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Perceptions of the nurse’s role by hospitalized children with chronic conditions Eikelhof, Elisa Mary 1995

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PERCEPTIONS OF THE NURSE’S ROLE BY HOSPITALIZED CHILDRENWITH CHRONIC CONDITIONS:•A NEO-PIAGETIAN INVESTIGATIONbyELISA MARY EIKELHOFDrs., The University of Utrecht (The Netherlands), 1989A THESIS SUBMITTED IN PARTIAL FULFILMENT OFTHE REQUIREMENTS FOR THE DEGREE OFDOCTOR OF PHILOSOPHYinTHE FACULTY OF GRADUATE STUDIES(Educational Psychology, Special Education)We accept this thesis as conformingTHE UNIVERSITY OF BRITISH COLUMBIAJuly 1995to the required standard© Elisa Mary Eikelhof, 1995In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall makeitfreely available for reference and study. I further agree that permission for extensivecopying of this thesis br scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(SignatureDepartment of ?The University of British ColumbiaVancouver, CanadaDate 9DE-6 (2188)ABSTRACTThis study investigated the relationship betweencognitive development and children’s understanding of thehospital nurse’s role. A group of 35 hospitalized childrenwith chronic conditions and without neurological deficits,aged 4 to 10 years, were given three tasks (i.e., theNurse’s Role Task, the Balance Beam Task, and the Task ofIntrapersonal Understanding), scored for developmental levelusing Case’s (1992) neo-Piagetian theory of cognitivedevelopment as a framework. A full sample of 4—year—oldswas not pursued due to the distracting hospital environmentwhich, in combination with the shorter attention span of the4-year-olds, rendered the interviews extremely difficult tocomplete. Descriptive results indicated a moderatelyadvanced understanding of the hospital nurse’s role by 8—and lO—year—olds, being on the order of one—third of asubstage (i.e., approximately 8 months ahead indevelopment), whereas 4— and 6—year—olds showed an age—appropriate level of understanding of the hospital nurse’srole. Analysis of Variance indicated a statisticallysignificant effect for age on all three tasks (p < .01).Six levels of social—cognitive development in understandingthe hospital nurse’s role were found, which were, insuccessive order: (1) Roles of the nurse as scripted actions(i.e., 4-year-old level), (2) Roles of the nurse asiimotivated action sequences (i.e., 6—year—old level), (3)Roles of the nurse as planned action sequences (i.e., 8—year—old level), (4) Roles of the nurse as generalizeddispositions toward action (i.e., 10—year-old level), (5)Roles of the nurse as demonstrating logically planneddecisions towards action (i.e., 12-year—old level), and (6)Roles of the nurse as demonstrating logically planned actionsequences (i.e., 14—year—old level). Furthermore, resultsindicate that a few 6- and 8-year-olds and the majority ofl0—year—olds could give an accurate description of theduties of the hospital nurse, that is, 1) nurses are thereto help children, 2) nurses have a responsibility for thewell-being of their patients, 3) nurses want to improve thephysical and emotional health of their patients, 4) nursesalso see their own shortcomings in their care for childrenand have good intentions, and 5) nurses are human and havetheir own feelings, thoughts, doubts, and ideas.Suggestions for future research have been provided inorder to further improve communication between health careprofessionals and hospitalized children with chronicconditions.iiiTABLE OF CONTENTSAbstract . .Table of ContentsList of TablesList of Figures.List of Appendixes.AcknowledgementsINTRODUCTION . .Research ObjectivesImportance of the Study.Definition of TermsREVIEW OF LITERATURE . .Psychodynamic Studies .Cognitive-Developmental StudiesPiagetian Studies that Includedthe Role of Medical PersonnelAdvantages of Neo-Piagetian TheoryCompared to Piagetian TheoryCase’s Theory: A Neo—Piagetian ViewExecutive Control StructuresCentral Conceptual StructuresNeo-Piagetian Interpretation of theCorrelation between Cognitionand Emotion . . . . .Neo-Piagetian Explanations ofSocial Role Perception . .Summary and Conclusions. .Research Questions . . .iiivviiixxixiiCHAPTER III METHOD . . . . . . .Introduction and Design.Hypotheses . . . . .Subjects. . . . . .Setting . . . . . .Tasks. . . . . . .Understanding of the HospitalNurse’s Role . . .Balance Beam . . .Intrapersonal IntelligenceProcedures . . . . .Analysis. . . . . .Quantitative Analysis.Contextual Illustration of the65• 656566• 70• 71• 71• 76• 77• 808383CHAPTER ICHAPTER II1569131319273234374248536263ivData. . . 87CHAPTER IV SCORING. . . . . . . . . . 89The Nurse’s Role Task . . . 89Level 1 (4 yrs.): Roles of theNurse as Scripted Actions. . 91Level 2 (6 yrs.): Role of theNurse as a Motivated ActionSequence . . . . . . . 97Level 3 (8 yrs.): Roles of theNurse as Planned ActionSequences . . . . . . . 102Level 4 (10 yrs.): Roles of theNurse as GeneralizedDispositions toward Action . 107Level 5 (12 yrs.): Roles of theNurse as DemonstratingLogically Planned Decisionstowards Action . . . . . 114Level 6 (14 yrs.): Roles of theNurse as DemonstratingLogically Planned ActionSequences . . . . . . . 123Task of Intrapersonal Understanding 131Balance Beam Task. . . . . . 136Summary . . 136CHAPTER V RESULTS. . . . . . . . . . 138Results of Quantitative Analysis. 139Question A (Nurse’s Role Task). 139Question B (Balance Beam Task). 149Question C (Nurse’s Role versusBalance Beam Task) . . . . 153Question D (Concept Task) . . 156Question E (Nurse’s Role versusConcept Task). . . . . . 161Contextual Description of the Data 164Age4 . . . . 165Age6. . . . . . . . . 169Age8. . . . . . . 173Age 10. . . . . . . 178Summary . . . . . . . . . 184CHAPTER VI DISCUSSION. . . . . . . . . 186Discussion of the Five ResearchQuestions . . . . . . . . 186Question A (Nurse’s Role Task). 186Question B (Balance Beam Task). 199Question C (Nurse’s Role Taskversus Balance Beam Task). . 200Question D (Concept Task) . . 202Question E (Nurse’s Role Taskvversus Balance Beam Task) 206Summary and Conclusion . 208Limitations of the Study . . 211Areas of Interest for FutureResearch 214Suggestions for Elaboration andImprovement of the PresentStudy . . . 214Suggestions for Related FutureResearch Topics . . 217Significance of the study 224REFERENCES . 227viLIST OF TABLESTable1 School-Aged Children’s Control Structures forAnticipating Action of Balance Beam . . . 392 Distribution of Chronic Conditions in Each AgeGroup . . . . . . . . . . . . 673 Verbal Descriptions of the Stories, Two forEach of the Four Functions of the Nurse’sRole . . . . . . . . . . . 734 Typical Level 1 Responses . . . . . . . 945 Typical Level 2 Responses . . . . . . . 986 Typical Level 3 Responses . . . . . . . 1037 Typical Level 4 Responses . . . . . . . 1098 Typical Level 5 Responses . . . . . . . 1179 Typical level 6 Responses . . . . . . 12510 Mean Scores and Standard Deviations for Levelsby Each Age Group and by Each Situationwithin Each Nurse Function Category . . 14111 Analysis of Variance of a Mixed Design for theNurse’s Role Task . . . . . . . . 14512 Number of Hospitalizations of Each Subject withHis/Her Mean Level Score on the Nurse’s RoleTask for Each Age Group . . . . . . . 14713 Percent of 6—, 8—, and 10—Year-Olds Respondingat Proposed Prototype, Above Prototype, andBelow Prototype (i.e., 1, 2, and 3 Substages)for Each Nurse Function . . . . . . . 14814 One-way Analysis of Variance for ObtainedLevels on the Balance Beam Task by Age Group 14915 Percent of 6—, 8—, and lO-Year-Olds Respondingat Proposed Prototype, Above Prototype, andBelow Prototype (0.5 and 1 Substage) on theBalance Beam Task . . . . . . . . . 15316 T—values for Comparisons Between the Nurse’sviiRole Task and the Balance Beam Task IncludingMean Scores for Each Age Group. . . . . 15417 Mean Scores and Standard Deviations of LevelScores for Each Age Group and Each Concept. 15718 Univariate Analysis of Variance of Each Conceptby Age Group, = 10 . . . . . . . . 15919 Percent of 6—, 8—, and l0-Year—Olds Respondingby. Concept at Proposed Prototype, AbovePrototype, and Below Prototype (i.e., 1, 2,and 3 Substages) . . . . . . . . . 16020 T—values for Comparisons Between the Nurse’sRole Task and the Task of IntrapersonalUnderstanding Including Mean Scores for EachAge Group ( = 10). . . . . . . . . 162viiiLIST OF FIGURESFigure1 Predicted structure of children’s knowledge atdifferent stages and substages of development 412 Central conceptual structure for quantitativereasoning. . . . . . . . . . . . 433 Mean level scores for all age groups on eachnurse function . . . . . . . . . . 1424 Mean level scores by age for each picture. . 1435 Box and whisker plot showing the range ofperformance of each age group on the Nurse’sRole Task. . . . . . . . . . . . 1446 Box and whisker plot showing the performance ofall subjects within each age group on theBalance Beam Task . . . . . . . . 1517 Mean level scores for each age group on theBalance Beam Task . . . . . . . . . 1528 Mean level scores at different age groups forboth the Nurse’s Role Task and the BalanceBeam Task . . . . . . . . . . . 1569 Mean level scores of each age group for eachconcept . . . . . . . . . . . . 15810 Mean level scores of the three age groups forboth the Nurse’s Role Task and the ConceptTask . . . . . . . . . . . . . 163C—i Graphic representation of Protection storieswith a girls’ and boys’ version . . . . 241C—2 Graphic representation of Teaching stories witha girls’ and boys’ version . . . . . . 246C—3 Graphic representation of Nurturance storieswith a girls’ and boys’ version . . . . 251C—4 Graphic representation of Care stories with agirls’ and boys’ version . . . . . . 256D-l Procedures used by children at different agesixfor solving the Balance Beam Task . 261E—i The dimensional balance beam instrument . . 262N-i Information about box and whisker plots . 285xLIST OF APPENDIXESAppendixA American Nurse’s Association Standards ofMaternal and Child Health Nursing Practice . 236B Standards for Nursing Practice in BritishColumbia, Canada . . . . . . . . . 238C The Nurse’s Role Task . . . . . . . . 240D Procedures for Solving the Balance Beam Task. 261E The Dimensional Balance Beam Task . . . . 262F Task of Intrapersonal Understanding. . . . 266G Letter of Information to All Physicians ofBritish Columbia’s Children’s Hospital . . 270H Letter of Notification for Nurses on SixHospital Units . . . . . . . . . . 273I Parental Contact Form . . . . . . . . 276J Wording of How Parents Were ApproachedIncluding Introduction of Research andRequesting Consent. . . . . . . . 278K Wording of How Children Were Approached toAsk Their Participation in the Study. . . 279L Parental Consent Form . . . . . . . . 280M Letter of Notification to Physicians WhosePatients Participated in the Study . . . 283N Box and Whisker Plot. . . . . . . . . 285xiACKNOWLEDGEMENTSI would like to thank the members of my committee forthe devoted support and advice that enabled me to carry outthis study. My thesis supervisor, Dr. Marion Porath who wasnever too busy to give me advice or answer my questions andwho made the extra effort to correct my English when needed,Dr. Virginia Hayes who helped me go through the mazes ofhospital policies and who advised me in regard to severalaspects of nursing, and Dr. William McKee who advised andassisted me in my statistical analysis.I am very grateful to all the children who participatedin this study for continuing to share themselves even whenit was a very difficult time for them. Their openness andhonesty has helped to better understand their perception ofthe hospital nurse’s role. I also wish to thank all thenurses and doctors of British Columbia’s Children’s Hospitalin Vancouver who gave me permission to spend time with thechildren and who were never too occupied to provide me withbackground information about the children. I amparticularly grateful to Carolyn Graves who supported myproposal at the Hospital-In-Patient-Review-Committee, and toDr. Betty Davies who represented my study as a staff memberof British Columbia’s Children’s Hospital. Furthermore, myspecial thanks go to all the nurses of CIF (ClinicalInvestigations’ Facility) from whose ward I recruited themost children and, particularly, to their unit clerk, LyndaFynn, who was always willing to help.Though I did not use their facility, I am grateful tothe staff of Mount Saint Joseph Hospital in Vancouver whoalso gave me the permission to recruit children from theirChildren’s Center.I am indebted to my dearest friend Annemarie Strayerwho shared her artistic talents by drawing the pictures forthe Nurse’s Role Task.My thanks also go to the Dr. Hendrik Muller’sVaderlandsch Fonds and the Fundatie van de Vrijvrouwe vanRenswoude (The Hague, the Netherlands) for their generousawards and to the University of British Columbia for threetimes awarding me the “Rick Hansen ‘Man—In—Motion’ GraduateFellowship”.I wish to thank my family for encouraging me to goabroad and for the support they have given me in continuingmy education. Furthermore, I would like to especially thankmy mother for her love, support and coming over to Canadatwice to care for me as I had to undergo surgery during mystudies and my father for his unconditional love andsupport.Lastly, I would like to thank my husband, Dylan Hoey,for his love, help, and encouragement and for always beingthere for me, even in my most difficult times.xiiCHAPTER IINTRODUCTIONThe main issue examined in this research is thequestion of what kind of influence direct and prolongedexposure to hospitals and medical procedures, such as isexperienced by children with chronic or long-term healthconditions, has on these children’s conception of thehospital nurse’s role. Case’s (1992) neo-Piagetian theoryof development was used to analyze this issue.Cognitive—developmental studies that have been done sofar have been concerned primarily with the specific andunique ways in which children conceptualize causes ofillness (Bibace & Walsh, 1980; Brewster, 1982; Brodie, 1974;Campbell, 1975; Neuhauser, Amsterdam, Hines & Steward, 1978;Perrin & Gerrity, 1981; Potter & Roberts, 1984). Most ofthese studies suggest that children’s concepts of illnessdevelop through a systematic and predictable sequence ofdevelopmental stages, such as those described by Piaget(1929), ranging from the global and phenomenologicalconcepts characteristic of preoperational thought to themore sophisticated psychophysiologic concepts characteristicof formal operational thought (Bibace & Walsh, 1981).Only a few studies included the child’s understanding1of the role of medical personnel (Brewster, 1982; Haight,Black & DiMatteo, 1985; Redpath & Rogers, 1984).Piagetian stage theory appears inadequate to explainthe child’s conception of role for several reasons. First,if we look at the few studies that examined the child’sconception of medical personnel (e.g., Brewster, 1982;Redpath & Rogers, 1984), the age ranges used to interpretthe data are too broad. According to Piagetian theory, achild’s perception of medical personnel is basically thesame from age 7 till 10. Case’s (1992) neo—Piagetiantheory, however, subdivides one stage into three substagesand details changes in children’s thinking from age 7 to 10,allowing for a more detailed analysis of the data.Second, Piagetian Stage Theory is considered to be toomonolithic to explain the child’s conception of role (Case,1992). Piaget saw the child as a young intellectual,structuring the world around him/her by applying a set oflogical tools of increasing generality and power. Thesetools were understood as being logico—mathematicaloperations that were universal in nature and applicable to awide variety of tasks. Piaget did not see children’sunderstandings in different domains as being determined to amajor extent by their domain—specific experience. Instead,Piaget interpreted children’s understanding by the generalset of operations that they applied to their experience, andthe general set of auto—regulative processes by which these2operations were gathered into stable systems or groups(Case, 1992). Therefore, Piaget neglected the fact thatchildren’s intellectual development is dependent on theculture in which they are raised, the amount of instructionthey receive and their individual learning history. Hence,he overlooked the influence of the child’s personalexperience on his/her cognitive development. A child with achronic condition who has experienced multiplehospitalizations is assumed to have a different individuallearning history than a child who has never beenhospitalized before. The individual learning history of thechild with a chronic condition might influence developmentwithin a specific domain.Case (1992) hypothesizes a number of “centralconceptual structures” to account for domain—specificity indevelopment. Different domains demand different executivecontrol structures to solve different sorts of problems.The specific executive control structures for each domainform the basis for a central conceptual structure. Thechild’s conception of role, in this study the hospitalnurse’s role, is considered to be part of the social—cognitive domain (Goldberg-Reitman, 1992). This socialcognitive domain has its own underlying “central conceptualstructure” to represent social understanding.Third, the fact that Piaget, contrary to Case, does notacknowledge the influence of different learning experiences3within each domain makes it impossible to look at whatimpact emotions have on the child’s cognitive development.Case, Hayward, Lewis, and Hurst (1988) have suggested that,in contrast to certain psychoanalytic theories, chronicinternal conflict and anxiety will lead only to a verymodest deceleration in children’s normal rate of cognitivegrowth. They even suggested that many specific situationsthat are emotionally disturbing for the child might actuallylead to an acceleration of children’s cognitive growth inthe relevant domains. Therefore, the cognitive developmentof a child with a chronic condition might actually beadvanced in the area of understanding of the nurse’s role,because of more frequent exposure to hospitalization andmedical treatments.There is little research on the child’s perception ofthe hospital nurse’s role. Brown and Ritchie (1990)described how nurses perceive parent and nurse roles incaring for hospitalized children but not how childrenunderstand the role of the hospital nurse. The few studiesthat examined the child’s understanding of the role ofmedical personnel (Brewster, 1982; Eiser, l989b; Haight etal.., 1985; Redpath & Rogers, 1984) mainly focus on the roleof doctors and nurses in general without defining theirspecific functions. Brewster (1982) is the only author thatincluded a wide age-range (5- to 12-year-olds), which makesit possible to examine developmental change. The role of4the hospital nurse was just a small part of her study andthe data she provided about the role of the nurse is verygeneral.No “neo—structural” analysis has been done in the areaof conception of the hospital nurse’s role by children withlong—term health conditions. In other words, no analysis isreported that uses the finer grained classification systemneo-Piagetian theory provides. Since Goldberg-Reitman(1992) looked at different aspects of the young girl’sperception of the mother’s role by using Case’s theory, herstudy was used as a basis for interpreting possibledevelopmental trends in the understanding of the hospitalnurse’s role of children with chronic conditions. Themother role and hospital nurse role show similarities in thesense that some of the mother’s functions are temporarilytaken over by the nurse during some periods of the child’shospitalization. The nurse may be the one who provides somenurturance for the child when he/she is upset or may protectthe child when he/she feels ill. Furthermore, the nurseprepares and instructs the child for medical procedures andcares for the child’s physical well-being. These fourfunctions are normally done by the mother or father ifshe/he is the adult primarily present during thehospitalization.Research Obl ectivesTwo general objectives form the basis for the study:51. To conduct a developmental analysis of perceptions ofthe hospital nurse’s role by children with chronic healthconditions, within the framework hypothesized by Case(1992)2. To examine the influence of exposure to hospitalizationand/or medical treatments on the child’s understanding ofthe hospital nurse’s role.Importance of the StudyThere are several reasons why children’s conceptions ofthe hospital nurse’s role need to be examined. First ofall, the research that has been done on children’sunderstanding of medical personnel’s roles has frequentlyused faulty methodology. Burbach and Peterson (1986) pointto inadequate descriptions of samples, instruments andprocedures, observer bias and expectance effects, control ofconfounding variables and issues of questionnairereliability and validity as general shortcomings in studiesof children’s understanding of medical roles. Therefore, aclearer outline of the specific and unique ways in whichchildren perceive the roles of medical personnel over thecourse of cognitive development is needed.According to Eiser (1989a), research concerned withchildren’s conceptions of health and illness has beenheavily based on interview data and has paid littleattention to the reliability and validity of the interviewschedules. The few studies (Brewster, 1982; Haight et al.,61985; Redpath & Rogers, 1984) that not only focused on thechild’s perception of illness, but also examined the role ofmedical personnel, provided limited data. Haight et al.,for example, examined only 4— and 5—year—old children andRedpath and Rogers restricted their study to preschoolersand second graders. Brewster included several age groups inher study (ages 5 to 12), but provided poor task descriptionand global summaries of the data.The second reason why it is important to examinechildren’s perceptions of the hospital nurse’s role isbecause of the criticism of the theoretical underpinnings ofchildren’s conceptions of illness, and the nurse’s role inparticular (Eiser, 1989a, l989b). The majority of previousstudies rely on Piagetian Stage Theory, which appears to belimited considering the shift that has taken place in thevarious developmental “schools of thought.” For example,Stage Theory is generally criticised for its failure toexplain how the transition from one stage to another occurs,and for the assumption that children develop within avacuum, with little acknowledgement of the role ofexperience or social or cultural factors (Nelson, 1986).Third, a better understanding of children’s conceptionsof the nurse’s role can be used to facilitate or improve theservices currently offered by paediatric health careprofessionals. For example, Perrin and Perrin (1983)emphasized the lack of accuracy of medical personnel in7estimating the age at which children give developmentallycharacteristic answers to a series of questions aboutillness and made clear that a better understanding of thechild’s development by medical personnel will improve themedical treatment of the child.Fourth, Garbarino and Stott (1990) emphasized theimportant role the nurse plays for the hospitalized child.Nurses temporarily take over the mother’s role to a certainextent and may interact with the child more than the motherduring a hospital stay. According to Garbarino and Stott,the hospital nurse’s role consists not only of a technicalor clinical component, but also of an affective, nurturingcomponent. Brown and Ritchie (1990) stated that nurses’perceptions of parent and nurse roles in caring forhospitalized children show many similarities. For example,both parents and nurses provide psychosocial care, such asnurturance and emotional support.Health education is another important role played bythe hospital nurse (Whaley &c Wong, 1991). Health educationinvolves informing parents and children about condition—related matters and their treatment, encouraging children toask questions about their bodies, referring families tohealth-related professional groups, and supplying patientswith appropriate literature. According to Garbarino andStott (1990) optimal understanding of the child’s perceptionof the hospital nurse’s role is required for the nurse.8Therefore, it is important to examine children’s concepts ofthe hospital nurse’s role in more depth.Definition of TermsThe following terms will be used throughout the thesisand are defined below.Central Conceptual Structure:A central conceptual structure is an internal networkof concepts and conceptual relations that plays acentral role in permitting children to think about awide range of situations at a new epistemic level andto develop a new set of control structures for dealingwith them. (Case, 1992, p.130)Furthermore, central conceptual structures can be applied toa wide range of content, but only within a specific domain(Case & Griffin, 1990). Consequently, within each domainspecific central conceptual structures will be constructedby the child.Structure: Case (1992) states, “By a ‘structure’ wemean an internal mental entity that consists of a number ofnodes and the relations among them” (p. 130).Conceptual: “By ‘conceptual’ we mean that the nodesand relations are semantic: that is, they consist of‘meanings’, ‘representations’, or ‘concepts’ that the childassigns to external entities in the world, rather thansyntactic devices for parsing such meanings (Case, 1992,p.130) .“Central: By central Case (1992) means “structures that(a) form the core of a wide range of more specific conceptsand (b) play a pivotal role in enabling the child to make9the transition to a new stage of thought, where theseconcepts are of central importance (p.130).”Executive Control Structures: Case (1987) describedexecutive control structures as comprising three components:(1) a representation of a particular set of recurrentenvironmental features, (2) a representation of thegoals and subgoals that are most typically occasionedwhen these features are present, and (3) arepresentation of the sequence of operations (i.e.,strategy) which gradually emerges, as a means forachieving these goals and subgoals. (p. 782)Chronic or Long-Term Health Condition:A chronic condition is any anatomical or physiologicalimpairment that interferes with the individual’sability to function fully in the environment. Chronicconditions are characterized by relatively stableperiods that may be interrupted by acute episodesrequiring hospitalization or medical attention. Theindividual’s prognosis varies between a normal lifespan and unpredictable early death. Chronic conditionsare rarely cured, but are managed through individualand family effort and diligence. Chronic illness,long—term illness, and chronic condition are termsoften used interchangeably in the literature (Thomas,1987, p.5).Whaley and Wong (1991) define chronic illness as “acondition that interferes with daily functioning for morethan three months in a year, causes hospitalization of morethan one month in a year, or (at time of diagnosis) islikely to do either of these” (p.993).Perrin, Newacheck, Pless et al. (1993) recommend that achronic condition should be described as follows:Ideally, a definition should be comprehensive, generic,and flexible. We believe that a two-level approach todefining chronic conditions satisfies these criteria.For the first, most inclusive level, duration alone isthe decisive consideration. We recommend that acondition be considered chronic if it has lasted or is10expected to last more than 3 months. A second levelattends to the further specification of a condition.We recommend that the second level of a broaddefinition takes into account the impact of a conditionon the child. For example, the level of functionalimpairment or the use of medical attention greater thanthat expected for a child of the same age might beconsidered in adopting a working definition for serviceor research applications (p. 792).Perrin, Newacheck, Pless et al.’s definition was adhered toby the researcher in the current study.Approximately 15-20% of children have a chroniccondition (Olson, Johansen, Powers, Pope, & Klein, 1993).Examples of chronic conditions are asthma, cystic fibrosis,diabetes, sickle—cell anaemia, orthopaedic disorders, spinabifida, haemophilia, rheumatic fever, and cancer.Exposure to hospitalization and/or medical treatment:It is expected that a child with a chronic conditionwill be exposed to medical treatments, such as doctor’sappointments, hospital visits, daily medical treatments,medical assessments, tests and diagnosis, and possiblehospital admissions for at least one month in a year (Whaley& Wong, 1991). In their daily functioning they also mightreceive assistance from a local community health nurse.Paediatric nurse’s role:The paediatric nurse’s role includes family advocacy,illness prevention/health promotion, health teaching,support—counselling, therapy, coordination/collaboration,ethical decision making, research and health care planning(Whaley & Wong, 1991).11Literature pertinent to children’s understanding ofillness and health care will be reviewed in the followingchapter.12CHAPTER IIREVIEW OF LITERATUREThough relatively few studies have examined children’sunderstanding of health care, particularly the child’sconception of the hospital nurse’s role, some authors haveexamined developmental changes in children’s affective andcognitive responses to illness (Bibace & Walsh, 1980;Brewster, 1982; Brodie, 1974; Campbell, 1975; Neuhauser etal., 1978; Perrin & Gerrity, 1981; Potter & Roberts, 1984).These cognitive-developmental studies are relatively recentin origin (Burbach & Peterson, 1986). In the past, morestudies were focused on the psychodynamic aspects ofphysical illness. A historical overview of both thepsychodynamic and the cognitive-developmental approach willbe given here to provide a framework for drawing possibleparallels to children’s understanding of the hospitalnurse’s role and for establishing the nature ofdevelopmental change. This will provide a background forusing Case’s (1992) theory of development.Psychodynamic Studies.Psychodynamic studies (Deutsch, 1942; Faistein, Judas &Mendelson, 1957; A. Freud, 1952/1977; Jackson, 1942;Jessner, Blom & Waldfogel, 1952/1977) emphasized theintrapsychic impact of illness. They described conceptions13involving mutilation, hostile acts, or castration withrespect to treatments, anaesthesia, and surgery. Thepsychoanalysts explain children’s conceptions of health andillness in terms of fear, deserved punishment and guilt (fora review, see Vernon, Foley, Sipowicz & Schulman, 1965).For example, Anna Freud (1952/1977) was of the opinion thatchildren in the phallic phase (from approximately 4- to 6-years—old) tend to interpret surgery, no matter on what partof the body, as injury to the genitals. The Oedipus complexor Electra situation, depending on the gender of the child,can occur during this phallic-oedipal phase (S. Freud,1908/1963). The child shows possessiveness of the parent ofthe opposite gender, and jealousy of and rivalry with theparent of the same gender. Often the child demonstratesexhibitionistic attitudes and castration anxiety.Similar ideas relating castration fears or guiltfeelings associated with masturbation and interpretations ofhospitalization as injury or punishment have been shared bymany other authors (Deutsch, 1942; Erickson, 1958; Jackson,1942). Jackson (1942), for example, argued that even if theOedipus complex (‘Electra situation’ for girls) is notcompletely accepted as an origin for fantasy fears, it maystill be assumed that an extraordinary situation such ashospitalization may have an enormous impact on the child’snewly found sense of physical self. Bergmann and A. Freud(1966), for example, suggest that children’s behaviour14towards the surgeon should be understood in terms of theirage—adequate emotions, drives, and internal conflicts. Achild might respond to the surgeon in several ways. Forexample, the child might express fear of castration andmutilation towards the surgeon and see him/her as apunishing castrator. This is usually the case for boysduring the Oedipal phase. The child might show passivedependence on the doctor because he/she is seen as thepossessor of the child’s body and a substitute for theparent. The child might express masochistic tendencies.This is especially the case with girls who have strongpassive components. Or the child might look up to thedoctor with total admiration. Consequently, the child willshow heroic endurance of medical treatments.The hospital experience can be a threat at this agewhen the child is forming a concept of him/herself as aphysical being, is becoming identified with his/her owngender, and is concerned with his/her own limitations andcapabilities.According to the psychoanalytic perspective,therapeutic interventions should be oriented to theaffective level and acknowledge these negative feelings,such as guilt and castration (A. Freud, 1952/1977). AnnaFreud believed that fantasies aroused by a child’s illnessmay negatively influence the child’s cooperation withmedical procedures, self—esteem, and successful adjustment15to the strain of both acute and chronic disease. Forexample, a young child after the toddler stage may be wellable to understand the importance of medical treatment, torecognize the role of doctor or nurse as a beneficent oneand the necessity for medicines no matter how they taste,but, according to Anna Freud, this understanding cannot beexpected to last very long. The minute the visit to thedoctor comes to a close, all reason disappears and the childgets overwhelmed by fantasies of castration or violentassault. Additionally, Anna Freud (1952/1977) stated thatthe response of a child to surgery does not depend on thetype or seriousness of the operation which has beenperformed, but on the type and depth of fantasies aroused byit.Anna Freud (1965) believed that a child in illnessshould be regarded and treated as potentially regressed, andthat much of his/her age-adequate functioning may bereduced. Severe libidinal (also called sexual) and egoregression, that is, fantasies of mutilation, castrationand/or violent assault, may be the result of psychic pain intraumatic situations, such as hospitalization and anxiety.During the whole period of growth, however, it has to beconsidered legitimate for children to revert periodically,to seek comfort and safety (especially in anxiety anddistress) by returning to early forms of being protected andenjoying the symbiotic and preoedipal mother-child16relationship (A. Freud, 1965).But, even within the psychoanalytic orientation, itbecame clear that feelings of the sick child were related tobeliefs or concepts about illness and that these beliefs orconcepts were related to the cognitive level of the child(Bibace & Walsh, 1981). Factors related to the child’sstage of development and cognitive functioning werefrequently mentioned in psychoanalytic studies (Chapman,Loeb & Gibbons, 1956; Fineman, 1958; Vander Veer, 1949).The negative feelings or affect of the sick child were seento be in some way related to the child’s cognition orunderstanding of the causes of the illness but, according tothe psychoanalytic perspective, the child’s cognition wasmainly driven by underlying emotions which change over time.For example, children at the phallic or oedipal phase(approximately 4 to 6 years of age) are dominated by theintrusive mode and tend to explain injections, surgery, andother medical procedures as aggressive intrusions whichmight lead to fear of castration. They have a large residueof guilt derived from oedipal problems which leads to theinterpretation of hospitalization as punishment (Erickson,1958). Children in the latency phase (from approximately 6to 10 years old) are more prone to the containment of theirsexuality and consequently their fear of castrationdisappears (Kavka, 1962/1977). Around the age of twelve,when the ego is stronger, hospital treatment is no longer17fraught with terror.The psychoanalytic view, however, was too limited toexplain fully the variety of children’s responses and toaccentuate the developmental aspects of these responses.According to Bibace and Walsh (1981), it was too focused ondistorted ideas about hospitalization and illness, andneglected the importance of the child’s cognitivedevelopment. In contrast to the psychoanalytic approach,which has tried to account for children’s conceptions ofhealth and illness in terms of fear of punishment, thecognitive—developmental approach has its main focus on thedegree of differentiation between self and others (Piaget,1930/1960; Bibace & Walsh, 1981). Piaget (1930/1960),writing twenty years later than Sigmund Freud, focused noton physiological immaturity as Freud did but on thecognitive—structural system through which children transformincoming information. According to Piaget’s stages,children have an increasing ability to separate internalrealities such as wishes, needs, and thoughts from theoutside world. For example, young children between 2 and 6years of age are unable to distance themselves from theirenvironment (Piaget, 1930/1960). Their explanations ofillness are based on their immediate perceptual experiences(Bibace & Walsh, 1980). At the age of 11 years childrenwill be able to differentiate between themselves andperceptual experiences completely.18Piaget’s theory of cognitive development formed thebase for many studies examining the child’s conception ofillness. In the next section the influence of Piaget’stheory on studies that focused on children’s conceptualdevelopment of illness will be discussed in more detail.Cognitive-Developmental StudiesCognitive—developmental studies have been focusedmainly on the more specific and unique ways in whichchildren conceptualize illness (Burbach & Peterson, 1986).Most of these studies suggest that children’s concepts ofillness develop through a systematic and predictablesequence of developmental stages, such as those described byPiaget (1929), ranging from the global and phenomenologicalconcepts characteristic of preoperational thought to themore sophisticated psychophysiologic concepts characteristicof formal operational thought (Bibace & Walsh, 1981). Onlya few cognitive—developmental studies, however, provided anoverview of the development of children with chronicconditions (Perrin & Gerrity, 1984; Yoos, 1987)In order to better understand the content of thedifferent stages developed by Piaget (1929), a shortoverview of his theory will be given. According to Piaget,certain basic and well differentiated cognitive operationswere acknowledged to be present at birth. These operationswere considered to be relatively reflexive and independentin nature. However, they were not seen as remaining19independent for long, but, with experience, as becoming moredifferentiated and coordinated into systems of increasingcomplexity and coherence (Case, 1992). Piaget was of theopinion that, at certain points in the child’s development,these systems would stabilize and would gain organizationalproperties which could be explained through symbolic logic.In other words, Piaget thought that similar understandingstend to be acquired around the same age across a widevariety of domains by suggesting that these understandingsall require the application of the same underlying logicalstructure. He considered these shifts in development totake place at the age of about 2 years, when the developmentof the child’s earliest sensory and motor capabilities iscomplete, and again at about the age of 7 years, when theappearance and development of a more advanced group ofoperations that are representational in nature occurs. Atthe beginning of adolescence the third major shift takesplace, with the emergence and development of a set ofrepresentations that are more abstract or formal in nature.These stable systems play a major role in shapingchildren’s perceptions of the world around them. Because ofthat, Piaget divided children’s cognitive development intofour general stages, taking into consideration theattainment or non-attainment of the thought that thesesystems allowed. Piaget called the four stages thesensorimotor stage (0 to 2 years), the pre—operational stage20(2 to 7 years), the concrete operational stage (7 to 10years) and the formal operational stage (11 to adulthood).Characteristics of the stages include the increasing abilityto engage logical thought and to separate internal realitiessuch as wishes, needs, and thoughts from the outside world.At the same time there is an increasing ability todistinguish other people’s points of view from the child’sown. For example, if we look at the child’s understandingof the intent of medical procedures and the role of medicalpersonnel, we notice a change in the pattern of responses ofthe child at different stages (Brewster, 1982). A five—year-old child is more likely to state that medicalprocedures are done to punish him/her for being bad, while aten—year—old can understand the intentions of doctors andnurses and why certain medical procedures have to be done.Piaget explained the transition from one of these stages tothe next by suggesting that both children’s active thoughtsabout the outcome of their current mental activity andtheir attempt to deal with the inherent contradiction thatthis reflection of thoughts causes, play an important rolein the stage—transition process.Piaget’s framework of cognitive development provided auseful theoretical perspective for a number of studies whichinvestigated the child’s capacity to view illness in alogical way (Bibace & Walsh, 1980; Brewster, 1982; Brodie,1974; Campbell, 1978; Cook, 1975; Neuhauser et al., 1978;21Perrin & Gerrity, 1981; Potter & Roberts, 1984; Redpath &Rogers, 1983). Children’s conceptions of illness can beseen to follow a developmental progression which parallelsshifts in the child’s cognitive processes, changing fromprimitive, egocentric reasoning to more abstract andconcretely logical views (Whitt, Dykstra, & Taylor, 1979).Only a concrete operational child can be expected todecenter from isolated perceptual symptoms of illness. Fullcomprehension of abstract notions of disease is to beexpected with the attainment of formal operational thinking(Bibace & Walsh, 1979).The most comprehensive account of children’s beliefsabout the cause and implications of illness as a function ofcognitive maturity has been proposed by Bibace and Walsh(1981). Bibace and Walsh (1979) mentioned three major typesof explanations of illness consonant with Piagetian stagesof cognitive development: prelogical, concrete logical, andformal logical. Within each of these major categories theydistinguished two subtypes of explanation:I. Prelogical Explanations (Approx. 