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Effect of guidance on learning in independent study Kotaska, Janelyn Gail 1973

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cl THE EFFECT OF GUIDANCE ON LEARNING IN INDEPENDENT STUDY by JANELYN GAIL KOTASKA B.S.N., University of Br i t i s h Columbia, 1961 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in the Department of Adult Education We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September, 1973 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis fo r scholarly purposes may be granted by the Head of my Department or by h i s representatives. It i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of The University of B r i t i s h Columbia Vancouver 8, Canada i ABSTRACT The recent proliferation of individual methods of learning i n continuing education coupled with the lack of research related to instruc-tional methodology led to this investigation of the effect of guidance on the learning of adults using an independent learning packet. The present study tested two hypotheses: 1. Mean scores on a criterion post-test w i l l be significantly higher for two groups who receive an independent learning packet than for a control group receiving no instruction. 2. Mean scores on a criterion post-test w i l l be significantly higher for a group receiving an independent learning packet including a study guide than for a group receiving the same independent learning packet without a study guide. Thirty-five Registered Nurses volunteered to study an independent learning packet entitled "Meeting the Emotional Needs of the Hospitalized Preschool Child", and twenty-one nurses were obtained for the control group. The post-test only control group design consisted of eighteen nurses systematically assigned to treatment Group A who studied the independent learning packet with a study guide designed to provide guidance of thinking. Seventeen nurses were assigned to treatment Group B, who studied an alternative form of the independent learning packet without the study guide. Group C acted as the control group. The independent variable was the method of instruction and the dependent variable was achievement as measured by scores on a criterion-referenced post-test, which was completed by a l l three groups. The Mann Whitney U test applied to the scores of Group A and B combined versus Group C yielded a significant difference in the predicted direction beyond the .00003 level. The difference in mean scores of Groups A and B failed to achieve a significance of .05 when the t test was applied. Therefore, the f i r s t hypothesis was confirmed but the second was not accepted. Analysis of the distribution of six known personal characteristics suggested that Groups A and B were equivalent, but that Group C was different from the other two. Interaction of the method of instruction with, the place of employment and the method of instruction with educational preparation produced the only significant effects (p<.025) on test scores when analysis of variance was carried out. Although the nu l l hypothesis, that guidance makes no difference, may be true, several sources of error variance were identified which could account for the results obtained. It was concluded that considerable learning can be achieved by studying an independent learning packet, but the study as conducted failed to detect any f a c i l i t a t i n g function served by guidance in the form of a study guide. The recommendation for replication of the study advised modification of the methodology to reduce possible sources of error variance. i i i TABLE OF CONTENTS Page LIST OF TABLES v Chapter I. INTRODUCTION 1 Theoretical Framework The Problem Purpose and Hypotheses Definition of Terms Plan of the Study II. RESEARCH REVIEW 10 The Amount of Guidance The Sequence of Instruction Questions as Guidance Summary III. METHODOLOGY. 19 Experimental Design Subjects Treatment Instruments Data Analysis IV. RESULTS AND DISCUSSION 30 F i r s t Hypothesis Second Hypothesis Factors Influencing Performance Discussion V. SUMMARY, CONCLUSIONS, AND IMPLICATIONS 40 Summary Conclusions Implications for Further Research REFERENCES 45 iv Page Appendix I. INDEPENDENT LEAENING PACKET 49 II. MODIFIED PORTIONS OF THE ALTERNATE 76 INDEPENDENT LEARNING PACKET III. CHI SQUARE CONTINGENCY TABLES 82 V LIST OF TABLES Page Table 1. Coefficient of Internal Consistency for Multiple Choice Test Items.... 2 6 2. Significance of Differences in Personal Characteristics of Groups A and B Versus C 31 3. Significance of Differences in Age, Number of Years Nursing Practice, and Number of Years not Practised Since Graduation Between Groups A and B 35 4. Significance of Differences in Educational Preparation, Place of Employment, and extent of Involvement in Pediatric Nursing Between Groups A and B 35 5. Summary Data for Analysis of Variance: Age and Method of Instruction 36 6. Summary Data for Analysis of Variance: Number of Years Nursing Practice and Method of Instruction 36 7. Summary Data for Analysis of Variance: Number of Years not Practised and Method of Instruction 36 8. Summary Data for Analysis of Variance: Educational Prep-aration and Method of Instruction 37 9. Summary Data for Analysis of Variance: Place of Employment and Method of Instruction 37 10. Summary Data for Analysis of Variance: Pediatric Involvement and Method of Instruction 37 11. Distribution of Age 83 12. Distribution of Educational Preparation 83 13. Distribution of the Number of Years of Nursing Practice.... 84 14. Distribution of the Number of Years Not Practised Since Graduation 84 15. Distribution of the Place of Employment 85 v i Page Table 16. Distribution of Involvement in Pediatric Nursing 85 17. Distribution of Educational Preparation Between Groups A and B 86 18. Distribution of Place of Employment Between Groups A and B 86 19. Distribution of Involvement in Pediatric Nursing Between Groups A and B 87 I CHAPTER I INTRODUCTION Individual methods of learning are assuming increasing importance in the f i e l d of education. This is particularly true of continuing education, where the explosion of knowledge and technology and the d i f f i c u l t i e s involved in disseminating information to adults have obliged both educators and learners to consider alternatives to the traditional class method. An improved understanding of the nature of learning and of adults has also served to convince educators that learning can be more efficient when methods and techniques other than the class and lecture are used. Correspondence study and programmed instruction are two well-established modes of individual learning, and other independent learning packages with a variety of names and formats are in earlier stages of development. Evaluation of the effectiveness of individual learning methods would be incomplete without examining the instructional methodologies involved. Unfortunately, research in this area i s sketchy and inconclusive. Although programmed instruction has received considerable attention with regard to methodology, conflicting data appear to cast doubt on the generality of many points and the subjects for almost a l l of the studies have been children or undergraduates, not adults. Despite the much longer period during which correspondence courses have been a major method of 1 2 individual instruction, Childs was not overstating the case when he noted that "we badly need research on the methodology of teaching by correspondence. Practically no research has been carried on in this important area." (8. p.116) Of 106 research studies reported in An Annotated Bibliography  of Correspondence Study, which reviewed the literature from 1897 to 1960, none dealt with effects of variation in instruction. (33.) And during the years from 1963 to 1969, Adult Education Dissertation Abstracts contained only one study related to methodology in correspondence instruction of a total of 802 studies in adult education. (9., 10., De Crow and Loague) Although i t i s apparent that programmed instruction and correspondence study programs have been successful in achieving a variety of instructional objectives for a variety of learners, problems inherent in the nature of these two modes of individual instruction have prompted recent attempts to develop other approaches. These newer modes of i n d i -vidual instruction provide written instruction which includes objectives, resource materials, learning a c t i v i t i e s , and evaluative self-tests. Examples of such alternatives include: independent learning packets C28. Kotaska) and independent study units (1. Adams) for the continuing education of nurses; individualized learning packets (11. Deep) for adult basic education; modules (13. Dychtenberg and Geis) for university courses; and learning activity packages (46. Smith and Wolfe) for self-directed high school students. These modes lack the highly structured control of stimuli and responses which tend to frustrate and bore many users of programmed materials. And unlike correspondence study programs, there is no two-way communication with an instructor for personal feedback. Feedback is self-contained within the learning program, and overcomes the high administrative costs and the problem of delayed feedback common to 3 correspondence programs. These new individual learning methods would seem to have much potential for providing learning opportunities for adult learners. Wedemeyer (45.) has said that educational systems must be altered to place greater responsibility for learning on the students, to enable operation anywhere there are students, to permit students to start, stop, and learn at their own paces, to enhance opportunities for adaptation to individual differences, and to free instructors to develop courses using a variety of appropriate methods and media so that each subject i s taught i n the best way known. If programs such as the independent learning packet are an attempt to provide for this type of system, then research should be undertaken to evaluate various instructional components of the packets. Such research would f a c i l i t a t e the systematic development and improvement of individual learning methods by contributing much needed knowledge to this neglected area of study. Theoretical Framework Although an instructional program is usually designed to optimize learning according to some suitable criterion or c r i t e r i a , i t has been pointed out by several authors that one of the chief problems in educational research has been a lack of theories of instruction. (14. Gage, 22. Groen, and 25. Hilgard) In the absence of a well-defined theory of instruction, grave d i f f i c u l t i e s exist in interpreting the results of experiments designed to evaluate the program. A theoretical framework for the present study is based on the work of Robert M. Gagne (19.). According to Gagne (19. p.304), the 4 components of instruction, or specific functions of the events of instruction, are as follows: 1. Gaining and controlling attention. 2. Informing the learner of expected outcomes. 3. Stimulating r e c a l l of relevant prerequisite capabilities. 4. Presenting the stimuli inherent to the learning task. 5. Offering guidance for learning. 6. Providing feedback. 7. Appraising performance. 8. Making provision for transferability. 9. Insuring retention. The present study is concerned with the f i f t h component, offering guidance for learning. Gagne states that the form of guidance for learning w i l l d i f f e r depending on the type of learning involved but usually consists of verbal communications. These verbal communications, often i n the form of questions, direct the learner's thinking u n t i l the essential performance i s achieved. The structure, sequence, and timing of directions are a l l important variables. It is following this event in the instruc-tional process that crucial learning occurs. Gagne affirms that there i s only a small amount of evidence regarding guidance of thinking, and that much more needs to be known about the effects of this variable. (20. p.288) Once the relevant pre-requisite capabilities have been recalled, instructions are used to promote their application to or integration into the performance of the new task. At a minimum, he says, this function of instructions may be provided by statements like "now do this new task" or "now put these ideas together to 5 solve this problem". Beyond this, thinking may be guided by instructions and suggestions which progressively limit the range of hypotheses enter-tained by the learner in such a way as to reduce the number of incorrect solutions he considers. Programmed instruction exemplifies the opposite end of the scale in providing a set of instructions which detail a step by step procedure for using previously acquired tasks in a new situation. The question of how much and what kind of guidance is most effective has not received a satisfactory answer. Gagne theorizes that the amount and kind of guidance necessary w i l l depend on the cognitive strat-egies possessed by the learner. (21.) Cognitive strategies are the intern-alized processes of learning, thinking, and remembering acquired by the individual through experience in learning. Although they have not yet been adequately defined, they include strategies of attending, encoding retrieval, and problem solving. It i s l i k e l y that individuals s k i l l e d in learning, that i s , those having well-developed cognitive strategies, w i l l need less direction and guidance than those who do not. Adults who are competent independent learners should therefore require less guidance than children and depend-ent adult learners. The instructional methods to which an adult has been exposed presumably affect the development of cognitive strategies. I f , for example, an adult has learned primarily by memorization of facts and principles, then s k i l l in problem-solving w i l l be poorly developed. 6 The Problem One reason for the lack of knowledge about guidance in the trad-i t i o n a l classroom situation i s the d i f f i c u l t y in predicting and control-ling the phrasing and timing of directions given. The directions provided with instructional materials designed for individual study, on the other hand, must be planned in advance and are necessarily uniform for a l l learners. It should therefore be possible to investigate the effects of guidance used in these methods, in this case, the independent learning packet. Since i t is impossible for the learner to ask for c l a r i f i c a t i o n , rephrasing, or additional information in order to ensure that directions are understood, i t would seem that well planned, clear, and meaningful instructions are c r i t i c a l i f the desired learning i s to occur. These directions, as Gagne indicates, guide thinking by suggesting appropriate learning tasks and their sequence. In an independent learning packet, such, guidance is provided by a study guide. Because the amount and kind of guidance necessary seems to depend on the learning a b i l i t i e s or cognitive strategies of the learners, the study guide should be designed to reflect these needs. With Gagne's theoretical foundation in mind, then, several questions arise in relation to individual adult instruction. Are verbal directions that guide thinking an essential component of individual instructional materials designed for adults with several years of post-secondary education? If so, what form should guidance take?. How closely does thinking need to be controlled? Is the sequence of instruction an important variable? Will questions designed to stimulate thought and problem-solving enhance learning when reference materials comprise the 7 content? Or, given behavioral objectives, content materials, and eval-uative tools, can continuing learners plan and sequence their own learning act i v i t i e s in order to achieve the specified objectives? The answers to these questions would be of value in adding to the body of knowledge related to the conditions of learning in adult education. Such knowledge could then be applied to the design and development of s e l f -instructional materials. Writing an effective study guide i s a time-consuming process and requires considerable s k i l l on the part of the instructor. If i t could be found that a study guide is not necessary to direct the learning of adults engaged in continuing their education, then the cost of developing self-instructional materials such as independent learning packets could be reduced measurably. If, on the other hand, research confirms the need for a study guide, then i t s importance must be stressed. Purpose and Hypotheses The present study does not seek answers to a l l the above questions, but rather focusses on two crucial concerns. F i r s t , i s exposure to an independent learning packet better than no instruction at al l ? If so, does guidance in the form of a study guide f a c i l i t a t e learning compared with no guidance? Since the theoretical framework suggests that the answers to both of these questions would be i n the affirmative, two hypotheses were formulated for the study: 1. Mean scores on a criterion post-test w i l l be significantly higher for two groups who receive an independent learning packet than for a control group receiving no instruction. 