responsible for teaching the adolescent, whether healthy or ill, is to be able to develop a mutually respectful, trusting relationship (Brown et al., 2007).
Adolescents, because of their well-developed cognitive and language abilities, can participate fully in all aspects of learning, but they need privacy, understanding, an honest and simple approach, and un-qualified acceptance in the face of their fears of embarrassment, losing independence, identity, and self-control ( Ackard & Neumark- Sztainer , 2001). The American Academy of Pediatrics Committee on Adolescence (2016) cites availability ability, visibility, quality, confidentiality, affordability, flexibility, and coordination as important factors in providing education effectively to the adolescent population.
The existence of an imaginary audience and personal fable can contribute to the exacerbation of existing problems or cause new ones. Adolescents with disfiguring disabilities, who as young children exhibited a great deal of spirit and strength, may now show signs of depression and lack of will. For the first time, they look at themselves from the standpoint of others and reinterpret behavior once seen as friendly as actually condescending.
Teenagers may fail to use contraceptives because the personal fable tells them that other people will get pregnant or get venereal disease, but not them. Teenagers with chronic illnesses may stop taking prescribed medications because they feel they can manage without them to prove to others that they are well and free of medical constraints; Other people with similar diseases need to follow therapeutic regimens, but not them.
Adolescents' language skills and ability to conceptualize and think abstractly give the nurse as educator a wide range of teaching methods and instructional tools from which to choose (Brown et al., 2007). The following teaching strategies are suggested when caring for adolescents.
For Short Term Learning
Use one-to-one instruction to ensure confidentiality of sensitive information. Choose peer-group discussion sessions as an effective approach to deal with health topics such as smoking, alcohol and drug use, safety measures, obesity, and teenage sexuality. Adolescents benefit from being exposed to others who have the same concerns or who have successfully dealt with problems like theirs.
Use face-to-face or computer group discussion, role playing, and gaming as methods to clarify values and solve problems, which feed into the teenager's need to belong and to be actively involved. Getting groups of peers together in person or virtually (eg, blogs, social networking, podcasts, online videos) can be very effective in helping teens confront health challenges and learn how to significantly change behavior (Snowman & McCown, 2015).
Employ adjunct instructional tools, such as complex models, diagrams, and specific, detailed written materials, which can be used competently by many adolescents. Using technology is a comfortable approach to learning for adolescents, who generally have facility with technological equipment after years of academic and personal experience with telecommunications at home and at school.
- Clarify any scientific terminology and medical jargon used. Share decisions making whenever possible, because control is an important issue for adolescents.
- Include adolescents in formulating teaching plans related to teaching strategies, expected outcomes, and determining what needs to be learned and how it can best be achieved to meet their needs for autonomy.
- Suggest options so that they feel they have a choice about courses of action. Give a rationale for all that is said and done to help adolescents feel a sense of control. Approach them with respect, tact, openness, and flexibility to elicit their attention and encourage their responsiveness to teaching-learning situations.
- Expect negative responses, which are common when their self-image and self-integrity are threatened.
- Avoid confrontation and acting like an authority figure. Instead of directly contradicting adolescents' opinions and beliefs, acknowledge their thoughts and then casually suggest an alternative viewpoint or choices, such as “Yes, I can see your point, but what about the possibility of...?”
For Long Term Learning
- Accept adolescents' personal fable and imaginary audience as valid, rather than challenging their feelings of uniqueness and invincibility.
- Acknowledge that their feelings are very real because denying them their opinions simply will not work.
- Allow them the opportunity to test their own convictions. Let them know, for example, that although some other special people can get away without taking medication, others cannot.
- Suggest, if medically feasible. setting up a trial period with scheduled medications further apart or in lowered dosages to determine how they can manage.
- Although much of patient education should be done directly with adolescents to respect their right to individuality, privacy, and confidentiality, teaching effectiveness may be enhanced by including their families to some extent (Brown et al., 2007) . The nurse as educator can give guidance and support to families, helping them to better understand adolescent behavior (Hines & Paulson, 2006).
- Parents should be taught how to set realistic limits and at the same time foster the adolescent's sense of independence. Through prior assessment of potential sources of stress, teaching both the parents and the adolescent (as well as siblings) can be enhanced. Because of ambivalence the adolescent feels while in this transition stage from childhood to adulthood, healthcare teaching, to be effective, must consider the learning needs of the adolescent as well as the parents (Ackard & Neumark-Sztainer, 2001 ; Falvo , 2011 ).
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