2-6/7 Years)Category 1: PhenomenismCategory 2: ContagionII. Concrete-Logical Explanations (Approx.7—11/12 Years)Category 3: ContaminationCategory 4: InternalizationIII. Formal-Logical Explanations (Approx.12 Years-Adult)Category 5: PhysiologicalCategory 6: Psychophysiological (Bibace &Walsh, 1980, p. 35)22Phenomenism represents the most developmentallyimmature explanation of illness. The child sees the causeof the illness as an external concrete phenomenon that maycome with the illness but that is unrelated spatially and/ortemporally to the illness (Bibace & Walsh, 1980). “How dopeople get colds? ‘From the sun.’ How does the sun give youa cold? ‘It just does, that’s all’”(Bibace & Walsh, 1981,p. 36).Contagion is the most common explanation given by themore mature child in the prelogical stage. Objects orpeople that are close to, but not in physical contact with,the child are seen as the cause of illness (Bibace & Walsh,1980)How do people get colds? “From outside.” How dothey get them from outside? “They just do, that’sall. They come when someone else gets near you.”How? “I don’t know -by magic I think.” How dopeople get colds? “When someone else gets nearthem.” (Bibace & Walsh, 1981, p. 36)Contamination characterizes children’s explanations inthe early concrete—logical stage. The child can nowdifferentiate between the cause of the illness and theeffect on his/her body. A person, object, or action that isexternal to the child and that has an aspect or quality thatwill have a bad or harmful impact on the body are seen asthe cause of illness (Bibace & Walsh, 1980).What is a cold? “It’s like in the wintertime.” How dopeople get them? “You’re outside without a hat and youstart sneezing. Your head would get cold, the coldwould touch it, and then it would go all over yourbody.” (Bibace & Walsh, 1981, p. 36)23Internalization is the most common type of illnessexplanation given by older children in the concrete-logicalstage. The cause of illness is seen now as being locatedinside the body, but its ultimate cause may be explained ascoming from outside the body. The child is capable ofrelating the internal effect of illness to the externalcause, usually a person or object, through a process ofinternalization (Bibace & Walsh, 1980).What is a cold? “You sneeze a lot, you talk funny, andyour nose is clogged up.” How do people get colds? “Inwinter, they breathe in too much air into their nose,and it blocks up the nose.” How does this cause colds?“The bacteria gets in by breathing. Then the lungs gettoo soft, and it goes to the nose.” (Bibace & Walsh,1981, p. 37)The younger children in the formal—logical stage aremore likely to give physiological explanations. They seethe cause of illness as the nonfunctioning or malfunctioningof an internal organ or process. The cause may be inducedby external events but the source and nature of the illnesslie in specific internal physiological structures andfunctions (Bibace & Walsh, 1980).What is a cold? “It’s when you get all stuffed upinside, your sinuses get filled up with mucus.Sometimes your lungs do too, and you get a cough.” Howdo people get colds? “They come from viruses, I guess.Other people have the virus, and it gets into yourblood stream and it causes a cold.” (Bibace & Walsh,1981, p. 37)Psychophysiological explanations represent the mostmature understanding of illness. The child is not onlyaware of the physiological aspects of illness but also the24psychological. The child understands now that also aperson’s thoughts or feelings might have influence on theway the body works (Bibace & Walsh, 1980).What is a heart attack? “It’s when your heartstops working right. Sometimes it’s pumping tooslow or too fast. “How do people get a heartattack? “It can come from being all nerve—racked. Youworry too much. The tension can affect your heart.”(Bibace & Walsh, 1981, p.38)Most studies of the child’s conceptual understanding ofillness have used the Piagetian approach. Burbach andPeterson (1986) give an overview of the different studiesbased on the Piagetian orientation. They divide the studieson the basis of health status of samples utilized becausethe health status of children has been hypothesized to havean important effect on children’s concepts of illness(Brewster, 1982; Cook, 1975; Redpath & Rogers, 1984). Forexample, Brewster’s study (1982) showed that there was norelationship between length of hospitalization or type ofillness and levels of cognitive understanding of illness.Cook’s study (1975), on the other hand, revealed that sickchildren were less mature than healthy children in theirexplanations of illness.The studies based on the Piagetian approach includedhealthy samples (Bibace & Walsh, 1980; Brodie, 1974;Neuhauser et al., 1978; Perrin & Gerrity, 1981; Potter &Roberts, 1984; Redpath & Rogers, 1983), hospitalized samples(Brewster, 1982; Campbell, 1978) and combined samples ofhealthy and hospitalized and/or chronically ill children25(Cook, 1975; Perrin, Sayer, & Willett, 1991; Shagena,Sandier, & Perrin, 1988). The hospitalized samplesconsisted of children with various illnesses (Brewster,1982; Campbell, 1978).The few studies that described the development ofchildren with chronic conditions from early childhood toadolescence (Perrin & Gerrity, 1984; Yoos, 1987) suggested,in general, that children’s development can best beexplained by referring to the common expectations for thecognitive and social—emotional development of all children.However, they also state that the cognitive and social—emotional development of some children with chronicconditions may be delayed at some stages due to the factthat physical illness may have certain implications at eachstage of development and can potentially interfere with orincrease the difficulty of optimal progression from onestage of development to the next. For example, physicalillness may restrict children’s ability to achieve certainmotor and social skills.Most of the studies based on the Piagetian approachemphasized conceptual understanding of illness, inparticular the child’s explanation of the cause of illness(Bibace & Walsh, 1980; Brewster,1982; Brodie, 1974;Campbell, 1975; Perrin & Gerrity, 1981; Potter & Roberts,1984). Only a few authors have included the role of nursesand doctors in their studies with children (Brewster, 1982;26Eiser, 1989; Haight et al., 1985; Redpath & Rogers, 1984).Studies that included the role of nurses and doctors willnow be examined for their contribution to articulating thenature of the child’s understanding of the nurse’s role.Piagetian Studies that Included the Role of MedicalPersonnel.Brewster (1982) focused on two areas, namely thechild’s understanding of the cause of his/her illness andthe child’s understanding of the reasons for medicaltreatment and the role that medical personnel play in thistreatment. According to Brewster, children’s comprehensionof illness, hospitalization, and medical personnel developsfrom finalistic and univariate thinking to more multiplecausal reasoning. For example, her data suggested that5- and 6-year-old children thought that medical procedureswere done to punish them. Children aged 7 to 10 years oftenwere aware of the fact that treatment is intended to helpthem get well, but they were limited in their ability tointerpret empathy of doctors and nurses. For example, theythought that nurses could understand their pain only if theywere screaming or crying. Children aged 11 years and olderconsidered their doctors and nurses as being empathetic,because of shared human experiences and because they couldput themselves in the child’s place. Some of the childrenat this level gave responses that doctors and nurses couldnever know exactly how they felt because only someone who27had suffered as much as they did could fully understand whatthey went through. Children at this age were able to give amore sophisticated response of how they viewed medicalpersonnel. Brewster’s hypothesis, based on psychoanalyticthought, that a child’s understanding of matters in highaffect areas (e.g., concerning the child’s own illness)might be regressed compared to his/her understanding of lowaffect areas was rejected. Brewster’s study also showedthat the level of response of children of highersocioeconomic class was significantly more advanced thanthat of children of lower socioeconomic class. The degreeof advancement in terms of stage was not mentioned in thisstudy.Redpath and Rogers (1984) compared the cognitiveunderstandings of never-hospitalized children with those whohad been hospitalized previously but who were healthy at thetime of the study. Their sample consisted only ofpreschoolers and second graders. The majority of thepreschoolers could not say what nurses do, whereas secondgraders could give more details about roles of doctors andnurses. Both preschoolers and second graders were betterable to explain the duties of doctors than of nurses. Bothage levels seemed to have a lack of ability to explain whydoctors and nurses use certain medical procedures.Haight et al. (1985) examined 4- and 5-year-oldchildren’s understanding of the social roles of doctor and28patient by using a brief clinical interview and puppet play.They suggested that children’s social role concepts andexplanations for certain medical procedures may be quitedifferent from those thought by the adult healthprofessional and they warn newly trained paediatric healthprofessionals to be aware of possible miscommunicationbetween themselves and the child. For example, a healthprofessional might try to calm a child down by carefullyexplaining the purpose for use of a certain instrument, suchas a tongue depressor. The child, on the other hand, may beimpatient with and unable to understand all the difficultconcepts such as inflammation or infection and would prefera concrete demonstration of how to use the instrument bylooking into his/her throat.According to Haight et al. (1985) the health careprofessional should also realize that children are nottotally passive. Children often strive actively tounderstand many aspects of the medical interview. Healthcare professionals should try to encourage children’squestions, disclosures and inquiries. However, Haight etal.’s study was limited by the small sample (ri=l3), thechildren’s age range (only 4 and 5 year olds were examined)and the middle—class socioeconomic status of the children.Eiser (l989b) attempted to apply the script theoryapproach instead of Piaget’s theory of cognitive developmentto an analysis of 4- and 8-year old healthy children’s play29using doctor and nurse dolls. Scripted episodes ofchildren’s imaginative play can be seen as “a sequence ofactions related temporally and causally” (Nelson, 1985, p.18). Eiser’s main objection to the Piagetian stage approachis that it focuses too much on verbal descriptions (see, forexample, Bibace and Walsh, 1981), while children’srepresentations of social events can also be examined byanalyzing fantasy play within a script framework (Nelson &Seidman, 1984). Children’s play can give us a widerperspective of what children really do know about illnessand not only what they tell us. For example, Eisermentioned the discrepancy in data obtained from very youngcancer patients on questionnaires about the cause of illnessor what happens in hospital, compared with observations ofthese children at play. These very young cancer patientswere better able to express their thoughts about andunderstanding of their condition through play than throughanswering questionnaires (Kendrick, Cullin, Oakhill & Mott,1986, cited in Eiser, l989b). Eiser’s data suggest thatPiaget’s stage approach is not invalid for examining howchildren conceptualize illness, but she points out thatvarious methods besides Piagetian tasks have to be used inorder to get a total understanding of children’s conceptualunderstanding of illness.Perrin and Perrin (1983) examined the accuracy ofmedical personnel in estimating the age at which children30give developmentally characteristic answers to a series ofquestions about illness. They conclude that medicalpersonnel do not have enough understanding about howchildren interpret the world around them. For example,Perrin and Perrin’s data suggest that medical personnel ingeneral either overestimate the conceptual sophisticationwith which young children think about illness, orunderestimate older children’s understanding.Therefore, a better understanding of children’sconception of a hospital nurse’s role can be used tofacilitate or improve the services currently offered bypaediatric health care professionals. To understand achild’s conception of the hospital nurse’s role better acloser look at this issue is necessary. Nurses interactwith children during many hospital activities, such asphysical examinations, informal and formal discussions, andactivities such as changing dressings, inserting intravenous(IV) needles, and giving medications and injections.Garbarino and Stott (1990) state that the nursing roleincludes both a technical or clinical component and anaffective, nurturing component. Nurses can become effectivecommunication mediators between children and their familiesand other health care professionals, which makes itimportant for them to understand the child’s understandingof the hospital nurse’s role.None of the studies described looked at the31Cl)Cl)U)ft3H)P.’ftP.’Cl)II-C)C)P.’ftC)tftft0H-HCD(i)1‘<IH-P.’0I00P.’0jP.’t3P.’P.’H)P.’U)CT)(1)Cl)lCD<P.’Cl)CDCDEnP‘0H)HCDC)‘dft10P.’‘PCDp.’C)ftdçtçtHCDCD‘-<h1IIH)CE)I1CD-HCl)HHEn<‘-CDP.’IIU)H-00H-‘-3<ftftEl)ft0CDHC)ftCDHCDHP.’b‘dU)-P.’HH-H)0P.’ftP.’P.’IICDHU)LH-01C)CDP.’—‘0IHHtftCDP.’00ftCDU)P.’CDHC)Cl)CDjP.’HIH0CDU)U)P.’EnDU)0ftftCD1NHC31LQU)‘<‘<H)P.’U)ft)•IIH<CDbH-•CDHftLi.CD0C)P.’CDP.’ft<P.’P3Cl)b0PP.’H)CD—CDC)Ht0bP.’ft‘<00dft0C)Cl)C)‘iI0ftH-CDH‘dftZ)-ft0ft‘t5-.1P3H)00P.’CDU)Z0PhCDk<CDHU)hHft-C)H-ftU)0CDCDP.’IICD0HU)‘<CD0ftU)P.’P.’ftCDCDIP.’0<CDHU)U)ftCE)CD•H-bH-.QQU)‘dIICD<dftft-P.’P.’H-HCD0t3CDCDHH-Cl<hCDCDU)P.’P.’HC)U)ftU)Enb’0P.’HP.’C)00CDU)ftdP.’U)ft-<H)0ftHH)C)-0‘d‘tH-CDP.’0U)CDP.’C)‘dP.’H0P.’HP.’U)U)P.’.QbH)CDC)P.’ftU)P.’CDH<H-ftftftft0CDU)CDCDC)P.’H-0CD‘-<CDHC)X-CDClU)ftClftEnH)P.’U)IU)HCDCD.DCDiiH-ft0P.’CDHCDHCDP.’ftH-HCDP.’H<0-<C)HEl)0CDCl)ftftU)CDP.’HHHH-ftCDU)CD‘-3CDC)P30U)ftH0CDftP.’0ftIHftH•10H)U)Ci0tJC)Cl)CD0‘<0P30—CDP.’CiCDP3ftClH0CiHCDCDCDH-Cl‘EH0HftC)El)P.’H-Hty‘-<ftCDP.’U)Clj‘..OhftHCDCD0iU)-U)CDH-‘.0P.’P.’P.’HtTHClU)H)ftcCl)0IH)CDhtJH-ClH)HCD1CDU)P.’IP.’H00P’ftftU)‘—C)<0ClCDCDftP.’Ci-JC)ftCDHtC)0ftCD0P.’IIftIIClCD><‘1bCD0ClH)-ClCDP.’ClP.’CDU)U)Cl)ftft0P.’CDftftCDftH-ft•0C)H)EnH-0C)0C)P.’P.’0CDP.’C)H-P.’t1H-H-ftP.’P.’IHIICDP.’HCDU)ft‘.Q0P.’.QEnP.’CDCD‘<H-0H-HH-1CD‘-30ftCDbCDHU)ClU)ClftfriU)CD‘.CDftCDCDftH--P.’U)•CDftft‘di.QCDP.’CD‘<•-Cl)‘QH-ftH)U)CDCDCD-ftCD00iiClCl)ftCDH)0H-C)ClIIC)U)H)P.’Ci0CDCDftftH-C)CD‘dU)-H-CD‘dU)P.’ft-3ftH-C)H-C)Cl)II0HtU)IU)P.’ftCDP.’P.’HCDH-00CDH0ftU)P.’P.’H-0H-H-CD00ftP.’H)ftClH0ft0ftU)ftHU)01H-C)H-H-H)P.’CD1CDH)H-P.’CDP.’<ft0CDH-C)C)P.’ftHCD‘.0Cl)0HCl‘.‘-<ClftCDP.’IH-IHCiP.’CDH-CiCDH-Cl)H0Ci-‘-<b‘.Cp.’H-<HCD0P.’HH-U)Cl)CDU)CDHCiCD<ftCD1i0k<•CDP.’ft-I-Cl)‘T3<H)1P.’U)0U)-ftCl)‘.H-CD0CDU)ClCDSecond, another advantage is that Case’s theorydistinguishes between domains and introduces domainspecificity. Each domain has its own “Central ConceptualStructure.” To the contrary, Piaget suggested that,regardless of the domain, children acquire a certain generallogical structure at different stages in their lives, a“structure of the whole,” which drives development acrossdomains. Piaget’s structure of the whole has itslimitations, because it cannot explain features such as theinfluence of instruction, the lack of cultural universalityin children’s experience, low intertask correlations, anddecalages. In other words, Piaget’s theory can not explainexceptions to the general pattern of development (Case,1992). For example, how could a cognitive system be open tocultural innovation when it only has a universal and closedset of logico—mathematical operations to rely on? When wewant to examine the hospitalized child’s understanding ofthe nurse’s role, for example, it may be impossible to counton a universal set of logico—mathematical operations alonefor explaining children’s conceptions. Hospitalizedchildren find themselves in special situations, which givethem different perceptions of the environment and theirsocial worlds. As suggested by Case, it may be moreappropriate to use a more specific approach that takes intoconsideration these experiences and the impact they mighthave on the child’s cognitive development. Case’s (1992)33data, for example, show that the content of socialstructures is quite different from the content of numericalstructures that were studied. Social structures appeared tobe subject to different sorts of influence.In the current research, Case’s theory (1992) lends adifferent theoretical background than has been tested onstudies done to date. Case (1985, 1992), who considershimself “neo—Piagetian,” suggests his own view to explainthe weaknesses of Piaget’s theory. He acknowledges theimpressive strengths in Piaget’s theory, but tries toaccount for more specific factors in development. Specificfactors take into consideration the environment the childlives in and the cultural and linguistic background thechild grows up in. Case’s theory will be described in moredetail and the way in which his theory adds to Piagetiantheory of cognitive development will be explained further inthe next section.Case’s Theory: A Neo—Piacietian View.Over the past few decades, several critiques ofclassical Piagetian theory have been formulated. The Neo—Piagetian movement (Case, 1978; Fischer, 1980; Pascual—Leone, 1976) addresses the perceived shortcomings inPiaget’s theory, namely:(a) the absence of a well—defined explanation of howchildren’s cognitive structures change from one stage tothe next. Children around the age of six develop more34complex mental structures which enable them to solveproblem situations in a more sophisticated fashion. Howdo 4 year olds come to acquire the increased complexityevident in 6 year olds?(b) the absence of an explanation for more specificperformance factors. What kind of factors affectchildren’s ability to apply particular structures inparticular contexts? For example, what is the influenceof instruction on the child’s performance?(c) the absence of any explanation of individual differencesin the cognitive development of children. Why is itthat a child’s problem-solving abilities can acceleratein one local problem domain under certain circumstancesand not in another?Case (1985, 1992) considers Piaget’s account of the“general” factor in development as a major strength thatexplains the universal way in which children controlstructures across domains once they are exposed to theappropriate opportunities for learning. On the other hand,Case acknowledges the more domain—specific and contextuallysensitive characteristics that subsequent studies havefocused on (e.g., Carey, 1985; Chi, 1988; Pascual—Leone,1976), because these theories try to explain features suchas the influence of instruction, the lack of culturaluniversality in children’s experience, low intertaskcorrelations and decalages which the general and monolithic35approach of Piaget could not account for. Carey (1985), forexample, is of the opinion that cognitive processes may beanalyzed as a set of basic categories or domains offunctioning. According to Carey, the origin of thesedomains lies in the modular structure of the human nervoussystem, in the evolutionary history of the human organism,and the modular structure of the cortex from which thishistory has emerged. Consequently, this modular structuremakes sure that any stimulus pertinent to each domain isbeing dealt with by its own distinctive neurological system.Children have their own individual way of responding tostimulation within each domain. Furthermore, the cognitiveprocesses they use for initiating the responses arestructured into corresponding and distinctive systems.According to Carey, the conceptual systems or theories thatchildren construct reflect this modular structure. In thecourse of development, children’s conceptual systems areregularly re—worked in either a major or a minor way.Recently, Case (1992) introduced the term “centralconceptual structure” to make a bridge between the moregeneral or “systemic” views that have been proposed byPiagetian and neo—Piagetian theorists and the more domain—specific views (e.g., Carey, 1985; Spelke, 1988). Hehypothesizes that children’s functioning in the domains ofquantitative, social, and spatial functioning may form thebasis for different “central conceptual structures.” In36order to understand the term “central conceptual structure”better, the term “executive control structure” has to beexplained first, because executive control structures formthe basic internal program a child uses for solvingelementary problems encountered in his/her daily life.Executive Control Structures.According to Case (1985), one of the most importantchanges that takes place in a child’s development is theability to put together “executive control structures” forsolving different sorts of problems. An executive controlstructure is defined as a mental scheme or plan for solvinga class of problems. These executive control structureshave three components, namely:(1) a representation of the problem situation; that is, thedesired state for which the plan is appropriate, and thecondition under which it may be put to practical use.(2) a representation of the problem objectives; that is, thegoal toward which the plan is directed, and theconditions that are desired for solution of the problemsituation.(3) a representation of the problem strategy; that is, themental and/or physical steps a child uses to go from theproblem situation to the problem objectives and to comeup with a solution to the problem situation.Case used several tasks to see what kind of executivecontrol structures a child has at different ages. One of37these tasks is the balance beam. Children aged 4, 6, 8, and10 will solve the problem tasks in different ways (seeTable 1). Both Piaget and Case recognize the majortransition in intellectual development from 4 to 6 years ofage. Piaget called it the time when the first “functionallogic” emerges, the logic from which the concrete—operational structure will ultimately be assembled (Piaget,1970). In Case’s theory, this is the time when thetransition occurs from a period of “relational” thought to aperiod of “dimensional” thought (Case, 1985). Furtherdevelopments take place from ages 6 to 8, and from ages 8 to10. The changes that take place from ages 6 to 8 and 8 to10 are not seen as involving major qualitative change, butrather a series of minor quantitative changes (see alsoFigure 1). These changes constitute a progressiveelaboration of the more fundamental change that takes placebetween the ages of 4 and 6.At the beginning of each stage, two formerly discreteand qualitatively different control structures areintegrated, so that a new unit of thought is created. Afterthe initial transition is made, there is a furtherprogression through a sequence of substages. During thesesubstages the number of such units can be considered asincreasing and the overall complexity of the child’s mentalfunctioning as increasing with it (Case, 1992).38Table 1School—aged Children’s Control Structures forAnticipating Action of Balance BeamPROBLEM SITUATION OBJECTIVE4 years . Balance beam with an . Determine which sideobject on each arm. will go down.STRATEGY1. Look at each side. Predictthat the one which looksheavy will go down, thelight one up.PROBLEM SITUATIONBalance with stack ofobjects on each arm.Each stack composed ofa number of identicalunits./STRATEGY1. Count each set of units;note which side has thebigger number.2. Pick side with biggernumber as the one willweigh more (and therefore go down).PROBLEM SITUATION OBJECTIVESPredict which side willof objects on each go down.side.• Each object stack______Determine side withcomposed of a number greater number ofidentical units, objects.• Each object at a Determine side withspecifiable distance weight at greaterfrom fulcrum, distance.STRATEGY1. Count each set of weights;note which side has greaternumber.2. Repeat 1 for distance pegs.3. If the weights are aboutequal, predict that the sidewith the greater distance6 years8 yearsOBJECTIVESPredict which side willgo down.Determine which sidehas larger number ofunits.• Balance beam with stack/39Table 1 (continued....)will go down.that the sidewill go down.PROBLEM SITUATIONBalance beam with stack_____of weights at variousdistances.• Action of weight and_ __distance in oppositedirections.• Each weight stackcomposed of equalamounts.Each distance composed•of number of equalunits. /Otherwise predictwith greater weightOBJECTIVESPredict which side willgo down.• Determine whetherweight has a greatereffect.• Determine relativenumber of weights oneach side.Determine relativedistance on each side.10 yearsSTRATEGY1. Count each distance; notesize as well as direction ofdifference.2. Repeat step 1 for weight.3. Compare the magnitude ofthe results in steps 1 and 2.Notice which is bigger.4. Focus on dimension ofgreater difference. Pickside with higher value asone which will go down.40VECTORIALSTAGESubstage3A17B1WM.(15l/2—19yl.)A2—B4Substage2A1B1(13—151/2yrs.)A2--BA1--BWMtortB4}Substage2A1B1(7—9yrs.)A2Substage1INTERRELATIONALSTAGE(5-7yrs.)A1--BW.M.AtortBA2—BSubstage2A1TB13(2—31/2yrs.)A2-—B2A17B1W.M.AtortBA—B4122development(Case,1992,p.346)4thORDERRELATiONSDIMENSIONALSTAGE3rdORDERRELATIONSSubstage3(9—11yrs.)Substage1(11—13yrs.)A—B2 1Substage3(31/2—5yrs.)A—B2ndORDERRELATIONSSENSORIMOTORSTAGE2 11stORDERRELATIONSSubstage3(12—16 mos.)Substage1(11/2—2yrs.)A—B2 1Substage2A1TBI3(8-12iiios.)A2---82Substage1A—B2(4-8mos.)orABSTRACTDIMENSIONALSTAGESubstage0AorB1(1-4mos.)JFigureTcte€uctureofchildren’sknowledgeatdifferentstagesandsubstagesof41Different domains require different executive controlstructures to solve different sorts of problems. Thespecific executive control structures for each domain formthe basis for a central conceptual structure. Thedescription of a central conceptual structure adds a moresemantic account of the conceptual knowledge childrenpossess at any level of development. According to Case(1992), it seems more useful to not only suggest acharacterization of development that focuses on proceduralcomplexity, such as is described by executive controlstructures, but also a characterization that concentrates onthe way children represent problems at different ages, suchas is proposed by central conceptual structures. Certainrepresentational functions seem to act as a restriction onthe acquisition of particular procedures; in other wordsthese functions have to be brought into place somehow beforethese executive control structures or procedures can bebuilt and applied with effectiveness and flexibility. Thenotion of “Central Conceptual Structures” will be discussedfurther in the next section.Central Conceptual StructuresCase (1992) hypothesized that children’s functioning inthe domains of quantitative, social, and spatial functioningmay have different underlying “central conceptualstructures.” For example, Figure 2 shows the hypothesizedunderlying central conceptual structure for solving the424 YRS:light (up) Heavy (down)6 YRS:1 2 3 4 5 6 7 8 9 10light (up) I I I Heavy (down)8 YRS1 2 3 4 5 6 7 8 9 10Near (up) I I I I I I Far (down)1 2 3 4 5 6 7 8 9 10Light (up)’’’’’ ‘‘‘ Heavy(down)10 YRS1 2 3 4 5 6 7 8 9 10Near (up) I I I j Far (down)1 2 3 4 5 6 7 8 9 10Light (up) I I I I Heavy (down)Figure 2. Central conceptual structure for quantitativereasoning (Case, 1992, p. 95).Balance Beam Task. This figure explains how childrenrepresent a problem, that is, their conceptual understandingof it, and demonstrates that it might be that 4-year-oldchildren are more likely to represent each possible variablein a global or opposite manner. For example, “Big thingsare worth more; little things are worth less” (Case, 1992,p. 95). Six year olds, on the other hand, are more likelyto represent variables in a continuous manner, that is, ashaving two poles on an actual number line and a number ofpoints in between. Furthermore, at this age children startto understand that these points can also be seen as lying on43a mental number line, so that higher values have a highernumber associated with them. For example, the number sixhas a higher value than the number four. Moreover, 8—year—olds might consider two independent quantitative variables(e.g., days and weeks in a month), but might not be able tomake the right comparisons between variations of each ofthem. For example, a child might understand that thirtyminutes is less than forty minutes, but might be unable tocomprehend that two hours consist of sixty minutes each.Finally, lO-year-olds might be able to make these successfulcomparisons by considering the interaction between twoquantitative variables (Case, 1992). For example, a 10-year—old child will use a compensation strategy for solvingthe balance beam task of either adding or subtracting theweights and distance from each side of the fulcrum and basetheir answer on either the greater number or the greaterdifference depending on which strategy they use. Both thedimensions of weight and distance are changed at this level(Case, 1985).Case and Griffin (1990) delineated the followingproperties of central conceptual structures.— Central conceptual structures are organized sets ofconcepts and conceptual relations, not logical relationslike those hypothesized by Piaget.— Central conceptual structures are universal with respectto sequence but likely more specific in their form and44frequency of occurrence. They are universal in the sensethat their sequence is dependent on the maturity of theworking memory regardless of which domain, but specific intheir form and frequency in the sense that theirdevelopment is related to a specific domain and dependenton the specific experiences of the child within eachdomain.— Central conceptual structures can be appliedto a wide range of content, but only within a certaindomain. For example, the same central conceptualstructure can be applied both to children’s understandingof empathy and their comprehension of social role which ispart of the social cognitive domain, but not to theiracquisition of mathematical knowledge. The latter is partof the quantitative domain.— Central conceptual structures can be instructed in arather direct manner. Training in understanding of onetask will affect the understanding of another task withinthe same domain because of the same hypothesizedunderlying central conceptual structure (McKeough, 1992b).— Central conceptual structures are obtained via sociallyencouraged processes (i.e., processes which draw thechild’s attention to specific factors, and stimulatecertain kinds of construction rather than others). Forexample, different cultural experiences (i.e.,opportunities presented by the environment to explore45spatial relationships, attendance at Western—type schools,social contact with urbanized people) will have animportant impact on the content of children’s centralconceptual structures and play an increasingly importantrole with age because the construction of these structuresare dependent on knowledge that is unique to the culturein which they were developed (Cole & Scribner, 1974;Vygotsky, 1934/1986).Case (1992) has different hypotheses about centralconceptual structures, which makes it possible to makecertain predictions.— Central conceptual structures permit a parallel set oftransformations in the structure of children’s knowledgeacross different domains simultaneously. In other words,each domain has its own underlying set of transformationsin children’s executive control structures, but thesestructures show similarities between the differentdomains. They show similarities because thetransformation of these different sets of executivecontrol structures in each domain is dependent on the sizeof the child’s working memory. The nature and degree ofher/his experience, on the other hand, will account forindividual differences between domains. There is a limiton the efficiency of any operation, no matter in whatdomain, which is defined by the degree of maturation ofthe related neurological system and, to make use of46whatever degree of maturation has been obtained, the childshould have a certain degree of practice with anyoperation. Practice will have the effect of automatingthe particular operation.— If each domain has a different underlying centralconceptual structure then children trained in one task ina domain should show similar improvement on another taskwithin that same domain. McICeough’s study (1992b), whichused various tasks within the social—cognitive domain,supported this hypothesis. She trained an experimentalgroup to construct stories that were one developmentallevel higher than those they would tell spontaneously.These children were not only able to construct stories onedevelopmental level higher, but they also transferredtheir learned knowledge to other intentional tasks, suchas the mother’s role tasks developed by Goldberg-Reitman(1992) and empathy tasks designed by Bruchkowsky (1992).Some processes which draw the child’s attention tospecific factors and which might accelerate the child’sdevelopment such as shown in McKeough’s study, will alsoinvolve emotional factors. In order to understand thepossible influence of emotions on the development of thechild’s social—cognitive domain, Case et al.’s (1988)studies, which address the effect of emotional distress oncognitive development, will be described in the nextsection.47Neo-Piagetian Interpretation of the Correlation BetweenCognition and EmotionCase et al. (1988) examined the link between cognitiveand emotional development. They hypothesized that anychange in the emotional system would have a synchronous orsubsequent effect on the cognitive system and vice versa.To test this hypothesis, three exploratory studies weredone. The first study looked at the emotional responses ofchildren at different cognitive stages to a situation inwhich the mother of the child neglects him/her for anotherchild, either a younger sibling or a peer. The second studyexamined infants’ emotional responses to a brief separationfrom their mothers as they approach and then transfer into anew stage of cognitive development. The third study focusedon the cognitive development of children who were eitheremotionally disturbed or normal, and who either had or hadnot experienced the death of a loved one at an early age.Results of these studies suggest that children’s levelof cognitive development can have a strong influence ontheir emotional experience, but particular emotionalexperiences that children are confronted with, and thestructures they assemble for dealing with them can alsoexert a strong impact on their cognitive development. Theresults of the third study are particularly relevant to thecurrent research. Contrary to the psychoanalyticperspective (Deutsch, 1942; Faistein et al. 1957; A. Freud,481952/1977; Jackson, 1942; Jessner et al., 1952/1977) whichproposed a regression in hospitalized children’s perceptionsand Piagetian studies which supported the notion of apotential delay in development of children with chronicconditions (Perrin & Gerrity, 1981, 1984; Yoos, 1987), Caseet al. (1988) hypothesized that chronic internal conflictand anxiety should only lead to a very minimal regression inchildren’s normal rate of cognitive growth if the anxiety isgeneral, since the experience of anxiety decreases theamount of attention that is available for processing and/orshort—term storage space by a small but measurable amount.It is further suggested that a child’s cognitive developmentmay be accelerated within a specific domain when there issome type of crisis event that occurs within that domain.This is presumed because a child who experiences a traumaticevent within that domain will spend more time dealing andcoping with this specific situation than a child who is notforced to focus on that specific event. Whether a childaccelerates or decelerates depends on the amount of time achild spends concentrating on the problem which he/she faceswithin that domain. For example, Hurst’s (Case et al.,1988) study about children who experienced the loss of aloved one prior to age five showed an acceleration in theirunderstanding of death. Although the magnitude of thisacceleration was not large, approximately one—third substageat any age level, it still was statistically significant.49The subjects who showed this acceleration were normalchildren who had experienced a traumatic loss prior to thedimensional stage. This accelerated understanding wasretained up to seven years after the loss. Hurst proposedthat a child who loses a family member develops a copingmechanism which will reduce the child’s emotional distress.This mechanism does not prevent the child from thinkingabout the loss but instead enables him/her to direct his/herattention to the topic of death. Consequently, because ofthe fact that the child’s attention is focused on dealingwith the loss, this allows the child to overcome his/hergrief and prevent him/her from becoming preoccupied with thetopic of death (Case et al., 1988).Hurst’s (Case et al., 1988) study is relevant to thecurrent research because if emotions influence the rate of achild’s cognitive development in the way suggested, ahospitalized child might also demonstrate an acceleration ofunderstanding of the hospital nurse’s role because of theamount of time these children spend in coping with theirillness and hospitalization.Garmezy and Rutter (1983) emphasized two reasons forthe different effects that stressful events, such ashospitalization, might have on children. First, most socalled stress situations have a multidimensional nature.For example, acute events may be infinitely more disturbingthan are chronic conditions to which one has adapted.50Second, there appears to be individual variation inresponsiveness to environmental conditions considereddistressing. For example, Appley and Trumbull (1967) havedescribed the relationship between a child and environmentalfactors that can influence vulnerability in relation tostress as follows:It is consistently found that these reactions vary inintensity from person to person under exposure to thesame environmental event.... It has also been notedthat, with few exceptions, the kind of situation whicharouses a stress response in a particular individualmust be related to significant events in that person’slife. Many people have used the terms “ego—strength,”“stress—tolerance,” and “frustration—tolerance.” It isperhaps doubtful that there is such a thing as ageneral stress—tolerance in people. There is morelikely to be a greater or lesser insulation from theeffects of certain kinds of stress—producers ratherthan others.... It seems more likely that there arediffering thresholds, depending upon the kinds ofthreats that are encountered and that individuals mustbe differently vulnerable to different kinds ofstressors.... To know what conditions of theenvironment are likely to be effective for theparticular person, the motivational structure and priorhistory of the individual would have to be taken intoaccount. Where the particular motives are known —where it is known what a person holds important and notimportant, what kinds of goals have for him been likelyto increase anxiety or lead to aversive or defensivebehaviour— a reasonable prediction of stress pronenessmight be made. (pp. 10-11)Mabe, Treiber, and Riley (1991) examined school—agedchildren’s emotional distress, such as anxiety anddepression, during hospitalization. Their data suggest thathospitalized children experience no greater distress thannon—hospitalized children. The number of medical proceduresseems to have little effect on the child’s emotional state.Furthermore, their findings indicate that previous51hospitalization experiences have little relationship to thechild’s level of emotional distress. Many children in Mabeet al.’s (1991) study had experienced multiple painfulmedical procedures and frequent previous hospitalizations.Mabe et al. conclude that children who experience multiplehospitalizations might habituate and adjust successfully tomany hospitalization experiences.Consequently, it can be assumed that hospitalizedchildren with chronic conditions will cope with theirillness and hospitalization in a less anxious fashion thanchildren who have never been hospitalized before, becausethey have habituated to their chronic conditions and dealtwith their fears. A child with a long-term health conditionwill spend more time thinking about his/her hospitalizationwhich might contribute to a reduction of his/her negativefeelings (Case et al., 1988).In this study, the focus will be on the social-cognitive domain and the influence emotions may have on thedevelopment within it. This domain will provide a structurefor examining the understanding of the nurse’s role byhospitalized children with chronic conditions. The child’sunderstanding of the nurse’s role is believed to be part ofthe social—cognitive domain, because the child interactswith the nurse in a social manner and refers to thisinteraction with his/her perception of the role each of themis playing. Since Case’s theory of cognitive development52will be used for this study, a brief description of a studyof young girls’ conceptions of their mothers’ role that usedhis theory and was done in the social-cognitive domain willbe given. Goldberg-Reitman’s (1992) study provides thebasis for the tasks and analysis in this research. Herstudy is relevant to the child’s understanding of thehospital nurse’s role, because it gives an outline of ayoung girl’s social role perception at different age—levels.Children’s understanding of their mothers and the many rolestheir mothers play in their lives is different from theirunderstanding of the hospital nurse’s role in certain ways.For example, the closeness and bonding between mother andchild develop over a lifetime, while the bonding between achild and a nurse will be only temporary. On the otherhand, these two roles show some similarities, both have acaring, protecting, nurturing, and educative character(Brown & Ritchie, 1990).Neo-Piagetian Explanations of Social Role PerceptionGoldberg-Reitman (1992) looked at the different aspectsof young girls’ perception of the mother’s role by usingCase’s theory. She distinguished four particular roles forthis purpose, namely those that involved protection,physical care, nurturance, and teaching. The categorieswere taken from the literature in sociology, socialpsychology, and family theory (Ainsworth, Blehar, Waters, &Wall, 1978; Bowiby, 1982; Lewis & Starr, 1979; Wilson,531975).Goldberg-Reitman defines the categories behaviorally asfollows:- Protection is any active attempt to guard a child from anykind of potential life threat or dangerous situation.