8 2. Mean scores on a criterion post-test w i l l be significantly higher for a group receiving an independent learning packet including a study guide than for a group receiving the same learning packet without a study guide. Definition of Terms The terms independent learning packet and study guide were defined for the purposes of this study as follows: Independent learning packet - a self contained unit of instruction de-signed to permit an individual learner to achieve a few well-defined objectives through study without the direct assistance of an instructor. An independent learning packet includes an intro-duction to the concept of the independent learning packet, behavioral objectives, a study guide, content materials, a l i s t of included references, objective self-tests, and a l i s t of references for further study. Study guide - a set of written instructions which guide the learner's thinking toward achievement of the objectives by specifying the learning tasks and their sequence. This i s a more restricted definition than i s frequently used. Childs (8. p.112) refers to the study guide in correspondence courses as being responsible for establishing objectives as well as determining learning experiences and indicating instructional materials to be used. Since Gagne believes that informing the learner of expected outcomes is a different component of instruction from that of offering guidance for learning, the study guide does not include the statement of objectives. Specifically, then, the study guide is restricted to directions regarding the sequence for using reference materials, and questions and problems designed to stimulate and guide thinking for effective learning of the content. Plan of the Study The remainder of the study is organized as follows. Chapter II reviews the literature related to the use of guidance in individual instructional materials. The methodology for the study is described in Chapter III i n terms of the research design, the subject population i n -volved, the treatment, the instruments used, and the methods of s t a t i s -t i c a l analysis employed. Chapter IV reports and interprets the results obtained, and Chapter V includes the summary, conclusions, and implica-tions for further research. IO CHAPTER II RESEARCH REVIEW No reports of research could be found which specifically examined the effect on learning outcomes of guidance in an adult s e l f -instructional program like the independent learning packet. Many of the studies of related areas of research involve programmed instruction, where prompts and cues control rather than guide thinking to the extent that incorrect responses are not expected to occur. Although the general-i z a b i l i t y of results to the less precise and controlled learning situation provided by an independent learning packet is questionable, the findings indicate some tentative guidelines for the present study. The studies reviewed f a l l into three major categories of research related to the amount of guidance, to sequencing of instruction as a function of guidance, and to questions as the form of guidance. The Amount of Guidance With regard to investigations of the amount of guidance, there is l i t t l e agreement among the findings. Gagne and his associates (16.) undertook to vary the amount of guidance and the amount of repetition of learning set tasks i n a Grade Seven programmed mathematics course. They found that achievement of tasks in a hierarchy of knowledge depended upon correct sequencing for prior achievement of subordinate learning tasks rather than the amount of repetition or guidance. With only one exception, 10 the amount of repetition of tasks and the amount of guidance in proceeding from one learning task to the next higher were not significant for know-ledge acquisition. In another experiment using programmed instruction in high school mathematics, Gagne and Brown (15.) found that a guided dis-covery program using questions in small steps produced significantly greater achievement than a discovery program with no guidance of thinking. Campbell (4. Briggs, p.33) conducted a series of experiments comparing the achievement of high school students for a variety of learning objectives in mathematics, geography, and history. She gave a lesson out-line, text, examples, explanation, and a self-test to one group, and pro-grammed instruction to another. The self-directed groups, who received no objectives or guidance for thinking, learned as much as the programmed instruction groups. However, the converse was true in a similar experiment using graduate university students, where Kearney (27. p.3725) provided behavioral objectives and reference materials for the experimental group. Despite significant gains by both groups (P<.01), the programmed instruction group acquired significantly more subject matter. Two studies examined the effect of varying amounts of guidance on adult learning. Melching and Nelson (32. p.223), using programmed instruc-tion to teach counterinsurgency to Army enlisted personnel, found that the presence of special practice frames enabled subjects to score higher on a written re c a l l type of achievement test, but did not affect scores on multiple choice or a short completion test. An explanation for these results might be that the practice frames aided integration of the concepts for better retention and subsequent r e c a l l when the test items offered no hints to f a c i l i t a t e remembering. In an experiment involving a Naval pre-flight course, Webb (44.) compared the learning achievement of students given a syllabus outline, a text, work-sheets for self-testing, and classroom lectures, with that of a group given the same materials but no lectures. The experimental group studied the materials independently and with other students, but had minimal contact with an instructor. Test scores indicated that students could learn as effectively by the experimental method. Although precise differences i n instruction between the two methods were not determined, the students in the experimental group complained of a lack of directions; for example, uncertainty regarding what was important and unimportant. In addition, the deletion of lectures probably materially reduced the amount of repetition. The conflicting results i n this group of studies relating to the amount of guidance are probably due to a variety of factors. Differences in types of populations used; differing types and qualities of instruction-a l programs; the dissimilarity of types of learning involved, varying from a knowledge of facts and concepts to application of principles using problem-solving; and differences i n the learners' prior familiarity with the subject matter may be important variables. In any event, there i s no consistent evidence to support Gagne's theory that guidance is an essential component of instruction. The only possible generalization i s that except for certain subjects, notably mathematics, i t appears that less guidance i s necessary than was i n i t i a l l y provided for in the design of many instruc-tional programs. The Sequence of Instruction Gagne believes that the sequencing of instruction i s a major function of guidance. (19. p.302) A great deal of research has been reported in this area, and examination of the findings provides an i n d i -cation of the relative importance of sequencing in the provision of guidance for independent study materials. Although most developers of programmed instruction believed that 'logical' sequencing of instruction would yield better learning achievement than a 'scrambled' or random order, many studies have not supported this theory. (egs. 23. Harrington, 33. Miller, 36. Niedermeyer, 37. Payne, 38. Roe, 43. Tobias) One of the problems seems to be that 'logical' sequences are usually determined by some arbitrary sequencing criterion such as tradition, chronological order, or the programmer's instinctive idea of how learning should best progress. It was believed by programmers that they could best test their assumptions by comparing their 'logical' sequence with a 'random' sequence. Another problem may l i e i n the fact that the programs used were very short (under two hours) or contained relatively few frames dealing with only one concept. Briggs (4. p.55) speculates that the programs were short enough that the learner was probably able to r e c a l l materials out of sequence and thus overcome the effects of scrambling. The findings of no difference cannot therefore be regarded as indications that sequence is of no importance in longer programs. Subsequent attempts to determine the conditions under which a logical order might enhance learning have indicated that the size of the learning unit (33. M i l l e r ) , the degree of prior knowledge of the topic (45. Tobias), and, more relevant in terms of this study, the type of learning task and the degree of experimenter control over sequencing are important variables. To elaborate on the latter two, i f the elements of knowledge and s k i l l to be learned during a given course of instruction are dependent upon one another (i.e. the learning of one transfers, thus f a c i l i t a t i n g learning of another), then careful sequencing of elements in the direction of such transfer is more effective than random sequence. (5. Brown, 16. Gagne, 33. Mi l l e r , 35. Natkin, 37. Payne) The structuring of such sequences requires analysis of the task into a hierarchy of sub-s k i l l s or subordinate competencies, and most task analysis efforts so far have been in the subjects of mathematics and science. If the elements of the material to be learned do not appear to require task analysis into a hierarchy of competences, then i t appears that the adult learner may be able to sequence learning materials and tasks for most eff i c i e n t learning. (4. Briggs, 30. Mager and Clark, 31. Mager) Mager and Clark (30.) gave adult trainees in electronics a detailed l i s t of instructional objectives and some suggestions on learning resources with freedom to follow their own sequence and schedule for learning. Unfortunately, in this preliminary study no measures of learning achievement were compared, but the learning time was decreased by an average of sixty-five percent from the time required for the formal course. The main point, however, i s that when the learner determines the sequence, i t differs from the sequence provided in texts and programmed materials. In a series of experiments, Campbell (4. Briggs, p.33) investi-gated learner-controlled sequences with different types of independent study materials which gave high school students freedom to select from the resources made available. In comparing the learning of these groups with others provided with programmed instruction, she found no significant differences between any of the pairs of groups. Since a l l conditions were as effective as a linear program, the decreased study time and lower cost of self-directed materials led Campbell to favor the more learner-determined procedures. One d i f f i c u l t y i n Campbell's experiments was that learners tended to take and use the material as they found i t and did not exercise much the self-directed freedom permitted. Also, because communi-cating behavioral objectives has often been shown to improve post test performance and retention (12. Duchastel and M e r r i l l ) , learning might have been increased even more had Campbell given the students prior knowledge of objectives. The results of these experiments on sequence provide some ra-tionale for the structure of the independent learning packet used i n the present study. A 'logical' sequence for learning was determined by the author. But since the type of learning tasks involved were not judged to require sequencing in a hierarchy of subordinate competencies, i t was f e l t that the influence of a predetermined sequence would be negligible. Also, despite the suggested sequence, the relatively loose organization of an independent learning packet compared with programmed instruction offers considerably greater learner control over the sequence, and there i s much more opportunity for him to make efficient use of the materials according to his particular learning needs. 16 Questions as Guidance The f i n a l area of related research involves the use of questions as a form of guidance for learning. Questionning to direct the learner's thinking may- be the primary function of guidance in independent study materials such as the independent learning packet, and the small amount of evidence that i s available tends to support this view. Gagne and Brown (15.), for example, investigated the effects of three methods of providing guid-ance in programmed conceptual learning materials for Grade nine and ten boys. Those using a guided discovery program which provided questions to aid in the discovery of concepts performed significantly better (P<.01) in a problem-solving test than groups provided with a rule and example program Grorstl or a discovery program without guidance (intermediate). Gagne postulated that the use of questions i n the guided discovery program required the learner to reinstate (actively produce or practise) the concepts, a feature which was lacking in the rule and example program. The discovery program may have produced such reinstatement, but in a less systematic manner. The f a c i l i t a t i n g effect of questions i s supported by several other studies which indicated that groups who were asked questions during the course of instruction learned significantly more than those who were not. (24. Hershberger, 39. Rothkopf, 42. Sime) Rothkopf also found that the effects of questions i n learning from written materials were greater when the correct answers were given after response than i f there was no knowledge of results. However, the questions required only short answers related to knowledge of specific facts. The answers to questions asked in the independent learning packet used for the present study were expected to be variable both in length and content. In other words, there was no one right answer, and the questions were designed to stimu-late the integration and application of knowledge rather than provide prompting or review for the testing of r e c a l l of specific facts. Know-ledge of results in this instance, was therefore considered neither reason able nor practicable. The problem of determining the most effective placement of questions for learning from written materials has also received attention. Since the independent learning packet involves a great deal of reference reading, the results of such research should have significance for the development of these packets. Several researchers have concluded that the optimum placement of questions i s following the reading of a moderately lengthy passage of material. (27. Hunkins, 39. Rothkopf) Briggs (4.) speculates that the