Nursing Education and Teaching Strategies for Middle and Late Childhood
What Is Middle and Late Childhood (6-11 Years of Age)
In middle and late childhood, children have progressed in their physical, cognitive, and psychosocial skills to the point where most begin formal training in structured school systems. They approach learning with enthusiastic anticipation, and their minds are open to new and varied ideas.
Children at this developmental level are motivated to learn because of their natural curiosity and their desire to understand more about themselves, their bodies, their world, and the influence that different things in the world have on them (Whitener et al., 1998 ). This stage is a period of great change for them, when attitudes, values, and perceptions of themselves, their society, and the world are shaped and expanded. Visions of their own environment and the cultures of others take on more depth and breadth (Santrock, 2017).
Developmental Aspects In Middle and Late Childhood
The gross and fine-motor abilities of school aged children become increasingly more coordinated so that they have the ability to control their movements with much greater dexterity than ever before. Involvement in all kinds of curricular and extracurricular activities helps them to fine tune their psychomotor skills. Physical growth during this phase is highly variable, with the rate of development differing from child to child.
Toward the end of this developmental period, girls more than boys on average begin to experience prepubescent bodily changes and tend to exceed the boys in physical maturation. Growth charts, which monitor the rate of growth, are a more sensitive indicator of health or disability than actual size (Crandell et al., 2012; Santrock, 2017).
Piaget (1951, 1952, 1976) labeled the cognitive development in middle and late childhood as the period of concrete operations. During this time, logical, rational thought processes and the ability to reason inductively and deductively develop. Children in this stage can think more objectively, are willing to listen to others, and selectively use questioning to find answers to the unknown.
At this stage, they begin to use syllogistic reasoning-that is, they can consider two premises and draw a logical conclusion from them (Bara, Bucciarelli, & Johnson Laird, 1995; Elkind, 1984, Steegen & De Neys , 2012 ). For example, they understand that mammals are warm blooded and whales are mammals, so whales must be warm blooded.
Also, children in this age group are intellectually able to understand cause and effect in a concrete way. Concepts such as conservation, which is the ability to recognize that the properties of an object stay the same even though its appearance and position may change, are beginning to be mastered.
For example, they realize that a certain quantity of liquid is the same amount whether it is poured into a tall, thin glass or into a short, squat one (Snowman & McCown, 2015). Fiction and fantasy are separate from fact and reality. The skills of memory. Decision making, insight, and problem solving are all more fully developed (Protheroe, 2007).
Children in this developmental phase can engage in systematic thought through inductive reasoning. They have the ability to classify objects and systems, express concrete ideas about relationships and people, and carry out mathematical operations. Also, they begin to understand and use sarcasm as well as to employ well-developed language skills for telling jokes, conveying complex stories, and communicating increasingly more sophisticated thoughts (Snow man & McCown, 2015).
However, thinking remains quite literal, with only a vague understanding of abstractions. Early in this phase, children are reluctant to exchange magical thinking for reality thinking. They cling to cherished beliefs, such as the existence of Santa Claus or the tooth fairy, for the fun and excitement that the fantasy provides them, even when they have information that proves contrary to their beliefs.
Children passing through elementary and middle schools have developed the ability to concentrate for extended periods, can tolerate delayed gratification, are responsible for independently carrying out activities of daily living, have a good understanding of the environment around them, and can generalize from experience (Crandell et al., 2012). They understand time, can predict time intervals, are oriented to the past and present, have some grasp and interest in the future, and have a vague appreciation for how immediate actions can have implications over the course of time (Kail & Cavanaugh, 2015) . Special interests in topics of their choice begin to emerge, and they can pursue subjects and activities with devotion to increase their talents in selected areas.
Children at this cognitive stage can make decisions and act in accordance with how events are interpreted, but they understand only to a limited extent the seriousness or consequences of their choices. Children in the early period of this developmental phase know the functions and names of many common body parts, whereas older children have a more specific knowledge of anatomy and can differentiate between external and internal organs with a beginning understanding of their complex functions (Raven , 2016).
As part of the shift from pre-causal thinking to causal thinking, the child begins to incorporate the idea that illness is related to cause and effect and can recognize that germs create disease. Illness is thought of in terms of social consequences and role alterations, such as the realization that they will miss school and outside activities, people will feel sorry for them, and they will be unable to maintain their usual routines (Banks, 1990; Koopman, Baars, Chaplin, & Zwinderman , 2004).
Marin (2010) found that concepts of ill ness in children vary depending on socioeconomic status (SES) and ethnicity, although she found no differences in their thinking based on gender. Children from lower SES levels and minority backgrounds had a less sophisticated understanding of the causes of illness compared with those children from higher SES levels and those belonging to the majority population.