— Physical care is any act that carries out the child’sdaily physical needs (such as clothing and eating), orthat takes away potential physical discomfort (i.e., coldand hunger).— Nurturance is any attempt to give a child the emotionalsupport he/she needs when he or she is feeling upset orconfused.— Teaching is any active attempt to pass on knowledge, setboundaries for the child’s behaviour and actions, or givethe child some moral values of what is right or wrong.Goldberg—Reitman’s categories can be used to look atthe nurse’s role perception of hospitalized children withchronic conditions because the nurse’s role shows aremarkable parallel to the mother’s role. In a hospitalsituation the nurse may temporarily take over the mother’srole with the child and take the responsibility for his/herown actions (see Appendixes A and B). The nurse is theperson who has to comfort the child when he/she does notfeel well and/or has to explain to the child the purpose ofdifferent medical procedures. The nurse is the one whohelps families to achieve and maintain a balance between the54personal growth needs of the child and the optimumfunctioning of the family (Whaley & Wong, 1991; see AppendixA). Brown and Ritchie (1990) also did a study that supportsthe idea that the mother’s role functions parallel nurses’functions.Brown and Ritchie (1990) looked at how nurses perceiveroles of parents and nurses in caring for hospitalizedchildren. They stated that nurses see their role asoverlapping the parents’ role in such a way that bothprovide psychosocial care, nonmedical, medical, and generalcare for children, and guide children’s activities of dailyliving. Psychosocial care involves providing emotionalsupport, giving information, hugging, and building arelationship with the child. Nonmedical care involvesattending to activities of daily living, such as feeding anddressing and encouraging development. Medical care includesgiving medication or treatments, evaluating the child’sphysical state, and taking care of the changed activities ofdaily life (e.g., changing the child’s position by turningthe child in his/her bed). General care involves generalcare or activities related to either a child’s care or tobeing in the hospital, for example, taking part in care, ororganizing care or information. The role of being agatekeeper is only fulfilled by the nurse. This roleincludes supervising parents and children and being anadvocate by making sure a child receives an ideal level of55care.The roles described by nurses (Brown & Ritchie, 1990)show similarities with the four functions of the mother’srole as delineated by Goldberg-Reitman (1992) in that bothnurses and mothers provide care, nurturance, teaching, andprotection. Psychosocial care parallels Goldberg—Reitman’snurturance function. The role of nonmedical and medicalcare shows similarities with the care function. The role ofgatekeeper and advocate corresponds to the protectionfunction.Several studies (Brown & Ritchie 1990; Knox & Hayes,1983) conclude that nurses and parents should cooperate asmuch as possible in caring for the hospitalized child.Although these studies state that nurses feel responsiblefor the care of the hospitalized child, they recommendinvolvement of the parents to prevent them from feeling leftout of their child’s care. Furthermore, they consider itadvisable for the nurse not to take over the parents’ rolecompletely while the child is hospitalized but to involvethem in many daily activities and to share responsibilitywith the parents for their child’s care. Aigren (1985)supports the mother’s involvement in care for herhospitalized child and encourages communication between thenursing staff and the mother. The role in the plan of careof both nurse and mother should be discussed by the nursingstaff and the mother to avoid frustration on both sides56according to Algren.In Goldberg-Reitman’s (1992) study, children went froman initial focus on events at 4 years, to a focus at 6 yearsthat included some notice of the main character’s internalstate (e.g., a desire or goal), to a focus at the age of 10on two or more such internal states in a more integratedmanner. Though Goldberg-Reitman did not include 8-year-oldsin her study, she made an assumption by following Case’stheory that children this age should be able to consider tworather than one unit of those given by the six—year—olds.McKeough (1992a) refers to this integration as tyingtogether the “landscape of action” with the “landscape ofconsciousness.” Bruner (1986) introduced these two terms toexplain the causal relation between the external world ofphysical states or actions on one hand, and the internalworld of feelings and mental states on the other.Other studies that have been done within the social-cognitive domain are those of McKeough (l992a), Bruch]cowsky(1992), and Griffin (1992). McKeough looked in her twostudies at the development of children’s narratives. In herfirst study she examined children’s narratives from agesfour to ten to see if she could support the underlyingstructural progression hypothesized by Case. In her secondstudy she went further by testing three implications of theneo—Piagetian model of narrative, namely the effect ofexplicit cuing, manipulation of structural complexity and57effects of instruction, described in her first study.Bruchkowsky (1992) examined children’s development ofempathic cognition by presenting children with threevideotaped vignettes, one each depicting happy, sad, andangry situations. Griffin (1992) did research on youngchildren’s awareness of their inner world, in other words,children’s intrapersonal intelligence. She was especiallyinterested in the growth of children’s understanding ofintentionality.NcKeough (1992a), Griffin (1992), and Bruchkowsky(1992) report an underlying structural progression that fitsthe general characterization suggested by Case’s theory, andthat particularly appeared very similar to the structuresGoldberg-Reitman (1992) found in her study. For example,the particular narrative structures that McKeough found inthe children’s stories showed a substantial resemblance tothose that were described in the study of Goldberg-Reitman.At the age of 4, children tell stories that are still veryuncomplicated, involve a sequence of temporally and causallyrelated events, and are close to their everyday lifeexperience. At six, their stories start to evolve around aproblem. At the age of eight, they not only tell storiesthat center around a problem but they also include a seriesof further complications, often ones that make solution ofthe problem more complicated. Finally at the age of ten,children tell stories in which they integrate major and58minor problems to come up with a solution.Although the surface features of the tasks of GoldbergReitman, Griffin, Bruchkowsky, and McKeough’s studies seemquite different, all these studies have suggested the sameunderlying structure for solution of the tasks. Thiscentral social structure is one that determines a sequenceof social events (i.e., Bruner’s [1986] landscape ofaction), on the one hand, and the psychological intentionsthat motivate these events (i.e., Bruner’s landscape ofconsciousness), on the other (i.e. feelings, desires,opinions etc.), integrated into a single coherent entity.Another study in the neo-Piagetiari tradition thatfocused on social role acquisition was done by Fischer andPipp (1984). Their study gives support to the developmentalargument that changes in children’s role acquisition arerelated to age. They tested the nature of children’s socialrole acquisition at different ages by using doctor and nursedolls. According to Fischer and Pipp’s approach, called“skill theory,” two types of processes take place to explaindevelopment and learning, namely optimal level and skillacquisition. Optimal level determines the upper limit onthe complexity of skill that an individual can control. Fora child to function at that upper limit, the child’sperformance must be supported by environmental factors, suchas practice and instruction. Skill—acquisition processesdetermine how the skills are actually put together, in other59words, how a child moves from a simple skill in a givencontext to a more complex or general skill in that samecontext.Fischer and Pipp (1984) divide the acquisition of skillstructures into three major cycles subdivided into tenlevels. The levels are explained structurally, in terms ofthree behavioral sets or categories, namely sensorimotoractions (from approximately 3—4 months to 4 years),representations (from approximately 4 to 10 years), andabstractions (from approximately 10 to 26 years) and typesof relations between those sets.According to Fischer and Pipp, a social role involves arelation between a primary role, such as a doctor, and acomplementary role, such as patient. They divided, forexample, the acquisition of the social role within therepresentational stage (from approximately 4— to 10—yearsold) into five steps. Initially at step 1, a child is ableto pretend that a doctor or nurse doll examines a patientdoll, who responds appropriately. They call this levelrepresentational mappings. At step 2, a child is capable oftransferring a skill mastered in one task to another,similar task. This is only possible when all except one ofthe components in the second skill structure are similar tothe first structure and when the single different one can betransferred to the other task (i.e., a child pretends thata doctor doll examines a mother doll instead of a patient60doll, who then responds appropriately). This is calledsubstitution. At step 3, a child is capable of changingfrom one skill to the other within a single task orsituation by focusing on either one of them (i.e., a childpretends that a doctor doll examines a patient doll, whointeracts correctly; and then changes to a nurse dollinstead of a doctor doll who examines the patient doll, whoalso interacts the right way). This is called focusing. Atstep 4, called compounding, two skills at a given level arejoined together to develop a more complicated skill thatunites the components into one (i.e., a child may combinetwo role skills, doctor/patient and nurse/patient, todevelop a new more complex structure, doctor/nurse/patient).At the last step, called intercoordination, a child cancombine skills to transfer behaviour to a higher level. Forexample, a child assumes that a doctor doll examines apatient doll and concurrently acts as a father to thepatient, who is his son or daughter. The patient doll actscorrectly as both patient and father’s child.Fischer and Pipp (1984) looked at the doctor’s andnurse’s actions in general without creating certain problemsituations a child might face when hospitalized. This is areason for using Goldberg-Reitman’s (1992) four levels(nurturance, teaching, care and protection) to give a betterunderstanding of the child’s perception of the nurse indifferent situations and circumstances. Goldberg—Reitman’s61four categories of roles laid the groundwork for an analysisof children’s social representations of the hospital nurse’srole.Summary and ConclusionsThere is little research on the child’s perception ofthe hospital nurse’s role. Garbarino and Stott (1990)emphasized the important role the nurse plays for thehospitalized child. The nurse interacts with the child in acaring, nurturing, protecting, and teaching manner andher/his role shows many parallels with the mother’s role(Brown & Ritchie, 1990). Perrin and Perrin (1983)emphasized that a better understanding of the child’sdevelopment by medical personnel will improve the medicaltreatment of the child. A better understanding of theperception of the nurse by a child with a chronic conditionwill contribute to improvement of the nurse’s role.Therefore, the purpose of this study was to obtain abetter understanding of hospitalized children’s perceptionof the nurse’s role. According to Case et al. (1988), achild with intensive experience in a domain will show aslight acceleration in development in that domain. Sincethe child’s understanding of the nurse’s role is part of thesocial—cognitive domain, a comparison with another domain isnecessary in order to demonstrate a potential difference inthe child’s level of understanding across domains.Consequently, the balance beam task which examines the62child’s level of causal reasoning and is part of thequantitative domain (Case, 1992) was used to make such acomparison. Furthermore, McKeough (1992b) stated that if achild shows advancement in one task within a domain (e.g., ahospitalized child’s understanding of the nurse’s role),he/she should also demonstrate advancement in understandingin another task within that same domain. Therefore,Griffin’s (1992) measure of intrapersonal understanding wasused to compare hospitalized children’s understanding of thenurse’s role with their intentional state understanding.Thus, the following research questions directed theresearch.Research questionsFive research questions form the basis for the study.A. Do the mean level scores of Case’s stages of cognitivedevelopment coincide with the mean scores of childrenwith chronic conditions on their perception of thehospital nurse’s roles (i.e., care, protection,nurturance, and teaching)?B. Do the mean level scores of Case’s stages of cognitivedevelopment correspond with the mean scores of childrenwith chronic conditions on a causal reasoning task?C. Are the mean scores of children with chronic conditionson their perception of the hospital nurse’s rolesadvanced, as compared to their mean scores on causalreasoning?63D. Do the mean level scores of Case’s stages of cognitivedevelopment coincide with the mean scores of childrenwith chronic conditions on their intrapersonalunderstanding (i.e., happy, sad, good, and bad)?E. Does advanced understanding of the hospital nurse’s rolecorrespond to an advanced understanding on another taskwhich is social in nature? In other words, do the meanscores of children with chronic conditions on theirperception of the hospital nurse’s roles coincide withthe mean scores of their intrapersonal understanding?64CHAPTER IIIMETHODIntroduction and DesignA descriptive (exploratory), theory testing design wasused. To test Case’s (1992) theory, descriptive data werecollected by assessing children using three developmentaltasks. These data were supplemented with narrative datacollected through audio—taped recordings of interactionswith the children and type-written field notes. Aconvenience sample was selected of children aged 4 to 10,who were hospitalized at the time. Data were transcribedand coded according to specified criteria. From these, asubsample of children was selected to provide contextualdescription of the data.Analyses of variance and t—tests were performed to testthe following hypotheses.HypothesesA. The mean level scores on the Nurse’s Role Task obtainedby children with chronic conditions will coincide withthose predicted by Case (1992) such that the means of 4-,6—, 8—, and 10—year—olds will be significantly differentfrom each other.B. The mean level scores on the Balance Beam Task obtainedby children with chronic conditions will coincide with65those predicted by Case (1992) such that the means of 4-,6—, 8-, and 1O-year-olds will be significantly differentfrom each other.C. There will be a significant difference between theunderstanding of the hospital nurse’s role of a childwith a chronic condition and his/her causal reasoning asmeasured by the Nurse’s Role Task and the Balance BeamTask, respectively, such that the understanding of thenurse’s role of a child with a chronic condition will beadvanced compared to his/her level of causal reasoning.D. The mean level scores on the Task of IntrapersonalUnderstanding obtained by children with chronicconditions will coincide with those predicted by Case(1992) such that the means of 4—, 6—, 8—, and 10—year—olds will be significantly different from each other.E. There will be no significant difference between theintrapersonal understanding of a child with a chroniccondition and his/her understanding of the hospitalnurse’s role.SublectsThirty-five children with chronic conditions wereselected from several units of British Columbia’s Children’sHospital (see Table 2). A non-categorical approach tosubject selection was used (Stein & Jessop, 1989). Steinand Jessop’s (1989) data suggest that diagnostic labels do66Table 2Distribution of Chronic Conditionsin Each Age GroupDisease or Condition Age group4 6 8 10yrs. yrs. yrs. yrs.Cystic Fibrosis 1 3 2 3Asthma ... 1 2Congenital Heart Defect ... 1 ... 1Pancreatitis ... ... 1Prune Belly Syndrome ... ... 1Spina Bifida ... 1 1Guillain-Barre Syndrome ... ... ... 1Tumour (benign) ... ... ... 1Hypospadias ... ... ... 1Orthopaedic Conditions 1 ... 1 1Chronic Pyelonephritis ... ... 1Crohn’s Disease ... 1Liver Transplant (biliary 1 ... ... 1atresia) ... ...Nephrotic Syndrome 1 ...Seizures ... 1Ectodermal Dysplasia With ... 1 ...SteatorrhoeaOther (multiple chronic 1 1 1 1conditions)Total 5 10 10 10not tell very much about many areas of concern in the livesof children with chronic conditions and their families. Onthe one hand, the diagnosis is a fundamental and importantfactor in treating the physical and bio-medical aspects of achild’s condition, but on the other hand, the medical67diagnosis should not be seen as fundamentally important toresearch on social domains, because it does not providemuch information about the status and situation of the childand family, information which is particularly important inthe context of the care of children with chronic conditions(Stein & Jessop, 1989). This means that the diagnosticlabel was not the key variable in choosing the subjects forthe proposed study.Direct advantages in research on chronic illness thatcan be expected from a noncategorical approach, according toStein and Jessop (1989), are:— Local communities are more likely to have children with awide range of conditions, but only a small number ofchildren that will have the same type of illness. Byusing a noncategorical approach to study children withchronic conditions the development and evaluation ofservice programs designed to meet the needs of thesechildren with a spectrum of conditions may be enhanced.— By focusing on the differences between children unrelatedto their chronic illness rather than disease—specificdifferences between them, the implementation of healthcare services would be more beneficial.— Exclusive concentration on disease—specific issues, andneglect of the traits common in these children, makesgeneralization based on past experience to children withdifferent kinds of chronic conditions impossible.68- The ability to look collectively at many small groups ofchildren significantly increases the possibilities ofdoing health care delivery research and research onpsychological and social issues with population-basedsamples.Randomization was not used because of feasibility; itwould have been difficult to get enough subjects who fittedthe qualifying criteria from the numbers available in thetargeted age group and geographic locations.Criteria for qualifying children for the study were asfollows: The children had chronic conditions, had parentsconsented to their participation, and had to stay in thehospital for a minimum of 3 days. The children had to bebeyond their diagnostic phase, which is the phase in whichchildren enter the hospital, have many tests and healthhistory interviews, receive medical diagnosis and commencemedical treatments (e.g., medication, operation, and/ortests).There were ten subjects at each of three age levels: 6,8, and 10 years old and five subjects at the 4-year-oldlevel. The male/female ratios for the 4—, 6—, 8—, and 10—year—olds was 2:3, 4:1, 7:3, and 1:1, respectively. Thecut—off age for the 4—year—olds was 3 years, 11 months and 3weeks to 4 years, 11 months and 3 weeks. The cut—off agefor the 6—year—olds was 5 years, 11 months and 3 weeks to 6years, 11 months and 3 weeks; for the 8—year—olds, 7 years,6911 months and 3 weeks to 8 years, 11 months and 3 weeks; andfor the 10—year—olds, 9 years, 11 months and 3 weeks to 10years, 11 months and 3 weeks. Mean ages and standarddeviations for each age group sampled, in order fromyoungest to oldest age group, were respectively: 4 yearsand 5 months ( = 3.27 mos.), 6 years and 4 months (.S12 =3.68 mos.), 8 years and 5 months (SD = 3.63 mos.), and 10years and 4 months ( = 4.93 mos.) These ages representthe beginning and end of the interrelational and dimensionalstages, as defined in Case’s (1985) neo-Piagetian theory.The focus in this research was on the three substages of thedimensional stage and the progressive elaboration that takesplace within this stage from ages 6 to 8, and 8 to 10.Children were excluded from participation in the study iftheir life was threatened, if it was their first in-patientadmission, if they were emotionally disturbed as determinedby the nursing kardex or nurse or parent report and/or ifthey had a neurological deficit.For the contextual description of the data, a subsampleof participating children was selected. Children (one fromeach age level, i.e., one 4—year—old, one 6—year—old, one 8—year—old and one 10—year—old) were chosen if it appearedthat they were well qualified to explain their views of thenurse’s role and if they showed a moderate advancement intheir understanding of that role.70SettingBritish Columbia’s Children’s Hospital is a moderntertiary paediatric facility in Western Canada. Thehospital consists of four—bed, two—bed, and private roomsarranged in 18—21 bed units around a nurses’ station. Eachward has a daily schedule which includes activities such asbreakfast, schoolwork (i.e., either in the hospital’sschoolroom or at the child’s bedside), lunch, medical checkups, quiet resting time, play time organized by Child LifeWorkers, and dinner. Hospital policies allow 24—hourvisiting for parents and provide rooming-in facilities andguidelines. Several Parents’ Lounges are available whereparents can go to be quiet or to smoke.The research was done at the child’s bedside duringeither lunch or rest time. Parents were allowed to bepresent during the research if it made the child feel morecomfortable. They were asked to observe during taskadministration and to wait with possible comments orquestions until after the tasks were done.TasksUnderstanding of the Hospital Nurse’s Role.In order to examine children’s understanding ofGoldberg—Reitxnan’s (1992) four categories, a set of picturesand stories were developed that deal with the real-lifesocial interactions a child experiences in hospital (seeAppendix C). Two series of pictures and stories represented71each category. Each story involved a mini-episode in whicha nurse could interact with the child in one of four ways.Similar methods have been utilized by Goldberg-Reitman(1984, 1992), Selman and Byrne (1974), and Turiel (1983).Story structure was held constant with respect to formby using the story grammar principles delineated by Schankand Abelson (1977). Similar to their story grammar format,the scripts in the present study were created so as tocontain the following elements:1. Setting (context)2. Initiating EventJf3. Reaction of Main CharacterIn the present context, these elements were specifiedby stories such as the following:1. Setting: A little girl/boy is in the bathroom.2. Initiating Event: All of a sudden she/he doesn’t feel sowell and wants to go to her/his bed soon.3. Reaction of Main Character: The little girl/boy pressesthe button and cries for help.Each story component was illustrated with one pictureframe (see Appendix C). Each picture series contained ashort hospital scenario and was explained verbally to thechild as it was presented (see Table 3). A boy’s versionand a girl’s version were designed.72Table 3Verbal Descriptions of the Stories,Two for Each of the Four Functions of the Nurse’s Role1. A little girl/boy is in thebathroom.2. All of a sudden she/he doesntfeel so well and wants to go toher/his bed soon.3. The little boy/girl presses thebutton and cries for help.1. The little girl/boysIntravenous or I.V. bottles aregetting empty.2. Her/his machine starts to beep.3. The little boy/girl starts topanic and calls for help.Care1. The little girl/boy sits onher/his bed and eats her/hisdinner.2. She/he turns around and her/hisfood falls off her/his plateonto her/his bed.3. The little girl/boy says, “Ifeel yucky and gucky.”1. A little girl/boy lies in bedand wants to sleep.2. She/he feels cold and starts toshiver.3. The little girl/boy would likean extra blanket and cries outfor help.Nurturance Teaching1. The little girl/boy’s mum is atthe cafeteria.2. She/he discovers that she/helost her/his favourite teddybeer.3. The little girl/boy feels sadand starts to cry.1. The little girl/boy wants to goto sleep. Mummy is not heretonight.2. She/he would like to have ahug.3. The little girl/boy cries anddoesn’t know what to do.1. The little girl/boy will have aspecial test today and is notallowed to drink or eatanything.2. She/he feels hungry andthirsty.3. The little girl/boy says, “1would like to drink something.”1. The little boy/girl has a smalloperation today and has to weara hospital gown.2. The little boy/girl refuses,because he/she wants to wearhis/her own pyjarnas.3. He/she is angry and starts tocry.Subsequently, the children were asked how they thoughtthe little boy/girl in the story would feel, how theythought the nurse of the little girl/boy would respond, whyProtect ion73they thought the nurse would respond that way and what theythought the nurse was thinking and feeling.The different story formats were kept similar to thosedeveloped by Goldberg-Reitman (1984, 1992). Furthermore, agroup of people knowledgeable in both the neo-Piagetian andnursing field examined the story formats together with thepictures and agreed that each of them appeared to measurethe functions of the nurse’s role, as were discussed in theprevious chapter, in an adequate fashion.Bruchkowsky (1992) criticized the use of cartoonpictures for eliciting children’s cognitive and affectivecapacities on the grounds that they do not give childrenenough realistic or comprehensive cues on which to basetheir analysis and that the paradigm of cartoon picturesrelies too much on how children express their thoughts andfeelings verbally. In an effort to mitigate these problems,the pictures that were designed for this researchrepresented certain hospital situations which provided morerealistic and comprehensive cues. The images portrayed werecloser to reality than the cartoons used for Goldberg—Reitman’s (1992) study.The child was given several prompts in order to achievean optimal level of response and to prevent putting him/herat a disadvantage because of insufficient language skills.For example, “What do you mean by .... (idea mentioned by thechild)? Tell me more about.... (idea mentioned by the74child)?” To further address the issue of language skills, a“bare—bones” response was scored as evidence of achievingthe structure of the appropriate stage to allow the child toobtain a score at his/her optimal level (Griffin, 1992).For example, if the child gave a response that met thecriterion for a certain structure but was minimallyarticulated, the score of that structure level was given.Once the child had been selected for the study andrapport with the researcher had been established, he/she wasgiven the following introduction:I’m very interested in how 4 (6-, 8-, 10-) year-oldsthink about nurses and what they think nurses will dowhen children have a problem. So I’m going to show yousome pictures and then ask you some questions aboutthem. I would like you to tell me as much as you canabout the story in the pictures.After the child had been told the story by showing thepictures (see Appendix C), the following standard questions,adapted from Goldberg-Reitman’s (1992) questionnaire, wereasked in the order indicated:* How do you think the little girl/boy feels?* What does the nurse do? Why?* What is the nurse thinking? Why?* How does the nurse feel? Why?* What does the little girl/boy do then? Why?* What is the girl/boy thinking then? Why?* How does the little girl/boy feel then? Why?Each story had the same structure and was followed bythe same set of questions. The syntactic and semantic75complexity of the stories did not vary across the variousstories. Each interview was audiotape—recorded andtranscribed for analysis. Scoring criteria are described indetail in the next chapter.Balance BeamIn order to compare the cognitive level of the childacross different domains, a second task was given. TheBalance Beam Task was developed by Siegler (1976) and wasused by many researchers (Case, 1985; Furman, 1981, cited inCase, 1985; Marini, 1984, 1992) to measure the level ofdevelopment within the quantitative domain (see Table 1, p.39). The test instrument consists of a wooden balance scaleand 10 metal washers. The arm of the balance beam is 32 in.long, with four pins on each side of the fulcrum. The firstpin on each side is 3 in. from the fulcrum, with each nextpin 3 in. from the pin before it. Two wooden blocks wereplaced under the balance beam arms during presentation oftest items to prevent the arm from going up and down.The Balance Beam Tasks were designed to elicit thestrategies used in the interrelational and dimensionalsubstages. The tasks that focus on the thinking strategy ofthe first vectorial substage were also included to give thechild the opportunity to achieve as high a score as possibleand to prevent the occurrence of a ceiling effect with 10—year—olds. The balance beam task was given in a basal—ceiling fashion. The examiner stopped the task when a child76missed both trials at a level.To start with, the child was shown the up and downmovement of the balance beam when there were no supportspresent. Then the child was shown how a washer placed oneither side of the beam would make it to go down.Subsequently, the child was asked to try out the procedurehim/herself. The child was assured that all the washers hadthe same weight, and were made out of the same material.Furthermore, the child was told that the pegs had equaldistances between them.The following instructions were given:Let’s see what you know about the balance beam. I’llput the weights on the pegs in different ways and youtell me whether this side would go down or this sidewould go down or whether they would stay like they arenow if I took the wood blocks away. The balance beamwon’t actually move, but you tell me how the beam wouldgo if the pieces of wood were not there. (Siegler,1976, pp. 491—492)Test items were given by changing weights and distanceson the balance beam (see Appendixes D and E). Two trialswere presented at each level. Subjects started at Substageo and went on until they failed both trials of a level.Each prediction and justification was written down andaudiotaped by the researcher. Then the wooden support wastaken away so that the child could see the result.Scoring criteria are discussed in detail in the nextchapter. A random sample of responses (five protocols ofeach age group) were scored by an independent rater who didnot know the ages of the children in order to obtain77interrater agreement (i.e., an indicator of reliability).Intrapersonal UnderstandingIn order to demonstrate advancement in understanding intasks within, the same domain, hospitalized children’sunderstanding of the nurse’s role was compared with theirintentional state understanding, both are considered to bepart of the social domain (Case, 1992). Griffin’s (1992)measure of intrapersonal understanding was used. Thisinstrument was utilized by several researchers that examinedchildren’s intrapersonal intelligence (Griffin, 1992;McKeough, l992b; Porath, 1995). The measure examineschildren’s explanations for four internal states (i.e.,happy, sad, good, and bad) by asking the child a set of fourquestions regarding each internal state. For example, theset of four questions for the internal state “happy” are asfollows: “What does it mean to be happy? What else can itmean? What is happening when you are happy? When you arehappy doing (child’s example), where does thehappiness come from?” (see Appendix F). The 4—year—oldswere also given some facilitating props (e.g., a stuffedanimal, named Mimi, that helped the child to feel at ease).The following instructions were given to 4—year—olds:I. Happy“Mimi the dog doesn’t know very many words. You knowlots of words and you can help Mimi. Mimi needs toknow what ‘happy’ means. Can you tell Mimi what itmeans to be happy’ Can it mean anything else’What is happening when you are happy’ When you arehappy doing (child’s example), where does the78happiness come from?You taught Mimi a lot about the word ‘happy’. Mimisays, •‘Thank you. ‘“II. Sad“Now Mimi has another word she wants to know about.The word is ‘sad.’ Can you tell Mimi what it means tobe sad’ Can it mean anything else’ What ishappening when you are When you are sad doing—(child’s example), where does the sadness comefrom?You taught Mimi a lot about the word ‘sad.’ Mimi says,‘Thank you. ‘“The same procedures were used for “good” and “bad.”Older children (6—, 8-, and 1O-year-olds) were given thefollowing introduction to the task:I am interested in how kids think and how kids feelwhen they are 6 (8, 10) years old. You know, when youget to be grown-up, you think differently than you didwhen you were 6 (8, 10) years old. You are 6 (8, 10)and you can really help me by telling me exactly howyou think and feel when I ask you some questions.There are no right or wrong answers to these questions.The best answer is for you to tell me just what youthink and just what you feel.The answers to the questions were tape—recorded andtranscribed word for word. Responses to the first threequestions were pooled for scoring. These questions arereferred to as the “Meaning” Tasks (Griffin, 1992) becausethey ask for a meaning for being happy, sad, good, and bad.Scoring criteria are discussed in detail in the nextchapter. A random sample of responses (five protocols ofeach age group) were scored by an independent rater who didnot know the ages of the children in order to obtaininterrater agreement.79ProceduresThe hospital setting was used as the place for theresearch. Before the research began, the experimentalprocedures were found to be acceptable on ethical grounds byboth the Behavioural Sciences Screening Committee forResearch Involving Human Subjects of the University ofBritish Columbia and the In-Hospital Research ReviewCommittee of British Columbia’s Children’s Hospital.Furthermore, all physicians whose patients might be involvedin the research were informed of the study, with aninvitation to request more information or to raise concernsprior to commencement of all data collection (see AppendixG). Head/charge nurses’ cooperation and assistance both toorient staff and help identify participants were obtained,before the rest of the nurses were informed both verballyand in writing (see Appendix H) . No concerns were raised byphysicians or nurses and the examiner started the research.Designated units were visited by the researcher on aregular basis. Children who were qualified to participatein the study were identified by using the nursing kardex ornurse and/or parent report and appropriate consultation ofnursing staff. Parents of qualified children were thengiven a letter by the nurse in which the purpose of thestudy was discussed and in which they were asked whetherthey wished to be contacted by the researcher or not (seeAppendix I). If they agreed to be contacted, and contact80was made, a short introduction of the purpose of the studywas given to them verbally (see Appendix J). Consequently,the parents were asked if they were willing to participateand possible questions were discussed. Children were askedin person if they were willing to cooperate with the study(see Appendix K). After written parental or guardianconsent (see Appendix L) had been given, an individual notewas sent to each affected admitting physician to informhim/her of the participation of his/her patient (seeAppendix M). This procedure was continued until thirty-fiveparticipants had been recruited.Confidentiality of the data was guaranteed. No namesof children were recorded on data forms; only code numberswere used. Protocols were maintained in a location whichensured strict confidentiality and to which only theresearcher had access. A master list was set up whichincluded the name, gender, age, address, and birthdate ofthe child. The data forms with the codes on them referredto the codes on the masterlist. Individuals will not beidentified in publications.All tasks were completed by the children in theirhospital bed unit. Three sessions, approximately 30 minuteseach in duration, were arranged with not more than two daysbetween them. Before undertaking the research tasks, thechild was introduced to the tape-recorder by letting him/herrecord him/herself on the tape. Then the tape was rewound81in order for the child to listen to his/her own voice.After the child had understood the process of tape—recording, the machine was placed in front of him/her andthe administering of the tasks was started. In the firstsession the task of intrapersonal understanding was given(see Appendix F). A stuffed animal, named Mimi, was usedfor the younger children to make them feel more at ease. Inthe first or second session, depending on the child’s age,the balance beam task was given. A demonstration of thebalance beam was given before administering the test items.A bed table was placed in front of the child and the balancebeam placed on it. The experimenter sat at the child’sbedside. The procedures for administering the balance beamtask are described in Appendix E.The Nurse’s Role Task was administered at the secondand third session, and if necessary, the fourth session.The eight picture series were given to the child in one, twoor three sessions, depending on the child’s age. Goldberg—Reitman’s (1992) study showed that the younger childrenneeded two sessions due to the lengthy demands of thevarious tasks. The time between sessions was no longer thantwo days. Some four— and six—year—olds needed more than twosessions to complete the Nurse’s Role Task. This was due tothe distracting hospital environment and/or fatigue of thechild.For contextual illustration of the data, one child of82each age level was chosen for further questioning if itappeared on the spot that he/she was well qualified verballyto explain his/her views of the nurse’s role. For example,children who could express their thoughts in more detailinstead of giving a bare—bones response were eligible formore in depth questioning (e.g., Child: “The nurse willbring her/him an extra blanket or will turn up the heatbecause the child is shaking and feels cold and the nursecares.” Experimenter: “Tell me more about why you think thenurse cares”).Analysesquantitative analysisFive analyses were done. An alpha level of .05 wasused for all statistical tests. The five 4—year—olds wereexcluded from quantitative analysis because of the smallnumber of 4—year—olds examined in this research.Consequently, quantitative analyses were conducted for threeage groups (6—, 8—, and lO—year—olds) of ten subjects each( = 30). The first analysis focused on the developmentallevel of the child’s understanding of the nurse’s role asmeasured by the picture task. The answers given by thechild were coded according to their level of functioning.The scores were submitted to a one—way analysis of variance.This test compares groups which differ on one independentvariable (in this case age) with two or more levels (in thiscase three levels: 6—, 8—, and l0—year—olds). The dependent83variables were the child’s obtained level scores on eachnurse function as depicted by the 8 pictures of the Nurse’sRole Task. In this analysis the null hypothesis andalternative hypothesis were,Ho: the means of the 6—, 8—, and l0—year—olds coincide.Hi: the means of the 6-, 8-, and iO-year-olds differ.While performing the analysis, the relationship betweenthe variables was tested for changes in the slope to checkfor linearity. Subsequently, Newman—Keuls’ test wasconducted to make post hoc comparisons between means.The second set of analyses examined the developmentallevel of causal reasoning as measured by the balance beamtask. Children’s level—scores of the balance beam task weresubmitted to a one-way analysis of variance (ANOVA). Theone-way ANOVA compared the three groups, which differed onone independent variable (in this case age) with threelevels (6, 8—, and l0-year-olds). The dependent variablewas the child’s obtained level score of causal reasoning asmeasured by the balance beam. In this analysis the nullhypothesis and alternative hypothesis were,Ho: the means of the 6—, 8—, and lO—year—olds coincide.Hi: the means of the 6-, 8-, and 10-year-old differ.While performing the analysis, the relationship between thevariables was tested for changes in the slope to check forlinearity. Subsequently, Newman—Keuls’ test was conductedto make post hoc comparisons between means.84The third hypothesis was tested by comparing the scoresof the picture task with those of the balance beam task tosee if there were significant differences in the child’slevel of understanding by performing a -test for Case IIresearch. This test examines whether the observeddifference between two sample means arises by chance orrepresents a true difference between populations. The —test compared the mean scores of the Balance Beam Task andthe mean scores of the Nurse’s Role Task for each age groupto see if there was a significant difference betweenchildren’s levels of understanding. In this case of adirectional alternative hypothesis, the null hypothesis andalternative hypothesis were:Ho: the mean score of the 6—, 8—, and 10-year—old child’sunderstanding of the nurse’s role is equal respectivelyto his/her mean score of causal reasoning.Hi: the mean score of the 6-, 8—, and 10—year—old child’sunderstanding of the nurse’s role is higher,respectively, than his/her mean score of causalreasoning.Since a —test was performed for each age group, threecomparisons were made.The fourth analysis examined the level of the child’sintrapersonal knowledge as measured by the task ofintrapersonal understanding (Griffin, 1992). Children’slevel—scores were submitted to a one—way analysis of85variance. The one—way ANOVA compared the three groups,which differed on one independent variable (age) with threelevels (6-, 8-, and lO-year—olds). The dependent variablewas the child’s obtained level score of intrapersonalknowledge as measured by the Task of IntrapersonalUnderstanding. In this analysis the null hypothesis andalternative hypothesis were:Ho: the means of the 6—, 8—, and i0—year—olds coincide.Hi: the means of the 6-, 8-, and lO—year-olds differ.To check for linearity, the relationship between thevariables was tested for changes in the slope.Subsequently, Newman—Keuls’ test was carried out to makepost hoc comparisons between means.The fifth analysis compared the scores of the Nurse’sRole Task with those of the Intrapersonal Understanding Taskto examine if there were significant differences in thechild’s level of understanding by conducting a f-test forCase. II research.In this case of a nondirectional alternativehypothesis, the null hypothesis and alternative hypothesiswere:Ho: the mean score of the 6—, 8—, 10—year—old child’sunderstanding of the nurse’s role is equal,respectively, to his/her mean score of intrapersonalunderstanding.Hi: the mean score of the 6-, 8-, 10-year-old child’s86understanding of the nurse’s role differs, respectively,from his/her mean score of intrapersonal understanding.A —test was performed for each age group. Therefore, threecomparisons were made.Contextual illustration of the dataTo illustrate the results obtained throughquantitative analysis and to give the reader some backgroundinformation or sense of the conditions under which the datawere collected, a subsample of participating children wasselected. One child of each age level (i.e., one 4—year—old, one 6—year—old, one 8—year—old and one 10—year—old) waschosen if it appeared that they were well qualified toexplain their views of the nurse’s role and if they showed amoderate advancement in their understanding of her/his role.These children were asked to talk a little more about theirideas. With the tape recorder running, probes were givenand clarifications were sought, such as: “What do you meanby .... (idea mentioned by the child)? Tell me more about(idea mentioned by the child).” Narrative data,transcriptions and field notes including observations wereused in the data analysis. The researcher made the fieldnotes subsequent to visiting the child which describedhis/her specific characteristics such as appearance,behavior, physical condition, temperament, and personality.The examiner interpreted the contextual findings withCase’s (1992) theory of development in mind. The87predictions of his theory were also used to design validscoring criteria for interpreting the data. These criteriaare discussed in further detail in the next chapter.88CHAPTER IVSCORINGScoring criteria for the Nurse’s Role Task, the Task ofIntrapersonal Understanding and the Balance Beam Task werebased on predictions from Case’s (1992) theory ofdevelopment. Several Neo—Piagetian studies (Goldberg—Reitman, 1984, 1992; Griffin, 1992; McKeough & Martens,1994; Salter, 1993) along with one Piagetian study (Selman &Byrne, 1974) that examined the social-cognitive domain wereconsulted to describe the six level—scores for the Nurse’sRole Task and the Task of Intrapersonal Understanding inorder to obtain a complete outline of each level ofunderstanding. Marini’s (1984) criteria were used forscoring the Balance Beam Task. It should be noted that whenthe role of the nurse is discussed, it applies to the roleof the “hospital” nurse.The Nurse’s Role TaskFor clarity, the coding criteria are supplemented withexamples of responses given by the four age—groups for eachnurse’s function. If elements of the child’s answer to astory showed evidence of more advanced understanding of thehospital nurse’s role, it was scored at the more advancedlevel. The 4— and 6—year—old children seemed to havedifficulty in responding to the question about nurse’s89thoughts. Either no answer was given, or a confusionbetween nurse’s thoughts and feelings emerged such that thesame response was given for both, or the child claimedshe/he had already answered that question. Furthermore,contrary to Goldberg-Reitrnan’s study (1992) which onlyincluded the mother’s action(s) and the rationale behind heraction(s) when scoring the child’s answer, it was decided toinclude both the nurse’s and the little girl/boy’s action,feeling, and thinking with their rationale in the codingprocedure. In other words, the child’s total response toeach story was considered in assigning a level score. Thisallowed the child to receive an optimal score for his/hertotal answer to the story because in most cases evidence ofa higher level response was not found in the rationale forthe nurse’s action but in the rationale for nurse’s feelingand/or thinking and/or in the little boy/girl’s rationalefor his/her action, feeling, and/or thinking.All scoring was performed by the researcher. A secondrater, blind to all features of the study except the scoringprocedure, also rated to provide a measure of interraterreliability for the Nurse’s Role Task, the Balance BeamTask, and the Task of Intrapersonal Understanding. Theindependent rater had a university degree and experience ineducational settings. This rater was given the levelcharacteristics. He was asked to study these, and was givenpractice items. When it was clear that the evaluation90process was understood, the rater was given 15 randomlyselected protocols to score, 5 for each age group. Nomarkings for age, chronic condition, or level scores werewritten on them, nor were they presented in any particularorder. Completed stories could not be repeated. Interraterreliability was computed for each task.Level scores correspond with the predictions of Case’s(1992) theory of development. Level 1 corresponds to thethird substage of the interrelational stage. Levels 2, 3,and 4 represent, respectively, the first, second, and thirdsubstage of the dimensional stage. Levels 5 and 6correspond, respectively, to the first and second substagesof the vectorial stage (see also Figure 1, p. 41).Children’s answers were coded according to thefollowing guidelines adapted from Goldberg-Reitman’s (1984,1992), McKeough and Martens’ (1994), Salter’s (1993), andSelman and Byrne’s (1974) studies.Level 1 (4 yrs.): Roles of the Nurse as ScriptedActions.- Appropriate predictions can be made by the child about thenurse’s behaviour towards him/her. For example, the nursewill come to fill it (I.V. Bottles) up.— The child can explain his/her answers by referring tothe preceding situation in which he/she findshim/herself. For example, the nurse will come because thelittle girl/boy is crying.91— An appropriate knowledge of the nurse’s action isdemonstrated, and the rationale for such actionconcentrates on the little boy/girl’s particularaction or situation. For example, the nurse will helpher/him find the teddy bear because he/she lost it.— Both his/her predictions and explanations are stillvery basic, concentrating on only one aspect of thepredicted action of the nurse or one aspect of thesituation that caused it to happen.— Children understand how the four categories of a scriptedaction (a setting, an initiating event, a response, and anoutcome) proposed by Schank and Abelson (1977) are relatedto each other and intuitively are able to give answersthat include all four categories. For example, the littlegirl/boy is sad because he/she lost his/her favouriteteddy bear. The nurse comes to help the little girl/boyfind the teddy bear. Little girl/boy is happy because thenurse found the teddy bear.The subsequent tables (i.e., Tables 4 to 9) provideexamples of typical levels 1, 2, 3, 4, 5, and 6 responsesand can be interpreted as follows:- The initial feeling of the little boy/girl refers to thefirst question asked of the subject after showing him/herthe scenario (i.e., how do you think the little boy/girlwill feel?)— The left column shows the subject’s response to how he/she92thinks the nurse will act, feel, and think and,consequently, how he/she thinks the little boy/girl willact, feel, and think in the particular situation.- The right column shows the subject’s rationale behind thenurse’s actions, feelings, and thoughts. That is, theresearcher (R.) asks the subject the question:”Why willthe nurse do, feel, and think ... (example given bysubject)?” and “Why will the little boy/girl do, feel, andthink ... (example given by subject)?”- If the researcher asked the child for furtherinformation, this was put between brackets (e.g., R.Why?).— From Tables 5 to 9 (i.e., examples for typical levels 2,3, 4, 5, and 6 responses, respectively) distinctive levelcharacteristics were put in italics and/or were furtherexplained between brackets.Examples from the data for typical level one protocolsfor one situation for each of the four nurse’s functions areshown in Table 4. The ages and medical diagnoses ofsubjects are mentioned for each example.93Table 4Typical Level 1 ResponsesCategory: Care (4—year-old girl with cystic fibrosis).SITUATION: YUCKY AND GUCKY.Initial feeling of the little girl:- Wet.Nurse’s action/feeling! Nurse’s rationalethinking (Researcher FR]. Why?)Action:— Well clean.. . dry her bed. — because .. . change. . .her- She goes and puts the girl bed. . . change her bed.on the bed.Feeling:- Sad.- because she thinks thatthe girl is bad.Thinking:- Mad.- because she thinks thatthe girl is bad.Little girl’s action! Little girl’s rationalefeeling/thinking (R. Why?)Action:— Go to bed.— because she is punished.Feeling:— Sad and lonely. — because she doesn’t haveher mum.Thinking:- Bad.Category: Protection (6—year-old boy with a congenital heartdefect)SITUATION: I.V. BOTTLESInitial feeling of the little boy:- Sad because he thought that was going to hurt him.• . . because he never had it before.Nurse’s action/feeling/ Nurse’s rationale (R. Why?)thinkingAction:- Come and help him. Tell - because he is crying.94Table 4 (continued...)him to stop crying. “Oh,stop crying.”Feeling:— Probably sad.— because he is crying.Thinking:- Crying a little bit.Little boy’s action! Little boy’s rationalefeeling/thinking (R. Why?)Action:- Stop crying.- because the beeping cameoff.Feeling:- Probably happy.- because it’s not beepingany more.Thinking:- Happy.- because the beepingstopped.Category: Nurturance (4-year-old boy with nephroticsyndrome)SITUATION: Teddy bear.Initial feeling of the little boy:- I feel really bad.Nurse’s action/feelinq/ Nurse’s rationale (R. Why?)thinkingAction:- She will try to find the - because. . . because...muff i. because. .he lost his muff i.Feeling:— She doesn’t feel like— because. . . .becauseanything. she won’t.Thinking:- She will think if she- because. . .he doesn’t..finds it then she will give because he was. . because heit to the little boy. was looking for it.Little boy’s action! Little boy’s rationalefeeling/thinking (R. Why?)Action:- He will cuddle with it.- because he has his muff i95Table 4 (continued...)back.Feeling:— He feels happy.- because the muff i is goingto be there.Thinking:- He will feel very better. - because he found hismuff i.Category: Teaching (4-year-old boy with nephrotic syndrome)SITUATION: Hungry and thirsty.Initial feeling of the little boy:- SadNurse’s action/feeling! Nurse’s rationale (R. Why?)thinkingAction:- She will give him a drink - because he didn’t haveof water anything to drink. Oh,because he spilledsomething.Feeling:- He (=little boy) would - because he can’t havefeel sorry. anything to eat or drink.Thinking:— I don’t know.Little boy’s action! Little boy’s rationalefeeling/thinking (R. Why?)Action:— He will get into bed.— because he can’t haveanything to drink or eat.Feeling:— sad.— because he can’t haveanything to drink.Thinking:— I don’t know.96Level 2 (6 yrs.): Role of the Nurse as a MotivatedAction Sequence.— The child can coordinate two previously separatestructures: a structure for examining external eventsequences or scripts (A), and a structure forinterpreting the nurse’s intention or plan for asingle event (B).- If the child mentions that the nurse will performmore than one action, these actions are usuallycomponents of the same plan, not alternative plans.— The nurse’s immediate plans or intentions for thechild’s physical, emotional, and/or educational wellbeing are mentioned.- The nurse pays attention to the little girl/boy’simmediate observable needs that she/he believes the littlegirl/boy has. The nurse has plans for the littlegirl/boy’s immediate future (e.g., The nurse will help thelittle boy/girl go back to his/her bed so he/she doesn’tfeel sick any more)For example, a prototypic 6—year—old response for thecategory nurturance and the situation of the loss of thefavourite teddy bear might be: “The nurse will try to findthe teddy bear because she/he doesn’t want me to be sad.”Examples of typical level 2 responses for one situationin each nurse’s role category are tabled below (Table 5).The ages and medical diagnoses of the subjects are given.97Table 5Typical Level 2 ResponsesCategory: Care (6-year-old boy with cystic fibrosis)SITUATION: BLANKETInitial feeling of the little boy:- He should push his button like this. . .Like this. . .becausethe nurse will come. It beeps at the nurse’s station andthen he will say:”Can you give me another blanket, please, Iam cold?”Nurse’ s action/feeling!thinkingAction:— So he is in five (childexplains how a beeperworks). She knows where fiveis, there is a button andthere is a circle of fiveand then she knows which onebecause it is five.. .That’sfive and if you press thenfive lights up. . Then shewill go into five and helphim and he will say:”I wouldlike a blanket.” Then shewill go get him a blanketand then she will come backand she will say:”There areno blankets.” So then shewill get some shirts but hisshirt is in the washer soshe gets another one. Thenhe will get bare naked andshe puts some hot water onhim. . She puts him in thesink and puts hot water onhim.Feeling:- Happy.— because the blankets aregetting washed.— because it will make himwarmer (nurse0 immediateplans) .. . And he will put onhis pyjamas and then he willget more hotter.— because there are noblankets.— because after his hotshower and hot bath and thenhe will go to sleep, he willsay:”Oh, I feel warmer.” No,maybe he has a water bedwhich is hot. . .more warmer.Nurse’s rationale (R. Why?)— because he needs ablanket.98Table 5 (continued...)Thinking:- She thinks about “Blacky.”- because that is his teddybear.Little boy’s action! Little boy’s rationalefeeling/thinking (R. Why?)Action:— He is going to sleep.- because he is tired.Feeling:- Happy. He will put a whole- because that will make himbunch of juices. . a whole happy.bunch of teddy bears, wholebunch of goodies. .wholebunch of drinks and a wholebunch of chocolate milks.Thinking:- He will be happy.- because he got a lot oftoys, a lot of goodies, alot of candies.Category: Protection (6-year-old boy with a congenital heartdefect)SITUATION: I.V. BOTTLES.Initial feeling of the little boy:- SadNurse’s action/feeling! Nurse’s rationale (R. Why?)thinkingAction:- She will fill it up.- to stop making it beep(nurse’s immediate plan).Feeling:- Happy- because she filled it upfor him to make it stopbeeping.Thinking:- She thinks that it came- because that’s why he isout crying.Little boy’s action! Little boy’s rationalefeeling/thinking (R. Why?)Action:99Table 5 (continued...)- He will stop crying. - because she made it stopbeeping.Feeling:— Good.— I don’t know.Thinking:- Put a bandaid on. - because it is still in.(R. Why does he think it isstill in?) I can’t say anymore. I don’t want to sayit any more. (R. Why does hethink that?) Because shedidn’t put a bandaid on.Category: Nurturance (6—year-old boy with asthma)SITUATION: HUG.Initial feeling of the little boy:— Sad because his mom is not there.Nurse’s action/feeling! Nurse’s rationale (R. Why?)thinkingAction:- Call the mummy up and - So the little boy will besay:”Come over to the happy (nurse’s immediatehospital.” plan).Feeling:— She feels sad.— because the boy is upset.Thinking:- She will not think- because not....anything.Little boy’s action! Little boy’s rationalefeeling/thinking (R. Why?)Action:— Feel a little bit happier. - that his mom is coming tothe hospital.Feeling:— Happy.— because he wants a hug.100Table 5 (continued...)Thinking:- He is thinking of her- because he got a hug.hugging him (the mom).Category: Teaching (6-year-old boy with cystic fibrosis)SITUATION: HOSPITAL GOWN.Initial feeling of the little boy:— Not very good because he doesn’t want to wear it. If heis not gonna wear it, she (the nurse) is mad.Nurse’s action/feeling! Nurse’s rationale (R. Why?)thinkingAction:— She makes him put it on.— Because she wants to warmhim up (nurse’s intention).Feeling:— She doesn’t feel very— because she is mad. (R.good. Why is she mad?) Because hedoesn’t want to put it on.Thinking:- I don’t know what she willthink.Little boy’s action! Little boy’s rationale (R.feeling/thinking Why?)Action:— He will go and run around.— to get real hot.Feeling:— Not very good.— because he doesn’t likeit.Thinking:— I don’t know.101Level 3: Roles of the Nurse as Planned ActionSequences.— Children understand that nurses may have more than oneintention and that they may also choose among more thanone possible action sequence to deal with the situationbut their responses for the nurse’s rationale are stillvery closely related to her/his actual behaviour.— Children usually introduce a second focus in the nurse’sactions and/or intentions.For example, a prototypic level three response for thecategory teaching and the situation of the small operationmight be: “The nurse will let me wear a hospital gown andwill say you have to wear it because it is clean and iseasier to take off.”Typical level three responses given by subjects arelisted in Table 6. The ages and diagnoses of the childrenare again noted.102Table 6Typical Level 3 ResponsesCategory: Care (8-year-old boy with cystic fibrosis)SITUATION: BLANKET.Initial feeling of the little boy:- Cold.Nurse’ s action/feeling!thinkingAction:- Probably get him anotherblanket (Action 1) and turnUP the heat (42).Feeling:- Sad.Thinking:- She thinks that he wantsanother blanket.Nurse’s rationale (R. Why?)— Because she doesn’t wantthe boy to be too cold(first intention of thenurse)— because he is cold andthat makes her sad.— because he is shiveringand she doesn’t like to seethat (second intention ofthe nurse).Little boy’s action!feeling/thinkingAction:- He will lay down in hisbed and go back to sleep.Feeling:- Happy.Thinking:- She is nice.Little boy’s rationale(R. Why?)— because he is tired andhas his blanket.— because the nurse helpedhim out.— because she gives himanother blanket.Category: Protection (8-year-old boy with asthma)SITUATION: BATHROOMInitial feeling of the little boy:- The boy feels bad.103Table 6 (continued...)Nurse’s action/feeling! Nurse’s rationale (R. Why?)thinkingAction:— She will give him medicine— Because she wants him tofor the pain in his belly feel better (first intention(Al) and give him a hug of the nurse).(A2).Feeling:— Really really bad. — because she wishes itdidn’t happen (secondintention).Thinking:— I don’t know.Little boy’s action! Little boy’s rationalefeeling/thinking (R. Why?)Action:— He will go to his bed — because he wants to resthis stomach.Feeling:— He will feel a lot more — because the nurse gave himbetter. medicine.Thinking:— He thinks that the nurse— because she gave him theis nice. medicine.Category: Nurturance (8-year-old girl with pancreatitis)SITUATION: TEDDY BEARInitial feeling of the little girl:- The girl feels upset because she can’t find her teddybear.Nurse’s action/feeling! Nurse’s rationale (R. Why?)thinkingAction:- She will help her find her- So she won’t be upsetteddy bear and look for it. (immediate plan of nurse toimprove child’s situation).Feeling:— Oh she feels sad also.— because she doesn’t likethe girl to be sad (firstintention).104Table 6 (continued...)Little girl’s action!feeling/thinkingAction:- She will start to calmdown.Thinking:- She thinks that this nurseis nice. She is helping mefind my teddy.Little girl’s rationale(R. Why?)— because she sees that they(the nurses) will find theteddy bear.— because someone wants tohelp her find her teddybear.— I don’t know.Category: Teaching (8-year-old girl with chronicpyelonephritis)SITUATION: HOSPITAL GOWNInitial feeling of the little girl:- The girl feels like she doesn’t want to do anything.Nurse’s action/feeling/thinkingAction:- The nurse will say thatshe has to do it.. .that shehas to wear it.Feeling:- She is mad.Thinking:— She will get really reallymad but she just doesn’tNurse’s rationale (R. Why?)— because it is easier tooperate because you can justlift it if you are doing iton the stomach and it mightget bloody when theyoperate.— because the girl won’t dowhat she wants her to do(first intention of thenurse)— because she wants to sortof like to cairn her down andThinking:- She thinks:”Poor girl, shelost her teddy bear, Ibetter help her.”— because she wants to helpher (second intention)Feeling:- She feels better.105Table 6 (continued...)want to show it.Little girl’s action!feelincr,f thinkingAction:- She might start kickingthe nurse.Feeling:— She will like scared. .No,she is already scared. Shewill feel.. . .Yeh, she willbe scared.Thinking:- She will think that shehas to do it but she stilldoesn’t want to.help her without getting toomad at her (B2 : secondintention).Little girl’s rationale(R. Why?)— because she doesn’t wantto do it.— because she doesn’t wantto get caught. (R. Why not?)because she doesn’t want to.- because she is stillscared. (R. For what?) Sheis scared for the surgery.106Level 4 (10 yrs.): Roles of the Nurse as GeneralizedDispositions Toward Action.— The child can conceive of several ways in which thenurse might react.- The child can identify some more abstract qualitiesof the nurse. The child’s description of the nurse as aperson has a more psychological focus (e.g., the nursehelps children out because she is a nice person and shewants to help).— The child can also identify and refer to a moreabstract set of goals that will lead the nurse to choose aspecific abtion sequence (e.g., caring, nurturing, loving,feeling sorry for). In other words, the nurse’s actionsare sometimes associated with the expression of internalstates such as loving and caring.- The child’s response shows flexibility through theuse of terms such as “perhaps,” “probably,” “maybe,”“possibly.” If such flexibility is not shown in thisparticular manner, the two or more distinct actions thatthe nurse might perform are presented in an “either/or”format. Even though 6—year—old children sometimes usewords like “maybe” or “probably,” their applicationusually refers to guessing what the nurse might, do, feelor think (e.g., the nurse probably feels angry).— The prototypic 10-year—old child includes in his/heranswer that the action of the nurse in any one situation107can be described as emerging from a series of potentialactions and the nurse’s rationale for her/his actions willhave either underlying plans for the little girl/boy’sfuture or the nurse’s rationale will show an intention onestep further removed from her immediate goals (e.g., thenurse will give the little boy/girl a blanket because shedoesn’t want the girl to get a cold so they can’t doher/his surgery).- Overall, the child can integrate multiple unitsidentified at level three in some fashion.For example, a prototypic level four response for thecategory care and the situation of the blanket might be:“The nurse will bring her/him an extra blanket or will turnup the heat because the child is shaking and feels cold andthe nurse cares.”Typical level four responses given by subjects ofvarious ages for one situation in each of the fourcategories are listed in Table 7.108Table 7Typical Level 4 ResponsesCategory: Care (8—year-old boy with cystic fibrosis)SITUATION: YUCKY AND GUCKYInitial feeling of the little boy:— Sad because his bed is all messy.Nurse’s action/feeling! Nurse’s rationale (R. Why?)thinkingAction:— She will probably clean— Because she probably careshis blankets and get him new for him and doesn’t want himones. to be dirty.Feeling:— She feels sad.— because he doesn’tbecause he probably willnot help her.Thinking:- She thinks that he is sad. - because his dinner isspilled.Little boy’s action/ Little boy’s rationalefeeling/thinking (R. Why?)Action:— Say:”Thank you.”— because the nurse is niceto help him.Feeling:— Then he will feel happy. — because the nurse cleanedit up for him.Thinking:- He thinks that she is- because she cleaned up thenice, mess.Category: Protection (10-year-old girl with a livertransplant)SITUATION: BATHROOMInitial feeling of the little girl:— Scared. (R. Why?) That the nurse won’t come and she has tothrow up everywhere.109Table 7 (continued...)Nurse’s action/feeling!thinkingAction:- She will probably help heror something and then takeher out and lay her down onher bed orsomething.. .Probably shewill.. .1 don’t knowFeeling:- It will make her probablyfeel better. It will makeher feel really good. Itwill probably make the nursefeel better and the girl.Thinking:— I don’t knowNurse’s rationale (R. Why?’)— Because the girl is cryingand she (the nurse) wants tohelp because she cares andthe girl doesn’t feel sowell.— because it makes her feelbetter for the girl becauseshe is not in so much painand it makes her feel betterfor the nurse because thenthe nurse doesn’t have tolook at the girl crying.Little girl’s action!feeling/thinkingAction:- She will probably just liedown or something.Feeling:- The little girl probablyfeels better.Thinking:- Probably the little girlis thinking about thankingthe nurse.Little girl’s rationale(R. Why?)— so she can rest.- because she got helpedthat’s what she wanted.- because probably thelittle girl feels betterthat the nurse helped her.Category: Nurturance. (10-year-old boy with a benign tumor)SITUATION: HUGInitial feeling of the little boy:- Awful. .. .probably sad that he misses his mum.110Table 7 (continued...)Nurse’ s action/feeling!thinkingAction:- She probably tells him togo to sleep and just, youknow, calm down, your mumwill be there in themorning.Feeling:- She probably feelslike:”Oh come on, notagain.”Thinking:- Okay, okay. I don’t know.Maybe she’ll think:”Well,don’t be so sad.”Little boy’s action!feeling/thinkingAction:- Maybe cries his littlehead out.Feeling:- Maybe tired.Thinking:- He probably thinks:”Uh, Iwish my mum was here.”Nurse’s rationale (R. Why?)— So that she doesn’t haveto give the kid a hug (R.Why not?). Oh she might, Idon’t know. Maybe she does,maybe she doesn’t. Maybe shedoesn’t want to hug him.Maybe because the kid hasbeen jumping around, goingaround in the dirt.— because every situationhere he is calling the nurseand things.— because she doesn’t liketo be bugged by kids ahundred times a day.Little boy’s rationale(R. Why?)— because he doesn’t havelike.. . let’s see here.. .hedoesn’t have his mum therebut doesn’t want to have ahug.- because it is night time.You are supposed to betired.—Yeh, you know, maybe hemisses her, maybe she wasn’tthere with him that day.Category: Teaching (8-year-old girl with multiple chronicconditions)SITUATION: HOSPITAL GOWNillTable 7 (continued...)Initial feeling of the little girl:- She feels sad and angry.Nurse ‘ s action/feeling!thinkingAction:— The nurse will say: “Youhave to wear it or else youwon’t get better because youneed the operation and youneed to wear this gown forit.”Feeling:- She will feel sad.Thinking:- Sorry for her. . . but shewill think that the littlegirl might not want to wearit.Nurse’s rationale (R. Why?)— Because if she wants herown pyjamas because herpyjamas don’t open at theback then they can’t.. .thenshe . .then they wouldn’t beable to do the operation onher. So they can’t do theoperation. (R. Why not?)Because her own pyjamasdon’t open anywhere. Theycan take them off but Idon’t think she wants to benaked though. (R. Why elsedoes the nurse say that?)Because she is in thehospital.— because she feels sorryfor the little girl that shehas to and she has to wearone of the hospital gownsand she doesn’t really wantto.- Because the little girldoesn’t like the hospitalgowns because she likes herown pyjamas because they arewarm and cosy.Little girl’s action!feeling/thinkingAction:- She will start crying asloud as she can.Little girl’s rationale(R. Why?)— because she doesn’t wantto wear them. . she doesn’tlike them.. . because it opensat the back and hers doesn’tand it might show herunderpants and she might notlike that either.112Table 7 (continued...)Feeling:— She will feel angry at thenurse.Thinking:- The girl thinks that shedoesn’t have to wear thehospital pyjamas because...— because she hates thehospital pyjamas, shedoesn’t like to put them onbecause. . .uhum.. they aretoo loose.— because her pyjamas arestill pyjamas and thehospital’s are pyjamas toobecause they are bothpyjamas.113Level 5 (12 yrs.): Roles of the Nurse as DemonstratingLogically Planned Decisions towards Action.— Children’s responses show evidence of not only“intentional reasoning” but also “interpretivereasoning” (McKeough & Martens, 1994) (i.e., the nurse’saction is explained in terms of personal historyand/or long-standing psychological traits). Whereas 10-year—old responses are more intentional in nature(i.e., the nurse’s action is accounted for on the basisof mental states that encourage it, such as feelings,motives, desires or judgements), 12—year—old responsesshow evidence of being able to describe the nurse’s orlittle girl/boy’s action in a way that goes beyond theimmediate situation and to consider longer—termpsychological factors such as past experiences that mighthave influenced the nurse’s life and shaped her/hiscurrent behaviour.— Children not only realize that the nurse has achoice of more than one action for any one nurse’sfunction, but they also have a clear idea of how thenurse decides to react towards the child. Morespecifically, children at this level see both the nurseand the little girl/boy as being of a certain “type”determined by their own history, previous experiences,mood, knowledge, and so forth. The nurse’s type respondsto the little girl/boy’s type and this guides the nurse’s114actions. The nurse is seen as an abstractor ofevaluations of the little girl/boy’s past, internal state,and future.- The child is also able to describe the nurse’s personalityin terms of the more enduring state or the type of personshe/he is due to influences and events (e.g., the nursedoes that for the kid because she is nice and that is thekind of person she is).— The child can express empathy or awareness of howcertain behaviour would have an impact on her/himself and,consequently, how this behaviour might also have the sameimpact on others (e.g., I feel scared when the nurse givesme a needle so the little girl probably feels scared too).This is called “self/other conscious projection” (McKeough& Martens, 1994); the child can project how his/her ownfeelings might be felt by others, in this case the nurseand the little boy/girl in the story. They can relateboth the nurse’s and the little girl/boy’s actions,feelings, and thinking to their own life experiences.— The nurse reacts because it is her/his patient, whomshe/he cares for and who needs or wants something. Thepossessive relationship between the nurse and her/hispatient is a causal factor at this level (e.g., the nursefeels that the little girl/boy is her/his responsibilityor it is her/his duty to help the little girl/boy).— The child’s response may show evidence of115metacognitive thinking (e.g, the nurse thinks that thelittle girl might think that the operation might hurt).The child is able to take a metaposition to thefeeling/thinking/action of the nurse (e.g., it wouldbother her conscience if she/he did not help the littlegirl/boy.)- The child can go beyond the two-person situation and lookat it from a third-person perspective. The child takesthe role of the spectator.For example,. a prototypic 12—year—old response for thecategory care and the situation of the blanket might be:“The nurse will bring the little boy/girl an extra blanketbecause she knows out of her own experiences how cold it canbe in a hospital and she doesn’t want her patient to getmore sick because the child is her responsibility.”Even though l2-year-olds were not included in thisstudy, several younger subjects showed advancedunderstanding of the Nurse’s Role which made it necessary toincorporate this level. Examples from typical level 5protocols for one situation in each of the four nurse’sfunctions are given in Table 8. The ages and medicaldiagnoses of the subjects are presented for each example.116Table 8Typical Level 5 ResponsesCategory: Care (10-year-old boy with hypospadias)SITUATION: YUCKY AND GUCKYInitial feeling of the little boy:- He feels like he wants to take a bath. He feels like. .hethinks he is in trouble because he spilled his food and thenhe thinks oh.. . oh... I am in pain and I have to get out ofthe bed so they can change my bed and I don’t have any morefood to eat. But he doesn’t need to worry about thatbecause the hospital is going to bring him food. So that’swhy.Nurse’s action/feeling!thinkingAction:— Well, she will tell himthat it’s okay.. you don’tneed to get out of bed. . youjust stay there. .we willjust take the front sheetoff and we will fixeverything.Feeling:— Then she will feellike.. .well I don’t knowwhat she will feel like butI will take a guess and shewould feel sort of . . shewill feel like giving a paton the back.Thinking:— Well she thinks that thekid is not going to cryagain. .because he knows it’sokay (metacognitivethinking) and she thinksabout what she should getfor the kid to eat.. .And shethinks. .should she ask himor should she just go andget him something to eat.And she thinks again if sheshould first get the food orfirst change the sheets.Nurse’s rationale (R. Why?)- So the kid won’t be hungryany more and he’ll be. .hewon’t need to worry aboutthe mess he made. He won’thave to be scared that he isin trouble.— So he doesn’t have toworry any more. Nothing iswrong and so the boy won’tcry or anything or be sad.