reason for these findings i s that reading materials such as texts are not optimally sequenced. Thus, the more loosely organ-ized the text, the greater the need for the learner to range about in the text to organize his thinking. Meaningful understanding of the entire learning task covered by the passage may be developed by the learner independent from the sequence of paragraphs. Briggs further speculates that the less sequencing necessary for achievement of the learning task, the longer the reading passage can be before questions are asked. Hunkins (26.) examined the nature of questions asked and sought to determine the influence of analysis and evaluation questions on achieve ment in sixth grade social studies. In his review of research, Hunkins found that the emphasis of questions in textbooks are primarily concerned with the memorization of facts rather than of the use of knowledge in thinking. Using the categories in Bloom's Taxonomy of Behavioral  Objectives to guide question construction, he developed two sets of text-type materials, one stressing questions requiring analysis and evaluation and the other containing questions stressing knowledge. The dominant use of analysis and evaluation questions produced significantly higher achievement. Besides supporting the contention that questions are an effec-tive form of providing guidance, the results of the studies on questions relate to the .present study i n two other ways. Because each of the reference materials included with the independent learning packet were related to a l l of the objectives, i t was considered adequate to ask the questions after reading a l l of the materials. And based on the belief that guiding learning at the levels of knowledge and comprehension would be inadequate to enable achievement of the objectives, the questions provided in the study guide emphasized the four higher categories of application, analysis, synthesis, and evaluation. (2. Bloom) Summary In the absence of research which specifically examines the effect of guidance on the learning of adults using independent learning packets, studies related to the amount of guidance, the sequence of instruction, and the use of questions were reviewed. The findings suggest that the influence of varying amounts of guidance i s unclear, that the sequence of instruction in self-directed learning materials i s of minimal importance for most learning tasks, and that questions placed after reading materials and designed to guide thinking rather than memorization w i l l enhance learning. CHAPTER III METHODOLOGY The research methods employed in conducting this experimental study are described in this chapter. Briefly, a post-test only control group design was selected, consisting of two treatment groups and a control group, with Registered Nurses as the subjects. The treatments were an independent learning packet with a study guide (guidance), and the same independent learning packet without the study guide (no guidance). An objective criterion post-test was used to test the hypotheses, and the resulting scores were analyzed using the Mann-Whitney U test for the f i r s t hypothesis, and the t test for the second. The experimental design chosen for this study was a post-test only control group design (6. Campbell and Stanley, p.25) as represented below. Experimental Design Group A (study guide) R Group B (no study guide) R 0 2 Group C (control) R 19 The dependent variable was achievement as measured by scores on the post-test, and the independent variable was the method of instruction. Group A was given the independent learning packet with the study guide while Group B received an alternate form of the independent learning packet omitting the study guide. Control for testing as the main effect of the treatment or method of learning was achieved by Group C, who completed the post-test only. This design was selected for several reasons. A pretest increases the reactive arrangements or a r t i f i c i a l i t y of the experimental setting and may jeopardize internal v a l i d i t y . (6. Campbell and Stanley, p. 20) This i s particularly true for adult populations who are unaccustomed to having to complete tests. Because frequent testing i s not characteristic of the population, reactive arrangements could also have affected the external v a l i d i t y of the results. The sensitizing effect of pretesting which would probably interact with the treatment in this experiment also jeopardizes external v a l i d i t y . Internal v a l i d i t y was controlled by random assignment to groups. Subjects The population used for this study consisted of graduate nurses li v i n g i n B r i t i s h Columbia. Groups A and B were nurses who requested to borrow the independent learning packet from the library of the Registered Nurses' Association of B r i t i s h Columbia, between March 1 and May 31, 1973. In order to obtain a sufficient number of respondents within the time limit set for the study, i t was necessary to announce the a v a i l a b i l i t y of the independent learning packet and to indicate that a number of nurses were needed to undertake study of the packet. Publicity was obtained in two ways. F i r s t , an item was published in the RNABC News, March 1973, in which an interview with the author about an evaluative study of the independent learning packet was reported. The features of this mode of learning were described, and directions for requesting the independent learning packet included, but the exact nature of the study was not out-lined. Secondly, a letter was sent to each chapter and d i s t r i c t of the Registered Nurses' Association, inviting nurses interested in studying the packet to borrow a copy from the library. This method of attracting respondents from throughout British Columbia was f e l t to be preferable to inviting selected health agencies to participate. Since i t was desirable for purposes of the study to control possible group influences on learning, i t was not appropriate to publicize the request for nurses i n an institutional setting where informal as well as formal groups are highly developed. Nurses working together might be more l i k e l y to study the packet together. Thirty-five nurses were recruited in this manner. To be able to place confidence i n ttie results, i t was considered necessary to have at least fifteen subjects in each group. Because i t was not possible to identify the total sample for Groups A and B before data collection began, random assignment was replaced by systematic assignment in the following way. The f i r s t five nurses who requested the independent learning packet were assigned to Group A, and the next five to Group B. This procedure was repeated u n t i l twenty packets had been distributed for each group. Subjects in excess of the number required were sent packets because i t was anticipated that some would not complete the test. After forty packets had been distributed, six packets without the study guide had been returned incomplete as had two packets with the study guide. The last names on the waiting l i s t were therefore assigned two to Group A and six to Group B. A total of four nurses in Group A and nine in Group B returned the packets without completing the test. In some cases, a note was attached giving the reason for non-completion as insufficient time for study of the packet. In addition, at least three were supervisors or directors of nursing who requested the packet in order to judge i t s suit-a b i l i t y for use by their staff rather than for personal study. Those nurses who did not complete the test were excluded from the study. The number of nurses obtained in the manner described was i n -sufficient to divide among three groups so a control group was acquired by posting an advertisement on the pediatric units of a large metropolitan hospital CThe Vancouver General Hospital). Since no learning using the independent learning packet was involved, there could be no interaction of group influences. There was also no reason to believe that inherent differences between subjects obtained by the two methods would have a significant influence on the results. Twenty-one subjects volunteered to complete the test. Treatment An independent learning packet developed by the author and entitled "Meeting the Emotional Needs of the Hospitalized Preschool Child" comprised the instructional materials for the study. (Appendix I.) An introduction to the concept of the independent learning packet provided the learners with the characteristics of the independent learning packet as an approach to continuing education and gave a brief description of the content and learning a c t i v i t i e s in the independent learning packet. Specific behavioral objectives were then stated. The objectives were limited to competencies that could be measured on an objective criterion examination. Although the independent learning packet was de-signed to emphasize the application of concepts to actual nursing situations i t was not possible within the scope of this study to measure learning outcomes which might demonstrate such a b i l i t i e s . Therefore, no objectives related to actual practice were included. The study guide included directions regarding the suggested sequence for studying the content materials followed by ten questions and problems designed to guide the learner's thinking. These questions em-phasized the four highest categories in Bloom's Taxonomy of Behavioral  Objectives in the cognitive domain. ( 2 . Bloom) Questions were included to stimulate the integration of previous knowledge and experience with the learning of new material, the application of new concepts to nursing practice, the analysis and evaluation of current nursing methods, and the synthesis through problem-solving of more appropriate policies and practices Content materials consisted of copies of pertinent reference materials placed in the order in which they were to be studied, a paper back book, a cassette audiotape, and summaries of content. An evaluative post test completed the independent learning packet. For purposes of this study, the answers to the self-test were deleted. The original independent learning packet was further modified to provide an alternative form for use by the second experimental group (Group B). (Appendix II) The introduction and purpose were edited to omit mention of the study guide, and the study guide was deleted. The only directions given asked the respondents to study the reference materials and then to complete the test. The order of placement of the reference materials was randomized to alter the sequence. Though.a minor point, one of the functions of the study guide was to suggest the sequence of learning tasks. Campbell (4. Briggs) found that even when freedom to choose the sequence was offered to learners, they tended to use materials in the order presented. It was therefore considered reasonable to alter the sequence of presentation despite the absence of the study guide i n order to offset the possible effect of sequence. Except for the test, the components of the independent learning packet were arranged in a binder with the book and tape attached i n separate envelopes. Fifteen copies of the independent learning packet were produced; five with the study guide, five without the study guide, and five interchangeable to preserve the system of assignment to groups while allowing for delays in the return of packets. A l l copies of the independent learning packet were placed in the library of the Registered Nurses' Association of British Columbia. The author handled distribution to ensure that the procedure for assign-ment to groups was followed. The appropriate form of independent learning packet was sent by mail to participants of Groups A and B as their requests were received. When the fifteen copies had been distributed, a reserve waiting l i s t was kept and a note sent to each nurse acknowledging her request and informing her that an independent learning packet would be sent as soon as possible. The respondents received instructions with the independent learning packet that the loan period was two weeks; the due date was stamped on the packet. However, Group A kept the packets for a minimum of eighteen days and a maximum of seventy-five days, with a median of twenty-three days. The minimum for Group B was six days, and the maximum thirty, with the median twenty-one days. Four respondents i n Group A and four in Group B stated that two weeks was too short a period for study of the packet. Generally, then, Group A had the independent learning packet at home for longer than Group B, and both groups kept the independent learning packet more than the suggested two weeks. Instructions with the independent learning packet asked the participants to study the materials and then to complete the test. For Group A, this involved answering the questions in the study guide as well. Although no attempt was made to control for the number of hours spent studying the packet, this information was requested. It is interesting to note that among the eleven who answered this question in Group A, a minimum of five hours, a maximum of thirty-six hours, and a median of ten hours was spent studying. Of sixteen replies in Group B, the minimum was two hours, maximum twenty hours, and median five hours. These figures suggest that Group A spent longer studying the packet than Group B. This tendency was expected since answering the questions in the study guide would require more time than studying the alternate packet in Group B. Instruments The instruments used for data collection were the post-test and an evaluation form. (Appendix I) The test was criterion-referenced, that i s , It was constructed to measure the achievement of the specified objectives. Nine completion items (Part A) were designed to measure the achievement of the f i r s t and second objectives in the knowledge category described by Bloom. (2.Bloom) Twenty-five multiple choice items (Part B) were constructed to measure the achievement of the third objective involving comprehension and analysis categories. Twenty-five multiple choice items (Part C) related to the fourth objective, involving the application and evaluation categories. Multiple choice items contained a minimum of four and a maximum of six alternatives. The total possible score was seventy-two, consisting of Part A - 22, Part B - 25, and Part C - 25. No estimate of r e l i a b i l i t y was made for the completion items. For the odd versus even-numbered multiple choice items, the coefficient of internal consistency was computed for each group. The Spearman Brown formula was used to correct the Pearson product-moment correlation coefficient with, the results shown in Table 1. TABLE 1.