She suggested that this may be a result of educational, cultural, and language differences and that healthcare professionals should consider a child's ethnicity and SES when communicating symptoms and causes of illness based on cultural health beliefs and practices.Also, research indicates that systematic differences exist in children's reasoning skills with respect to understanding body functioning and the cause of illness resulting from their experiences with illness.
Children suffering from chronic diseases have been found to have more sophisticated conceptualization of illness causality and body functioning than do their healthy peers. Piaget (1976) postulated that experience with a phenomenon catalyzes a better understanding of it.
Conversely, the stress and anxiety resulting from having to live with a chronic illness or disability can interfere with a child's general cognitive performance. Chronically ill children have a less refined understanding of the physical world than healthy children do, and the former are often unable to generalize what they learned about a specific illness to a broader understanding of illness causality (Perrin, Sayer. & Willett, 1991).
Thus, illness may act as an intrusive factor in overall cognitive development (Bell, Bayliss, Glauert, Harrison, & Ohan, 2016).Erikson (1963) characterized school-aged children's psychosocial stage of life as industry versus inferiority. During this period, children begin to gain an awareness of their unique talents and the special qualities that distinguish them from one another.
They begin to establish their self concept as members of a social group larger than their own nuclear family and begin to compare their own family's values with those of the outside world.
The school environment for children of this age facilitates their development of a sense of responsibility and reliability. With less dependency on family, they extend their intimacy to include special friends and social groups (Newman & Newman, 2015, Santrock, 2017). Relationships with peers and adults external to the home environment become important influences in their development of self esteem and their susceptibility to social forces outside the family unit. School-aged children fear failure and being left out of groups.
They worry about their inabilities and become self-critical as they compare their own accomplishments to those of their peers. They also fear illness and dis- ability that could significantly disrupt their academic progress, interfere with social contacts, decrease their independence, and result in loss of control over body functioning.
Middle and Late Childhood and Teaching Strategies
It is important to follow sound educational principles with the child and family, such as identifying individual learning styles, determining readiness to learn, and accommodating special learning needs and abilities to achieve positive health outcomes. Given their increased ability to comprehend information and their desire for active involvement and control of their lives, it is very important to include school aged children in patient education efforts as these “hands-on” experiences are important sources of learning (Hayes, 2015 ).
The nurse in the role as educator should explain illness, treatment plans, and procedures in simple, logical terms in accordance with the child's level of understanding and reasoning. Although children at this stage of development can think logically, their ability to engage in abstract thought remains limited. Therefore, teaching should be presented in concrete terms with step-by-step instructions (Pidgeon, 1985; Whitener et al., 1998).
It is imperative that the nurse observe children's reactions and listen to their verbal feedback to confirm that information shared has not been misinterpreted or confused.To the extent feasible, parents should be informed of what their child is being taught. Teaching parents directly is encouraged so that they may be involved in fostering their child's independence, providing emotional support and physical assistance, and giving guidance regarding the correct techniques or regimens in self-care management.
Siblings and peers should also be considered as sources of support. In attempting to master self-care skills, children thrive on praise from others who are important in their lives as rewards for their accomplishments and successes (Hussey & Hirsh, 1983; Santrock, 2017).
Education for health promotion and health maintenance is most likely to occur in the school system through the school nurse, but the parents as well as the nurse outside the school setting should be told which content is being addressed. Information then can be reinforced and expanded when in contact with the child in other care settings.
Numerous opportunities for nurses to teach the individual child or groups of children about health promotion and disease and injury prevention are available in schools, physicians' offices, community centers, outpatient clinics, or hospitals. Health education for children of this age can be very fragmented because of the many encounters they have with nurses in a variety of settings (Edelman, Mandle, & Kudzma, 2013).
The school nurse is in an excellent position to coordinate the efforts of all other providers to avoid duplication of teaching content or the giving of conflicting information as well as to provide reinforcement of learning. According to Healthy People 2020 (US Department of Health and Human Services [USDHHS], 2014), health promotion regarding healthy eating and weight status, exercise, sleep, and prevention of injuries, as well as avoidance of tobacco, alcohol, and drug use , are just a few examples of objectives intended to improve the health of American children.
The school nurse can play a vital role in providing education to the school-aged child to meet these goals (American Academy of Pediatrics Council on School Health, 2016). In support of this teaching-learning process, Healthy People 2020 has introduced the topic area “Early and Middle Childhood,” which recommends providing formal health education in the school setting (USDHHS, 2014). The school nurse is afforded the opportunity to educate children not only in a group when teaching a class but also on a one-to-one basis when encountering an individual child in the office for a certain problem or need.