— So she knows what to do.She doesn’t get mixed up.117Table 8 (continued...)Little boy’s action? Little boy’s rationalefeeling/thinking (R. Why?)Action:- The boy will help the - So he doesn’t spill itnurse take the sheet off and again.when the food comes he willget in his new bed and thistime he’ll eat careful.Feeling:— Well then he will feel — because he doesn’t need tomore careful. And then he worry about anything.will feel good that hespilled it.. that it is nothis fault and then he willfeel okay. He doesn’t needto worry about anything.Thinking:- he will think. . he gets a - because the other kidssecond meal for free. always get one meal and hegets to get two mealsbecause he spilled it and heate half of his first mealand spilled the rest. .so hegets a whole meal and ahalf. Yeh and he tries toshow off . . .like... I getmore food than youguys.. .ha. . .ha. . .Yeh heshows off with his partner(child takes role ofspectator).Category: Protection (8-year-old girl with multiple chronicconditions)SITUATION: I.V. BOTTLESInitial feeling of the little girl:- She might think that the machine. . that she might begetting really sick and that she might start to go.. . likeshe might start to die because the machine is beeping andshe might think that the machine is getting her really sick.118Table 8 (continued...)Nurse’ s action/feeling!thinkingAction:— The nurse does. . the nursefixes it. . and then shegoes:”It’s airight, nothingis going to happen.” Shepresses the buttons. (R.What else will she do?) Wellshe talks to the girl andshe says:”It’s airightbecause it is just themachine because the bags aregetting empty.”Feeling:— I don’t know.Thinking:- She thinks that the girlmight be thinking that. .wellshe might have to get a newneedle. . a new needle orsomething. She might get itin her hand or her armbecause my hands are free.Little girl’s action!feeling/thinkingAction:- She stops crying and willcalm down.Feeling:— She feels weirdNurse’s rationale (R. Why?)— because the buttons stopit from beeping.- because the girl is reallycrying loud and she ispanicking. The nurse mightthink that she is thinkingthat she needs a new needle(metacognitive thinking).Little girl’s rationale(R. Why?)— because the nurse istrying to calm her downbecause nothing is going tohappen. She won’t need a newneedle or anything.— because she feels weirdafter she was panickingbecause now she knows thatshe was. . .1 can’t reallyconcentrate (little childrenare crying in her room)because now she knows thatshe doesn’t have to panicand she felt weird becauseshe was yelling and cryingand stuff.119Table B (continued...)Thinking:- She thinks that it is o.k.and it is just because ofthe bottle.- She thinks that...because. . .because.. I don’tknow why.Category: Nurturance (10-year-old boy with Guillain-BarreSyndrome)SITUATION: Teddy bearInitial feeling of the little boy:- Terrible probably terrible. He would probablythink:”Where is my teddy?”Nurse’s action/feeling!thinkingAction:- She would probably lookaround the room. Or reportit. You know, the hospitalwill probably put it on theannouncement or something.It would say:”Have you seenthis teddy?”Feeling:— Stressed out.Thinking:- Probably. . . probably.. youknow she would say:”Okay, Imight as well ask anothernurse to do it.”Little boy’s action!feeling/thinkingAction:- He will probably just sitthere and worry.Nurse’s rationale (R. Why?)- Maybe she feels reallynice and she . . . maybebecause that’s her job.— because she has to searchall over the hospital forthis little teddy that isabout the size of that(points at his own teddy).— because you wouldn’t wantto do this (relating toone’s own situation) . Gothrough the whole hospitalthrough everywhere to findthis teddy bear.Little boy’s rationale(R. Why?)— because he knows he is notallowed to go around thehospital.120Table 8 (continued...)Feeling:- He will probablybe. . .probably he will feelreally like. . . reallynervous.Thinking:- He will probablythink. . . he will probablyfeel that the nurse ispretty nice.- She might find it or shemight not.— because she is going allaround the hospital to findthis teddy for him.Category: Teaching (10-year-old girl with cystic fibrosis)SITUATION: Hospital gown.Initial feeling of the little girl:— Oh disgusted because she doesn’t want to wear it and sheis mad and angry and probably she is already feeling sorryfor herself because she has to be in the hospital anyway.Nurse’ s action/feeling!thinkingAction:- She will probably say:”Youwill have to, you have tohave this surgery, you knowthat you have to have theoperation and you know youhave to wear it.. .thedoctors want you to (thirdperson involved in thestory)Feeling:- Oh kind of a bit angrywith her.Thinking:- She will probablythink:”Oh, this girl is alittle stubborn. But I mean,Nurse’s rationale (R. Why?)- Because it is lighter andit isn’t such as heavymaterial so it’s easier towork with. And I don’t meannot with.. .uhum like it’seasier to listen throughwith a stethoscope and thattype of stuff....- Because lots of the kidsjust go into it (comparisonwith other kids). Andprobably trying to help herand she will probably try tohelp her and soothe her intoit, right? And say: “It’so.k., it’s not gonna bite oranything, right?”— Because it is embarrassingto wear a gown like that.121Table 8 (continued...)huh, I don’t blame her. Ihave had to go into that oneand you can see your behindand every thing.” So she isthinking that in her head(refers to past experienceof the nurse)Little girl’s Little girl’s rationaleaction/feeling/thinking (R. Why?)Action:- She might get into it or - Uhum, because I wouldn’tshe might still refuse. know what to do... (refers toher own situation)Feeling:- Probably different- Like.. . the nurse cares forher. Probably she sees thatthe nurse kind of cares forher and that.. .and it’s onlyfor her own good. . . sherealizes that (metacognitivethinking) and then sheprobably gets into it.Thinking:- Well maybe she is right- Because that’s... it’s alot easier with that... andthat’s what the doctorwants, right?.. .and it’s formy own good.122Level 6 (14 yrs.): Roles of the Nurse as DemonstratingLogically Planned Action Sequences.- The child is not only able to interpret both the nurse’sand little girl/boy’s actions, feelings and thinking butalso can express alternate possibilities for his/herinterpretation. This level shows similarities with level3 in the sense that, at level 3, the child can give morethan one intention for the nurse’s and little boy/girl’sbehaviour whereas at level 6 the child can express morethan one interpretation for the nurse’s behaviour andlittle boy/girl’s behaviour.— The child can not only relate the nurse’s and/or littlegirl/boy’s behaviour, feeling and/or thinking to their ownlife experience but he/she also recognizes anotherpossible context. In other words, the child includes notonly him/herself in interpreting the situation the littlegirl/boy and nurse are in but also generalizes his/her ownaction, feeling and thinking to other people. The childincludes a fourth and/or fifth person in the story(besides the nurse, the little girl/boy and him/herself).For example, “The nurse might not want to see the littleboy/girl in pain because I wouldn’t like to see anotherperson suffer. Like when I am in pain, both my mother andmy father were very sad. My mother cried a lot and my daddidn’t know what to do.”— The child is able to give an alternate interpretation123and/or a second focus to an abstract notion. For example,the nurse feels responsible (abstract notion) for thelittle girl/boy because it is not only her patient sheneeds to take care of but she also wants the child to getbetter.— Overall, the child can express multiple perspectives!dimensions to the interpretation.Despite the fact that 14-year-olds were not included inthis study, it was noticed that some younger subjects gaveanswers at this level. Examples of their answers and theiractual ages and medical diagnoses are given in Table 9.124Table 9Typical Level 6 ResponsesCategory: Care (10-year-old boy with a benign tumor).SITUATION: YUCKY AND GUCKY.Initial feeling of the little boy:- He feels dirty and not clean and like:”Oh, get this foodoff my bed.”Nurse’ s action/feeling!thinkingAction:— Probably clean the messup. She will probably pathim on the back... and thenhe will probably throw up.Feeling:- She will probably feelpretty crappy.Thinking:— She feels like a slave(abstract analogy).Little boy’s action!feeling/thinkingAction:- He will probably go tosleep.Nurse’s rationale (R. Why?)— because that is herjob. . .No, she wouldn’t, shewould get the housekeeper toclean it up. And also hefeels really yucky and thefood, you know...,throwup... he has probably eatentoo much food.— because she has to cleanup his mess and help himthrow up and clean up thethrow—up. . . and....— maybe because, you know,he calls her a hundred timesa day (first interpretation)no. .and they don’t getpresents ... all the littlekids get presents and theyhave to serve the littlekids (second focus oninterpretation).Little boy’s rationale(R. Why?)— because, you know, he istired... you know, he has tohave a little rest.125Table 9 (continued...)Feeling:— Well after he sleeps... — because he threw up and hebetter. had a rest and things.Thinking:- He thinks it’s really bad — because he threw his foodthat he threw his food all all over his bed.over the bed.Category: Protection (10-year-old boy with hypospadias)SITUATION: BATHROOMInitial feeling of the little boy:— Makes him feel well. . . it makes him feel worried because heis afraid that the nurse might not hear him and not come.Nurse’s actiOn/feeling! Nurse’s rationale (R. Why?’)thinkingAction:- The nurse will try to - so she knows if it is• . the nurse will first knock serious or not.on the door. . see what. . .whyis he calling.- She will go and get him - so the pain will go away.aspirin probably.- She will try to get the - so the kid won’t cry andkid to go in his bed and not. . so he won’t be worrieduhum. . .have him. .have him any more.not cry any more.Feeling:— Makes her feel good...— because she made him stopcrying (firstinterpretation). Shecompleted something becauseshe is like. . .she has donethe mission (abstractnotion, analogy of“completing something”)like when you are on amission and if you finishit. .you feel good that youdid the job and you didn’tscrew up or anything (secondinterpretation).126Table 9 (continued...)Thinking:— Well that she . . she isafraid that she might notknow what to do.. . and shemight lose her job.Little boy’s action!feeling/thinkingAction:- Well he will sort of calmdown and won’t cry any moreand he’ll tell the nursewhat’s wrong.Feeling:— Then he will feel. . .wellbetter.Thinking:- Then he will. .he doesn’tthink. . he just feelscomfortable then.— because she doesn’t knowwhat to do. Because she isworried that she can’t doanything and she might loseher job. Yeh. . . because sheneeds her job and if shecan’t do anything and shelearned about that. . thenthat means that she hasn’tbeen listening in class andshe could just lose herjob. .to think that.- (R. Why else?) because shehas listened in the classbut the doctor (thirdcharacter involved in story)will think that she hasn’tbeen and the doctor willthink that she is not a goodnurse. She might lose herjob and she should know whatto do but she doesn’t• .That’s what she is worriedabout.. she is afraid thatshe will forget what she issupposed to do. . Yeh she willforget what to do.. that’swhat she is afraid of.Little boy’s rationale(R. Why?)— so the nurse would helphim and the pain will goaway. So the nurse wouldgive him an aspirin and thepain would go away.— because the pain is gone.— because he doesn’t need tothink if he feelscomfortable or not becausehe already knows he isbecause the pain is gone.127Table 9 (continued...)Category: Nurturance (10-year-old girl with cystic fibrosis)SITUATION: HUGInitial feeling of the little girl:— Probably lonely because I know how that feels. I felt likethat a lot yesterday. Because my mum wasn’t there and Iusually have the comfort of her to help me. Yeh. She kissesme good night and she helps me get to sleep. Thinking thatshe is there just helps me get to sleep, right? No. . .wellnot last night but the night before and especially thefirst... the first night I was really upset that I couldn’tget to sleep (first interpretation of the feeling “lonely”).Yeh and also . . . .Yeh, that’s what I felt when my dad had togo on the airplane... I really really missed him and Istarted to cry... And the nurses asked me why I was crying.And I said:”Oh, I am just cold because I didn’t really wantto tell them because they might think I was a baby orsomething.” (second interpretation of the feeling “lonely”)But now that I think about itNurse’s action/feeling! Nurse’s rationale (R. Why?)thinkingAction:— She will probably give her — because she cares for thea hug like she wanted.. . . and girl. Like I said before.comfort her.Feeling:- That will make her feel- because she helped her.that she helped some one and It’s hard to explain.warmer towards the girl.Thinking:- Probably. . oh poor little- because she is missing hergirl.. she is missing her mum and she is crying andmum. looks like that.Little girl’s action! Little girl’s rationalefeeling/thinking (R. Why?)Action:— She will probably feel a- because she feels a littlelot better. . .she might not bit better.feel totally better becauseit isn’t really her mum.It’s the nurse but sheprobably still feels better.And then probably goes to128Table 9 (continued...)sleep.Feeling:— She will probably feel alot more comfortable withthe nurse.. .just like allthe other stories.. . . shewill probably feel better.Thinking:— Well she’ll probablythink:”Well my mum is goingto come back tomorrow anywayso I will be seeing her thenshe will probably look atthe positive side instead ofthe negative side(alternative way ofthinking).— because she comforted her.— because she is feelingbetter.Category: Teaching (10-year-old boy with a benign tumor)SITUATION: HUNGRY AND THIRSTYInitial feeling of the little- “A little hungry.”boy:Nurse’s action/feeling!thinkingAction:— She will say “no.”Feeling:— It makes her feel kind ofmean not to let him eatanything.Nurse’s rationale (R. Why?)— Because it is a specialexamination and you can’teat. Maybe they want you notfull with food because theyhad to search through allthe stuff up here and theyhad to move some over and ifthis thing (stomach) willobviously easy to push overbecause it is not loadedwith food. They had to pushit over.., and like youcan’t do that.— because you know, shecan’t give him anything andshe feels like she is not129Table 9 (continued...)Thinking:— “I can’t let him haveanything to drink.”Little boy’s action!feeling/thinkingAction:- He will probably throw afit.Feeling:- He will feel kind of angryinside.Thinking:— He’ll say. .he’llalways. . .well. . she is thenurse for the day, right. .sowhen he gets his nextnurse. . and then maybe hegets that nurse again, thatdidn’t give . .that said “no”to him to the drink. hethinks he can’t haveanything to drink maybe.doing her job.— because that’s why...doctors (fourth personinvolved in the story) saidbefore the exam “not to eator drink” and they have toobey the doctors otherwisethey get fired. And thenthey have to go to collegeto get a new job. They haveto listen to the doctors.The doctors know.. .It’s likekings and queens (analogy).Doctors are like the kingsand nurses are like queensthat... They know what theyare doing . . .that’s why theyhave the power to orderpeople around (abstractthinking).Little boy’s rationale(R. Why?)— because the nurse is notgiving him anything and hewants it. He knows theywon’t give him anything.- I would get mad if I askedfor a drink and she said“no” (interpretation to hisown situation).— because she said “no” thelast time. He probablylooks at her and is probablypretty mad at her that shedidn’t give him a drink.130Interrater reliability for scoring the protocols was.92 (ranging. from .88 for the scenario “teddy bear” to .95for the scenario “hug”).Task of Intrapersonal UnderstandingThe criteria for scoring the answers of the “Meaning”Tasks as proposed by Griffin (1992), McKeough and Martens(1994), and Salter (1993) were as follows:A score of 1 was assigned if:— A child only mentioned observable events (B), externalactions or objects (e.g., “Sad” means you cry and youwant to go home; “happy” means you can go home from thehospital and eat cake; “good” means you get presents)- If a child, exclusively mentioned an intentional state (F)without referring to a behavioral event related tothe intentional state (e.g., “happy” means you arefeeling good, you are lucky).A prototypic level 1 response given by a 4-year-oldsubject is: “Good” means: “I make a picture for my mum (B).You get new stuff and you play with new stuff (B).”A score of 2 was given if:— The answer contained both a behavioral event and one ofthe following related intentional dimensions: (a) feeling(F) states (e.g, “ ‘Sad’ means feelings. I feel sad whenmy best friend doesn’t want to play with me”).(b) personal judgement (J) (e.g., “ ‘sad’ means that youare really upset —— when you don’t get the present you131wanted to get for your birthday”), (c) others’ judgements(J) (e.g., “Being ‘good’ means that you do the work yourteacher wants you to do”), (d) social judgments (J) (e.g.,“ ‘Good’ means that you listen to what your mommy wantsyou to do”).A prototypic answer given by a 6-year-old subject is:“Happy” means: “You are playing with somebody (B) and itmeans that you are just happy because you aren’t lonely (F).You play and you eat (B).”A score of 3 was assigned if:— The answer consisted of a behavioral event and twodistinct intentional dimensions. There are several formssuch responses can take. One form is that the answerconsists of a coordination of an event with a feelingstate and a judgmental perspective (B + F + J) (e.g.,”‘Happy’ means if you like something you do, you reallyfeel happy”). Another form is that the answer consists ofa coordination of an event with two judgmentalperspectives that are categorically different (B + J + J)(e.g.,”Being happy means when I like the things I amdoing, like walking my dog every day, and I am not doinganything I don’t want to do”).A prototypic level 3 response given by an 8-year-oldsubject is: “Happy means: You are laughing, you got whatyou wanted and there is something you like (B + J + J).”A score of 4 was given if:132— The answer consisted of a behavioral event andmore than two coordinated intentional dimensions(e.g., “being bad means that you are not listening to yourmom and that you are willing to do bad stuff and you wantto hurt somebody”).Griffin (1992) did not include l0-year-olds but it canbe hypothesized that children at the 10-year-old level canelaborate on the units that are coordinated at the 8—year—old level (Case, 1992).A prototypic level 4 response given by a 10-year-oldsubject is: “Sad” means: “When nobody likes you, when peoplecall you names, when they gave you put downs then you startcrying (B + J + J + J).”A score of 5 was given if:— The answer not only consisted of a behavioralevent and more than two coordinated intentionaldimensions but also showed evidence of interpretivereasoning (McKeough & Martens, 1994). For example,“Bad means if you steal someone’s possessions becauseno one has the right to do that. Like it wouldn’tmake you feel good if some one stole your favouritestuff.” Or, “My conscience usually bothers me if I dosomething bad.”Even though l2-year-olds were not included in thisstudy, some younger subjects’ responses showed evidence of amore abstract level of intrapersonal understanding133characteristic of the first and second substages of thevectorial stage. Therefore, it was decided to includelevels 5 and 6. Griffin’s study did not describe theselevels. Consequently, scoring criteria for these levelswere adapted from McKeough’s and Martens’ (1994) study andSalter’s (1993) study.A prototypic level 5 response given by a 10-year-oldsubject is: “Bad” means:” To do drugs. .to smoke. to disobeythe law . . uhum. . . to push people around and you are willingto do bad stuff. When you drink beer when you are only ten(interpretation of disobeying the law). That’s disobeyingthe law.. . You have to be over eighteen. You are notlistening to your conscience (voice within) .“A score of six was given if:- The child could describe an abstract notion and could givean alternate interpretation and/or a second focus to thisnotion.A prototypic level 6 response given by a 10-year-oldsubject is:• “Good” means: “To behave yourself and be helpfulto anybody who needs help or just be helpful and alsocooperatively (abstract notion) . . . like I am now with you(first interpretation of being cooperative) . . . with anybodythat needs your cooperation. Uhum.. .1 usually feel goodinside also. . . like happy inside when I am good. Like somedays I wake up early and I get dressed and I go downstairsand I set the table and everything without anybody knowing134and then I do my breathing (subject needs to do breathingexercises for her cystic fibrosis) and then I get backupstairs and go to my room and start reading and nobodyknows that I did that. I feel happy inside when they tellme: ‘Oh thanks E..’ Then I feel really happy because.. .1have been thanked (second focus on being good, cooperative,helpful) .“The fourth question was categorized as to whetherchildren cite an internal or external source for theirfeelings. This question is referred to as the “Source” Taskbecause it requests the source for each intentional state(e.g., “When you are not listening to what your mom wantsyou to do, where do you think the badness comes from?”).Responses were scored as coming from an internal sourcewhenever the intentional state was seen to be located withinthe physical or psychological self (e.g., “It comes from myheart, my brain, my feelings”). Responses were scored ascoming from an external source whenever the intentionalstate was seen to be coming from an object, an action, or apart of the body that could be observed from the outside(e.g, “It comes from my mom, from my tears, from everybodyelse”). Responses that fell in neither the internal nor theexternal source category were put into an “I don’t knowwhere it comes from” category.Interrater reliability was computed for the fourconcepts happy, sad, good, and bad at .81, .89, .95, and135.96, respectively.Balance Beam TaskSubjects were expected to make predictions and givejustifications that reflected the strategy used tocoordinate the dimensions of weight and distance (Marini,1984). In order to pass an item the relationship betweenthe prediction and justification had to be very clear. Ananswer was assigned the score of a particular level only ifthe prediction was sufficiently explained by thejustification (see also Table 1, p. 39).Considering the fact that two trials were given at eachlevel, a child’s final score was calculated by adding up thetotal number of level scores and dividing it by two. Alevel 5 (i.e., approximately age twelve) was also includedto prevent a ceiling effect. Interrater reliability for theBalance Beam Task was calculated at .95.SummarySix level scores were described to provide acomprehensive and structured basis for scoring children’sresponses on the Nurse’s Role Task and the Task ofIntrapersonal Understanding ranging from mainly script—basedresponses characteristic of levels 1 and 2 to the moreinterpretive responses characteristic of levels 5 and 6.Examples of responses at each level were given. Some 8— andlO—year—olds were able to also give answers at levels 5 and6 (i.e., approximately age 12 and 14, respectively). Five136level scores were obtained for the Balance Beam Task. Afterall scoring was completed and an interrater agreement wascalculated, the quantitative analyses were performed.Results of these analyses are described in the next chapter.137CHAPTER VRESULTSThirty-five hospitalized children (five 4—year-olds,ten 6—year-olds, ten 8-year—olds and ten lO-year—olds) withvarious chronic conditions were given the Nurse’s Role Task,the Task of Intrapersonal Understanding and the Balance BeamTask. Half-way through the data collection it was decidedto discontinue recruiting 4-year-olds for the study. It wasvery difficult for them to complete all three tasks forseveral reasons. First, the short length of hospitalizationoften made it impossible to spread the tasks out over theseveral sessions which were needed to keep the 4—year—oldchild concentrated. Second, the distracting hospitalenvironment did not provide an optimal situation to do threelengthy tasks. The Nurse’s Role task, in particular, tookthem too long. They generally lost interest in the taskrather quickly. Their response to the protocols will bediscussed in the section, “The contextual description of thedata.”All children were interviewed at their bedside and weregiven a present after they completed all tasks. Presentsawarded were plush animals, drawing books with crayons,little toy cars and pencils. Interviews were tape recordedand then transcribed. The majority of children referred to138the role of the nurse as that of a woman instead of a man.For clarity, the results will be presented in twoparts, addressing the quantitative and the contextualdescription of the data, respectively.Results of quantitative analyses.Five analyses were done. The 4—year—olds were excludedfrom quantitative analyses because of the number of childreninterviewed in the age group. Consequently, there werethree age groups (6—, 8—, lO—year-olds) of ten subjects eachfor quantitative analysis. Results of the five analyseswill be presented in five parts, addressing the fiveresearch questions initially set out. An alpha level of .05was used for all statistical tests.Question A. Do the mean level scores of Case’s stagesof cognitive development coincide with the mean scores ofchildren with chronic conditions on their perception of thehospital nurse’s roles (i.e., care, protection, nurturance,and teaching)?To address this question, overall means (with standarddeviations in parentheses) for the 6—, 8-, and lO-year-oldson the Nurse’s Role Task were computed; these were 2.06(1.18), 3.35 (0.11), and 4.3 (1.06), respectively. Thereader will remember that the predicted scores according toCase’s (1992) theory of development for 6—, 8—, and 10-year-old children are 2.00, 3.00, and 4.00, respectively. Thesepredicted scores will be graphically represented in the139related figures as the theoretical line. The age means foreach nurse function are plotted in Figure 3. Furthermore,the mean scores for each age group on the eight pictures aregraphically depicted in Figure 4. In addition, the meanscores and standard deviations for levels by each age groupand by each situation within each nurse function category ispresented in Table 10. Figure 5 presents the range ofperformance of each age group (6—, 8—, and lO—year—olds) onthe Nurse’s Role Task.Children’s level scores on the nurse’s role task wereinitially submitted to a one—way analysis of variance.Results of this analysis indicated that the effect of agewas statistically significant, (2, 27) = 26.32, p =.001.The power of this analysis was 0.998.Furthermore, Newman—Keuls’ comparisons of means wereperformed to determine where significant differences amongage groups were to be found. It appeared that there was aconsistent age—related increase in children’s understandingof the hospital nurse’s role; significant differences werefound in overall mean scores between each of the three agegroups. A test of linearity showed a linear trend in thedata, (2, 27) = 52.30, p = .001. No significant deviationfrom the linear trend was apparent, (2, 27) = 0.34, p =• 565.In order to check if there were any effects forfunction and pictures, an analysis of variance of a mixed140TABLE10MeanScoresandStandardDeviationsforLevelsbyeachAgeGroupandbyeachSituationwithineachNurseFunctionCategoryNurseFunctionCategoryTEACHINGPROTECTIONNURTURANCECAREH.GOWNTHIRSTYH&TBATHROOMIVB&IVTEDDYHUGT&HYUCKYBLANKETY&BMSDMSDMSDMSDMSDMSDMSDMSDMSDMSDMSDMSDAGE6YRS.2.300.821.900.322.100.012.100.742.200.792.150.042.200.922.300.822.250.141.700.481.800.631.75-0.198YRS.3.200.633.500.853.35-0.033.300.823.401.263.35-0.053.701.253.300.823.500.103.100.883.201.033.20-0.0310YRS.4.300.954.501.274.350.024.400.974.300.954.350.044.101.294.101.104.10-0.254.500.974.300.954.400.22Note.=10foreachagegroup.141::.r6yrs. 8yrs. 1Oyrs.S4.543.53Mean level2.5SCOres21.510.50Teaching Protection NurturanceNurse functionsFigure 3. Mean level scores for all age groups on each nursefunctiondesign with subjects nested within levels of age and levelsof nurse functions nested within levels of pictures was alsoconducted, the results of which are presented in Table11.Significant main effects were found for age and notfor nurse function or pictures nested within levels of nursefunction. Furthermore, no significant interaction effectswere found. Therefore, the hypothesis that the means of the6—, 8—, and 1O-year-olds would differ was supported.Care1426 observed mean scorestheoretical line5iOyrs.scores26yrs1101 2 3 4 5 6 78PicturesNote. Pictures 1 to 8 represent the situations hospitalgown, hungry and thirsty, bathroom, I.V. bottles, teddybear, hug, yucky and gucky, and blanket, respectively.Figure 4. Mean levels by age for each picture.143-,6543wGROUPNote. For further information on how to interpret thisfigure, please refer to Appendix N.Figure 5. Box and whisker plot showing the range ofperformance of each age group on the Nurse’s Role Task.0IT II III 1 11 1111111 II1_o 106yrs 8yrs lOyrs144Table 11Analysis of Variance of a Mixed Designfor the Nurse’s Role TaskSource df FBetween subjectsAge (A) 2 26.18**AXBa 6 1.14A x Cb(B) 8 0.95SC within-grouperror 27 (3.85)Within subjectsB 3 0.74C(B) 4 0.18S x B(A) within-group error 81 (0.53)S x C(AB) withingroup error 108 (0.36)Note. Values enclosed in parentheses illustrate mean squareerror. 93 = Nurse functions, bC = Pictures,Cs = Participants. C(B) = Levels of nurse function nestedwithin levels of pictures. = 10 for each age group.**p < .01.145These results indicated that a) performance of allnurse function situations changed with age; b) each agegroup responded similarly to nurse functions situations; andthat C) there was no significant difference betweenstory situations (pictures) within nurse functions.In order to check if an increase in the number ofhospitalizations had any effect on the child’s level ofunderstanding on the Nurse’s Role Task, the number ofhospitalizations together with the child’s mean level scorewere tabulated (see Table 12). Through visual inspection ofthe data, it appeared that there was no obvious relationshipbetween the number of hospitalizations and the child’s levelof understanding on the Nurse’s Role Task.Furthermore, an item analysis was performed for the 8pictures of the Nurse’s Role Task to estimate the internalconsistency of the obtained scores. A reliabilitycoefficient alpha of .96 was obtained.Overall, a modest acceleration in cognitive developmentin the social domain was found, being of the order of one—third substage at the 8- and 10—year-old level ofunderstanding by hospitalized children with chronicconditions. However, 6-year-old hospitalized children didnot show any notable acceleration in their socialdevelopment as measured by the Nurse’s Role Task.146Table 12Number of Hospitalizations of Each Sublect with His/Her MeanLevel Score on the Nurse’s Role Task for Each Age GroupSublect 6 yrs. 8 yrs. 10 yrs.A 2 1.63 2 3.25 2 3.88B 2 1.63 3 3.63 3 3.88C 3 2.63 6 3.63 3 5.75D 4 2.63 6 3.50 3 5.75E 5 2.00 6 2.75 3 4.00F 5 2.00 7 4.00 4 3.88G 5 2.13 8 3.63 4 4.00H 6 2.13 10+ 4.25 10+ 5.13I 10 2.00 10+ 2.75 20+ 3.88J 10+ 1.88 20+ 2.00 20+ 2.88Note. # refers to the number of hospitalizations. = 10for each age group.The percentage of 6—, 8—, and 10—year—olds respondingat, above, or below the prototypic level for their age(i.e., level 2, 3, and 4, respectively) is presented inTable 13.147Table 13Percent of 6—, 8—, and 1O—year—olds Responding at ProposedPrototype, Above Prototype, and Below Prototype (i.e., 1, 2,and 3 substages’) for Each Nurse FunctionNurse Function % Prototypic % Above % Below1 2 3 1 2 3Protection 75 5 10 10Care 65 5 306 Nurturance 55 20 10 15Teaching 75 10 5 10Protection 55 15 10 5 15Care 30 35 5 308 Nurturance 45 15 15 5 20Teaching 50 35 5 10Protection 50 20 15 15Care 45 25 15 1510 Nurturance 45 5 20 25 5Teaching 50 15 20 10 5Note. fl = 10 for each age group.148Question B: Do the mean level scores of Case’s stagesof cognitive development correspond with the mean scores ofchildren with chronic conditions on a causal reasoning task?Means (with standard deviations in parentheses) for the6—, 8—, lO—year—olds on the balance beam task were 2.25(.35), 2.83 (.35), and 3.85 (.85), respectively. Asdelineated in the description of the method used, level-scores on the balance beam task were submitted to a one—wayanalysis of variance (ANOVA), the results of which arepresented in Table 14.Table 14One—Way Analysis of Variance for Obtained Levels on theBalance Beam Task by Age GroupSource if MS FBetween groups 2 6.55 19.67**Within groups 26 0.33(error)**p < .001Note. Including all subjects, the effect of age was alsostatistically significant,. (2,27) = 14.10, p = .0001.149Subjects were divided into three age groups, 6-, 8- and 10-year—olds respectively ( in each group = 10). It wasdecided to omit one 8-year-old subject in group 2 (seeFigure 6). This subject didn’t achieve optimally at thetime the task was given for medical reasons; his performanceresulted in an extremely low score. The examiner was of theopinion that the subject’s obtained level score on thebalance beam was not a valid representation of his level ofcausal reasoning.The results of the one—way analysis indicatedsignificant differences at the .05 level between the threeage groups. Therefore, the hypothesis stated in Chapter 3,that the means of the three age groups would coincide, wasrejected. The power of this analysis was 1.00.Subsequently, Newman—Keuls’ test was conducted to makepost hoc comparisons between the means of the three agegroups. As hypothesized, there were significant differencesbetween all three age groups. These results support Case’stheory of cognitive development (1992).A test of linearity showed a linear trend , (2, 26) =38.47, p = .0001 (see Figure 7). No significant deviationfrom the linear trend was apparent, ((2, 26) = 0.88, p =36.1505432’108yrsGROUPNote. Participant 13 was omitted from the analysis formedical reasons (extreme low score). For furtherinformation on how to interpret this figure, please refer toAppendix N.Figure 6. Box and whisker plot showing the performance ofall subjects within each age group on the Balance Beam Task.I llllllllI{o6yrse1 310lOyrs15143.532.5Level 2score1.5I___________0.50Figure 7. Mean level scores for each age group on theBalance Beam Task.The percentages of 6—, 8—, and lO—year—olds respondingat, above, or below the prototypic level for their age(i.e., level 2, 3, and 4, respectively) are presented inTable 15.theor.linegr. meangr.median6yrs. 8yrs. lOyrs.Age152-b1CDU)C)IC)U)IIiPioIaaIIH-P303P3P3CDIa101IIICDCD•HC)b(flirtki-<I’-<00IIU)CD03U)U)0Li.dlCDilICtctCtC)CD•HP3CDCDCD1IC!)IC’)IC’00CD-C)03CDH-H-K)C)C)CDctCtCtCD.QU)0(flC)IctCtICtCDCD0)CDlCDClIb03CDI-iC)lU)flI0’03CDCD0Irt<CDCDClP)00In-p3CDIH-103IlcClU)HIH-U)HHI0CDh0CDCl10<00CD0CDU)H-I0—•IH--1CU)HU)I-a-CtIQ(ii0PU)CtCtClCDICt03Cl03CDU)03H-loH030CtCflbU)0hCl0•CtQ3CD0)H-CD•0P3(flCD‘.QH-P3ClCtIIH-iII-ClHLI-U)C)00P0P3H-cYCD“iCDCDCDCDH)II‘-3CtC)•C)0ClClII03Cl)0Cl0)Ct1ZCtCt0iDU)CtCtCDP3HPCDCt0U)U)CDCDH)U)0ClU)CtH-P30P3H‘-a)10lo\0CtCDIP3H-CDC)H-C)10HoI•P3U)U)-000CDP3Cl101iCDP30U)tP3H.PIt3CD00)P3Ct-dCD0•1HU)HCD0)P311En0I<01ICDH-U)U)0hIIC)U)H-lCD00CtHCDCDCDC)U)a-P3HPCDCld0—ICl01H-0CtCtCDnt-1-ClU)H)CDCtH-CDP3HIPH-H-CD03CD00U)-00C)CtU)CtH-ClP3Ct00ICt0•Cl)CDCD<Ct0H)CDHU)CtClCtCDCDCDH•0HH-cU)H-C)-IU)0ClH-Ct03CtCtCtH-CD:3HU)H-0CDP3ClH)HCDPP3HH)CDCtH)CDClCDcHHloIth°CDCDU)H-0P3III0PI.I0CD10CD0)001ICDHU)P3U)IHlCDP3CtCDU)k<ClIP3CtC)U)t03C)H-CDU)10CD00U)H-0CtH-P3IClU)P3C)1II0)CtIl‘1‘10CDCDHI0CDCt1ClU)0HCDCDH0HH0CDU)0Cl0U) CD0ClH)-*Z0<0ZtU<0POrt1-3H0Idçl))1iP)DII0)iItiI•Ct1H0H-0hHII010CD<CDCDAU)0)U))U)0)H-l0)•CD0)CD0)CD0)IdH--C)••-C)••-C)••0)ICUICDHU)CDHU)CDHHCD00CDWCDt’iCDH0)U)IIHCD0CD0CD0CDC)F-bHH0)HH0)OI—’0)CD0d0CDCCDCDF-CF-b‘1CDC)Ct0F-CU)U)0)0H1U)oi:.J‘JI0)(.)O0J001O01r”l(I)0)F-IU)0)CDC)U)HtU••••Cl)••Cl)CD‘-3011‘.D0)01l-JWl.)P.Ct0)0W01H010101H-CDHCtCDCD HCDCDCt0)HC)frtIIrth-i-CD0CD‘1d•Ct0I-CCDH)F-$10CDCDH-F-CCl)-C)Cli0)LH‘-C00‘-C011HCD‘diCD0)0)UIC’)C)0-0) U)U)IIC’)H.IC’)H.IC!)HPIH-I0IH-IPIH-I•IICCt0PCtCtCD0)0)*0)0)H-H-HPPPbetween mean scores on the Balance Beam Task and the Nurse’sRole Task for groups 1 and 3, 6—year—olds and lO—year—olds,respectively. However, significant differences wereobserved for group 2. In other words, the 8—year—oldchildren’s understanding of the hospital nurse’s role wassignificantly higher than their understanding of causalreasoning. The power of the three f—tests was 0.12, 0.92,and 0.26 for respectively groups 1, 2, and 3.Consequently, the hypothesis that subjects’ mean levelscores on the Balance Beam and the Nurse’s Role Task wouldcoincide was accepted for groups 1 and 3 and rejected forgroup 2.Furthermore, the mean scores for each age group on boththe Nurse’s Role Task and the Balance Beam Task compare tothe theoretical prediction (Case, 1992) as follows: Sixyear—olds were approximately one—fifth of a substageadvanced in their level of understanding on causal reasoningcompared to their level of understanding on the Nurse’s RoleTask. However, both 8— and 10—year—olds showed a moderateacceleration in their level of understanding on the Nurse’sRole Task as compared to their comprehension on the BalanceBeam Task, being of the order of approximately three-fifthsand half of a substage, respectively. To illustrate thedifferences in findings between the Nurse’s Role Task andthe Balance Beam, mean levels are graphed by Age (seeFigure 8).155Figure 8. Mean scores at different age groups, for both theNurse’s Role Task and the Balance Beam Task.Question D: Do the mean level scores of Case’s stagesof cognitive development coincide with the mean scores ofchildren with chronic conditions on their intrapersonalunderstanding (i.e., happy, sad, good, and bad)?Mean scores (standard deviations) for each concept andthe means (standard deviations) for the overall scores onthe four tasks are described in Table 17.Nurse’s roleTheor. lineBalance beamMean levelscores54.543.532.521.510.506 8 10yrs. yrs. yrs.Age156Table 17Mean Scores and Standard Deviations of Level Scores for eachAge Group and by each Concept (happy. sad, good, and bad)Task of Intrapersonal UnderstandingHAPPY SAD GOOD BAD GROUP MEAN6YR 2.60 1.07 2.40 0.70 2.10 1.20 2.40 0.97 2.38 0.572.70 0.67 3.10 0.74 2.80 1.03 3.20 0.63 2.95 0.481OYR 2.90 0.99 3.70 1.06 3.90 1.20 4.10 1.10 3.65 0.91Note. n = 10 for each age group.To illustrate the findings, mean levels for each conceptwere graphed by age groups for each concept (Figure 9).Initially, a one—way analysis was performed on thethree group means of all four concepts. Results indicatedthat there was a significant effect for age, F(2, 27) =8.87, p = .001. The power of this analysis was 0.96.Subsequently, Newman—Keuls’ test was conducted for makingpost hoc comparison between the means of the three agegroups. There were significant differences between groups 1and 3, respectively 6— and 10—year—olds, and between groups2 and 3, respectively 8- and 10-year-olds, but not forgroups 1 and 2, respectively 6- and 8-year-olds. A test oflinearity showed a linear trend in the data, (2, 27) =157543 r9[6yrs.Mean levelscores 28yrs.1O yrs.10Happy Sad Good BadFigure 9. Mean level scores of each age group for eachconcept.17.69, p = .0003. No significant deviation from the lineartrend was apparent, F (2, 27) = 0.06, p = .81.After inspection of the data and out of conceptualinterest, it was decided to conduct a multivariate analysisof variance (MANOVA) with the four different concepts asdependent variables. Using MANOVA, a significant age groupeffect was found. The value of Wilks’ Lambda was 0.53. Theapproximate F value with 8, 48 degrees of freedom associatedwith this Wilks’ Lambda is 2.24, p = .04. Wilks’ Lambda was158the criterion of choice because of its power (Tabachnick &Fidell, 1989). Follow-up univariate i—tests showed asignificant group effect for the concepts sad, good, andbad. However, no significant group effect was found for theconcept “happy.” Results of the univariate analysis arepresented in Table 18.Furthermore, an item analysis was performed for the 4concepts of the Task of Intrapersonal Understanding toestimate the internal consistency of the obtained scores. Areliability coefficient alpha of .76 was found.The percentage of 6—, 8—, and lO—year—olds respondingas per, above, or below the prototypic level for their age(i.e., level 2, 3, and 4, respectively) is depicted in Table19.Table 18Univariate Analysis of Variance of Each Concept (happy, sad,cood,and bad) by Age Group (6-, 8-, 10- years)Source MS F PHappy 0.23 0.27 .766Sad 4.23 5.89 .008*Good 8.23 8.28 .006*Bad 7.23 8.53 .001*(2, 27), *p < .01.Note. n = 10 for each age group.159Table 19Percent of 6-, 8-, and 1O-year-olds by Concept, Respondingat Proposed Prototype, Above Prototype,and Below Prototype (i.e., 1, and 2 substages)Concept % Prototypic % Above % Belowa aHappy 50 10 30 10Sad 40 50 106 Good 30 10 20 40Bad 60 10 20 10Happy 50 10 40Sad 50 30 208 Good 30 30 30 20Bad 60 30 10Happy 40 10 50Sad 50 10 30 1010 Good 30 20 10 30 10Bad 20 30 10 40Note. j = 10 for each age group.160An analysis of age—level responses to the “source”questions for each concept indicated that an internal sourcewas given by a majority of l0—year-olds and 8-year—olds inthe sample for each of the four concepts examined (rangingfrom 60% to 70%, and 40% to 80%, respectively), and by aminority of 6-year—olds (10% to 30%). The remaining 6-year-olds provided either an “unknown” source (2 0%) or anexternal source (58%).Question E: Does advanced understanding of the hospitalnurse’s role correspond to advanced understanding on anothertask which is social in nature? In other words, do the meanscores of children with chronic conditions on theirperception of the hospital nurse’s roles coincide with themean scores of their intrapersonal understanding?To answer this question a f—test for paired samples wasperformed to compare the overall mean scores of each agegroup for both the Nurse’s Role Task and the Task ofIntrapersonal Understanding to examine if there weresignificant differences in the child’s level ofunderstanding.Results of the fl-tests are presented in Table 20.The fl-tests indicated significant differences between themeans across tasks on the Nurse’s Role Task and the Task ofIntrapersonal Understanding for groups 1 and 3, 6—year—oldsand lO—year—olds respectively. In other words, 6—year—oldand 10—year—old subjects scored significantly lower and161Z*C)0ZC)<0ZC)<0Cl)ftHH-0td0CUII0CUFl0CUFl0I‘P(fl‘PftIIII0IIII0II‘100CD<CDACl)0H-Cl)0H-Cfl0H-II0)CD•CDCDCUCDCDCUCDCDCUCDI-HH0II•-rJ••-.