-Coefficients of internal consistency for multiple-choice test items Test Part Group A Group B Group C B .56 .81 .55 C .65 .48 .49 B+C .61 .74 .64 The coefficients varied from .48 to .81 for Parts B and C of the test, but when both parts were combined, the coefficient was .61 for Group A, .74 for Group B, and .64 for Group C. The r e l i a b i l i t y of the test was therefore considered adequate for purposes of this study. The instrument appeared to have content vali d i t y when the items were judged for their representativeness and relevance i n measuring the stated objectives. It was not considered necessary to examine the construct va l i d i t y extensively, however, confirmation of the f i r s t hypothesis would tend to indicate that the instrument possessed some degree of construct vali d i t y . The test was self-administered at home by subjects in Groups A and B upon completion of study. Written directions at the beginning of the test requested that the subjects refrain from referring to study materials. Names were not written on the tests. However, because names and addresses were required for returning the corrected tests and because the professional association was involved in the distribution of independent learning packets, a note stressing the confidentiality of scores and signed by the author was attached. It was presumed that the testing situation would not be considered of sufficient importance to warrant cheating. Group C completed the test during working hours on a day when minimal a c t i v i t y was expected on the units and sufficient free time would be available for the nurses to participate. A room some distance from the wards was provided and each nurse came when i t was convenient for her. No time limit was imposed for completion of the test. No verbal information regarding the independent learning packet was given, and names were not requested. The investigator was in attendance to distribute and collect the tests. The post-test was scored as follows. Incorrect responses and blanks were given no score. A score of one was given for each correct response, except for Part A, items seven and nine. The total possible score for item seven was ten points and for item nine five points. Each correct part response received a score of one. Data collected through completion of an evaluation form was supplemental to the hypotheses formulated, but provided useful informa-tion. The form consisted of (a) seven questions requesting biographical data, (b) an attitude scale regarding the independent learning packet, and Cc) questions related to the u t i l i t y of the independent learning packet as a method of continuing education. Information obtained from Part (a) of the evaluation form was used in discussing and interpreting the results obtained and the answers to a question in Part (c) regarding the number of hours spent studying the packet were reported in the section describing treatment. Data Analysis The f i r s t hypothesis was tested using the Mann-Whitney U Test. (41. Siegel, p.116) Although the criterion of interval measurement was met, use of a parametric test was unjustified because i t could not be assumed that the groups were a l l drawn from the same population. The Mann-Whitney U Test was the appropriate non-parametric test because i t i s designed to test the prediction that the means of the samples w i l l occur in a specific order. Although the precise variables which might influence learning were not identified, i t was possible to determine the equivalence of the groups with respect to certain known personal characteristics. The Chi square test was applied to a number of 2X2 and 2X3 contingency tables in order to compare the combined Groups A and B with Group C in relation to variables of age, educational preparation, the number of years nursing practice, the number of years not practised since graduation, place of employment, and the extent of involvement in pediatric nursing. For the second hypothesis, the t test was applied. Since Groups A and B were drawn from the same population, use of the parametric test was appropriate. There was no evidence to indicate that the pop-ulation was not normal or that variances were heterogeneous. Neverthe-less, Bartlett's test for homogeneity of variance was applied to remove this criterion from the assumption class. The equivalence of Groups A and B were estimated with respect to distributions of the characteristics noted above. To do so, the t test was used for age and the number of years practised and not practised. The Chi square test determined the significance of differences in the distribution of the remaining three variables. An ex post facto attempt to determine relationships between test scores and the biograph-i c a l characteristics was carried out by two-way fact o r i a l analysis of variance. CHAPTER IV RESULTS AND DISCUSSION The results of s t a t i s t i c a l testing of the two hypotheses are presented in this chapter. Following the report for each hypothesis, the factors which, influenced performance are described. Discussion of the results follows for the purpose of interpreting the findings. F i r s t Hypothesis The f i r s t hypothesis predicted that post-test scores for Groups A and B combined would be significantly higher than for Group C. In oth_er words, those using the independent learning packet would achieve higher scores than those who did not. The Mann Whitney U test confirmed this hypothesis in that the scores for Groups A and B combined were significantly greater than Group C beyond the .00003 level of significance. Although Groups A and B were obtained by a different method than Group C, a l l subjects were licensed to practise nursing i n Br i t i s h Columbia. It was assumed, therefore, that differences in individual characteristics between groups obtained by the two methods would not influence the results. Unfortunately, such influences on test scores could not be determined, since, as Siegel suggests, suitable nonparametric methods are not yet available for testing interactions in the analysis of variance model. (41.) However, the Chi square test was applied to determine the equivalence of the combined Groups A and B with Group C 30 with respect to certain known personal characteristics. Contingency tables summarizing this data are presented in Appendix III. The results of the Chi square tests, summarized in Table 2, indicate that Groups A and B combined were significantly different from Group C on a l l of the characteristics tested. The nature of Group C, however, would lead one to suspect that the subjects possessed at least the same potential for achievement as Groups A and B, had they been exposed to the independent learning packet. Members of Group C were generally younger and a l l were employed in f u l l time hospital pediatric nursing. Because the subject matter dealt entirely with hospital nursing practice and involved concepts taught only i n recent years to nursing students, this group should have been generally more familiar with the material than Group A or B. TABLE 2.-Significance of differences in personal characteristics of Groups A and B versus Group C Personal Characteristics X2 P Age 17.5266 <.001 Educational Preparation 4.1360 <.05 Number of Years Nursing Practice 10.1272 <.01 Number of Years Not Practiced Since Graduation 10.3577 <.01 Place of Employment 13.4396 <.01 Extent of Involvement in Pediatric Nursing 14.6459 <.001 Although interpretation, of the results would have been strength-ened had Group C been chosen from the same population as Groups A and B, the extremely high level of probability yielded by the U s t a t i s t i c warranted confidence in the results. The f i r s t hypothesis was therefore accepted. Second Hypothesis The second hypothesis predicted that of the two groups using the independent learning packet, those who had access to the study guide would achieve significantly higher mean scores than those who did not. The t test yielded no significant difference in scores. In fact, the mean score for both groups was exactly the same to one decimal place at 55.56 for Group A and 55.53 for Group B. The t value obtained was .0117 which i s below the c r i t i c a l value for the .25 level of significance for a one-tailed test. Since the r e l i a b i l i t y of Part A of the post-test was unknown, the t test was also applied to the scores on a subtest consisting of Parts B and C of the test. The t value of .4090 also failed to attain the .05 level of significance. The second hypothesis was therefore not accepted. In order to substantiate the assumption of homogeneity of variance which underlies the use of the t test, Bartlett's test for homo-geneity of variance was applied to the variance of both groups. The result, x 2 = .2105, was not significant at the .05 leve l . In fact, this conservative test Indicated that there was a 70% chance that the difference in variances was due to chance; therefore, use of the t test was j u s t i f i e d . Factors Influencing Performance Although the stated hypotheses did not involve variables other than test scores and method of instruction, i t was of interest to analyze the information collected regarding personal characteristics of the nurses. Comparison of the distribution of these characteristics i n Groups A and B was carried out as follows. The t test was applied to age, number of years nursing practice, and number of years not practised since graduation. The Chi square test was used to compare the differences in educational prep-aration, place of employment, and the extent of involvement in pediatric nursing. Contingency tables for the Chi square test are shown in Appendix III and the results of the comparison of personal characteristics are summarized in Tables 3 and 4. Since none of the differences attained the .05 level of s i g n i f i -cance, i t can be concluded that the groups were equivalent with respect to the variables tested. Because the size of the groups was comparatively small, i t was possible that, despite systematic assignment to groups, individual differences among subjects could vary significantly between the groups. The results tend to lend weight to the assumption that the sub-jects of Groups A and B came from the same population, although they may have differed in relation to other relevant but unknown characteristics. Analysis of variance was carried out to determine i f any of the known characteristics of the nurses interacting with the method of instruc-tion had an effect on test performance. The catergories of variables used to perform the analysis were as follows: Method of instruction Age Number of years nursing practice Number of years not prac-tised since graduation Educational preparation Place of employment Extent of involvement i n pediatric nursing 1. Independent Learning Packet with study guide 2. Independent Learning Packet without study guide 1. 21 to 30 years 2. over 30 years 1. 0 to 5 years 2. 6 to 10 years 3. over 10 years 1. 0 years 2. 1 to 5 years 3. over 5 years 1. hospital school only 2. further formal education 1. hospital 2. other than hospital 3. unemployed 1. f u l l time pediatric nursing 2. some pediatric nursing a c t i v i t i e s 3. no pediatric involvement The results of the analysis of variance, presented in Tables 5 to 10, indicate that of the six variables tested, educational preparation and the place of employment interacted with the method of instruction at the .025 level of significance. No other variables had a significant effect. Inspection of the data suggests that neither of these variables had a consistent effect which could be interpreted as a predictor of test scores. With regard to place of employment, the mean scores of those working in hospital showed l i t t l e difference between Group A (54.25) and Group B (55.27). Those working elsewhere in Group A had a considerably higher mean score (60.33) than a l l the others and the unemployed in Group B were second highest (56.33). 35 TABLE 3.-Significance of differences in age, number of years nursing practice and number of years not practised between Groups A and B Personal Characteristics Mean Group A Scores Group B t P Age 36.33 33.05 1.0443 <.25 Number of Years Nursing Practice 9.38 8.19 .5739 >.25 Number of Years Not Practised Since Graduation 3.75 3.03 .4190 >.25 TABLE 4.-Significance of differences in educational preparation, place of employment, and extent of involvement i n pediatric nursing between Groups A and B Personal Characteris tics X2 P Educational Preparation .0269 > .80 Place of Employment .7448 > .30 Extent of Involvement in Pediatric Nursing .3769 > .50 36 TABLE 5.-Summary data for analysis of variance: Age and method of instruction Source SS df ms F P Total 1422.69 34 age 1.34 1 1.34 .0294 n.s. method of instruction .05 1 .05 .0011 n.s. age x method 9.21 1 9.21 .202 n.s. error 1412.04 31 45.54 TABLE 6.-Summary data for analysis of practice and method variance: Number of of instruction years nursing Source SS df ms F P Total 1422.69 34 number of years nursing practice 17.5 2 8.75 .1894 n.s. method of instruction .05 1 .05 .0010 n.s. years practice x method 19.4 1 19.4 .42 n.s. error 1385.84 30 46.19 TABLE 7.-Summary data for analysis of variance: Number of practised and method of instruction years not Source SS df ms F P Total 1422.69 34 number of years not practised 77.19 2 38.49 .9509 n.s. method of instruction .05 1 .05 .0012 n.s. years not practised x method 128.0 1 128.0 3.154 n.s. error 1217.55 30 40.58 37 TABLE 8.-Summary data for analysis of variance: Educational preparation and method of instruction Source SS df ms F p Total 1422.69 34 educational preparation .53 1 .53 .0142 n.s. method of instruction .05 1 .05 .0013 n.s. education x method 273.15 1 273.15 7.369 <.025 error 1449.06 31 37.06 TABLE 9.-Summary data for analysis of variance: method of instruction Place of employment and Source SS df ms F p Total 1422.69 34 place of employment 76.76 2 38.38 1.070 n.s. method of instruction .05 1 .05 .0013 n.s. place of employment x method 270.69 1 270.69 7.552 <.025 error 1075.29 30 35.84 TABLE 10.-Summary data for analysis of variance: method of instruction Pediatric involvement and Source SS df ms F P Total 1422.69 34 pediatric involvement 59.16 2 29.58 .6922 n.s. method of instruction .05 1 .05 .0011 n.s. involvement x method 81.39 1 81.39 1.904 n.s. error 1282.19 30 42.73 38 Educational preparation interacting with the method of instruction seemed to have most influence on test performance for those in Group A with education beyond the hospital school level (58.10) and those of Group B with only hospital education (58.11). There was also l i t t l e difference between mean scores of those in Group A with hospital preparation (52.38) and those in Group B with further education (52.63). Only one nurse of the eight in Group A with hospital preparation worked f u l l time on a pediatric unit and four were unemployed. Compared with eight f u l l time pediatric nurses of the nine hospital educated in Group B, i t i s possible that the place of employment interacted with educational preparation to offset the effect of the study guide. If this were the case, then the failure of the study guide to produce a significant difference in mean scores could be at least p a r t i a l l y explained. However, the lack of sufficient numbers of subjects to permit three-way analysis of variance prevented further exploration of this p o s s i b i l i t y . In any event, the contradictory data suggests that interaction between other variables was probable. Discussion Although there was no significant between-groups variance nor within-groups variance, i t could not be assumed that no difference meant guidance had no effect. It is possible, of course, that the second hypothesis i s , in fact, "false", and that the null hypothesis i s therefore "true". However, two other p o s s i b i l i t i e s exist. One i s that the no difference result happened by chance; that i s , i t occurred due to error variance. The second is that some unknown extraneous and uncontrolled factor or factors were operating to obscure the differences. Individual differences among subjects, which could be such a factor, ordinarily constitute systematic variance. But when such variance cannot be adequately identified and controlled, then i t must be included as error variance. There are several possible sources of error variance which could account for the failure to confirm the second hypothesis. Unknown variables, such, as the amount of pediatric nursing education and experience, s k i l l in independent learning, experience in raising children, or the amount of time spent studying the independent learning packet may have influenced test performance. The relatively small samples involved may have increased the sample variance. The measures used may not have been suf f i c i e n t l y reliable. The study guide may not have been capable of guiding thinking towards achievement as measured by the post-test. Since the study guide was sp e c i f i c a l l y designed to guide think-ing rather than to ensure learning of specific facts required for the test, this might have Been a factor. Short of resorting to giving hints which would influence test scores, perhaps a different study guide would have resulted in significantly higher scores for those exposed to i t . In addition, the extent to which subjects in Group A made use of the study guide was unknown. It may be that many chose not to follow the study guide. Because there was no supervision during administration of the test, another p o s s i b i l i t y i s that the subjects referred to study materials in order to seek answers. If Group B, presumably having learned less, re-sorted to this tactic, then their scores would have been inflated. Unfortunately, in the present study, i t was impossible to determine whether any of these factors were responsible for the result showing no significant difference between Groups A and B. CHAPTER V SUMMARY, CONCLUSIONS AND IMPLICATIONS This last chapter recounts the study in summary form. The results give rise to two major conclusions concerning the study, and the implications include specific suggestions to aid researchers contemplating further research related to independent learning packets. Summary The recent proliferation of individual methods of learning i n continuing education coupled with the lack of research related to instruc-tional methodology led to this investigation of the effect of guidance on the learning of adults using an independent learning packet. Although a theoretical rationale exists which suggests that guidance is an essential component of instruction, l i t t l e research has been reported to substantiate or refute this theory. A review of related research indicated that the influence of varying amounts of guidance is unclear, that the sequence of instruction in self-directed materials i s of minimal importance for most learning tasks, and that questions placed after reading materials and designed to guide thinking w i l l enhance meaningful learning. The present study tested two hypotheses: 1. Mean scores on a criterion post-test w i l l be significantly higher for two groups who receive an independent learning packet than for a control group receiving no instruction. 