The specific conditions that may come to the attention of the nurse in caring for children at this phase of development include problems such as behavioral disorders, hyperactivity, learning disorders, obesity, diabetes, asthma, and enuresis. Extensive teaching may be needed to help children and parents understand a condition particularly related to them and learn how to overcome or deal with it (Edelman et al., 2013).
The need to sustain or reinforce their self-image, self-concept, and self-esteem requires that children be invited to participate, to the extent possible, in planning for and carrying out learning activities (Snowman & McCown, 2015). For young children receiving an x-ray or other imaging procedure, for example, it would be beneficial to have them initially simulate the experience by positioning a doll or stuffed animal under the machine as the technician explains the procedure.
This strategy allows them to participate and can reduce their fear. Because of children's fears of falling behind in school, being separated from peer groups, and being left out of social activities, teaching must be geared toward fostering normal development despite any limitations that may be imposed by illness or disability (Falvo, 2011; Leifer & Hartston, 2013),
Children in middle and late childhood are used to the structured, direct, and formal learning in the school environment; Consequently, they are receptive to a similar teaching-learning approach when hospitalized or confined at home. The following teaching strategies are suggested when caring for children in this developmental stage of life (Edleman et al., 2013; Falvo, 2011; Hayes, 2015; Leifer & Hartston, 2013; Snowman & McCown, 2015).
For Short Term Learning
- Allow school aged children to take responsibility for their own health care because they are not only willing but also capable of manipulating equipment with accuracy. Because of their adeptness in relation to manual dexterity, mathematical operations, and logical thought processes, they can be taught, for example, to apply their own splint or use an asthma inhaler as prescribed.
- Teaching sessions can be extended to last up to 30 minutes each because the increased cognitive abilities of school-aged children make possible the attention to and the retention of information. However, lessons should be spread apart to allow for comprehension of large amounts of content and to provide opportunity for the practice of newly acquired skills between sessions
- Use diagrams, models, pictures, digital media, printed materials, and computer, tablet or smartphone applications as adjuncts to various teaching methods because the increased facility these children have with language (both spoken and written) and mathematical concepts allows them to work with more complex instructional tools.
- Choose audiovisual and printed materials that show peers undergoing similar procedures or facing similar situations.
- Clarify any scientific terminology and medical jargon used.
- Use analogies as an effective means of providing information in meaningful terms, such as “Having a chest x-ray is like having your picture taken” or “White blood cells are like police cells that can attack and destroy infection.” Use one-to-one teaching sessions as a method to individualize learning relevant to the child's own experiences and as a means of interpreting the results of nursing interventions specific to the child's own condition.
- Provide time for clarification, validation, and reinforcement of what is being learned.
- Select individual instructional techniques that provide opportunity for privacy an increasingly important concern for this group of learners, who often feel quite self-conscious and modest when learning about bodily functions.
- Employ group teaching sessions with others of similar age and with similar problems or needs to help children avoid feelings of isolation and to assist them in identifying with their own peers.
- Prepare children for procedures and interventions well in advance to allow them time to cope with their feelings and fears, to anticipate events, and to understand what the purpose of each procedure is, how it relates to their condition, and how much time it will take .
- Encourage participation in planning for procedures and events because active involvement helps the child to assimilate information more readily.
- Provide much needed nurturance and support, always keeping in mind that young children are not just small adults. Praise and rewards help motivate and reinforce learning.
For Long Term Learning
- Help school-aged children acquire skills that they can use to assume self-care responsibility for carrying out therapeutic treatment regimens on an ongoing basis with minimal assistance.
- Assist them in learning to maintain their own well-being and prevent illnesses from occurring.
- Research suggests that lifelong health attitudes and behaviors begin in the early childhood phase of development and remain intrapersonal consistent throughout the stage of middle to late childhood (USDHHS, 2014). The development of cognitive understanding of health and illness has been shown to follow a systematic progression parallel to the stage of general cognitive development (Koopman et al., 2004). As the child matures, beliefs about health and illness become less concrete and more abstract, less egocentric, and increasingly differentiated and consistent.
- Motivation, self-esteem, and positive self-perception are personal characteristics that influence health behavior. Research has shown that the higher the grade level of the child, the greater the understanding of illness and an awareness of body cues. Thus, children become more actively involved in their own health care as they progress developmentally (Farrand & Cox, 1993; Whitener et al., 1998).
- Teaching should be directed at assisting them to incorporate positive health actions into their daily lives. Because of the importance of peer influence, group activities are an effective method of teaching health behaviors, attitudes, and values.
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