•-.•(flCl)H)-I0Cl)ci-HCl)ftH(flftHCl)CDo(31CDCDt’JCDHH)UICUHIIII0CD0CU0CU0CUII0H)ci-ci-VIHHCl)HHCDGHCl)H0IId0CD0CDCDP.CUCDCUHi-dC)H1C)H)CD(t0II(I)Cl)ci-0H)II-IICl)••IICDCl)<•CUH0)CDCDIICU<0wo‘1OHouiuio’o0CU0bt.‘PCl)Cl)CDCDHci-CDft:II‘P•Ct)••C!)CDCDC!)CD‘Ia.L01ft0)CDft0—1O01—1CUCDCDHIICDCDci-1II•H-(flftt’3CDCDCUci-0‘P-Cl)•Cl)IIftIIftt’)IftCDH•H••ZLi-0H—1CD0HH0111C)CDHCl)ftCDCDCl)<0--CDCl)HCl)IICl)-I-bH-0ftHCD0CDIICUCl) ftCDCUCU0CUCl)IC!)t’JIC!)t’).IC!)M0IH-HIH-I0IH-IH-ftHI.QftHci-ftCU*P2CU*Cl)‘PCDH-H-H-HHHof the Nurse’s Role Task and the Task of IntrapersonalUnderstanding was found for group 2 (8-year-olds). Thepower of the three fl—tests was 0.30, 0.29, and 0.32 forgroups 1, 2, and 3, respectively.To illustrate the differences in findings between theNurse’s Role Task and the Task of IntrapersonalUnderstanding, mean levels were graphed by age (see Figure10).54Mean 3levelscores 210Nurse’s roleTheor. lineConcepttas IC8 yrs.6yrs. lOyrs.AgeFigure 10. Mean level scores of the three age groups forboth the Nurse’s Role Task and the Concept task.The observed mean scores of each age group on both theNurse’s Role Task and the Task of Intrapersonal163Understanding compare to Case’s (1992) theoreticalpredictions in the following way: Six-year-old hospitalizedchildren with chronic conditions were one—third of asubstage advanced in their understanding of the fourconcepts in relation to their understanding of the hospitalnurse’s role. However, both the 8— and 1O—year—olds showedan acceleration in their understanding of the nurse’s rolecompared to their comprehension of the four concepts, beingof the order of approximately two-fifths and two-thirds of asubstage, respectively.Implications of the results of the five analyses arediscussed in further detail in the next chapter.Contextual description of the dataIn order to provide some background and/or contextualinformation about the circumstances under which the datawere collected, an overview of the characteristics of eachage group is given. Subsequently, specific characteristicsof four hospitalized children with chronic conditions, a 4-year—old, a 6—year—old, an 8—year—old, and a 10—year—old,respectively, are discussed in further detail. Thesechildren were chosen because of their advanced understandingof the hospital nurse’s role. To elaborate on the findingsfor these four children, their explanations of the fourconcepts (i.e., happy, sad, good, and bad) together withtheir level of understanding on the Balance Beam Task arealso given. The situations and experiences that may have164affected their perceptions are described as far as they wereknown by the examiner. Typical level characteristics wereput in italics and/or were further explained betweenbrackets. Their actual names have been changed to protecttheir privacy.Acre four:Overall, it was difficult to interview 4—year—oldhospitalized children. They are too young to concentratefor the time necessary to complete the tasks. Furthermore,the distracting hospital environment, where children’s timeis occupied or frequently interrupted for most of the day,was not optimal for collecting the data. Reflecting amodern trend that keeps the length of children’shospitalizations at a minimum, time was often too short tocomplete all three tasks. Therefore, it was decided halfway through the data collection to discontinue interviewingthis age group. All 4-year-olds who were interviewed had nounderstanding of the reason why they needed to behospitalized. They either responded with “I don’t know” or“just because “ Despite the fact that all 4-year—oldsstrongly disliked medical procedures such as “pokes” (needleinsertion) and going for tests, they liked being in thehospital because they could play with other children in theplay room. For example, one little 4—year—old boy whosuffered from nephrotic syndrome said the following about“getting a shot”:165It will hurt. (R. Why does it hurt?) Because it is ashot. (R. How does that make you feel to get a shot?) Ifeel upset. (R. Why do you feel upset?)Because. . .because. . . .because. .. .because... (whisperssoftly).On the other hand, one 4-year-old with a multiplechronic condition (i.e., cystic fibrosis and asthma) whoaccording to his mother “loved being in the hospital” saidthe following to the question “What does it mean to behappy?”:I feel happy right now because I get to play in theplayroom. . . My body just wants to be happynow.. .Uhum. . .My body just wants to be like that. (R.Why is your body happy right now?) Uhum.. . .1 don’t knowthat. (R. And where does your happiness come from?)From my body.This little boy’s mother tried to make his hospitalizationas pleasant as possible by talking and playing with her sonas much as she could. He didn’t finish all three tasksbecause he preferred playing instead of participating inthis study till the end.One of the four 4-year-olds who completed all threetasks showed an advancement of approximately two—thirds of asubstage in her understanding of the hospital nurse’s role.To illustrate, the interview with this 4-year-old girl willbe presented in further detail.Denise, a 4-and-a—half year old girl with cysticfibrosis, was hospitalized for her fourth time. Over a twoweek period, Denise received medication through anintravenous drip. She was cooperative with her medicaltreatments, although the insertion of her I.V. needles (this166had to be done twice over a period of two weeks) caused hera lot of distress. She was a talkative and affectionatelittle girl who loved the Lion King. She watched the moviethe “Lion King” over and over again.Denise came from a single—parent family. Both hermother and grandmother visited her on a regular basis. Eventhough they did not stay with her in the hospital overnight,one of them was always there when some medical procedureneeded to be done with her. Both her mother and grandmotherspent a long time explaining to Denise what her treatmentswere for and why certain procedures needed to be done.Consequently, her knowledge of certain medical treatmentswas remarkable for her age. For example, one of herroommates had to receive medication through a gastric tube.Her response to him wearing a tube in his nose was asfollows: “He got a tube in his nose. . . . It goes all the waydown to his stomach. The tube is checking what his stomachis doing.” Even though the purpose of this gastric tube wasnot to check what the roommate’s stomach was doing but toprovide the little boy with more adequate nutrition, sheunderstood that the tube went into the nose all the way downto the boy’s stomach. It also shows that her understandingwent beyond the boundaries of perception alone because thegoing down of the tube into the stomach is not directlyobservable. Furthermore, Denise understood that you getmedicine through an intravenous (I.V).167It was not difficult to interview Denise because sheloved the attention it provided. Even though she thoughtthe Nurse’s Role Task was kind of tedious after a while, shecooperated till the end. Denise’s level of performance onthe Nurse’s Role Task was advanced. Her level ofunderstanding on six out of the eight stories was at the 6-year—old level. Even though her explanations of thehospital nurse’s intentions were still basic, she understoodthat nurses have reasons for their actions and that thesereasons are to improve the little girl’s well—being. Forexample, her response to the “bathroom” situation was:She (nurse) will take her to her room and lay her down.(R. Why?) Because so the pain will go away (nurse’splan to improve the little girl’s immediate future).(R. How will that make the nurse feel?) Sad. (R. Why?)Because she doesn’t want the kid to be having a bellyache (immediate intention of the nurse).Denise also showed some advancement, although minimal,in both her understanding of the four concepts happy, sad,good, and bad (mean level 1.25) and causal reasoning astested by the balance beam task (level 1.5). For example,her explanation of the word “bad” was as follows:Throwing stuff around (Behavior) and you get angry(Judgement) and you are mad (Feeling). (R. What ishappening when you are bad?) Then youbreak. . . . break. . . break glass (B). (R. And when youbreak glass, where do you think your badness comesfrom?). Your heart (internal source).Denise’s advanced understanding on all three taskscould be explained by the fact that both her mother andgrandmother discussed Denise’s hospitalization openly with168her and gave, the special attention needed for her to copewith the hospitalization stress. This encouraged Denise toask questions about her treatments and receive adequateanswers.Age six:The 6—year-old hospitalized child with a chroniccondition is similar to a 4—year—old child in the sense thathe/she needs a familiar person, in most cases the parents,to be with him/her during the hospital stay. Most parentsof the children who participated in this study stayed withtheir children in the hospital overnight or spent the nightin a hotel nearby. If one of the parents was not close by,the child could phone his/her parent at any time of the dayto be comforted or the parents phoned at least once a daythemselves. Most medical procedures were stressful for the6-year-old child. The children either did not know thereason for their hospitalizations or gave simple answersreferring to external symptoms. For example, a 6—year—oldboy with Crohn’s disease explained the reason for hishospitalization as follows:For uhum for my bum. (R. Does it hurt?) Yes.Or the response of a 6—year—old boy suffering from seizureswas:Something wrong with me. (R. Do you know what happened?What was wrong?) I don’t know yet.Just like the 4-year-olds, all 6-year-olds who wereinterviewed strongly disliked receiving “pokes” (i.e.,169needle insertion) and were quite upset getting them. Mostchildren were amazingly well acquainted with certainhospital equipment. For example, one girl with a multiplechronic condition (i.e., cystic fibrosis and seizures)repeatedly wanted to play with the nursing equipment broughtin by the researcher. She used all the play equipment(i.e., a stethoscope, injection needle, blood pressure cuff,I.V. machinery) appropriately. Children understood the useand operation of an intercom (e.g., see Table 5, p. 97).Children with cystic fibrosis, in particular, understood theprocedures involved with operating the intravenous drip, away of receiving treatment frequently used with thiscondition. For example, one girl with a multiple chroniccondition (i.e., cystic fibrosis and seizures), whose I.V.machine alarmed/”beeped” constantly because of her abruptmovements, operated her own I.V. machine by pressing thebuttons and unplugging the electrical cable whenever shewanted to go for a walk.All children understood that hospital nurses haveintentions for their behaviour. However, the explanationsof these intentions were still very basic and often referredto improving the immediate future of the little boy/girl.Most children responded at the prototypical age-level on theNurse’s Role Task, although a few children were able todescribe more than one intention for the nurse’s action, acharacteristic of the 8-year-old level of understanding.170For example, the response of a 6—year—old girl withectodermal dysplasia (i.e., failure to thrive) to thescenario “bathroom” was:The nurse will help her. Give her some medicine. Sothe pain will go away (immediate plan to improve thelittle girl’s well—being). (R. Why else?) Because shewants to make the girl feel better (nurse’s intention).(R. How will that make the nurse feel?) She will feelhappy because she helped the girl. (R. What does thenurse think then?) She thinks about that she alwayshas to help kids (knowledge of role of the nurse)because. they are sick.A typical 6-year-old explanation of the nurse’sintention for her/his behaviour was that she/he acts acertain way because she/he has to help the little girl/boy.The majority of children were able to describe the nurse’sthoughts, something that was difficult for their 4-year-oldpeers. Most 6—year—olds did not understand the reason whychildren need to wear a hospital gown before an operation;neither did they comprehend the reason behind not beingallowed to eat or drink before a test. One 6—year-old witha congenital heart defect, however, said the following tothe scenario “hospital gown”:She (nurse) will put it on. (R. Why?) Because she wantshim to. (How will that make the nurse feel?) Sad. (R.Why?) Because she wants him to put it on. (R. What willthe nurse think then?) She thinks, she doesn’t want theblood to go on his shirt. (R. Why?) Because then hismom will be mad.Whereas most children either did not show anyadvancement in their understanding or demonstrated a minoradvancement, it is worth mentioning the interview with one6-year-old boy suffering from Crohn’s disease. Robert had171been hospitalized many times (i.e., his mom lost count). Hewas an intelligent and compassionate little boy. Histouching and thoughtful reaction to the pain of one of hisroommates was:Poor guy.. .he is on pills and feels bad. It’s notfunny (Robert wanted to get out of his bed to comfortthe little guy). I think he is crying about his mom.Robert’s mother was present during his entire hospitalstay. She stayed in the hall-way during the interview andhe needed to be confirmed of her presence several times.Robert did all three tasks in one session. He wanted tocomplete them all because he was looking forward to gettinga present at the end. He took the questions very seriously.His understanding of the role of the hospital nurse wasslightly advanced (his mean level score was 2.25). Robertoften projected his own situation to that of the little boyin the pictures without directly referring to it. Forexample, in the scenario “hospital gown” he said:She will say:”Sorry, but you have to wear it orelse. . . if you don’t wear it then you might get intotrouble.” (R. Why is that?) Because if he is notwearing it and he has to or else. .she gets mad at you..the nurse might get mad at you. (R. Why would the nurseget mad?) Because you have to wear it. If you don’tthen you can’t get the surgery done. Maybe that guy’sbutt is sore (projection to his own situation). (R. Howwill that make the nurse feel?) Sad because the kiddoesn’t want to and she is mad at him but she doesn’twant (Bi: first intention of the nurse) to feel sad.(R. Why not?) Because she wants him to get better (B2:second intention of the nurse).Robert’s level of performance on the Task ofIntrapersonal Understanding was advanced for his age (his172mean level score was 2.5). Overall, his responses were atthe 8—year—old level of understanding. For example, hisexplanation of the concept “happy” was:It means you be happy about trees and forest. Trees,farms, and chickens and all the animals and grass. Itmeans to. . it means to hope you get better and do stuffyou like (B + J + J). And you be thankful for thestuff you get and you have to like it, you can’t hateit (B + J + J). And you are really proud of yourself(F). (R. And when you get stuff and you are proud ofyourself, where do you think your happiness comesfrom?) Uhum.. . . from God (external source).Furthermore, Robert’s level of performance on the BalanceBeam Task was age appropriate.Age eight:The reaction of an 8-year-old child with a chroniccondition to hospitalization is similar to that of the 10-year-old child in the sense that they are familiar with thehospital routines and more acquainted with medicalprocedures. Most children were beginning to understand thereason behind wearing a hospital gown when you go for anoperation but still gave a basic explanation for rationalebehind not being allowed to eat or drink before a test. Forexample, one girl with pancreatitis said the following aboutthe nurse’s action and rationale in the scenario “hospitalgown:The nurse will say: “No, you have to wear the nursegown.” (R. Why does she say that?) Because it is clean.Her pyjamas may have not been washed. Because theydon’t want you to have any germs in the place that youhave an operation. The gown also opens at the backwhich makes it easier for them to take it off. Her ownpyjamas may not open at the back.173Another boy with asthma gave the following basic explanationto the action and rationale of the nurse in the scenario“Hungry and Thirsty”:She says:”NO.” (R. Why does she say “no”?)Because. .uhum. .he is not allowed to because the test.Because if he doesn’t listen to the rules, he might besick and he would have to stay in the hospital longer.In some cases the child not only explained the hospitalprocedure accurately but also referred to a fantasy thelittle girl/boy in the story might have. For example, agirl suffering from chronic pyelonephritis not onlyexplained the purpose of an I.V. correctly but she alsomentioned a fantasy the little girl in the scenario “I.V.bottles” might have about the beeping of the machine whenthe medication runs out. Her response to the little girl’sinitial feeling was:She feels really scared because it started to beep. (R.Now why would that make her scared?) She thinks all theblood work will be sucked out because. . . . like a vampireis drinking her blood. But it is only an empty bottleor the medicine stopped going in.Most children showed curiosity instead of anxietytowards medical equipment (e.g., an I.V. device). Themajority of children began to understand the reason fortheir hospitalization. For example, the answer of an 8—year-old boy with asthma to the question why he was in thehospital, was as follows:I am in the hospital because I have asthma very bad.I got it when I was turning one, I think, and I havehad it pretty bad and it hits me through a pretty badspot. About three or four years ago I had to go infive times in six months. Last year I came in174September for three weeks because of my asthma and whenI came back my dad had put a vent, an air purifier andtile floors down in my room so.. .1 feel much better nowin my room.A couple of children with chronic conditions showed aremarkable advancement in their understanding of thehospital nurse’s role. They not only were able to give morethan one intention for the action of the nurse but alsocould sometimes interpret and compare the little boy/girl’ssituation to their own. They started to express empathy forthe role of the hospital nurse. One 8-year-old boy withasthma mentioned the fact that the nurse might feel sadabout the little boy losing his teddy bear in the hospitalbecause “it makes her think about her own young years whenshe (nurse) lost her teddy bear in the hospital too.”Furthermore, this boy referred to the feelings of the nurseas if she/he was caring for the little boy as she/he wouldcare for her/his own son. This reflects the possessiverelationship the nurse might have with her/his patient.However, these characteristics are presumed to appear at theage of twelve/thirteen (Goldberg-Reitman, 1984).In contrast, though one boy with cystic fibrosisunderstood that nurses act in a particular fashion becausethey care for the child and was able to give answers at theprototypical age level, this boy also interpreted certainactions of the nurse (e.g., her/him not giving a drink orfood before a surgery) as her/him being mean to the littleboy. This boy was also extremely upset with the nurses when175he needed a nose tube for a couple of days.Anna, an 8-year-old girl with multiple chronicconditions (i.e., cystic fibrosis, food allergies, and acongenital heart condition), showed significant advancementin her understanding of the hospital nurse’s role. Her meanlevel score on the Nurse’s Role Task was 4.25 (theprototypical level for her age is 3). She had beenhospitalized more than 10 times in her life, approximatelytwice a year. Therefore, she was familiar with her room inthe ward and felt at ease with all the hospital personnel.Anna was a very talkative and approachable little girl. Shewas curious to know more about her food allergies from thedietitian and wanted to know what exactly she was allowed toeat. It was obvious from Anna’s behaviour that she was wellacquainted with the hospital environment. Her mothervisited her on a regular basis and treated Anna like amature little girl.Her behaviour during the interview was “high—strung”and she had a hard time sitting still. Even though it wasdifficult for her to concentrate till the end, her answerswere evidently above her age level. She showed multiplesigns of metacognitive thinking, an aspect characteristic ofthe vectorial stage. For example, in the scenario “I.V.Bottles” she mentioned the following:She (nurse) thinks that the girl might be thinking(metacognitive thinking) that. . .well she might have toget a new needle... a new needle (often children thatare on an I.V. for more than a week, need a new needle176inserted) or something. She might get it in her handor her arm because my hands are free (refers to her ownsituation) because the girl is really really cryingloud and she is panicking.Furthermore, Anna could interpret the nurse’s feelingsby referring not only to her own life but also to that ofher parents, a characteristic that is assumed to appear atthe 14—year—old level. For example, in the scenario “teddybear” she described the nurse’s feelings the following way:It makes the nurse feel sad to see the little girl crybecause she might not want to see her cry. My dad feltthat when I had to go for my operation. Yeh, my mumstarted crying because of the breathing machine. Itstopped working for a couple of seconds and she wascrying a little bit because it was breathing for me.Consequently, she was aware of the fact that otherpeople do not like to see a little child suffer and she wasable to generalize a feeling among more than one person(e.g., sadness). She also understood how the little girl inthe story might feel because she had felt similarly in thepast. For example, in the teddy bear scenario she stated,“The little girl really wants her teddy bear because shemight be scared because she has to go for an operation andshe might be scared that it might hurt. I was scared when Ihad my operation. I started screaming. Every one heard mein the whole ward.”Moreover, Anna’s performance on the Task ofIntrapersonal Understanding was advanced as well. Themajority of her responses were at the 10—year—old level. Toillustrate Anna’s advanced understanding on the Concept177Task, the following response on the concept bad is given:Bad means when I yell at my mum (B), I don’t want mymom that much (J) because she yells at me too. And Ifight when I am not good (B + F)). And I don’t likeanybody (J) and I am mean (F). (R. What is happeningwhen you are bad?) I get really bad and like I feellike breaking everything in my room (B + F). (R. Andwhen you feel really bad and you want to breakeverything where do you think your badness comesfrom?). From.. . .1 don’t know.Even though Anna’s explanations of the four conceptsdid not show any signs of abstract or metacognitive thinkingas her answers on the Nurse’s Role Task did, her responsesdemonstrated the ability to describe a concept in a multidimensional fashion characteristic of a more advancedunderstanding.Anna’s performance on the Balance Beam Task wasappropriate for her age.Age ten:The 10-year-old hospitalized children with chronicconditions were considerably more responsive. The majorityof the children in this age group seemed to have adjustedwell to the hospital environment. They understood the dailyroutines and why things were done the way they were. Theyunderwent their medical treatments in a more relaxed mannerthan their younger peers because they had a more thoroughunderstanding of their purpose. The majority of childrenunderstood the reason for having to wear a hospital gownwhen going for surgery and not being allowed to eat or drinkbefore a test. For example, a boy with a congenital heart178defect gave the following answer to the nurse’s action andrationale in the scenario “hospital gown”:Put it on now . . .or I will give you a needle. She willmake him put it on. She will tell him why he has toput it on. (R. Why does he have to put it on?). So itis easier... .They don’t have to start like pulling onhim and stuff.. .try to get off the top so theycan. . . they want to cut. Your own shirt could havegerms on it.The same boy said the following in the scenario “hungry andthirsty”:Say “no” and tell him why he can’t have anything todrink. (R. Why?) Because he can’t have that before thesurgery. (R. Why not?) So you don’t, I guess, puke itup and then you choke. Because they want your stomachto be empty.Most children had a comprehensive understanding of thecause of their hospitalization. For example, theexplanation for hospitalization of a 10-year-old girl withcystic fibrosis was as follows:I have cystic fibrosis and I was coughing and it wasvery hard to breathe and then my lungs needed to be alittle bit cleared out and I also had this bug growingin my lungs and I forget what it was called but. . . andit was making more and more mucus so I had to have anI.V. and all that stuff. Now it is doing a lot better.Most 10-year—olds stayed concentrated till the end ofthe interview. Some children even wanted to complete allthree tasks. in one session. The 10—year—old hospitalizedchild with a chronic condition could make appropriatepredictions about the nurse’s action and also showed theinitial signs of abstract thinking. They expressed empathyfor the situation the little boy/girl in the stories of theNurse’s Role Task was in and imagined the way he/she might179feel and think. Often they related the little girl/boy’ssituation to their own (e.g., “Oh I know how thatfeels...”). A 10—year-old girl suffering from cysticfibrosis, for example, said the following about one of herroommates, a 10—year—old girl who was also suffering fromcystic fibrosis:She (i.e., her roommate) is so quiet and she doesn’twant to play with anyone. I think she is really sadabout something. Do you think maybe I should go up toher and talk to her?Tom, a 10-year—old boy with hypospadias, is also a goodexample of a child who showed compassion for the characterin the story and related the little boy’s situation to hisown. Tom came from Iran a few years ago and had beenhospitalized three times before. According to Tom, he hadno problem putting himself in someone else’s shoes becausehe has a dog at home which barks when he wants something andwhich he learned to understand. His mom was a nurse in Iranduring the war and she used to talk to Tom about her nursingexperiences. She stayed with him during the days in thehospital but left him in the evenings. Tom has an olderbrother at home whom he admires a lot. His knowledge of theintentions of the nurse was advanced for his age (his meanlevel score was 5.75) and he showed various signs ofabstract thinking by using concepts like “listening to yourconscience” appropriately. He often explained the nurse’sfeelings towards the little boy as her/him feeling“responsible” for the child. Consequently, the reason why180the nurse feels responsible for the little boy is because heis her/his patient for whom she/he is scared that somethingmight go wrong and she/he is to blame. For example, in thescenario “hungry and thirsty” Tom responded as follows:Makes the nurse feel responsible and scared too. (R.Why?) Because she doesn’t want him to.. so she has towatch him all the time and that is a waste of her time.Because she has to help other people that need her andshe can’t because she has to watch the kid so hedoesn’t eat anything. (R. Why is it that the littleboy is not allowed to eat or drink?) Because after thetest.. oh actually when he is having the operation. . . ifhe drinks milk he could throw up during the operationand the barf could go into his lungs and he could dieor he might have to go to the washroom while he ishaving the surgery and that will get everything messy.Then she thinks that she doesn’t know what to dobecause if she only follows him around and then thepeople will be in pain and they will need the nurse butthe nurse has to watch the kid. Then she is afraidthat she’ll . . .that the kid will eat something or drinksomething and she will be confused. . . she will beconfused what to do.Tom was not only able to interpret the intentions ofthe nurse by giving a second focus to her/his rationalebehind her/his actions but he also showed empathy forher/his role. He gave a human touch to the nurse’spersonality by describing her/him as trying her/his utmostto improve the little boy’s well-being. He acknowledged thefact that nurses can also be worried about making mistakesand that they are responsible for their actions. Forexample, in the situation about I.V. bottles he describedthe nurse’s thinking and feeling as follows:(R. What will the nurse think then?) She thinks aboutwhy the kid is calling out for help. (R. Why?) Wellbecause the kid doesn’t know what is happening... hethinks the needle might have cut his vein and he could181die or something or he did something wrong and thething is broken and his parents have to pay for it. (R.So how does that make the nurse feel?) It makes herfeel responsible because she should have told himbefore if that goes beeping, he shouldn’t benervous... .he should have been told. . . she should havetold him.His knowledge of medical procedures went beyond theconcrete dimensional thinking characteristic of his agegroup. For example, in the scenario “blanket” his responsefor the nurse’s thinking about giving the little boy ablanket was as follows:She thinks that the kid might catch a cold (if heshivers) and he might get infected when he has hisoperation. (R. Why?) Because if he catches a cold theoperation.. .part of the operation. .he could easily getinfected and then he might have to stay in for sixmonths and I don’t think anybody would like that(nurse’s thoughts go one step beyond the directobservable situation).Tom often used abstract notions such as “feelingembarrassed,” “feeling responsible,” “getting confused,”“feeling comfortable,” and “being worried” and was able tointerpret these notions in several ways. For example, inthe scenario “teddy bear” he referred to the nurse’sfeelings as follows:It makes her feel sort of responsible. (R. Why?)Because she doesn’t know where the parents are . . . butshe should know that (first interpretation why thenurse feels responsible) and also she should know whatto do to calm down this kid and she should know what tosay. . .well she doesn’t (second interpretation why thenurse feels responsible) . . so she feels responsible butshe really isn’t.Or in the scenario “blanket” he said the following about thelittle boy’s feeling and the consequent actions of the182nurse:Well he feels cold and he is maybe afraid he might wakeup his friend sitting .. .that is sleeping beside him(Tom shows compassion for other people) so he is tryingto yell for help quietly but then he is worried thatthe nurse won’t hear him. (R. So what will the nurse dowhen she hears him?) The nurse will come and give himan extra blanket and sort of warm him up and tell himit’s okay.. .1 will shut the door so the wind . . .so thecold air won’t come in and then so the kid isn’t coldany more. (R. Why does she do all that?) So she couldbe a better nurse. • .so she won’t lose her job and shecould help out other.. That’s what her job is and thatis what she likes to do so that’s why she wants to helpout people. So she is always worried what to do. Andthe kid shouldn’t be worried because the nurse isreally nice so he doesn’t need to worry.His articulate description of other people’s action notonly manifested itself in his knowledge of the nurse’sbehaviour but also in that of his mother. For example, hegave his mom advice about and reasons for bringing coffee tothe hospital.Oh she (mother) is going to get some coffee (in thecafeteria of the hospital)... I tell her all the timeshe should spare her money (advice 1).. she shouldbring coffee from home (advice 2)... it’s much better(rationale behind advice).., she has those tea cupthings that you go camping with... I tell her to bringcoffee here with that tea cup thing but she won’tlisten (stubborn characteristic of mother) and shespends her money. . .1 tell her, save your money forsomething better (advice 3).Tom’s levels of comprehension on the Task ofIntrapersonal Understanding and the Balance Beam Task (meanlevel score 4.5) were also moderately advanced. Hisperformance on the Task of Intrapersonal Understandingfluctuated. He was advanced in his understanding of theconcepts “good” and “bad” (both level 5) but not of “happy”183and “sad” (levels 2 and 4, respectively). His explanationof the concept “good” was as follows:When you help out others and do certain things. Whenyou don’t do anything bad. You recycle. . .when you don’tdo drugs and you obey the law (abstract notion). Youare helping out others.. you are listening., you areobeying the law. . . and you are listening to yourangel. .. .your guardian (your inner voice) . (R. And whenyou are listening to your guardian angel where does thegoodness come from?) Your heart (internal source).Tom was an intelligent boy who liked doing theinterview. It appeared to distract him from his ownphysical discomfort. Factors other than his chroniccondition might have influenced his advanced understandingnot only of the nurse but also of people in general. Forexample, the fact that his mother was a nurse in Iran duringan extremely stressful time of war, might have contributedto his mature understanding of the medical world. She oftentalked with him about her personal experiences as a nurse.Moreover, Tom wanted to become a heart surgeon himself inthe future which made him eager to learn about certainhospital procedures.SummaryFive quantitative analyses were conducted to examinethe research questions originally posed. Furthermore,illustrative findings were described for each age group toprovide the reader with some contextual information aboutthe circumstances under which the data were collected. Onechild within each age group was discussed in further detail.These children demonstrated an advanced understanding of the184hospital nurse’s role.Both the results of the quantitative analyses and theillustrative findings of the data will be discussed furtherin the next chapter.185CHAPTER VIDISCUSSIONThe primary goal of the present investigation was tooutline the development of the understanding of the hospitalnurse’s role by hospitalized children with chronicconditions. This chapter will address the following fiveareas: (1) the five research questions originally proposed,(2) summary and conclusion, (3) limitations of the study,(4) areas of interest for future research, and (5)significance of the study.Discussion of the five research questions.For clarity, each research question will be discussedseparately, taking both the quantitative and contextualdescription of the data into consideration.Question A. Do the mean level scores of Case’s stagesof cognitive development coincide with the mean scores ofchildren with chronic conditions on their perception of thehospital nurse’s roles (i.e., care, protection, nurturance,and teaching)?From the results obtained, it appears that theprogression of hospitalized children’s understanding of thehospital nurse’s role is congruent with Case’s (1992) stagesof development. Furthermore, these findings are supportiveof Fischer and Pipp’s (1984) theoretical argument that186changes in children’s role acquisition are related to age.In accordance with the results obtained, there was asignificant main effect for age and not for nurse functionor pictures nested within the nurse function. Nosignificant, interaction effects were found.However, this study was particularly focused ondetermining if there were any advancements in the child’slevel of understanding of the hospital nurse’s role. Thisinterest sprang from Case et al.’s (1988) hypothesis that achild’s cognitive development may be accelerated within aspecific domain when there is some sort of crisis event thatoccurs within that domain. According to the results of thepresent study, some acceleration in cognitive developmentwas found for the 8— and lO—year—olds, being of the order ofone-third of a substage (i.e., approximately 8 months).These findings support Hurst’s (see Case et al., 1988) studyabout children who experienced the loss of a loved—one priorto age five. These children showed an acceleration in theirunderstanding of death of the order of one-third of asubstage. On the contrary, 6—year—olds did not show anynotable acceleration in their understanding of the hospitalnurse’s role; nor did they demonstrate any regression intheir rate of cognitive growth within the social domain.These results contradict some studies which suggestthat a chronic condition may impede a child’s expected rateof development (Perrin & Gerrity, 1981, 1984; Watterson187Wells, DeBoard-Burns, Cook, & Mitchell, 1994; Yoos, 1987).Perrin and Gerrity’s (1984) study, for example, emphasized apotential delay in development that may occur in the contextof a chronic condition depending on individual differencesin temperament and personality, the family’s interpersonalfunctioning, social support network and finances, siblings’and peers’ responses to the child with a chronic condition,and the responses of teachers, physicians, nurses and otherprofessionals. Moreover, Watterson—Wells et al. (1994)stated that a child who grows up in a hospital setting maymiss many of the early life experiences such as certainbiological, psychological, and social events which may leadto delayed development of many psychosocial skills.Although these issues must definitely be taken intoconsideration when examining children with chronicconditions, it should also be noted that children withchronic conditions, when having the proper support andguidance, may learn from their experiences in a positivefashion. Fischer and Pipp (1984) support this notion. Theystate that environmental support is one of the most potentconditions under which spurts in development may occur.According to Fischer and Pipp, children with the propersupport and guidance from their environment may perform ator near their upper limit in the related domain (i.e., inthis study the social cognitive domain).The more advanced understanding of the hospital nurse’s188role at the. 8— and 10—year—old level