40 2. Mean scores on a criterion post-test w i l l be significantly higher for a group receiving an independent learning packet including a study guide than for a group receiving the same independent learning packet without a study guide. Thirty-five Registered Nurses volunteered to study an independent learning packet entitled "Meeting the Emotional Needs of the Hospitalized Preschool Child", and twenty-one nurses were obtained for the control group. The post-test only control group design consisted of eighteen nurses systematically assigned to treatment Group A who studied the independent learning packet with, a study guide designed to provide guidance of thinking. Seventeen nurses were assigned to treatment Group B, who studied an alternative form of the independent learning packet without the study guide. Group C acted as the control group. The independent variable was the method of instruction and the dependent variable was achievement as measured by scores on a criterion-referenced post-test, which was completed by a l l three groups. The Mann Whitney U test applied to the scores of Group A and B combined, versus Group C yielded a significant difference i n the predicted direction beyond the .00003 level. The differences i n mean scores of Groups A and B failed to achieve a significance of .05 when the t test was applied. Therefore, the f i r s t hypothesis was confirmed but the second was not accepted. Analysis of the distribution of six known personal characteristics suggested that Groups A and B were equivalent, but that Group C was different from the other two. Interaction of the method of instruction with, the place of employment and the method of instruction with educational preparation produced the only significant effects (p<.025) on test scores when analysis of variance was carried out. Although the null hypothesis, that guidance makes no difference, may be true, several sources of error variance were identified which could account for the results obtained. Conclusions Two major conclusions arise from this study. The f i r s t is that considerable learning can be achieved by studying an independent learning packet, and i t i s therefore a useful mode of instruction for the continuing education of nurses. The second conclusion i s that the study as conducted failed to detect any- f a c i l i t a t i n g function served by guidance in the form of a study guide. This result may have occured because of a failure to minimize error variance sufficiently to enable systematic variances to show their significance, i f they were significant. Implications for Further Research So l i t t l e research, has been carried out in relation to indepen-dent learning and individual instruction among adults that the p o s s i b i l i -ties seem endless. The questions raised by this study concerning guidance, however, emphasize the need for careful examination of instructional components in individual methods. Although adequate control of variables in experiments of this nature may be d i f f i c u l t , further attempts to determine the nature and effect of guidance for self-directed study would be of considerable benefit to continuing educators. F i r s t of a l l , i t would seem obvious that the experiment needs to be replicated. The methodology should, however, be altered to reduce the possible sources of error variance. Larger samples would f a c i l i t a t e 43 controlling for individual differences among subjects and would decrease sample variance. Use of an independent learning packet of interest to a greater number of nurses or other adults would help to ensure a larger potential subject population. If sufficient subjects are obtained, then one of the weaknesses of the present study could be eliminated by assigning a l l subjects randomly to groups. In addition to the variables considered in the present study, i t would be useful to control for other individual differences such as the amount of time spent studying. Many researchers have found that of the variables studied, study time was the most predictive of the amount of learning by different methods. (eg. 7 . Campbell) In the event that i t becomes possible to clearly identify and measure cognitive strategies, then controlling for s k i l l in independent learning would also be an impor-tant factor. With regard to the design of the independent learning packet, i t would seem useful to allow a longer period for study. An independent learning packet of a similar nature and length to the one used in the present study should probably be available for three or four weeks instead of two. Careful attention should be paid to the development of the study guide so that i t s intent regarding guidance is clearly defined and under-stood by the researcher as well as by the user of the materials. In addition, more comprehensive studies related to guidance in study guide form might be undertaken. Comparison of the effects of differing amounts or kinds of guidance on specified learning outcomes could provide useful knowledge regarding adult needs for guidance. And attempts to determine differences in the nature of guidance optimal for a variety of cognitive learning outcomes might include a number of independent learning packets each representing one of a hierarchy of learning capabilities ranging from the acquisition of verbal information to creative problem-solving. Comparative studies also need to be done between the independent learning packet method and other methods of instruction such as the lecture, correspondence study, and programmed instruction. Although the present study confirmed that considerable learning can be achieved through study of an independent learning packet, i t s effectiveness in comparison with other methods i s unknown. However, such studies should be regarded only as the foundation for concentrating further research on specific instructional components so that a definitive theory of adult instruction can eventually be realized. fs1 REFERENCES 1. Adams, Shirley. "A Self Study Tool for Independent Learning i n Nursing," The Journal of Continuing Education in Nursing, II, No. 3 (May-June, 1971), 27-31. 2. Bloom, Benjamin S., ed. Taxonomy of Educational Objectives. New York: David McKay Co. Inc., 1956. 3. Briggs, Leslie J., et a l . Investigations of Thinking via Self-Iristructiorial Programs. 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Pennsylvania: The Pennsylvania State University Press, 1971. 9. De Crow, Roger and Loague, N., eds. Adult Education Dissertation Abstracts: 1963-1967. Adult Education Association, December 1970. 10. De Crow, Roger, and Loague, N., eds. Adult Education Dissertation Abstracts: 1968-1969. Adult Education Association, December 1970. 11. Deep, Donald. "Individualized Learning for Adults - The ILA Project," Adult Leadership., XX, No. 8 (February 1972), 291. 45 46 12. Duchastel, P.C., and M e r r i l l , P.F. The Effects of Behavioral Objectives on Learning: A Review of Empirical Studies. Tallahassee: Florida State University, 1973. 13. Duchtenberg, Anne, and Geis, George L. "Modularized Instruction at McGill", Learning and Development (McGill University), IV, No. 3 (Novemb er, 1972). 14. Gage, N.L., (ed.). Handbook of Research on Teaching. Chicago: Rand McNally, 1963. 15. Gagne, Robert M., and Brown, Larry T. "Some factors i n the Programming of Conceptual Learning", The Journal of Experimental Psychology, LXI, No. 4 (October, 1961), 313-321. 16. Gagne, Robert M. et a l . "Factors in Acquiring Knowledge of a Mathematical Task," Psychological Monographs, LXXVI, No. 7 (whole No. 526) 1962. 17. Gagne, Robert M. "The Acquisition of Knowledge", Educational Technology, Readings in Programmed Instruction. De Cecco, John P. (ed.) Nevr York: Holt, Rinehard, and Winston, Inc., 1964. 18. Gagne, Robert M. "Problem Solving", Categories of Human Learning. Melton, Arthur W. (ed.). New York: Academic Press, 1964. 19. Gagne, Robert M. The Conditions of Learning. 2nd ed. New York: Holt, Rinehard and Winston, Inc., 1965. 2Q. Gagne, Robert M. "The Acquisition of Knowledge", Learning: Theory and Practice. Johnson, Paul E., (ed.). New York: Thomas Y. Crowell Co., 1971. 21. Personal interview with Robert M. Gagne. April 5, 1973. 22. Groen, G.J., and Atkinson, R.C. "Models for Aptimizing the Learning Process", Learning: Theory and Practice. Johnson, Paul E., (ed.), New York: Thomas Y. Crowell Co., 1971. 23. Harrington, Charles F. "An Evaluation of the Effects of Logical and Random Sequencing of a Self-Instructional Program in Educational Measurement. Dissertation Abstracts, XXVII, No. 8-A (1967), 2391. 24. Hershberger, W.A. Learning via Programmed Reading and Cue Versus Response in Programmed Reading. American Institute for Research Technical Report AIR-C28-7/63-TR, July 1963. 25. Hilgard, E.R., (ed.). Theories of Learning and Theories of Instruction. (63rd National Society for the Study of Education Yearbook, Part 1), Chicago: University of Chicago Press, 1964. 26. Hunkins, Francis P. The Influence of Analysis and Evaluation Questions on Achievement and C r i t i c a l Thinking in Sixth Grade Social Studies. Seattle, Washington: University of Washington, 1968. 27. Kearney, Patricia A. "Structural Parameters of an Autoinstructional Experiment Involving Adult Learners", Dissertation Abstracts, XXVII, No. 11-A (1967), 3725. 28. Kotaska,- Janelyn G. "The Development of Independent Learning Packets for Practising Nurses". Unpublished term paper, Department of Adult Education, University of B r i t i s h Columbia, 1972. 29. Lysaught, Jerome P. Research on the Use of Programmed Instruction Among Adult Learners in Professional Health Fields. Paper presented at the National Seminar on Adult Education Research (Chicago: February 11-13, 1968), 1968. 30. Mager, Robert F., and Clark, C. "Explorations i n Student-Controlled Instruction", Psychological Reports, XIII, No. 1 (1963), 71-76. 31. Mager, Robert F. "On the Sequencing of Instructional Content", Educational Technology, Readings i n Programmed Instruction. De Cecco, John P., (ed.). New York: Holt, Rinehard, and Winston, 1964. 32. Melching, W.H., and Nelson, F.B. "The Influence of Practice Frames and Verbal A b i l i t y on Programmed Instruction Performance", Adult Education, XVII 0-966-67), 223. 33. M i l l e r , H.R. "Sequencing and Prior Information in Linear Programmed Instruction", Audio-Visual Communication Review, XVII (Spring 1969), 63-76. 34. National University Extension Service, An Annotated Bibliography of Correspondence Study: 1897-1960. Prepared by The Committee on Research, Division of Correspondence Study. National University Extension Service, 1960. 35. Natkin, Gerald L. "Research and Theory on the Effects of Instructional Sequencing", Research in Education, V, No. 11 (1970), 95. 36. Niedermeyer, F.C. "Relevance of Frame Sequence in Programmed Instruction", Audio-Visual Communication Review, XVI ( F a l l , 1968), 301-317. 37. Payne, D.A., and Krathwohl, D.R. "The Effect of Sequence on Programmed Instruction", American Educational Research Journal, IV, No. 2 (1967), 125-132. 38. Roe, K.V., et a l . "Scrambled Versus Ordered Sequence in Auto-Instruc-tional Programs", Journal of Educational Psychology, LVIII (April, 1962), 101-104. 48 39. Rothkopf, Ernst Z. "Learning From Written Instructive Materials: An Exploration of the Control of Inspection Behavior by Test-Like Events", Learning: Theory and Practice. Johnson, Paul E., (ed.). 40. Sepede, John H. "Individualizing ABE Programs Through Learning Packets", Adult Leadership, (February, 1972), 289-290. 41. Siegel, Sidney. Nonparametric Statistics for the Behavioral Sciences. New York: McGraw-Hill Book Co. Inc., 1956. 42. Sime, M., and Boyce, G. "Overt Responses, Knowledge of Results, and Learning", Programmed Learning and Educational Technology, VI, No. 1 (July, 1969), 12-19. 43. Tobias, Sigmund. The Effect of Sequence and Familiarity with Subject Matter in Achievement from Programmed Instruction. New York: City University of New York, July 1971. 44. Webb, Wilse B. Student-Centered Instruction in a Pre-Flight Course. Special Report No. 55-17, Naval Air Station, Pensacola, Florida, 1955. 45. Wedemeyer, Charles A. "Rationale for Independent Study". Presentation made at the Northwest Institute on Independent Study: The Adult as a Self-Learner, The University of Br i t i s h Columbia. February 23-24, 1970. 46. Wolfe, A.B., and Smith, J.E. "At Nova, Education Comes in Small Packages; Learning Activity Packages", Nation's Schools, LXXXI (June, 1968), 48-49+. APPENDIX I Independent Learning Packet To avoid bulkiness, the reference materials have not been included. MEETING THE EMOTIONAL NEEDS OF THE HOSPITALIZED PRESCHOOL CHILD by JANELYN GAIL KOTASKA, B.S.N, an INDEPENDENT LEARNING PACKET PEDIATRIC NURSING NO. 1 THE REGISTERED NURSES' ASSOCIATION OF BRITISH COLUMBIA APRIL, 1972 INTRODUCTION TO INDEPENDENT LEARNING PACKETS This packet i s one of a series which have been developed to help you continue your nursing education and keep up to date. They have been designed with you in mindl You can study at home and at your own speed. You don't need to search for books or a r t i c l e s on the topic since a l l the materials you need are included in each packet. The topics are purposely limited to small areas of nursing practice so that you can select only those that seem most pertinent to your needs. However, i f you want to learn more after completing a learning packet, a l i s t of other related materials i s included, any of which w i l l be sent to you on request. To help you study e f f i c i e n t l y and learn as much as possible, a study guide has been prepared for each packet which gives specific directions about how to proceed. As you may have guessed by now, using an independent learning packet requires you to actively participate i n learning, which i s really the only way one truly learns. Reading literature and listening to lectures may provide information, but whether one really understands, remem-bers, and i s able to apply the information to practical situations depends on the thinking and action that follow. Therefore, the study guide includes problems, questions, and projects to assist you in learning. The objectives t e l l you what you can expect to have learned when you fi n i s h the independent learning packet, and you should refer to these to decide whether you have actually achieved them. In addition, at least one test i s included which you can complete i n order to judge what you have learned. The test w i l l be marked and returned to you with corrections. And f i n a l l y , there i s an evaluation form provided for you to t e l l us what you think about the independent learning packet. It i s the only way we w i l l know i f the packet was what you needed or expected so that improvements can be made i f necessary. Independent learning packets are loaned to you for two weeks. Please do not write on any of the materials except the evaluation form and the test. Return the entire packet when you have completed your study. 52 MEETING THE EMOTIONAL NEEDS OF THE HOSPITALIZED PRESCHOOL CHILD PURPOSE The purpose of this independent learning packet i s to provide: 1. information related to the emotional needs of the hospitalized three to five year old child. 2. learning a c t i v i t i e s which w i l l assist the nurse in learning the important concepts so that she may apply them in nursing situations. OBJECTIVES Upon completion of this independent learning packet, the nurse w i l l be able to: 1. Describe hospitalization in terms of i t s meaning to the pre-school child. 2. Explain why the presence of the preschool child's mother during hospitalization i s v i t a l to his emotional health. 3. Recognize the typical behavior indicative of emotional trauma in the preschool child when separated from his mother. km Identify ways in which the emotional health of the preschool child may be maintained and protected during hospitalization. PREREQUISITE KNOWLEDGE It would be helpful to review the growth and development of the pre-school child prior to studying this topic. References for reviewing growth and development are l i s t e d at the end of this packet. I f i t would be more suitable for you to undertake the review after completing this packet, ref-erences which are available on loan from the RNABC are indicated. 2 5 3 STUDY GUIDE A. Introduction: The emotional needs of children and the ways in which nurses and hospitals can help meet them vary with each age. The infant, the one and two year old, the preschool child (3-5 years), the elementary school aged child, and the adolescent a l l require different approaches according to the stage of growth and. development and the ability to cope with hospitalization. This independent learning packet focusses on the emotional needs of the hospitalized three to five year old child. However, i t must be remembered that the chronological age of an individual child does not necessarily mean that his emotional, phys-ical, or mental development is equivalent to the average for his age. For example, there are two year olds who are more mature than some three year olds, and six year olds who are not as mature as the average five year old. Therefore, one must be careful not to rely on chronological age alone when judging the emotional or physical maturity of an indiv-idual child. The need of preschool children for a close and continuous rel-ationship with one person is the most important concept underlying the study of this topic. In most instances, this person is the child's natural mother, but "mother" should be interpreted as the person who usually cares for the child or with whom he has the most continuous and close relationship. It may be the adoptive or foster mother, the father, a housekeeper, a grandmother, or other relative. Occasionally, there may be not only one, but two or three people who seem equally import-ant to the child. Keep in mind, then, that references tc a child's "mother" may not,, in individual cases, mean his natural mother. B. Study the resource materials in the order in which they are listed on the following page (page 4). These resources contain the information content of this course. They have been selected from a multitude of references related to this topic. C. Read the summaries on pages $ - 8 of the study guide. 3 54 LIST OF RESOURCE MATERIALS (included in packet) A. THE MEANING OF HOSPITALIZATION, RESPONSES OF PRESCHOOL CHILDREN TO HOSPITALIZATION, AND FAMILY-CENTERED PEDIATRICS 1. Yourg Children in Hospital, by James Roberston. London: Tavistock Publications Ltd., 1958. (Book) 2 . The Hospitalized Child, by Barbara Brodie and Maxine Berlinger. Video Nursing Inc., Evanston, I l l i n o i s , 1967. (Audiotape #PN 211-201) . 3 . "Viewpoints on Children in Hospitals", by Florence Erickson, Hospitals, vol. 37f May 16, 1963, pp. 47 -48 . 4 . "The Case for Parent-Child Nursing", by Constance Nissen. RN, September I969, pp. 80-82 , 84, 87, 89. 5 . "Pediatric Rooming-In: Its Meaning for the Nurse", by Claire M. Fagin. Nursing Cl i n i c s of North America, March I 9 6 6 , pp. 83-93* 6 . "Parental Involvement Program", by Joanne Shope. Nursing Outlook, A p r i l 1970, PP. 32-34. 7. "Parents Assist in Care of Hospitalized Children", by Barbara Cavitch. Nursing World, May 1959, pp. 25-26. 8. "Parents on Pediatrics: Problam or Pleasure?", by Ann Lore. RN, December 1969, pp. 44 -45 , 62-63. B. PREPARATION OF CHILDREN 9. "Preparing Children for Procedures and Operations", by Mary Sca h i l l . Nursing Outlook, June 1969, pp. 36-38 . 10 . "The Seventh Right", by Barbara Conway. American Journal of Nursing, May 1970, pp. 1040-1043. 1 1 . A Child Goes to Hospital, by Harold Geist. Springfield, I l l i n o i s : Charles C. Thomas Publisher, 1965. Chapter II. "Suggestions to Parents", pp. 12 -28 . 12 . Your Child in Children's Hospital, Children's Hospital, Vancouver, BC. (Pamphlet) 13. Surgical Day Care Information, Children's Hospital, Vancouver, BC. (Pamphlet) 14 . "Our Child at Home". Children's Hospital, Vancouver, BC. (Mimeographed) C. FLAY 15. "Rxi. Play PRN in Pediatric Nursing", by Jacqueline Hott. Nursing Forum, IX, no. 3 , 1970, pp. 297-307. (Section entitled Play Therapy) 16. "Why Play in the Hospital?", by Mary M. Brooks. Nursing Clinics of North America, September 1970, pp. 431-441. 17 . "Preventing Hospital Trauma in Pediatric Patients", by Madeline P e t r i l l o . American Journal of Nursing, July I968, pp. 1469-1473. 18 . " B i l l y Needs to Play", by Margaret A. Murrin. RN, December 1969, pp. 38-43 . 4 SUMMARY OF CHANGES EXPERIENCED BY THE PRESCHOOL CHILD DURING HOSPITALIZATION Separation from: 1. People - mother, father, siblings, friends, relatives 2 . A c t i v i t i e s - play, nursery school, day care center, usual home routines 3. Things - home, furnishings, clothes, toys Introduction to: 1. New people - nurses, doctors, and others in large numbers, other children and adults whose appearance may be un-usual 2 . New a c t i v i t i e s - routines, procedures (painful or otherwise), meals, baths, etc. 3..New things - equipment, furnishings, size and appearance of hospital rooms and halls Separation complicated by: 1. Illness - child not as adaptable as i f he were feeling well 2 . Anxiety without outlet - the limitations set on a child's physical a c t i v i t y prohibit behavior that helps him to dissipate anxiety -- running around, active play, getting r i d of 'steam' 3. Suddenness - whether elective or emergency, hospitalization to a preschool child i s sudden, and even appropriate preparation before hospitalization cannot adequately prepare him for the absolute strangeness of the hospital environ-ment. 56 SUMMARY OF FACTORS WHICH AFFECT THE ADJUSTMENT OF A PRESCHOOL CHILD TO HOSPITALIZATION A. Factors outside the child himself 1. Attitudes of parents - general attitudes towards the child, illness, hospitalization, etc., and attitude towards the specific i l l n e s s or reason for hospitaliation 2. Length of hospitalization 3. Quantity of hospital experiences - how many new and d i f f i c u l t experiences the child must undergo 4. Quality of hospital experiences - hospital policies and prac-tices which minimize detrimental effects of hospitalization; attempts to make hospital environment more pleasant; a t t i -tudes of personnel regarding emotional needs and problems B. Factors within the child 1. A b i l i t y to cope - depends on (a) age - most d i f f i c u l t for one to five year olds (b) intelligence (c) nature of i l l n e s s or operation 2. Physical and personality characteristics - the attractive, outgoing child has a very different hospital experience from the withdrawn, ugly, or disfigured child because of the amount of attention and type of responses he receives from hospital personnel 3. Attitude of child - depends on attitudes of parents and his preparation for hospital 6 SUMMARY OF RESPONSES OF PRESCHOOL CHILDREN TO HOSPITALIZATION INDICATIVE OF EMOTIONAL TRAUMA Common Responses during the stage of protest: - loud and constant crying - calling for mother - uncooperative behavior - resists care - rejection of nurses and doctors - cries even more when anyone app-roaches, won't look at them or talk to them - excessive physical activity - throwing self around - restlessness - i n a b i l i t y to sleep - h o s t i l i t y , aggressive behavior - refusal of food - constant searching for sight of mother - regression - bedwetting, thumb sucking, etc. - clutching a toy, blanket, etc. brought from home This behavior i s evidence of feelings of fear, anger, insecurity, anxiety, frustration, grief, bewilderment, abandonment Common responses during the stage of despair: - monotonous, bitter, intermittent crying - sad appearance - withdrawn, apathetic - no interest in a c t i v i t i e s or surroundings - quiet - seemingly less distressed - less active - return to loud crying during or following mother's v i s i t s This behavior i s evidence of feelings of intense grief for loss of mother, hopelessness, fear, anxiety, guil t Common responses during the stage of denial: - more interest in surroundings - smiles, responds to play - seemingly 'happy' - friendly towards nurses and others - demands and thrives on attention - wants and accepts care - may be overly dependent - no longer cries at v i s i t i n g times, but may appear sad when v i s i t ends - may be-unresponsive towards.parents when v i s i t i n g - appears "well-adjusted" This behavior i s evidence of repression of the child's feelings, because he cannot tolerate the intensity of distress due to separa-tion from his mother. He denies his need for his mother, home, and family. The stages of protest, despair, and denial are not distinct and separable, and the changes in behavior are very gradual. A child's behavior may be characteristic of different stages at different times. Common responses following hospitalization: - regressive and dependent behavior - aggressiveness and anger towards mother and others - nightmares - negativism and defiance - refuses to do as parents wish - hyperactivity - temper tantrums - destructiveness - clinging to mother, or won't l e t her out of sight - i f child reached the state of denial in hospital, shows no affection towards parents and resists their attempts to be affectionate - i n a b i l i t y to sleep, fear of the dark - fear of strangers, doctors 8 D. Answer the following questions and problems. Refer to the resource materials i f you wish. 1. What are the present policies and practices of your hospital towards the preschool child in relation to the following: (a^ pre-hospital preparation of children (b) admission procedure (c) provision for the presence of the mother (d) provision for care of the child by his mother (e) v i s i t i n g hours for fathers, siblings, friends, and other relatives (f) f l e x i b i l i t y of routines such as waking, bdtime, naps, bathing, TPR, etc. (g) provision for play (h) bringing toys from home (i) taking temperature rectally (j) provision for physical activity; i e. allowing the child to be out of bed unless immobility absolutely necessary (k) dressing children i n clothes (l) assigning one nurse to provide consistent care for the child during the day (m) preparation of parents for post-hospital care of the child 2. What changes i n these policies and practices would you propose to improve the likelihood of maintaining the emotional health of the preschool child? 3. Which of your proposed changes do you feel would not be acceptable to the hospital or nursing administration? How could you go about obtaining acceptance? Write as many ideas as you can think of that would help achieve these changes. Hake a plan for implementing the most suitable suggestions, and carry out your plan! I f you have formed a group to study this topic, this i s an ideal situation where the weight of a group may help to bring about improvement in existing practices. 4. In addition to pressing for changes in hospital policies and practices, what changes in your nursing care of preschool children w i l l you make i n relation to the following: (consider both three and five year olds i f the appropriate care w i l l differ.) (a) your explanation to the child in preparing him for an injection (b) your approach when administering an oral medication to a child. (c) how you w i l l provide for appropriate play (d) your explanation to the parents and care of a child crying when his parents must leave (e) your attitude towards a mother who stays with her child most or a l l of the day. (f) your handling of the situation i f a mother participates in the care of her child even though i t i s not "hospital policy" (g) how you can assist the mother in planning to remain with her child as much as possible. (h) your handling of the admission of a child (i) your handling of a child who refuses to eat (j) your handling of a child who regresses to soiling or wetting. (k) your care of the child who i s immobilized (eg. in traction or cast) 5. What information would you li k e to know about a preschool child to help him accept and trust you and to make l i f e in hospital seem less strange and more lik e home? If your hospital already has an information sheet to be completed by the mother, study i t and decide i f there i s any further information you would obtain from the mother. 9 60 6. Young children experience three stages of adjustment or "settling-in" when deprived of their mothers' care. Refer to the 'Summary of Responses of Preschool Children to Hospitalization Indicative of Emotional Trauma', on pages 8 and 9 of the study guide. How can the nurse help minimize the emotional trauma of separation when a child's mother i s unable to stay with him during hospitalization? Discuss only the stages of protest and despair and consider your answer in terms of both a three year old and a five year old child. V/here the appropriate nursing approaches and a c t i v i t i e s d i f f e r because of the child's age, give reasons for the difference. 7. Illness and hospitalization of a child are stressful to the parents as well as the child, and their reactions w i l l affect the child's adjustment to hospital. The following situations i l l u s t r a t e a variety of behaviors which may indicate anxiety i n parents. Describe how you would handle each situation. (a) the mother i s standing outside the child's room, crying. (b) the mother t e l l s you she won't be coming to v i s i t . (c) the mother and father both v i s i t frequently, but never talk to you or ask any questions (d) the mother becomes angry and t e l l s you that you are not caring for her child properly. (e) the father says, " I f only I had been watching Johnny more closely, he would never have been hit by that car." (f) the mother appears very nervous and i s overly solicitous towards the child. She asks you the same questions over and over. 8. Assume that the mother i s permitted to room-in with her child and to care for him. (a) What aspects of care do you think are appropriate for the mother to assume? (b) How do you feel about her presence while you are performing treatments and giving injections? (c) What i s the mother's role in being with her child during treatments and injections? (d) How would you explain the mother's role to her? Give examples of explanations and directions you would give to the mother when she i s staying with her child during treatments, including injections. (e) What eating and sleeping arrangements could be made for the mother within the existing hospital environment? What other improvements i n f a c i l i t i e s for mothers could be made without major reconstruction? (f) How w i l l your communication with the mother d i f f e r from talking with mothers who v i s i t for only an hour or so? (g) How w i l l you react towards a mother who asks a lot of questions? (h) How would you expect a preschool child to behave i f his mother rooms-in with him? 9. Most five year olds are interested in everything that i s going on, like to ask many questions, and enjoy conversation. How would you take advantage of these characteristics in preparing a five year old for a diagnostic or treatment procedure and in assisting with or carrying out the procedure? Select a specific procedure that i s usually frightening or painful to child-ren and which you are frequently or l i k e l y to be involved i n . 