may be explainedseveral ways. First, as was stated by Case et al. (1988),many specific situations that are emotionally disturbing forthe child can lead to an acceleration of the child’scognitive growth in the relevant domains. In order for ahospitalized child with a chronic condition to cope with anenvironment that is often considered emotionally disturbing(Eiser, 1990; Perrin, 1993), he/she increases the amount oftime spent in thinking about his/her situation and is drivenby his/her feelings to reconstruct a new understanding of it(Case et al., 1988). Consequently, this may result inadvanced social role understanding by 8— and 10—year—oldchildren with chronic conditions because of more frequentexposure to hospitalization and medical treatments.Second, 8— and 10—year—old children have had more timethan 6-year-olds to come to terms with theirhospitalizations and their chronic condition. According toPerrin and Gerrity (1984), school-aged children with achronic illness seek answers to their questions relating totheir illness in order to give it meaning and to give them asense of control over it. Consequently, a 6—year—old childwith a chronic condition may have just begun to seek answersabout his/her own condition and the requiredhospitalizations that come with it.Third, children with chronic conditions have frequentand prolonged contact with adults when hospitalized or189receiving treatments. These children are frequently exposedto adults (e.g., parents, nurses, and doctors) who arethemselves adjusting and seeking to understand theimplications of the child’s condition. For example,children may notice the anxiety and tension of their parentswhen they have to go for surgery or they may sense the shockand disbelief their parents go through when notified oftheir condition (Turnbull & Rutherford Turnbull, 1990).Furthermore, parents, nurses, and doctors often are the oneswho communicate with the child about the cause of his/hercondition and the reason for certain medical procedures.They also are responsible for helping the child to adjustand cope with the situation. Thus, children’s social roleunderstanding may be accelerated through their closeobservance of the adults’ perception of the situation (e.g.,parents, nurses, and doctors). For example, most 8—year—oldand 10—year—old children’s responses showed empathy andmature understanding of the hospital nurse’s role, anunderstanding that went beyond Case’s (1992) categorizationof the dimensional way of thinking. These children were notonly able to explain the nurse’s intentions for her/hisactions but they could also identify with her/his role byinterpreting the nurse’s feelings and thoughts as if theywere their own. Some children were able to speak of theirparents’ feelings relating to their child’s medicaltreatments. A remarkable awareness of other people’s190feelings and thoughts were found among children within theseage—groups. It appeared that some 8— and lO—year—olds wereable to demonstrate much compassion towards other people.Fourth, the hospital environment itself may alsocontribute to advancement in social role understanding.Perrin (1993) noted that increased exposure to the hospitalenvironment may help children to further their socialawareness. According to Perrin, hospitalization may providean opportunity for children to increase their understandingof their illness and their participation and sense ofcompetence in their care. Furthermore, a hospitalenvironment provides children with the opportunity tointeract directly with health care providers and otherchildren about their illness. A hospital stay also may be atime for children to expand their social networks in a non—threatening way because they meet other children withmedical concerns similar to their own which may in turncontribute to an advancement in social role understanding.Havermans and Eiser (1994) state similar beliefs aboutsiblings of a child with cancer. They suggest that amajority of siblings benefit from their experiences ofhaving a sister or brother with cancer. These siblings seemto adopt different values in life, feel more mature andbecome more caring toward other people as a result of theirbrother/sister’s condition.Walker’s (1993) study shows similar results. She191states that siblings of oncology patients scoresignificantly higher in five areas of prosocial behaviour(i.e., helping, giving gifts, praising, sharing, and showingaffection). Walker also suggests that a life—threateningdisease may facilitate advancement in emotional developmentby creating more opportunities for prosocial behaviour.According to the results of the present research, itcan be assumed that it is not only the siblings of childrenwith chronic conditions who benefit from their experienceswith these conditions, as was suggested by Walker (1993) andHavermans and Eiser (1994), but also the children with thechronic conditions themselves. Their personal experienceswith their chronic condition as well as its required medicaltreatments may increase their awareness of other people’sintentions, feelings, and thoughts. This was especiallyapparent with some 8- and 10-year-old children in this studywho were able to demonstrate a higher level of understandingof the nurse’s intentions, feelings, and thoughts which theywere then able to transfer to themselves and other people.This latter observation supports Case’s (1992) notionof central conceptual structure. That is, children are ableto transfer their level of knowledge within the same domain(e.g., projection of other people’s thoughts, intentions,and feelings to their own), in this case the social domain.The transfer of within-domain knowledge is supported byMcKeough’s (l992b) study, in which she used various tasks192within the social-cognitive domain. She trained anexperimental group to construct stories that were onedevelopmental level higher than those they would tellspontaneously. These children were not only able toaccomplish this, but they also transferred their learnedknowledge to other intentional tasks, such as the mother’srole tasks developed by Goldberg-Reitman (1992) and empathytasks designed by Bruchkowsky (1992). In other words,hospitalized children with chronic conditions who show anadvanced knowledge of the hospital nurse’s role may well beable to transfer this knowledge to other roles (e.g., themother’s role).Though the majority of hospitalized children withchronic conditions scored either at or above an age—appropriate, level in their understanding of the hospitalnurse’s role, a few 6—, 8—, and 10—year—old children weredelayed. Some of such cases can be explained by the degreeof illness at the time of interviewing. One consequence oftheir current condition was that their answers were shortand vague which often resulted in the examiner’s decision topostpone the continuation of the interview. Consequently,since completed stories could not be repeated, such achild’s overall score usually fell below his/her actuallevel of understanding.Some of the children’s lower scores do not have anyapparent explanation. It may be suggested, though, that193these children were still in the initial stages of adaptingto their condition or to a recent change in their conditionand that, consequently, they were not yet able to fully copewith their medical treatments and hospitalizations. Theresults of Olson et al.’s (1993) study support this notion.Olson et al. imply that the rate of expression of cognitivecoping strategies increases with age. Furthermore, theysuggest that children with chronic conditions may graduallydevelop cognitive strategies to deal with familiar painfulevents in situations specific to them. For example, in thepresent study, the examiner learned that one child whoshowed a delay in his understanding of the hospital nurse’srole had just undergone dialysis for the first time only twomonths before the interview. As a result of this newmedical treatment, the little boy would have had tofamiliarize himself with a totally new routine of havingdialysis a few times a week. His way of dealing with thenew situation seemed to be to answer the questions byescaping into a fantasy world and by avoiding any realisticconversation about the hospital nurse’s role. Possibleeffects of toxicity from inadequate excreted waste products,however, may also have somewhat contributed to this littleboy’s delayed performance on the Nurse’s Role Task.Another explanation for the delayed understanding insome children could be that at each level of developmentindividuals are functioning under certain processing194constraints (Case, 1992). That is, children can onlymanipulate a finite set of symbols (be they sensorimotor,representational, or abstract) for any single operation.Case’s (1992) model of development, with influence fromPascual—Leone (1976), incorporates this notion of limitedcapacity. Case stresses the importance of the maturity andlimited information—processing capacity of working memory atcertain (sub)stages of cognitive development. Consequently,a child whose working memory is preoccupied with processingnumerous new stimuli, such as new medical treatments, mightshow a temporary delay in his/her cognitive development.Furthermore, as was mentioned in Perrin, Ramsey, andSandier’s (1987) report, it should be stated thatdifferences in social development in children with chronicconditions may be caused by variations in individualcharacteristics (i.e., age, gender, socioeconomic status,intelligence, and temperament), and illness characteristics(i.e., severity, visibility, prognosis, social stigma, andcare requirements). Perrin et al. ‘s study emphasized thedirect contribution of various characteristics of a long—term physical illness to the development and competence ofan affected child.The number of hospitalizations (i.e., in this study twoor more) didn’t appear to influence the child’s level ofnurse’s role understanding. Some children, for example, whowere hospitalized more than 10 times were advanced in their195understanding while others were either delayed or scored atan age-appropriate level. This may be explained by thefollowing two possibilities. First, as was mentioned byPerrin and Gerrity (1984), individual differences inchildren’s personality, temperament and environmentalfactors may cause fluctuations in children’s level ofunderstanding. Second, it may be hypothesized that aceiling effect may occur for the number of hospitalizations.This may be due to processing constraints of the workingmemory which was discussed before or to habituation of thechild to the hospital environment. That is, children mayinitially grow from their hospital experiences but mayeventually adapt to them in such a way that they becomefamiliar situations for them. Olson et al. (1993) supportthis by stating that children with chronic conditions maylearn cognitive strategies for the familiar painful eventsin situations specific to their care and may, therefore,habituate to them.Through analyzing the content of the data it wasapparent that although one 8-year-old boy could understandthe good intentions of the nurse, he also referred toher/his actions as “being mean.” Brewster (1982) and Eiser(1990) support this notion. These authors state thatchildren can come to believe that doctors and nursesintentionally inflict pain. Brewster’s study, for example,found that children aged 7 to 10 years understand that196treatment is intended to help them get better but that theycan be limited in their ability to infer empathy.Furthermore, it was noted that a few 6— and 8—year—oldsand the majority of lO—year—olds could give an accuratedescription of the duties of the hospital nurse, that is,1) nurses are there to help children, 2) nurses have aresponsibility for the well—being of her/his patients,3) nurses want to improve the physical and emotional healthof her/his patients, 4) nurses also see their ownshortcomings in their care for children and have goodintentions, and 5) nurses are human and have their ownfeelings, thoughts, doubts, and ideas.Moreover, the results indicate an age—appropriateunderstanding of the hospital nurse’s role by 4—year—olds,and are supportive of Nelson’s (1986) script theory.Although a limited number of cases was examined in thisstudy and no statistical analysis could be performed,results suggest that 4-year—olds are able to predictbehavioral sequences in others appropriately. Four of thefive 4—year—olds were not yet able to understand that nurseshave intentions for their actions. In other words, they didnot approach the dimensional stage (Case, 1992). However,one 4-year—old girl showed the initial signs of dimensionalthinking by referring not only to the nurse’s actions butalso to some intentions the nurse might have for her/hisactions. The notion of a major shift in development that197takes place between ages 4 and 6 can not be fully supportedby the present study due to the limited number of 4-year-oldchildren examined.Of course, it could be argued that the advancement inunderstanding of the hospital nurse’s role by 8- and 10-year-olds could be an artifact of the scoring criteria thatwere employed. Scoring criteria of several Neo—Piagetianstudies (Goldberg—Reitman, 1992; Griffin, 1992; McKeough &Martens, 1994; Salter, 1993) along with one Piagetian study(Selman & Byrne, 1974) that examined the social—cognitivedomain were consulted in a direct and explicit attempt toinduce a common structure across age. In fact, anotherinterpreter of the current data who has the intention todiscover regressed understanding across all ages might havebeen able to reduce the observation of an advancedunderstanding to nil by searching for and identifyingconsistent signs of age—appropriate and/or delayedunderstanding among responses to different situations.While this argument has some validity, it should be notedthat 1) the present scoring system included objectivecriteria; 2) good levels of reliability emerged, that is,the criteria identified can be considered reliable as afunction of objective reliability testing; 3) as was statedbefore, scoring criteria of several highly respected studieswere consulted to obtain valid and reliable scoringcriteria; 4) although the overall mean scores of the 8— and19810—year—olds showed an advancement, by using the scoringcriteria a few observations of delayed understanding alsowere observed; and 5) although others may find alternativefeatures which do in fact differentiate responses to thevarious stories in the present data, and although othersperhaps would not choose to focus on the criteria dealt within this study, these factors do not negate the fact that thecommonalities found between subjects within each age groupare present and reliable.Although future research is obviously indicated, thepresent results suggest that 8— and 10-year—old hospitalizedchildren’s understanding of the hospital nurse’s role isadvanced on the order of one—third of a substage and that4— and 6—year—olds score at age—appropriate levels on thistask.Question B: Do the mean level scores of Case’s stagesof cognitive development correspond with the mean scores ofchildren with chronic conditions on a causal reasoning task?As was predicted by theory (Case, 1992), the childrenin this study demonstrated progression of their levels ofcausal reasoning with age. The results indicate that therewere significant differences between the three age groups.When examining the means of the three age groups on theBalance Beam Task, the 6-year-olds are slightly advanced intheir level of causal reasoning, whereas the 8— and 10—year—olds demonstrate performance slightly below but very close199to the predicted scores and correspond to Marini’s (1992)findings with the Balance Beam Task.Further discussion will follow in the next sectionwhich looks at the observed difference in level ofunderstanding between the Nurse’s Role Task and the BalanceBeam Task.Question C: Are the mean scores of children withchronic conditions on their perception of the hospitalnurse’s role advanced as compared to their mean scores oncausal reasoning?Results indicate no significant differences betweenmean scores on the Balance Beam Task and the Nurse’s RoleTask for groups 1 and 3, 6— and lO—year—olds, respectively.These results are contrary to the predictions posed in thisstudy. It was assumed that hospitalized children withchronic conditions would score significantly higher on theNurse’s Role Task than on the Balance Beam Task. However,it should also be noted that the power of the -tests forgroups 1 and 3, 6— and 1O—year—olds, respectively, was low.This means that the risk of making a Type II error is ofgreat concern. In other words, the risk of concluding thatthere are no significant differences between mean scores onthe Balance Beam Task and the Nurse’s Role Task for groups 1and 3 when, in fact, there are true differences, is high.The small sample size (i.e., only 10 subjects for each —test) may have negatively influenced the power.200Despite these statistical results it can be concludedthat lO—year—olds’ level of understanding on the Nurse’sRole Task is approximately half a substage more advancedthan their level of causal reasoning. Though notstatistically significant, these results favour thepredictions initially posed.However, a higher level of understanding on the Nurse’sRole Task was not observed with the 6-year-olds. Theirlevel of understanding on the Nurse’s Role Task, though age—appropriate, was slightly lower than on the Balance BeamTask. This could be for several reasons. First, 6—year—olds were less able on the Nurse’s Role Task than on theBalance Beam Task to concentrate till the end. The natureof the Balance Beam Task was such that it allowed for onlyone right answer and was a relatively short task toadminister, as compared to the Nurse’s Role Task, which wasa much longer and diverse task and asked for a longerattention span. Second, with the Balance Beam Task theoutcome of the question was directly observed by the child.The suspense, whether the child’s prediction was right ornot, appeared to add to his/her level of concentration. Inaddition, a right prediction gave the child a feeling ofsuccess (despite the fact that the prediction might beinsufficiently explained by the justification) which alsoadded to the child’s level of concentration.Contrary to the 6- and lO-year-olds, the 8-year-olds’201level of understanding on the Nurse’s Role Task wassignificantly higher than on the Balance Beam Task. Thisadvancement (i.e., approximately two—thirds of a substage)in understanding of the hospital nurse’s role is inagreement with the predictions originally posed. It is alsoin accordance with Case et al’s (1988) assumption that achild with intensive experience in one domain will show aslight acceleration in development in that domain but notnecessarily in another. This advancement could partially beexplained by the fact that 8-year-olds had a higher ceilingthan lO-year—olds on the Nurse’s Role Task. That is, 8-year—olds could score up to a level 6 which is 3 substageshigher than their prototypical level of performance (i.e.,level 3), whereas lO—year—olds could also score up to level6, which is only two levels above their prototypical levelof performance (i.e., level 4).question D: Do the mean level scores of Case’s stagesof cognitive development coincide with the mean scores ofchildren with chronic conditions on their intrapersonalunderstanding (i.e., happy, sad, good, and bad)?Results indicate that children’s overall understandingof the Concept Task significantly progresses with age whichsupports Case’s (1992) theory of development. However,though Griffin’s (1992) results demonstrated a consistencyof children’s performance across the four tasks, this wasnot apparent for the concept happy in the present study.202Ten—year—olds scored approximately one substage higher onthe concepts sad, good, and bad than on the concept happy.Consequently, after performing univariate tests it was notedthat no significant difference for age was found for theconcept happy. That is, the mean level of understanding ofthe concept happy by 6-, 8-, and l0-year-olds wasapproximately equal (see also Table 17, p. 157). Thisinsignificant difference could be explained as follows.First, the concept happy was presented to the subjectsas the first research item of not only the task but also thewhole research protocol. Therefore, it could be argued thatthe 10-year-old subjects were not acquainted with theresearch format yet and that their scores for this item weredepressed due to the unknown situation of the testingenvironment. A counterbalanced procedure, which varies theorder of presentation of the tasks, is recommended forfuture research to control for first—research—item effects.The question remains, however: Why didn’t 6— and 8—year—olds (i.e., their score on the concept happy was two—fifths of a substage higher than the prototypical level andat an age—appropriate level, respectively) show a similarlyregressed mean score? To answer this question, it can beargued that the mean score of the 10—year—olds on theconcept happy was artificially depressed by the low score offour children (i.e., their score was 2). Two of these fourlO-year-olds were feeling quite sick at the time the task203was given. Their performance was two substages below theprototypic level on the concept happy and one substage onthe concepts sad, good, and bad. The low score of the othertwo children cannot be explained. These low performances byfour subjects will noticeably influence the mean scores whenthe sample size is small (i.e., each score carries 10% ofthe power to influence the score). However, the followingargues in favour of their low performance on the concepthappy.Second, one could also argue that the nature of theconcept happy invites a hospitalized child to think aboutbetter and more joyful times than he/she currently is in.It can be assumed that a hospitalized child might want toexplain the word happy by mentioning happy events and/ormemories in order to escape his/her own seemingly sadsituation. As a result, an answer for the concept happy,which consists of only adding up all the joyful/happy eventsa hospitalized child might think of without referring tofeelings and judgements, is scored at a lower age—level(i.e., level 1 or 2 responses which are primarily script—based) than is predicted by theory (Case, 1992).Contrary to the lO—year—olds, the 6—year—olds scoredapproximately two-fifths of a substage higher than theirage—level on all four concepts. Some 6—year—olds were ableto mention several judgements and feelings to explain aconcept. In order to check if the content of their204judgements was understood, the examiner requested and wasgiven more justified clarifications. This advancedunderstanding is in favour of the prediction thathospitalized children are advanced in the social cognitivedomain and supports McKeough’s (l992b) transfer paradigmwhich will be discussed in the next section.Furthermore, it is interesting to note that 6- and 8-year—olds were advanced in their understanding of theconcept sad and all three age—groups were advanced in theircomprehension of the concept bad. That is, some 6— and 8—year—olds could explain the concepts sad and bad byreferring to multiple judgements and feelings which ischaracteristic of the elaborated multiple dimensionalsubstage. Moreover, some lO—year—olds went one step furtherby interpreting the word bad in an abstract dimensionalmanner. Both concepts (sad and bad) have a negativeconnotation to them which could be congruent to thesituation the hospitalized child is in. Some childrensupported this notion of a negative connotation throughexplaining the words bad and sad by referring to their owncircumstances which is characteristic of a higher level ofthinking.Through analyzing the content of the data, it wasevident that the majority of 4-year-old children explainedthe four concepts by mentioning observable events, externalactions or objects which is congruent with Griffin’s (1992)205findings. Moreover, if the child’s answer referred to anintentional state, such as feelings and judgements, this wasusually done without mentioning a behavioral event relatedto the intentional state.question E: Does advanced understanding of thehospital nurse’s role correspond to advanced understandingon another task which is social in nature? In other words,do the mean scores of children with chronic conditions ontheir perception of the hospital nurse’s roles coincide withthe mean scores of their intrapersonal understanding?Results indicate that, overall, 1O—year—olds scoredsignificantly higher on the Nurse’s Role Task than on theTask of Intrapersonal Understanding. This contradicts theidea that two tasks within one domain (i.e., the Nurse’sRole Task and the Task of Intrapersonal Understanding) thatshare the same central conceptual structure should show thesame level of understanding for both tasks and disputes thepresence of a transfer paradigm (McKeough, 1992b). However,it could be argued that the pictures of the Nurse’s RoleTask, which were specially designed for this specific groupof subjects, provide more realistic and comprehensive cuesfor children who are hospitalized than the Task ofIntrapersonal Understanding. The pictures relate to theirpresent situation and, therefore, seem to evoke moreelaborate responses from the children. In addition, themajority of hospitalized children with chronic conditions206who were examined for this research had an extensive amountof experience of being hospitalized and, consequently, werewell acquainted with the role of the hospital nurse (seealso Table 12, p. 147). As was mentioned in the previoussection, these significant differences may also be theresult of the extremely low mean score by lO—year—olds onthe concept happy which caused an overall depressed meanscore on the Task of Intrapersonal Understanding.Though no significant difference between the 8-year-oldsubjects’ understanding of the Nurse’s Role Task and theTask of Intrapersonal Understanding was found, a similarstand can be taken for this age—group. Their overall scoreon the Nurse’s Role Task was approximately two—fifths of asubstage higher than on the Task of IntrapersonalUnderstanding. They also showed a moderate advancement intheir understanding of the hospital nurse role (i.e., one—third of a substage) while their level of IntrapersonalUnderstanding appears age-appropriate. Contrary to the 10-year-olds, however, these insignificant findings support thepredictions initially posed and strengthen the notion of acentral conceptual structure. That is, a child’sperformance on two tasks within the same domain should besimilar. However, it should also be noted that the power ofthe -test for group 2 (i.e., 8—year-olds) was low. Thisincreases the risk of making a Type II error and means thatcautiousness of making a false conclusion is indicated.207That is, concluding that there is no significant differencebetween 8—year—old’s level of understanding on the Nurse’sRole Task and the Concept Task when, in fact, there mightbe.Six—year—old children’s level of understanding on theNurse’s Role Task was significantly lower than on the Taskof Intrapersonal Understanding. This significant differencecontradicts both McKeough’s (l992b) notion of a centralconceptual structure and the predictions initially posed.The sections that deal with questions A and D providearguments to justify 6-year-olds’ prototypic level ofunderstanding on the Nurse’s Role Task and advanced level ofcomprehension on the Task of Intrapersonal Understanding,respectively.Summary and ConclusionThis study provided a variety of data to analyzeperceptions of the hospital nurse’s role in hospitalizedchildren with chronic conditions. The main purpose of thestudy was to achieve a better understanding of the child’spoint of view with respect to certain problem situationsexperienced when hospitalized which are related to the roleof the hospital nurse. Another objective of this study wasto conduct a developmental analysis of perceptions of thehospital nurse’s role by children with chronic conditionswithin the framework hypothesized by Case (1992).Case’s (1992) neo-Piagetian theory provided a basis for208analyzing and interpreting the data by acknowledging theinfluence of specific factors on development. Specificfactors take into consideration the environment the childlives in and the cultural and linguistic background thechild grows up in. A hospitalized child with a chroniccondition has different experiences than a healthy childwhich have a significant influence on his/her development(Committee on Children With Disabilities and Committee onPsychosocial Aspects of Child and Family Health, 1993).The child was given three tasks (i.e., the Nurse’s RoleTask, the Balance Beam Task, and the Task of IntrapersonalUnderstanding) at his/her bedside. The Nurse’s Role Task,which was specifically developed for this research,addressed eight problem situations that were common to thehospital environment. The Task of IntrapersonalUnderstanding and the Balance Beam Task were also given inorder to detect the presence of an underlying centralconceptual structure to account for domain—specificity indevelopment as was predicted by theory (Case, 1992).Results indicated a moderate advancement inunderstanding of the hospital nurse’s role by 8- and 10-year—old hospitalized children with chronic conditions andan age-appropriate level of understanding of the hospitalnurse’s role by 6—year—olds with chronic conditions.Although no quantitative analysis could be performed, thefive 4-year-olds who participated in this study also showed209an age—appropriate understanding of the hospital nurse’srole. However, contrary to what was predicted by theory(Case, 1992), the presence of an advanced central socialstructure was not consistently apparent because nosignificant difference in level of understanding was foundfor 6— and lO—year—olds on the Balance Beam Task and theNurse’s Role Task and no congruent level of understandingfor the 6— and 10— year—olds on the Nurse’s Role Task andthe Task of Intrapersonal Understanding was apparent.Justifications and arguments have been provided to explainthese results.Though the stressful aspects of hospitalization maytemporarily disrupt the quality of children’s cognitivefunctioning, it may advance their level of socialunderstanding in the long run. By working through verystressful and sometimes traumatic events, children gain aconsiderable amount of knowledge. They learn what kind ofimpact certain pain and fear have on themselves and,consequently, they can project these experiences onto thefeelings of other people. Such working through increaseschildren’s empathetic and social awareness. Believing inand supporting children’s capability to positively makesense out of their experiences will allow them the space toadapt to and further their understanding about their chroniccondition.Limitations of the Study210The limitations of this study revolve around the extentto which the results can be generalized to otherpopulations. Generalizability depends upon the nature ofthe sample, in this case a convenience sample, and themethodology employed.The sample did not contain all possible clinicalsubjects because 1) a small non—randomized sample was used,2) some parents refused permission for their children’sparticipation, and 3) some children failed to complete allthree tasks. No reason for the lack of parental permissionwas asked for but in some cases parents reported that theyfelt their child had been subjected to enough testing. Insome other cases parents indicated that their child refusedto take part in a study which emphasized hospital nurse’scare and medical treatments because these were aspects thatcaused the child a great deal of stress and anxiety.Consequently, the nature of the sampling criteria make itnecessary to examine a larger population of hospitalizedchildren with chronic conditions in order to generalize theobtained results.In addition, the nature of the Nurse’s Role Task issuch that it asks the child about certain medical proceduressuch as wearing a hospital gown when going for an operationor not being allowed to eat or drink when going for a test.In a few cases, the scenario of the story was not applicableto the situation of the child being tested. For example, a211child with juvenile arthritis does not necessarily have toundergo surgery. Although little knowledge about certainmedical procedures usually did not interfere with theirlevel of understanding on the Nurse’s Role Task, thesechildren were little acquainted with the rationale behindthe nurse’s action. Consequently, they had difficultyresponding to some of the questions.Moreover, it was mentioned that the concept happy ofthe Task of Intrapersonal Understanding may not be anappropriate measure to obtain a maximum level ofintrapersonal understanding for some hospitalized childrenwith chronic conditions. Especially, lO-year—olds who arewell aware of their situation may answer below their levelsimply because the word happy reminds them of better timesand provokes a response containing an enumeration of eventscharacteristic of a lower level reply (i.e., a level 1 or 2which primarily accounts for script—based explanations).Furthermore, possible side—effects of medication and/orillness may have depressed some children’s level scores.Though this aspect is hard to control for in a hospitalsetting, and among children with chronic health conditions,it is necessary to take this issue into consideration whenevaluating the findings.Some of the responses that were observed in this studycould also be due to conditioning. For example, childrencould be regurgitating known approved positions or lines.212Although the examiner tried to account for this as much aspossible by having the child explain and justify theirexpressions, it may have influenced some children’s scores.In addition, the low power found in some of the f—teststhat were conducted for questions C and E should be takeninto consideration when interpreting the data. As wasmentioned in the sections that dealt with questions C and E,the chance of making a Type II error was high. A largersample size is indicated for future research to reduce thisrisk.Lastly, the constraints of time and place ofinvestigation made it necessary for the researcher toexamine a couple of children in a shorter time frame thanwas preferred. This fact combined with the distractingenvironment, of the hospital, may have somewhat depressedthese children’s scores.Overall, however, the results of this study indicate amoderate advancement in understanding of the hospitalnurse’s role by 8— and 10-year-old hospitalized childrenwith chronic conditions despite all the constraints andlimitations faced by the examiner. Furthermore, this studyhas attempted to address the criticisms of methodologicalweaknesses which Burbach and Peterson (1986) found inprevious studies, that mainly dealt with children’sunderstanding of illness-causality, by performing interrater reliability in order to minimize the effects of213observer bias and expectance effects, by obtaining high andaverage reliability coefficients for the Nurse’s Role Taskand the Task of Intrapersonal Understanding, respectively,and by providing adequate description of samples,instruments and procedures.In the next section suggestions for future researchwill be given.Areas of Interest for Future ResearchThe following two sections are similar in nature asthey both express areas of future interest for eitherresearchers or health care professionals. However, thefirst section, “suggestions for elaboration and improvementof the present study,” is derived from the current findingswhereas the second section, “suggestions for related futureresearch topics,” results from mainly the researcher’spersonal experiences and observations while collecting thedata.Suggestions for Elaboration and Improvement of thePresent StudyThough the present investigation has provided insightinto the nature of the developmental process of theperception of a hospital nurse’s role by hospitalizedchildren with chronic conditions, its results were based ona relatively small sample size. Furthermore, the nature ofthe sampling criteria made random sampling impossible, andtherefore, a convenience sample needed to be used. However,214in order to fully support the notion of advanced social roleunderstanding by children with chronic conditions and to beable to generalize the obtained results, a larger samplesize is required. This could be realized by pooling datafrom different centres which may permit randomization.In addition, the present study focused on the role ofthe hospital nurse in relation to a young hospitalized childwithin certain common hospital situations using Case’s(1992) theory of development. How does the hospitalizedchild with a chronic condition relate to other familialand/or well—known roles (e.g., the doctor, his/her mother orfather, his/her peers). Though the present data show someevident signs of transfer of advanced understanding to otherroles, this was not its original focus. Further studiesshould investigate whether the advanced understanding of thehospital nurse’s role by hospitalized children with chronicconditions is also transferred to their comprehension ofother roles. In other words, does an advanced roleunderstanding by hospitalized children with chronicconditions exist in general and, consequently, is thepresence of an underlying central conceptual structureconfirmed?It would be particularly interesting to examine if anadvanced level of social role understanding by children withchronic conditions also relates to their level ofunderstanding of how other people (e.g., the nurse) perceive215them? An elaborated version of the Nurse’s Role Task couldfunction as a basis for such a study.Moreover, the present study supported some notion of anadvanced central conceptual structure for the 8—year—olds bycomparing their level of understanding of the hospitalnurse’s role with their level of comprehension ofintrapersonal concepts. However, 6— and 10—year—oldchildren scored significantly differently on both taskswhich contradicted the predicted notion of an advancedcentral social structure. Though the possible causes of thedifferences in performance have been discussed, furtherstudy is indicated.Furthermore, the sampling criteria of the present studyrequested the examination of children with chronicconditions who were hospitalized more than once and werebeyond their diagnostic phase in order to observe childrenwho had extensive hospital experiences and to eliminate theparticipation of those children who were dealing with thestress of adapting to a recent discovery of a chroniccondition. However, there was also an indication ofregressed social role understanding by children who had arecent dramatic change in treatment and/or chroniccondition. It would be interesting to examine the time-span(i.e., how long will it take the child to adjust to the newmedical treatment and/or change in chronic condition) andthe extent of potential delay under these new circumstances.216Lastly, as was suggested earlier, hospitalized childrenwith chronic conditions are likely to be in closer contactwith adults than with their healthy peers which may have aconsiderable impact on their level of social roledevelopment. Future research should examine the amount ofimpact adult contact has on the level of social roleunderstanding by hospitalized children with chronicconditions. Case’s (1992) neo-Piagetian perspective ofdevelopment could be used to examine this because it takesinto account the influence of specific experiences on thechild’s progression in development.Suggestions for Related Future Research TopicsAs the result of interviewing 35 children with chronicconditions within a hospital setting, the researcher notonly collected data but also made many personalobservations. These observations combined with the findingsof the present study have led the researcher to thefollowing five topics/questions which she feels areimportant areas of research to be examined in the future andwhich could hopefully point the way towards futureimprovement of child care within the hospital.1. Preconceived NotionsA. Results of this study indicate a moderately advancedunderstanding of the hospital nurse’s role by 8- and 10-year-old children with chronic conditions, contrary tostudies that assumed a regressed level of understanding217(Perrin & Gerrity, 1984; Watterson-Wells et al., 1994;Yoos, 1987). This contradiction should raise thequestion of how we perceive children with chronicconditions and