10 61 10. Most three year olds have a limited vocabulary and understanding of words. They are less independent than a five year old, are more afraid of new experiences and less curious about them. How would you use this knowledge in preparing a three year old child for a diagnostic or treatment pro-cedure, and what would be your approach in carrying out or assisting with the procedure? Again, select a specific procedure that i s usually frighten-ing or painful to children and which you are frequently or l i k e l y to be involved i n . E. Complete the self-test. F. F i l l in the evaluation form. G. I f you wish to study this topic further or to review the growth and devel-opment of children, please refer to pages 2 0 - 2 3 . Make a l i s t of the starred a r t i c l e s that you would l i k e copies of. You may also request copies of any of the a r t i c l e s included in this packet for your reference. Please enclose ten cents per page to cover the cost of Xeroxing. The audiotapes on growth and development are available on loan. H. Please return a l l the materials in the independent learning packet i n the package you received them i n . A return address label i s enclosed for you to attach over your address on the envelope. 11 SELF-TEST Please complete a l l of the test before checking your answers with the answer sheet. Do not write on the test paper. Please use your own paper. Complete the following statements. 1. The most important source of emotional support for the hospitalized preschool child i s . 2. This source i s particularly important for the preschool child because 3. The three stages which characterize emotional trauma during hospitali-zation are: . When hospitalized, the most overwhelming fear of a preschool child i s 5. The hospitalized preschool child frequently has guilt feelings and interprets hospitalization as . 6. The greatest fear during hospitalization of children five years and older i s usually . 7. Ten aspects of hospital l i f e which are commonly upsetting to preschool children, not including procedures specific to the treatment of a part-icular child are: 8. The most important way to reduce emotional trauma in the preschool child i s 9 . Five other ways in which emotional trauma can be reduced are: A number of statements are l i s t e d below which describe common behavioral responses of hospitalized preschool children. Match each statement with the most l i k e l y of the following four situations. (a) a hospitalized preschool child in the stage of protest. (b) a hospitalized preschool child in the stage of despair. (c) a hospitalized preschool child in the stage of denial. (d) a hospitalized preschool child whose mother stays with him during much of his hospitalization. 1. jumps up and down and shakes the crib 2. maintains his present stage of growth and development 3. cooperates with nurses but i s unresponsive towards his mother cries monotonously and intermittently 5. feeds himself as he did at home 6. acts out or verbalizes feelings with h o s t i l i t y and anger 7. l i e s quietly and disregards his surroundings 8. i s friendly towards the nurses and shows off to attract attention l 2 9. learns how to t i e his shoes ( 10. regresses to wetting and soiling ( 11. cries when a nurse approaches to talk to him ( 12. plays happily and i s affectionate towards his mother ( 13. i s happy to see his mother but cries b i t t e r l y when she leaves ( 14. picks at the blankets, sucks his fingers, and clutches his teddy bear ( 15. constantly asks for new toys and candy ( 16. cooperates during treatment procedures, but cries i f he i s hurt ( 17. shares his toys with other children ( 13. stutters, bangs his head at night ( 19. appears anxious when admitted, but soon becomes interested in ward a c t i v i t i e s ( 20. refuses to eat unless fed ( 21. clings to his mother and cries even when she i s present ( 22. talks a great deal, and enjoys chatting with the nurses as well as his mother ( 23. i s very dependent on nurses for care ( 24. l i e s quietly, looking sad ( 25. cries when meals are brought to him and eats very l i t t l e ( . Multiple choice. Select the best answer to the following items. 1. In preparing her three year old child for hospital, a mother should: (a) Describe in considerable detail what a hospital i s l i k e and what w i l l happen to him. (b) Begin preparing the child for hospitalization several weeks in advance. (c) Not t e l l the child anything u n t i l the day he i s to be hos-pitalized. (d) A day or two in advance of hospitalization, explain why the child must go to hospital and b r i e f l y describe what he may expect. (e) Take the child to v i s i t the hospital a few days prior to hospitalization. (f) Read a story book about hospital to the child. 2. In explaining a forthcoming operation to a preschool child, the nurse should: (a) Answer only the questions the child asks concerning the operation. (b) T e l l the child's mother how to explain the operation to her child. (c) Assist the mother in explaining the operation to the child, using frequent repetition. (d) T e l l the mother that the nurse w i l l explain the operation to the child. 3. When administering an Injection for preoperative sedation to a child, the nurse should ask the mother to: a) Hold the child in her arms. b) Leave the room. (c) Hold the child firmly in bed. (d) Comfort the child following the injection. 13 64 4. I f a mother says she i s unable to stay with her child during hospital-ization and can v i s i t only briefly, the nurse should: (a) Respect the mother's wishes, (b) Explain the importance of the mother's presence to the well-being of her child. (c) Find out why the mother cannot stay with her child, (d) Suggest the mother try to arrange for a substitute person to stay with her child. (e) Assure the mother that the nurses w i l l take good care of her child. 5. I f a mother says she wishes to remain with her child during a painful or upsetting procedure, the nurse should: (a) Explain tactfully that i t i s impossible since i t i s against hospital rules. (b) Permit her to remain but explain the procedure carefully and ask her to hold the child's hand during the procedure. (c) Explain that the procedure i s painful and/or upsetting and suggest that she go and have a cup of coffee instead. (d) Permit her to remain i f she does not seem anxious and you think she may be of help i n immobilizing the child. (e) Permit her to remain, but warn her that she may have to leave i f she or the child become too upset. 6. I f a child cries when his mother must leave him, the nurse should: (a) T e l l the mother to leave quickly while the nurse diverts his attention. (b) Explain to the mother that children are naturally upset when parents leave, but that the nurse w i l l stay with him for awhile. (c) T e l l the child that his mother w i l l be back soon. (d) Explain to the mother that crying i s normal but the child w i l l soon stop after she leaves. (e) T e l l the mother not to v i s i t too often, as her departure i s upsetting to the child. 7. I f a child begins to cry and cling to his mother during admission, the nurse should: (a) Ask the mother to leave and come back later after the admission procedures are finished. (b) T e l l the child that crying w i l l not do any good and that his mother w i l l have to leave i f he continues. (c) T e l l the child that he can have some toys as soon as the admission procedures are finished. (d) Proceed matter-of-factly with undressing the child, taking his temper-ature, etc., and ignore his crying. (e) Delay the admission procedures, allow the mother to hold the child, and show him his room, bed, the bathroom, kitchen, play area, etc. (f) Ask the mother to undress her child and get him into bed, and plan to complete the admission procedures later. 8. I f the mother v i s i t s infrequently and the child cries a lot, the nurse should: (a) Realize that the child i s grieving for his mother, but that he w i l l soon settle down. 14 65 (b) Hold the child frequently and talk to him, though he struggles to get away from her. (c) Divert his attention with toys and give him treats. (d) Explain that he won't get better i f he keeps on crying. (e) Be responsible for a l l the child's nursing care, and assure him that his mother s t i l l loves him and he i s not being punished. (f) Arrange for volunteers to spend time with the child. 9. To help a child express his feelings following a painful or frightening procedure, the nurse should: (a) Allow him to cry as much as he wants without interference. (b) Ask the child to t e l l her about the procedure. (c) Have dolls and a doctor kit accessible at a l l times for the child to play with by himself or with the nurse's help 0 (d) Give the child dolls and a doctor kit immediately following the procedure, and assist him in acting out his feelings. 10. I f a preschool child appears happy though his mother v i s i t s infre-quently, the nurse should assume that: (a) He i s exhibiting emotional trauma in the stage of denial. (b) He has accepted hospital and understands that the nurse i s doing a l l she can to make him well. (c) He i s a quiet, well-behaved child at home, and has adjusted to hospital as he would to any situation. (d) The child has been hospitalized before, and knows what i s ex-pected of him, 11. I f a five year old exhibits naughty behavior such as refusing to coop-erate, hitting the nurse, throwing his food, etc., the nurse should: (a) Assume that he has been poorly brought up at home, and try to correct his behavior through discipline. (b) Realize that his behavior ref l e c t s angry feelings and try to correct his behavior through discipline. (c) Accept his behavior and avoid being with him unless necessary. (d) Assume that he doesn't l i k e her, and ask to have a different nurse assigned to him. (e) Explain that she understands he i s feeling angry, and ask him to draw some pictures to show her just how angry he feels. 12. I f a three year old who was t o i l e t trained before hospitalization regresses to wetting and soiling, the nurse should: (a) Make a schedule for to i l e t i n g him every two hours. (b) Put diapers on and ignore the regressive behavior. (c) Explain that this sometimes happens in hospital and that he w i l l stop having accidents when he feels better. (d) Ask the mother how she handled t o i l e t training at home, and use the same procedure. 13. 2" a preschool child refuses to eat, the nurse should: (a) Leave foods that he likes at the bedside in addition to providing meals at the regular times. (b) Take him the regular tray at mealtimes, and remove i t without comment after a reasonable length of time. (c) Sit with the child during mealtimes and coax him to eat. (d) Encourage his mother to come at mealtimes to feed him. (e) T e l l the child that he w i l l have to have needles i f he doesn't eat. 15. 14. When a mother stays with her child most of the day, the nurse should: (a) Stay away from the child's bedside unless absolutely necessary. (b) Clarify the nurse's role, and encourage the mother to care for her child as she would at home. (c) Explain to the mother that since she i s going to stay, she should help with the child's care. (d) T e l l the mother what she i s allowed to do for the child, and what the nurse w i l l do. (e) Closely supervize the mother's care of her child. 15. When a preschool child whose mother roomed-in with him goes home from hospital, he would l i k e l y : (a) Become angry i f his mother doesn't do as he wishes, (b^ Prefer to stay at home with his mother, (c) Be very active during the day and dream a lot at night. (d) Play hospital with his friends at nursery school. (e) Refuse to do as his father wishes, 16. A five year old i s crying following his mother's v i s i t . The nurse should: (a) Say, "Your mother w i l l be back in a l i t t l e " while." (b) Hold him and say, "You miss your mother." (c) Give him a toy. (d) Put her arm around him and say, "Your mother wouldn't want you to cry this way." 17. The nurse must administer an oral medication to a four year old who says, "I won't take that medicine because I hate you." The nurse should reply: (a) T e l l me why you hate me? (b) It's not nice to hate people, (c) You can't get well unless you take your medicine. (d) Here, hold the cup and take the medicine yourself. 18. The nurse i s meeting a three year old for the f i r s t time. His mother i s present. The nurse would be most l i k e l y to establish a quick, friendly relationship with the child i f she: (a) Calls him by name while offering him a toy. (b) Says, "Well, don't you look fine." (c) Greets him quickly by name and asks his mother to leave. (d) Picks him up and says, " I ' l l look after you while you are sick." 19. If a four year old arrives with his mother for an elective admission and you hear her say, "I'm sorry, but we aren't going to v i s i t grandma. You have to stay in the hospital instead," the nurse should: (a) Ask the mother why she didn't prepare her child for going to hospital. (b) Pick the child up and say, "Never mind, you'll be able to v i s i t grandma in a few days." (c) S i t down with the mother and her child and say, "I guess mummy didn't t e l l you about coming to the hospital, so let's talk about i t now." (d) Call the doctor and ask him to come and talk to the mother. 16 20. A five year old i s extremely fearful about having a tonsillectomy, scheduled for the next day. He has been well prepared for hospital, his mother i s staying with him during the daytime, and he talks know-ledgeably about the operation and operating rooms. It i s most l i k e l y that he i s afraid of: (a) Not waking up. (b) Being put to sleep. (c) The equipment and machines which he expects to see. (d) Doctors and nurses with masks and gowns on. (e) What w i l l be done with his removed tonsils. 21. A three year old child must be put in an oxygen tent (or Croupette). To help prevent a fearful reaction, the nurse should: (a) T e l l him he has to stay in a tent l i k e he would i f he went camping. (b) Set up the oxygen tent and help him play experimentally in and out of i t for awhile. (c) Explain that the oxygen tent w i l l help him to breathe better. (d) Show him another child in an oxygen tent. (e) T e l l him he w i l l not be able to hear or see what i s going on outside the tent very well. 22. To minimize fear in a preschool child awakening from anesthesia, the nurse should: (a) Assure that his mother i s at his bedside when he wakes up. (b) Make sure that medication for pain or sedation are administered as ordered. (c) Stay with the child u n t i l he i s f u l l y awake and assure him that he w i l l feel better soon. (d) Avoid disturbing him unless absolutely necessary so that he can rest quietly. (e) Quietly explain exactly what you are doing when caring for him, 23. I f a child whose mother rooms in with him refuses to cooperate during nursing procedures and i s very fearful, i t i s l i k e l y that: (a) He i s spoiled and overly dependent on his mother. (b) He was not adequately prepared for hospital, (c) His mother i s a very anxious person. (d) The nurse has not used the right approach in educating the mother and child. 