if we really do them justice by makingpredictions about their level of cognitive development.As Perrin and Gerrity (1984) suggest, each child isdifferent in temperament and personality, comes from adifferent family and socio—economic background and hasdifferent life experiences which also influence his/herrate of development. Individual differences inchildren’s level of understanding were also found in thepresent study.B. Nursing kardexes or medical reports often providedetailed information about a child’s emotional andbehavioral background. As health care professionals, weshould take note of such information but also reserve theright to judge for ourselves. Approaching a child with apreformed perception, which may be created by theinformation given in a kardex, might negatively influenceone’s relationship with that child. By partiallyignoring the background information given in the kardexor report, it allows the health care professional toestablish a fresh relationship with the child. Forexample, the examiner was aware of the reportedaggressive mood swings of a boy suffering from a severeform of spina bifida, but by approaching him with an open218mind it allowed her to observe the boy’s positivecharacteristics and to discover his mature understandingof both the nurse and other people.Turnbull and Rutherford Turnbull (1990) supportedthe notion of having a nonjudgemental attitude towardchildren with exceptionalities. They also emphasized theimportance of recognizing the fact that interpretationsare different from observations. That is, two mayobserve the same event but interpret it totallydifferently. For example, one professional may interpretthe aggressive mood swings of the boy with spina bifidaas attention—seeking behaviour, whereas another may seeit as an expression of pain and frustration. The latterprofessional will likely deal with the child’s behaviourin a more positive manner which will minimize its impactand enhance the relationship with the child.This leads the researcher to conclude that there can beno sure way yet of predicting the level of social-cognitivedevelopment of hospitalized children with chronic conditionsand brings to the surface the following question: Do healthcare professionals have preconceived notions about childrenwith chronic conditions with respect to their socialcognitive development and how do these notions effect theirinteraction with them?2. The effectiveness of self disclosure.Self disclosure is a technique which may be used by219health care professionals when dealing with a child’sinitial fears, stress, and anxiety with respect tohospitalization, new medical treatments, and chroniccondition. Dealing with the stresses of a chronic conditionin a warm and understanding environment will enhance thechild’s self-understanding and understanding of others. Itwas apparent in the observations that a child has to adaptto and familiarize him/herself with the use of new medicalequipment/treatment in order to overcome the initial stressand anxiety. For example, a child might respond in shock tothe initial use of a ventilator. However, by sharing one’sown related medical experiences with the child, eitherpersonal or observed, the child’s fears might be reduced andhe/she may grow from the new experiences.This concept is referred to as appropriate use of self—disclosure by Gazda, Asbury, Balzer, Childers, and Walters(1984) and is considered an appropriate interpersonalcommunication skill by Turnbull and Rutherford Turnbull(1990). For example, one little 6—year-old boy with cysticfibrosis, who participated in this study, was very upsetwhen he was told that he had to begin using an aerosol maskseveral times a day. Through the researcher’s sharing ofher personal experiences with her initial agony andconsequent pride toward the use of a cane, the boy’s unhappydisposition was observed to change instantly. He appearedto be relieved and less frustrated with his newly acquired220mask and showed curiosity and pride towards not only hismask but also the cane by walking and running around withthem throughout the ward. Another example of effectiveself-disclosure happened with the 8-year-old boy with spinabifida, who was mentioned in the previous section. This boywas characterized by the nursing staff as having aggressivemood swings. His limited range of motion (i.e., the boy wasparalysed from the waist down) seemed to frustrate him tothe extent that he often wanted to physically hurt the staffand use abusive language. Through sharing personalexperiences of frustration and anger toward a mobilityimpairment the examiner suffers from, the boy, who initiallydid not want to cooperate with the interview, calmed downand responded to the questions in a very mature, cooperativeand empathetic manner. Consequently no signs of aggressivebehaviour were apparent during the interview and a closefriendly bond was formed between the examiner and the boy.The researcher observed the benefits of self—disclosurein helping children to cope with their chronic conditionsand hospitalizations. This leads to a second question whichis the following: Is self-disclosure an effective techniqueto be used by health care professionals when working with achild with a chronic condition who is upset, frustrated andconfused?3. Children’s understanding of their own reason forhospitalization and the nature of their chronic221condition.Though children’s understanding of their reason forhospitalization was not the focus of this research, eachchild was asked if he/she knew the reason for his/herhospitalization. consequently, the data of this studyindicated that both 4- and 6-year-olds had littleunderstanding of the reason for their hospitalization.Four—and 6—year—old children either did not know the reasonfor their hospitalization or gave a simple answer referringto external symptoms. On the contrary, 8— and 10—year— oldsbegan to have a good comprehension of not only the reasonfor their hospitalization but also the nature of his/herchronic condition. These findings support Bibace andWalsh’s study (1981) which demonstrated that hospitalizedchildren’s understanding of illness—related conceptsprogresses with age.Moreover, Shagena et al. (1988) suggested thatchildren’s knowledge of disease concepts may be advanced byproviding them with health-related information at orslightly above their level of understanding. However, inorder to design an effective communication program forchildren with chronic conditions, Brewster (1982) stressedthe need for health care professionals to gather informationabout how each child views the reason for treatment firstbefore giving information.Furthermore, Haight et al. (1985) stated that the222health care professional should also realize that childrenare not totally passive. Children often strive actively tounderstand many aspects of the medical interview.Consequently, another possible research topic to beexamined would be: How does the child’s understanding of thereasons for his/her hospitalizations when suffering from achronic condition develop and how does this level ofunderstanding benefit the child’s well-being during thesehospitalizations?4. Side effects of certain medication.Hospitalized children are often under the influence ofpain medication such as morphine and codeine. Though themajority of health care professionals and/or educators areaware of this, it is easy sometimes to forget or overlookthis aspect. Often with good intentions (e.g., wanting todistract the child from his/her pain) we might ask too muchfrom the child or underestimate the child’s potential levelof functioning. For example, the side—effects of morphineand to a lesser extent codeine may cause the child to feelextremely sleepy, light headed, and dizzy and to have a lowattention-span (Reiss & Evans-Melick, 1984). Data from thecurrent research indicate that children under the influenceof narcotic medication were considerably less able toconcentrate and, consequently, may have scored below theirlevel of development.These observations lead the researcher to the following223question: How conscious are health care professionals of theside—effects of certain medication in their day to dayinteractions with the child and do they sometimesoverestimate the child’s level of functioning when beingunder the influence of such medication?5. Parental involvementThe data indicate that children as old as four willcomprehend certain medical routines when these routines areexplained to them, especially by the family. For example,Denise, the 4-year-old girl with cystic fibrosis who wasdiscussed in Chapter 5, showed a moderate understanding ofthe purpose of a gastric—tube. Her mother and grandmotherdiscussed medical procedures with her in an open andsupportive fashion which allowed her to express herunderstanding of phenomena which lay beyond the boundariesof perception alone, a characteristic of children at thisage—level (Perrin & Gerrity, 1984).Brewster (1982) supported the involvement of the familyto help the child adjust by concluding that the temperamentof the child, the severity of his/her illness, andparticularly the coping style of his/her family, seemed tobe the more significant predictors of adjustment totreatment. Furthermore, Perrin, Ayoub, and Willett (1993)stressed the importance of the joint contribution of thefamily to the adjustment of a child with a chroniccondition. Perrin et al. emphasize the need of clinicians224to collaborate with parents, teachers, and others whoparticipate. in the life and care of the child in order tounderstand the complexity of influences by maternal, family,and illness—specific characteristics.Consequently, the following question can be raised:What is the effect of the joint effort of health careprofessionals and parents when explaining certain medicalprocedures on the child’s emotional well-being while in thehospital?Significance of the StudyThe detailed outline of how children at different(sub) stages of development perceive the hospital nurse’srole, which was provided in Chapter 4, may give health careprofessionals a more accurate knowledge of how hospitalizedchildren at different ages may perceive their role. It mayalso prevent health care professionals from eitheroverestimating the conceptual sophistication with which theyoung child reasons about the motives behind medicalprocedures or underestimating the older child’sunderstanding of these motives. When health careprofessionals are aware of the fact that, for example, a 4—year-old child has trouble with understanding the intentionsbehind their actions (e.g., medical procedures), they canadjust their way of interacting with that child byunderstanding the child’s perception of the situation (i.e.,mainly script-based) better and by lowering their225expectations.Another unique contribution of this study is that ithas offered a different outlook on the social—roledevelopment of hospitalized children with chronicconditions. Though several studies argued for a potentialdelay in cognitive development within the social domain bychildren with chronic conditions (Perrin & Gerrity, 1981,1984; Watterson—Wells et al., 1994; Yoos, 1987), the presentstudy supports an advanced understanding of the hospitalnurse’s role by 8- and 10-year-old hospitalized childrenwith chronic conditions, being of the order of one-third ofa substage (i.e. 8 months). An advancement of 8 months innurse’s role understanding by 8— and lO-year—olds withchronic conditions can be considered clinically significantand needs to be taken into consideration when interactingwith these children. Health care professionals need to beaware that some children with chronic conditions have abetter knowledge of other people’s feelings, and thoughtsand may be approached in a more mature manner whenexplaining medical procedures to them.226C)00OOC)CI)Qf-.U)PittbD00O0-b0i—’CDcn•H0-H(DOCDCD0P)-3‘1U)H1PJCD0C(DHHU)OO•WH-H(tWhiU)ib1p3rt(fl’H‘-11t-CCDCDU)CD••0r1H•(DH0))-‘HPiCD•dOHD•I-’••0CDHCDbi-i‘dU)LrtCDCD-C)•çtP.-•-‘xJOU)p)-p3C)1P)•CZ-’DU)(flCD-(DEn(flU)ObI1U)C)WOHCDO(D(DHCDnH00)-CDct.Q’<03(fl•CDCDCfl•(DP3ct•ci-ctOZ-(flOCD-OCD0)--0-O--CDp3-ctHCiOIIOOH0O•EnHPiCDct..q••P)(flH•ci--H--bil••OHOctici-H-HO•C).Cfl•O•fl.i<F•N.Ci2t’<10)CD•OJCD-C1O-O3‘21CDOD)P)•0)O0-DR—.d•—0(D’R’Of-••••ZI-iU)HCl-H“0)ctcU)CDORI-•0<—‘1EnCD-(DjCDU)—Cl)U)CD••0—s)HCDCD•CDH-0—.HOqcl-H.p)CDR’‘dR-’-ct0DOI-QP3‘-<---ctp)HHDHP)Ci)0•OOhi’—frj-O)—(I)P3U)It)I—’IH--xjH-I-OI-ct•OCDP)iP.(Df-••EnC)U)bPOU)cti-CDucN-.—.P3CDH-0)c-I----CDH(D-H-P)U)CDCDrt(1)0)•t’iCDHHU)CDH<‘<H—-En.En-)1OCD•HHP)’.Dct-HCDci-IHP)HP)I—<H0DH•OCDH•Oci-bi••-O03-I•I-CDCD(DC)-JM-hC03P)CDtj(D•I-b•rtOH0CD(Dtic-i-P)0H<—C)•U)C)(flU)•t1iHCDH’OH-P)CDP)0HOwU)En.CDH”0CDcl-tiH0)HC)tiP)Ol-•P)Hci-HZ”CDcl-HCDCDtibH,I-’H-CD—.HH—-.03—’H’dqH—.H.‘.DiHc-I-HI-Hti•QCD“C)EnHCDH•CDP)ci-O(DD(DD‘-<t-•CDH-Efl(DCDJHLQD0CDU)H-‘En—Icia’,I—(DC)C)U),10J.D‘.0)U)F-P)bPJ’—HOU)’.DO’)HCD0j(1)CDQC)—.C)OCDt-bOfJ•<o-’•PEn•—H-ti’.D-(flU)•too<Qç-i-(lU)-I-..<.00”U)cttiC)EnP)’djCDtsti•P3HH-O1OHCDH-ICDct•C).—0)I-•<(DHHHHtiC)ri-’—O0P)CDCD0Ici-0—H-OCD0CD(flU).CDC)Hrl0U)F-H’dW0OH-U)IHEn<Hø<HH•P3CDOCD(1).U1ctOU)tiP)U)CDQCDcl-f-’HOCl)(iCD•EnHcI-O•U)tiHHHU)ct-H’,HH-CDO’HtiU)•CDQO00CDtitiC)HH.ci-c-I-ti).4::.j_.C)—a’•CDCD03H—)P3-iiC)•<Ici----00CDoi00HCDEnci-0H-U)CDdCnCD0Pitt030)HCC)tiH•HNCDHH•Hci-Oct(D0CDCD0CDCDCDCDti01ctGHtI)H-Oi-JtsiP3U)titi1C)OO‘.DNH—HzIC0)CDH(nc-i-H-U)H—rdCDICD—‘dQjC)‘.01-h01-C)HH-tiP)dHP)•‘dtiCDHIU)CD0)0)U)rtci-Hti(.i(D—.1(J’JttHHOHH01J01(-‘)itt•0.P30HHH-’---H-0‘.001H—HH0—l-C)•IlEnOCD•IciU)•U)‘-0U)U)•CDBurbach, D.J., & Peterson, L. 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AmericanJournal of Diseases of Children, 137, 874-878.232C)OIDO0ctH•OZfloP)OCD(flOjP)P3’-<CDCflP)CD9)I-’OCnP)bP)DH•(DctC)HCDOHOUE’JtlHd0CDC)OWCDOWP3CDP)HHCtCDCI)HH-P)P)W(DCD‘dCiOCl)H-Cl)ctc-t-Cl)CflP)irtP30rtf-0WH0H-HctWrct0dCDP3C)tH•P)OCDH-CDCDctrtOH-0HH•H•)-’-OH•OCDCI1(D(DWP)OHCtP30(D<H(DOH•O01CflH•ct003CDrtP)P)rt1$1CDCDPJDrt•IIH(l)•-tH--Oct‘-<CDP)••H-’-<CDirtOCD•P3W—CDWOWWW030CDrtCD•CDCDH)H-C)Hrt••--rtOW0OçtHtctHP)P3()P3-i-OrtCD-H-OO-H,CD-0-D-03-F--H--F-’--I-’tl03ObIP30-W0•H,L.)P)CDjP3tiI--’,HH-ctri03-htJqOCtCIqn<•rntxjf-’HP)•CD•3H•—C()OOOH-••ct•‘-CD•0•(flt3’C)OCDq•CD•rtOO•i•Ob•C)CD03.WP3•P3-H-’dC)0HOP)—CD—.En—’h—P-C)O.fl•H-ct-•C)EnHrt.•H<P3F-HOHrtH‘CDEn-(D’<)030—’HEft-OCDOR’ct(DDODDCDPJCI)1H•0HCDH-’1OJ-1-0triM-t’PJCDH03C/)CDH-3D0tiCD0H•C)(31H-C)0DH-‘-<1P3P3HCflbIH-U)Dct<EftH)CDC)O‘-H’——P)—P)CD0<H-ct(3(nO)CD-qC)ctO’<”1CDWOCD3h-•O-DCDH-CDCDC4••‘-CDrt-CDCDH•HOWO’I-’H1CDCl)••HI-’-b03‘<CDCDCDCDEn0CiH,IqCnCDOHrtOCD0CDOO0HP)frH-0C1)rtOd-tWCDH-OCDW•ct0-c-tCDOCDCDH-En(-)CD-ctrt”—CDH-C)<H-CDQPjWCDH--0jCDH1ct-ICDCflCD•çt’030tn•(D•HH-HP3t’3CflCDP.-<0ctH-3O•rt•4I—’’xiHCDct•EDH-PJHC)—lrt-•••P3OCDHHOH-0•P3,.H-U1W•CD.rtH-flH(fl••-C)HP)C)hCD,<HH-•‘0.s’-Cl)i-3••rI‘O-H-0—0)—-.O-0•P3H-••H,H-CD0-0iCDCD’OI-1HF--’I-Hictt-hCD—ctHCDYCDOOPJH-W0R’01.0CD1.00CD0CD—.PHOCDHO•OtftHCDOE/-03•‘riH(11.0CD(1(11O0IH-OH<CDP)‘riIO4—J0II0)H-1.DH-OOCDH--0GHCDOCDO)H—Z—ct(1CD—CDOOC)000HH-rIHr10(1OCD•••CtCD•HfrtCD’—0)-P3‘CD01.0(1rtO(DH(1aiqCDct1.0H-H’--OCD•ctCD•CDCDrtH•ct•0)H-P3•II03‘tjH-P3rtq03••Cl)l)2jH4OC),H-(10H-rt-P3CDH--0-W0rtOba’-(1CD1P3H,H-CDWOH-bbictHH-ctHP3•H-(1CDctH-P3CDCD•0O•cttxiP3H-CDH,0CflP3H-RHP3(ftP)O-<WP3‘-<OH0H-En•—.0(t—.P3C)0(1ct0-Cl)OH,0HHH-ctCDWOCDH••CDCD003(1H,P3Hl.0)flH,HZCD<P30H-<H1.0CD—.100OHqt-H-CctCDHH03HP3CDCD••3-<OCDWCDiCDH-b’—HO1.OH1.DH-HH•Cfl00rtrtCDP3CDct0H(1-<03H-(ftCD0HO(I)CI’)(3C)HHE!)P3(1HP3H,HO)0rtMCDH-H0‘<H(1rtOdOHOJJH—.bCD)Q)OH-NCDIctçt(fl0)”Cfl0(t0)HCD-.J-oH-•OWct•rt-rtI-Wb0•HCDI—’0WHCDCDHH•CDl—F-1<ct-—.<H-0<CDH-CDI-3P<0-3W<3ZCt)H--WCflOCI)CDI-H,I-D)(fl9)0)-3’-<I-b0)f—CDl—’9)Wct-0P’OOrt-“dC--CD0-ctCDHci-.QH--D(I)Cl)I1IICDbOct-CD$1CDCD0-ct-W00CDH-a(DH-—0NH-P)H-‘CD-CDLQ<CD•CDI11ctF-’NUlOtH•CDH-b•CDd•0)W0)0•c1-Cl)H-H•(flCI-•CDW9)—CDHHdH-Cl)•ct3CDCI)WOCDCDct-CD0•(l)Ci-W-cl•-•hF--•O1-CDCtH-’0CD-•froo0W’-<HH-OHCDH-0H000)-0)0iO-<CDCDZHr-!j(.)()(fl00••Hti0HHII-j••••H-WCD(D(D•I0•ctc’H-LiW0•0HOCDi-0WI-(fl‘-<H-0)-0)-3•H9)Ct)•3DCD9)•I1•00)•W•0—.M1•ci-F—’51CD0f-(D•CJ)CDCD4-HH-Ct)I<HF-—H-•H-WCD•Cl)H”t1-.Q•0)C2Cfl•00-‘sD•ci--(flC))-‘CD--%ci-H-CD0-Cl)OHH--1•I1--OH-HçtØ00CDf-H----9)-HDb—.HH-0HI)QOoDH-•HUR-U1D<HciH-O-D)HCDHi•-He’Z—WO0-CDW‘dCDH-OCDOI-HDWHOO0Cl)<•HCl)CD—1U)CDq—0O--H-H10•(D—HHIJiCfl—.••9)••‘—•R-0CD•0—Or-•-•OCDOCDU1’dHi<0)•CDHCfl•Cl)-(l)H-H-0•Cl)‘<IH-D••0)ctO-DJZOWI-0C19)C/)1.U)H---Jci-49)0JHCDH-H-0.DCDH00OLQ(Dct_H-‘-3•0F-9).D1(D—-39)C.•H—9)I-CflctCD9)-Icl-OCD0I10H-H‘d0H••OCDI-bIIPJ‘XJH-.Il‘-<HMI-0dP)OH-0X0H-CD-0OHCD0)WH-LJ.CD0(DM0)1bi)I-•CD’-H-0t_P<0•I1•CDU1H-HH-PjZLQHCfl(DCDWHCDP.CDI-H-’dq—0dMOH-<(flU)H-CDHCDHH-H-0-0••H-ct(D9)Io11b(Dci-‘-H-H-O)ct0Qct-•H-O(I)MHI—br1-(flCDCD0’-dCD’-dH-9)OH-CI)9)—H0O’tU1HHCD9)b00“9)Q-<.(DOHH-0)H-(DCDOH‘-CDCDHCfl0’-<H-CD••I-H-0•CDCD0)QH-0(DH-CD09)b<3QH)Cl)-O)HO<ct-CDHWI-bCl)0•b-CDci-9)0)Mct-’DU)H-H-OCDCl)H0CD‘.DF-N0HH-Hh9JD‘.DO’—t1••HU)9)WO-.)9)CDct0-H-ct-H(nOH-11•9)H10CDct’d•CD.P9)(nH-H-I-bCDHP‘tt’D0F-0)Cl)•CD9)ctCDci-(flOCD—CDH-CDMH-ct-•Lct-H-W‘<U)t0•0000)-M9)-‘ctO•••00)’—‘.D09)•0H1319)•H-H-s(DH0Cl)-0OIIct-ZCD•Cl)‘-QCDZ•-0ICDct-H-II0‘—I-H-ci-CD01(l)-—H-qCl)0‘-)1CDH0HCD0)0’HIH-—1OP.••O-10)H-CDIQI-.)0‘<OCl)DCflH9)Oct-HIOH-ct-ci-HNO9)CD‘.DCl)ct0H-H-•H-0)-o)H-0•9)ct-C!)qo‘tICDO.ctH0)H0)H-Hii0OH)9)0—OQJHCl)H(fl•ctCDCDH-baH-OIICDI-bCD0‘<0)-CDCDCflCDI<H-OH-•H-HH-U)H-Oci•9)HçtWCfl0OS0)-0)HCD(flPJH-HCD0H-H-W•0)Whaley, L.F., & Wong, D.L. (1991). Nursing care ofinfants and children. St. Louis, MO: Mosby.Whitt, J., Dykstra, W., & Taylor, C. (1979). Children’sconcepts of illness and cognitive development. ClinicalPediatrics, 18, 327—335.Wilson, E.O. (1975) Sociobiology: The new synthesis.Cambridge, MA: Belknap Press, Harvard University.Yoos, L. (1987). Chronic childhood illnesses:Developmental issues. Pediatric Nursing, 13, 25-28.235Appendix AAmerican Nurse’s Association Standards ofMaternal and Child Health Nursing PracticeStandards were obtained from Whaley and Wong (1991, p. 22).Standard IThe nurse helps children and parents attain and maintainoptimum health.Standard IIThe nurse assists families to achieve and maintain a balancebetween the personal growth needs of individual familymembers and optimum family functioning.Standard IIIThe nurse intervenes with vulnerable clients and families atrisk to prevent potential developmental and health problems.Standard IVThe nurse promotes an environment free of hazards toreproduction, growth and development, weliness, and recoveryfrom illness.236Standard VThe nurse detects changes in health status and deviationsfrom optimum development.Standard VIThe nurse carries out appropriate interventions andtreatment to facilitate survival and recovery from illness.Standard VIIThe nurse assists clients and families to understand andcope with developmental and traumatic situations duringillness, childbearing, childrearing, and childhood.Standard VIIIThe nurse actively pursues strategies to enhance access toand utilization of adequate health care services.Standard IXThe nurse improves maternal and child health nursingpractice through evaluation of practice, education, andresearch.237Appendix BStandards for Nursing Practice in British Columbia, CanadaDeveloped by the Registered Nurses Association of B.C.Standard ISpecialized body of knowledge: Bases practice on nursingscience and on related content from other science andhumanities. For example, a nurse shares her/his knowledgewith clients or others.Standard IICompetent application of knowledge: Diagnoses actual orpotential problems and strengths plans interventions,performs planned interventions and evaluates outcomes.For example, a nurse sets priorities when planning andgiving care and evaluates client’s response to interventionsand revises them as necessary.Standard IIIProvision of a service to the public: Provides nursingservices, coordinates activities and collaborates withothers in providing health care services.For example, a nurse explains health care services toclients and others.238Standard IVCode of ethics: Adheres to the ethical standards of thenursing profession.For example, nurse acts as an advocate to protect andpromote a client’s right to autonomy, respect, privacy,dignity and access to information.Standard VSelf—Regulation: Assumes primary responsibility formaintaining competence fitness to practice, and acquiringnew knowledge and skills.For example, nurse invests time, effort or other resourcesin maintaining knowledge and skills required for practice.Standard VIResponsibility and Accountability: Maintains standards ofnursing practice and professional behaviour determined bythe Nurses (Registered) Act, RNABC and the practice setting.For example, a nurse is accountable at all times and takesresponsibility for own actions.239Appendix CThe Nurse’s Role TaskThe nurse’s role task consists of eight drawings thatdeal with the real-life social experiences a childencounters in hospital. There is boy’s and a girl’s version.Two drawings represent each category which illustrates therole of the nurse. These categories are nurturance,teaching, caring, and protection. Each story involves amini-episode in which a nurse interacts with the child inone of the four ways.After the child has been told the story by showing thepictures, the following standard questions, adapted fromGoldberg-Reitman’s (1992) questionnaire, will be asked inthe order indicated:* How do you think the little girl/boy feels?* What does the nurse do? Why?* What is the nurse thinking? Why?* How does the nurse feel? Why?* What does the little girl/boy do then? Why?* What is the girl/boy thinking then? Why?* How does the little girl/boy feel then? Why?Each story has the same structure and is followed by thesame set of questions.240Figure C—i. Graphic representation of Protection storieswith a girls’ and boys’ version (i.e. intravenous bottle andbathroom, respectively).241dTitrIiz -‘ I rnFigure C-2. Graphic representation of Teaching stories witha girls’ and boys’ version (i.e. hospital gown and hungryand thirsty, respectively).246(iiJ‘jorr-z01-x.Jco(-cc”C’ 0 0>cc0J,e‘J)•1El)-IIL(E70EfFigure C—3. Graphic representation of Nurturance storieswith a girls’ and boys’ version (i.e., teddy bear and hug,respectively).251P01 t’)C’9U)3:SI-1w£F.I.“Iu{..LQuJbLTr:3-4U)U-IIf)“4xCIxt’J‘-7’8 —Ic’lXr Qzo[(L0I1..£1U,U,1Figure C—4. Graphic representation of Care stories with agirls’ and boys’ version (1. e •, yucky and gucky and blanket,respectively)256rr1Izif’ C 0110’ r (pt’J.OilIi zo zC (TI D LI’ 0 LI’ 0 z 0“IS\‘(IN1 (51‘7:.1I,CAppendix DProcedures for Solving the Balance Beam Task4 YRS (predimensional strategy):Classify Side A w/r* WeightClassify Side B w/r WeightIf A (or B) Big w/r WeightAnd Other Side Not,Predict That A or B Will Go Down (or vice versa)(otherwise Guess)6 YRS (unidimensional strategy):Count Weights on Side A QWeight (A)Count Weights on Side B QWeight (B)Compare MagnitudeIf QWeight (A) > QWeight (B) (or vice versa)Predict That (A) Will Go Down (or vice versa)(otherwise predict “balance)8 YRS (bidimensional strategy):Count Weights on Side A QWeight (A)Count Weights on Side B QWeight (B)Compare Magnitude .Store.Count Distance on Side A QDistance (A)Count Distance on Side B QDistance (B)If QWeight (A)- QWeight (B)And QDistance (A) > QDistance (B) (or vice versa)Predict That A Will Go Down (or vice versa)(otherwise proceed as at 6)10 YRS (integrated bidimensional strategy):Count Weights on Side A QWeight (A)Count Weights on Side B QWeight (B)Compute Different .Store. QDiff (weight)Count Distance on Side A QDistance (A)Count Distance on Side B QDistance (B)Compute Difference .Store. QDiff (distance)If QDiff (weight) > QDiff (distance)Predict Side with Greater Weight Will Go DownIf QDiff (distance) > QDiff (weight)Predict Side with Greater Distance Will Go Down(otherwise predict balance)*w/r = with regard toFigure D-1. Procedures used by children at different agesfor solving the balance beam task (Case, 1992, p.94).261Appendix EThe Dimensional Balance Beam TaskThe test instrument of the balance beam task contains awooden balance scale and ten metal washers. The arms of thebalance beam are supported by two upholders to prevent themfrom going up and down. The total length of the arm is 32”and has four pegs on each side of the fulcrum. The distancebetween the four pegs on each side of the fulcrum is 3 in.Subsequently, the distance between the two closest pegs fromthe fulcrum is 6 in., 3 in. on either side.Figure E—l. The dimensional balance beam instrumentDimensional balance beam tasksThe balance beam tasks are described as follows. Thesubjects have to evaluate and coordinate the differences inweight and distance in order to solve the problems.1. Substage 0 - Operational Consolidation6 2I I I I I I262PredictionWhy?2.3 7I IPredictionWhy?3.substage i - Unifocal CoordinationPredictionWhy?4.4 5I I IPredictionWhy?2635.substage 2 - Bifocal Coordination4 4I I I IPredictionWhy?6.5 5I I I I I IPredictionWhy?7.substage 3 - Elaborated CoordinationI IPredictionWhy?2648.2 4I I I I IPredictionWhy?9.Substage 1 - Vectorial-Unifocal Coordination1 3I I I IPredictionWhy?10.1 2I I I IPredictionWhy?265Appendix FTask of Intrapersonal UnderstandingI. HAPPYWhat does it mean to be happy?What else can it mean?What is happening when your are happy?When you are happy doing (child’s example), wheredoes the happiness come from?266II. SADWhat does it mean to be sad?What else can it mean?What is happening when you are sad?When you are sad doing (child’s example), wheredoes the sadness come from?III. GOODWhat does it mean to be good?267What else can it mean?What is happening when you are good?When you are good doing (child’s example), wheredoes the goodness come from?IV. BADWhat does it mean to be bad?What else can it mean?268What is happening when you are bad?When you are bad doing (child’s example), where doesthe badness come from?269Appendix GLetter of Information to All Physicians ofBritish Columbia’s Children’s Hospital.270THE UNIVERSITY OF BRITISH COLUMBIADepartment of Educational Psychologyand Special EducationFaculty of Education2125 Main MallVancouver, B.C. Canada V6T 1Z4— /— / 1994 Tel: (604) 822-8229‘‘ Fax: (604) 822-3302Dear Physician,I would like to inform you about my study ofhospitalized children’s understanding of the nurse’s role.This study is being conducted in B.C.’s Children’s Hospitalfor my doctoral research in Educational Psychology andSpecial Education at the University of British Columbia. Thestudy has as its focus the ways in which children ofdifferent ages understand what a nurse does for the childwhen he/she is in hospital. This study will be useful inimproving and facilitating the explanations to children ofservices currently offered by nurses (e.g., medicaltreatments and daily care). This study has been approved byboth the U.B.C.’s Ethical Review Committee and theBCCH In-Hospital Review Committee.Forty children (10 each at four age levels; 4,6,8, and10 years old) with various chronic conditions will beselected by using the nursing kardex or nurse and/or parentreport and appropriate consultation of nursing staff.Children will be excluded from participation in the study iftheir life is threatened, if it is their first in-patientadmission, if they are emotionally disturbed, or if theyhave a neurological deficit. Children that are selected willbe asked to complete three easy-to-do tasks that childrenusually find fun. Tasks will be given during sessions ofhalf an hour each at the child’s bedside in his/her hospitalroom. The tasks are usually beneficial to children becausethey are temporarily distracted from hospitalization,treatments, etc. If signs of fatigue are observed by theresearcher and/or mentioned by the child the session will bepostponed or discontinued. Parents are allowed to be presentduring the research if it makes the child feel morecomfortable. All the data will be collected by myself. Ihave a master’s degree in Clinical Pedagogics and haveexperience with working with children with chronicconditions.If one of your patients has been selected for thisresearch and both the child’s parents and the childhim/herself have agreed to cooperate, you will be notified.Should you have any questions or concerns, either I or my271dissertation supervisor would be pleased to discuss themwith you (Els Eikelhof, 222-8164; Dr. Marion Porath, 822-6045). Thank you very much for your interest andcooperation.Sincerely,Eikelhof, MA272Appendix HLetter of Notification for Nurses on Six Hospital Units273THE UNIVERSITY OF BRITISH COLUMBIADepartment of Educational Psychologyand Special EducationFaculty of Education2125 Main MallVancouver, B.C. Canada V6T 1Z4Tel: (604) 822-8229— / — / 1994 Fax:(604) 822-3302Dear Nurse,I am a doctoral candidate in Educational Psychology andSpecial Education at the University of British Columbia. Iam doing a study on hospitalized children’s understanding ofthe nurse’s role and would like to ask for your assistancewith this study. The study has as its focus the ways inwhich children of different ages understand what a nursedoes for the child when he/she is in hospital. This studywill help nurses to improve and facilitate theirexplanations to children of the services they offer (e.g.,medical treatments and daily care).Forty children (10 each at four age levels; 4,6,8, and10 years old) with chronic conditions will be selected byusing the nursing kardex. Children that are selected will beasked to complete three easy-to-do tasks. Children usuallyenjoy these tasks very much because they are temporarilydistracted and are able to express themselves about theirhospital stay in a non-threatening way. Tasks will be givenduring three sessions of half an hour each at the child’sbedside in his/her hospital room. If signs of fatigue areobserved by the researcher and/or mentioned by the child thesession will be postponed or discontinued. Parents areallowed to be present during the sessions if it makes thechild feel more comfortable.I would like to ask you to give a letter to the parentsof each selected child. In this letter parents will be askedwhether they do or do not want to be contacted in relationto this study. This way the privacy of the parents and thechild will be respected. If they agree to be contacted Iwill then approach them in person and ask for their consent.Please indicate in the space below if you do or do not wantto cooperate with this study and return this form to me assoon as possible. If you have any questions do not hesitateto contact me (tel: 222-8164) or my dissertation supervisor(Dr. Marion Porath, tel:822-6045).I,__________________________________ would like tocooperate in this research and am willing to contact the274parents of selected children in relation to this study.YES_______NO_________Thank you very much for your interest and cooperation.Sincerely,Els Eikelhof, M1.275Appendix IParental Contact Form276THE UNIVERSITY OF BRITISH COLUMBIADepartment of Educational Psychologyand Special EducationFaculty of Education2125 Main MallVancouver, B.C. Canada V6T 1Z4Tel: (604) 822-8229— / — / 1994 Fax: (604) 822-3302Dear Parent,Els Eikelhof is a doctoral candidate in EducationalPsychology and Special Education at the University ofBritish Columbia. She is doing a study on hospitalizedchildren’s understanding of the nurse’s role and would liketo contact you regarding this study. Her study has as itsfocus the ways in which children of different agesunderstand what a nurse does for them when they arehospitalized. This study will help nurses to improve andfacilitate their explanations to children of the servicesthey offer (e.g., daily care and medical treatments).Therefore, your child is asked to participate in the study.If you and your child agree to take part in the study,your child will be given three easy-to-do tasks. Childrenusually enjoy these tasks very much because they aretemporarily distracted and are able to express themselvesabout their hospital stay in a non-threatening way.Your assistance with this study would be greatlyappreciated. Please indicate in the space below whether youdo or do not want to be contacted in relation to this studyand return this form to the nurse’s station within threedays. Should you have any questions before that time, pleasedo not hesitate to contact Els (tel: 263-4342) or herdissertation supervisor (Dr. Marion Porath, 822-6045). Thankyou very much for your interest and cooperation.I, parent or guardian ofwould like to receive more information about this study andam willing to be contacted by Els Eikelhof.YES_______NO_______277Appendix JWording of How Parents Were Approached IncludingIntroduction of Research and Requesting Consent.“Hello, my name is Els Eikelhof and I would like to askfor your child’s participation in my research. I am adoctoral student in Educational Psychology and SpecialEducation at UBC. I am looking at how children ofdifferent ages understand the role of the nurse. Thereason why I want to examine the role of the nurse isbecause I would like to get more information about howa hospitalized child with a chronic conditionunderstands what a nurse does for him/her in thehospital. This information can then be used to improvethe communication between the nurse and the child. Forchildren that have to be hospitalized often because oftheir illness, it is especially important for the nurseto know how, for example, a four—year—old child looksat him/her. This better understanding can improvemedical treatments and daily care done by the nurse. Iwould like to give you a letter of consent, so that youcan think about whether you would like your child toparticipate in this research or not. If you approve, Iwould like to see your child three times for about halfan hour each time to give three tasks that are fun todo. If you are interested, I can show you these tasksand explain what they examine. If you want to, you canalso be present during the assessments of your child ifyou think it will be more comfortable for him/her. Ifyou have any questions about the tasks, I will bewilling to answer them after I have finished doing themwith your child. Here is the form that asks forpermission for your child’s participation. Can youbring the completed form back to the nurses’ station assoon as possible? Thank you for your time and interestand I hope to see you and your child again.”278Appendix KWording of How Children Were Approached to Ask TheirParticipation in the Study.“Hello, my name is Els. I am writing a book about howchildren think about what a nurse does for them whenthey are in the hospital and I would like you to helpme with my book. The reason why I want you to help meis because I would like to know how a child of your agethinks about certain things that happen in the hospitaland what you think the nurse will do when these thingshappen. If the nurse knows how a child of your agethinks about her/him, it will make her/him working withyou easier because she/he understands you a lot better.I have three nice tasks for you to do. I will come toyou three times for a short time. If you are too tiredor don’t feel too good, please tell me and I will comeback another time. If you don’t feel like helping meany more, please tell me that too. Then we will juststop. So do you think you want to help me with mybook?”279Appendix LParental Consent Form280THE UNIVERSITY OF BRITISH COLUMBIADepartment of Educational Psychologyand Special EducationFaculty of Education2125 Main MallVancouver, B.C. Canada V6T 1Z4Tel: (604) 822-8229— / — / 1994 Fax: (604) 822-3302Dear Parent,I am doing a study of hospitalized children’sunderstanding of the nurse’s role. This study is beingconducted for my doctoral research in Educational Psychologyand Special Education at the University of British Columbia.The study has as its focus the ways in which children ofdifferent ages understand what a nurse does for the childwhen he/she is in hospital. This study will be useful inimproving and facilitating the explanations to children ofservices currently offered by nurses (e.g., medicaltreatments and daily care).Children will be asked to complete three easy-to-dotasks. Children usually enjoy these tasks very much becausethey are temporarily distracted and are able to expressthemselves about their hospital stay in a non-threateningway. One task will focus on the child’s level ofunderstanding of the nurse’s role. Your child will be showna set of pictures that deal with real—life socialinteractions a child experiences in hospital. The secondtask will concentrate on how your child will solve problemsthat involve weights on a balance scale. In the third taskyour child will be asked the meanings of happy, sad, good,and bad in a short interview. Tasks will be given duringthree sessions of half an hour each at the child’s bedsidein his/her hospital room.All of the data will be coded by number to ensureconfidentiality. Your child may withdraw from the study atany time if he/she wishes. Refusal to participate will notjeopardize medical treatment. If signs of fatigue areobserved by the researcher and/or mentioned by the child thesession will be postponed or discontinued. All the data willbe collected by myself. I have a master’s degree in ClinicalPedagogics and have experience in working with children withchronic conditions.I would greatly appreciate your assistance with thisstudy. Please sign this letter in the space below indicatingwhether you do or do not agree to let your child participate281and return this form to the nurse’s station as soon aspossible. Please also sign and retain a second copy for yourown records. Should you have any questions, either I or mydissertation supervisor would be pleased to discuss themwith you (Els Eikelhof, 263—4342; Dr. Marion Porath, 822-6045). Thank you very much for your interest andcooperation.Sincerely,Els Eikelhof, MA.I,___________________parentor guardian of______________________ dodo not consent to allow my child to participatein the study described above. I acknowledge that I havereceived a copy of this consent form.Signature: Date:______________________282Appendix MLetter of Notification Given to Physicians Whose PatientParticipated in the Study283THE UNIVERSITY OF BRITISH COLUMBIADepartment of Educational Psychologyand Special EducationFaculty of Education2125 Main MallVancouver, B.C. Canada V6T 1Z4Tel: (604) 822-8229— / — / 1994 Fax: (604) 822-3302Dear Dr.I would like to inform you of the participation of yourpatient___________________________________(patient’s name) in my study. Both the child’s parents andthe child him/herself have agreed to cooperate. I am doing astudy on hospitalized children’s understanding of thenurse’s role. This study is being conducted for my doctoralresearch in Educational Psychology and Special Education atthe University of British Columbia. The study has as itsfocus the ways in which children of different agesunderstand what a nurse does for the child when he/she is inhospital. This study will help nurses to improve andfacilitate their explanations to children of the servicesthey offer (e.g., medical treatments and daily care).Forty children (10 each at four age levels; 4,6,8, and10 years old) with chronic conditions will be selected byusing the nursing kardex. Children that are selected will beasked to complete three easy-to-do tasks. Children usuallyenjoy these tasks very much because they are temporarilydistracted and are able to express themselves about theirhospital stay in a non-threatening way. Tasks will be givenduring three sessions of half an hour each at the child’sbedside in his/her hospital room. If signs of fatigue areobserved by the researcher and/or mentioned by the child thesession will be postponed or discontinued. Parents areallowed to be present during the sessions if it makes thechild feel more comfortable.Should you have any questions, either I or mydissertation supervisor would be pleased to discuss themwith you (Els Eikelhof, 263-4342; Dr. Marion Porath, 822-6045). Thank you very much for your interest andcooperation.Sincerely,Els Eikelhof, MA.284Appendix NBox and Whisker PlotsInformation about how to interpret Figures 5 and 6 (p. 144,and p. 151, respectively). These two figures are called boxand whisker plots and can be explained as follows (seeFigure N-i):* values more than 3 box—lengths from 75thpercentile (extremes)o values more than 1.5 box—lengths from75th percentile (outliers)largest observed value that is not anoutlier50% of 75th percentilecases havevalueswithin the medianbox25th percentilesmallest observed value that is notan outliero values more than 1.5 box—lengths from75th percentile (outliers)* values more than 3 box—lengths from 75thpercentile (extremes)Figure N-i. Explanation of how to interpret a box andwhisker plot (Norusis, 1993, p. 186).285

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