2h. In order to provide suitable play for a hospitalized preschool child, i t i s necessary to have: (a) A well equipped playroom. (b) A "play lady" who i s trained for her job. (c) A nurse who knows how to play with a child while she i s performing nursing care. (d) Sufficient staff so that the nurse can spend time playing with the child. 25• A lumbar puncture i s ordered for a five year old child. In explaining the procedure to the child, the most important thing the nurse should do i s (a) Show him how he w i l l have to l i e . (b) T e l l him the doctor w i l l take a sample of spinal f l u i d from his back. (c) Draw him a picture showing what the doctor w i l l do. (d) T e l l him that he w i l l feel a prick for a few seconds and that she w i l l be with him. (e) T e l l him he must l i e very s t i l l . 1? 68 ANSWERS TO SELF-TEST A. 1. his mother 2. he i s s t i l l dependent on his mother for a l l his needs, and does not feel secure in a strange environment without her. He has l i t t l e under-standing of his environment, and depends on a continuous relationship with his parents for protection from i t . During his preschool years, he gradually learns that he can be confident when separated from his mother for a few hours in a familiar environment because he knows she w i l l soon be with him again. 3. protest, despair, and denial. 4. abandonment by his mother 5. punishment. 6. fear of being hurt. 7. any ten of the following: absence of his mother; unfamiliar routines; large numbers of strange people; strange sounds; strange smells; strange furniture, equipment, and rooms; strange food; uniforms and masks; unusual appearance of other patients; wearing hospital clothing; get-ting undressed; taking away of personal possessions - clothes, toys; temperature-taking; absence of his usual a c t i v i t i e s ; physical r e s t r i c -tion - crib, bed, restraints ; absence of father, siblings, friends; 8. to provide for the presence of his mother at a l l times: rooming-in or unrestricted v i s i t i n g hours for parents; care of child by mother. 9. any five of the following: provision for: - l i b e r a l v i s i t i n g hours for siblings, relatives, and friends. - play appropriate to the child's stage of development. - pre-hospital preparation of the child, appropriate to his stage of development. - preparation by mother, doctor, and/or nurse - a l l ages - orientation v i s i t to hospital - five years and up - stories about hospital written for children - four years and up - home-like hospital environment - nursing care which focusses on the emotional needs of children - assignment of one nurse to care for child - informal admission procedure - education of parents and appropriate explanations to reduce anxiety - appropriate explanations and approach re nursing a c t i v i t i e s and treatments to reduce fear and anxiety - nursing a c t i v i t i e s only when necessary - eg. TPR, no rectal temperature - maintain usual a c t i v i t i e s of child as much as possible - obtain sufficient information about the child to enable individualized care - physical a c t i v i t y out of bed - dress in clothes - appropriate routines - waking, bathing, etc. - has own favorite toys as well as those provided by hospital B. 1. a 6. a 11. a 16. d 21. a 2. d ?. b 12. d 17. d 22. d 3. c 8. c 13. b 18. c 23. c 4. b 9. d Ik. b 19. d 24. b 5. d 10. a 15. c 20. b 25. a 18 C. 1. d 2. c 3 . a 4. c 5. b 6. b 7. e 8. e 9 . c 10. a 11. e 12 . c 13. d 14. b 15 . d 16. b 17. d 18. a 19. c 2 0 . e 21 . b 22. a 2 3 . d 24. c 2 5 . d Scoring: Score one point for the correct answer to each item except: A. 7. - 10 points, one for each correct part of the item 9 . - 5 points, one for each correct part of the item The total possible score i s 82. I f you did not obtain at least 75 points, you should follow the study guide again. I f you obtained more than 75 points, congratulations! You are well aware of the concepts related to meeting the emotional needs of hospitalized preschool children. One f i n a l question to think about: Are you practising what you know? 19. 70 SUGGESTIONS FOR FURTHER STUDY FAMILY-CENTERED PEDIATRICS AND ROOMING-IN  Book Haller, J. Alex, ed. The Hospitalized Child and His Family. Baltimore: The John Hopkins Press, 1967. Chapter 1. The Effects of Hospitalization upon the Child, by Robert C. Cooke, pp. 13-17. Chapter 2. Preparing a Child for His Operation, by J . Alex Haller, pp. 19-31. Chapter J. Advantages of Mother Living in With her Hospitalized Child, by Alexander J . Schaffer, pp. 33-41. These are the most pertinent chapters. Ar t i c l e s * Condon, Maryrose and Peters, Carolyn, "Family Participation Unit", American Journal of Nursing, March 1968, 504-507. - describes a pediatric unit where mothers l i v e with their children and give most of the care. Katz, Geneva, "Mothers Help Care for Sick Children i n Experimental Unit", Hospitals, vol. 38 (July 1, 1964), pp. 38-42. - discusses the kinds of care given by mothers during hospitalization and the effects of their care. * MacDonald, E.M., "Parents Participate in Care of the Hospitalized Child", Canadian Nurse, December 1969. PP« 37-39* - report of a study at the Hospital for Sick Children i n Toronto concerning the amount of care a parent i s willing to give the hos-pitalized child, and the factors affecting her decision. * McClure, Mary Jo and Ryburn, Ann C , "Care-By-Parent Unit", American Journal of Nursing, October I969, pp. 2148-2152. - describes an experimental unit where mothers look after their own children during convalescence; unit i s a kind of "half-way house" between the acute care unit and home. Meagher, Sr. Margarita, "Family-Centered Pediatrics", Hospital Progress, vol. 48 (November 1967), pp. 100-102. - explains the philosophy of permitting parents to participate i n the care of their children from the viewpoint of a nursing administrator. * Scofield, Cheryl, "Parents i n the Hospital", Nursing C l i n i c s of North America, vol. 4, no. 1 (March 1969), pp. 59-67. - describes family-centered care, particularly the nurse's interactions with the parents. * Smith, Margo, "Ego Support for the Child Patient", American Journal of Nursing, October I963, pp, 91-95. - personality development of the child with practical suggestions for nurses in assisting the child to cope with the demands of r e a l i t y . 20 71 EMOTIONAL PREPARATION OF CHILDREN  Book Geist, Harold, A Child Goes to Hospital. Springfield, I l l i n o i s : Charles C. Thomas Publisher, I965. - the chapter "Suggestions to Parents" i s included in this packet, but the entire book i s excellent. Chapter III - "Hospital Procedures" and Chapter IV - "Suggestions for Nurses" are particularly pertinent. Articles * Abbott, Nancy C. et a l . , "Dress Rehearsal for the Hospital", American Journal of Nursing, November 1970, pp. 2360-2362. -describes a program designed to orient well children to hospital through nurses' v i s i t s to kindergartens with hospital equipment. The children familiarize themselves with the equipment and play hospital with the nurses. * Brown, Margaret Joan, "Pre-Admission Orientation for Children and Parents", Canadian Nurse, February 1971. pp. 29-31. - describes pre-admission v i s i t s to hospital of children and their parents prior to elective admission. They are acquainted with the hospital environment,&there i s a party for the children while the parents attend a discussion regarding how to explain hospitalization to children of various ages. Rey, M.E. and Rey, H.A. Curious George Goes to the Hospital. Boston: Houghton M i f f l i n Co., 1966. - a story for children from about four years and up, describing the hospitalization of a monkey; excellent. This book i s l i k e l y a v a i l -able in your public library. EMOTIONAL NEEDS Book * Wallace, Margaret A. J., Handbook of Child Nursing Care. Toronto: John Wiley and Sons, Inc., 1971. - nursing care of children with emphasis on children's emotional needs. A r t i c l e * Burnie, Robin, "Two Year Old Michael - 111 and in Hospital", Canadian Nurse, November I969, pp. 46-49. - explains reasons for reactions and behavior in hospital in terms of PLAY growth and development. Book Noble, Eva. Play and the Sick Child. London: Faber and Faber, 1967. - report of two studies done in England concerning play for the hos-pitalized preschool child. Detailed discussion of observations of their play under various hospital conditions with suggestions for appropriate provision for play. 21 PLAY (con't) Articles Davis, Vicki, "Through the Bars of a Crib", American Journal of Nursing, September 1971, pp. 1752-1753. - describes how a nurse used play to discover how a five year old immobilized for six weeks viewed hospitalization. Erickson, Florence, "Reactions of Children to Hospital Experience", Nursing  Outlook, September 1958, pp. 501-504. ........ - report of a study to determine how children express their feelings about hospital experiences through play. Erickson, Florence, "The Toddler During Illness", Hospital Topics, Septem-ber 1964, pp. 95-97. - how toddlers cope with i l l n e s s via symbolic play and tension-reducing a c t i v i t i e s . GROWTH AND DEVELOPMENT Audiotapes Growth and Development! Birth Through Adolescence. Video Nursing Inc., I 9 6 7 . - a series of twenty three 44 minute classes. Audio portion available., A good review of growth and development. Developed for student nurses but appropriate for practising nurses; ignore references to students. A l i s t of the tapes with their catalogue number follows: GD 311-301 Overview GD 311-302 Heredity and Behavior GD 311-303 Unfolding Infant Behavior GD 311-304 Understanding Infant Behavior GD 311-305 Emerging Consdcousness GD 311-306 The Infant and Society GD 311-307 Emotional Development of the Infant GD 311-308 The Toddler: Origins of Independence GD 311-309 Language Development GD 311-310 Rudiments of Self Concept GD 311-311 Coping with the Toddler GD 311-312 Consolidation and Growth GD 311-313 Preschooler: Psycho-sexual Development GD 311-314 Preschooler: Concept Development GD 311-315 Play A c t i v i t i e s : Ages 6-13 GD 311-316 Peer Group: Ages 6-13 GD 311-317 Sex Roles: Ages 6-13 GD 311-319 Cognitive Functioning: Ages 6-13 GD 311-320 School and the Child GD 311-321 Adolescence: A Cultural Phenomenon GD 311-322 Adolescent Sexuality GD 311-323 Adolescent Idealism and Realism GD 311-324 Path to Adulthood Books Breckenridge, Marian E. Growth and Development of the Young Child. Toronto: W.B. Saunders Co., 1969. Armstrong, Inez L. and Browder, Jane J. The Nursing Care of Children. Phila-delphia: F.A. Davis Co., 1964. 22 GROWTH AND DEVELOPMENT (con't) Woodward, 0. M. The Earliest Years: Growth and Development of Children Under  Five. Toronto: Permagon Press, I966. (Paperback - $2.^5) - easy to read description of the growth and development of children under five. Not technical or f u l l of tables re physical growth that are difficult to understand! * Copies of starred items are available from the RNABC library, Two book stores which would order unstarred books for you are: Duthie Books Ltd., McAinsh and Co. Ltd., . 23 74 INDEPENDENT LEARNING PACKET EVALUATION FORM Please complete this form after you finish your study and return i t with the independent learning packet in the envelope provided. A. General Information 1. What i s the highest formal nursing education you have attained? technical institute or school community college hospital school some university credits university diploma or certificate Baccalaureate degree some graduate credits Master's degree Other (please specify) 2. Where do you work? 3. What i s your position? 4. I f you are employed in a hospital, i n what c l i n i c a l area are you working? 5. How many years have you practised as a nurse since graduation? 6, How many years have you not practised as a nurse since graduation? 7. How old are you? ' B. Rate the following statements according to how much you agree or disagree with each one. Circle the number which best represents your feeling about each statement. 1. The packet was relevant and applicable to my learning needs, 1 2. I feel I achieved the stated objectives. 3. The study guide helped me to achieve the objectives. 4. The resource materials were interesting and helpful. 5. The directions i n the study guide were clear and under-standable, ty. The packet required too many hours of study. 1 2 3 4 5 CO > S 3 c/> C+" OT ro Ct-H rj C 5." rl o CO <-+• ,£ o a CO H OT >£-OT P> Os r—1 (0 H CD ^ cm I-* H CO CD OT CO CD 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 75 7. The assigned problems and questions helped r.e to learn. 1 2 3 4 5 8. I feel that more information should have been included in the packet. 1 2 3 4 5 C. Please answer the following questions. 1. Did you study the topic according to the study guide provided? Yes No 2. Did you study the packet with other colleagues? Yes No If yes, how many? Did studying with others help you to learn? Yes No Somewhat 3 . Has a taps recorder available for you to listen to the enclosed audiotape? Yes No 4 . How many hours did you spend studying this packet? 5. Would you like to study other topics using independent learning packets? Yes No Why? " 6. What other topics would you like to study using independent learning packets? 7. Are there any changes you would propose for improving this independent learning packet? &. Have you further comments or suggestions? 2 APPENDIX II Modified Portions of the Independent Learning Packet without the Study Guide INTRODUCTION TO INDEPENDENT LEARNING PACKETS This packet i s one of a series which have been developed to help you continue your nursing education and keep up to date. They have been designed with you in mind! You can study at home and at your own speed. You don't need to search for books or a r t i c l e s on the topic sinseall the materials you need are included in each packet. The topics are purposely limited to small areas of nursing practice so that you can select only those that seem most pertinent to your needs. However, i f you want to learn more after completing a learning packet, a l i s t of other related materials i s included, any of which w i l l be sent you on request. The objectives t e l l you what you can expect to have learned when you fi n i s h the independent learning packet, and you should refer to these to decide whether you have actually achieved them. In addition, at least one test i s included which you can complete i n order to judge what you have learned. The test w i l l be marked and returned to you with corrections. And f i n a l l y , there i s an evaluation form provided for you to t e l l us what you think about the independent learning packet. It i s the only way we w i l l know i f the packet was what you needed or expected so that improve-ments can be made i f necessary. Independent learning packets are loaned to you for two weeks. Please do not write on any of the materials except the evaluation form and the test. Return the entire packet when you have completed your study. MEETING THE EMOTIONAL NEEDS OF THE HOSPITALIZED PRESCHOOL CHILD PURPOSE • The purpose of this independent learning packet is to provide information related to the emotional needs of the hospitalized three to five year old child. OBJECTIVES Upon completion of this independent learning packet, the nurse will be able to: 1. Describe hospitalization in terms of its meaning to the preschool child. 2. Explain why the presence of the preschool child's mother during hospitalization is vital to his emotional health. 3. Recognize the typical behavior indicative of emotional trauma in the preschool child when separated from his mother. 4. Identify ways in which the emotional health of the preschool child may be maintained and protected during hospitalization. PREREQUISITE KNOWLEDGE It would be helpful to review the growth and development of the preschool child prior to studying this topic. References for review-ing growth and development are listed at the end of this packet. If i t would be more suitable for you to undertake the review after com-pleting the packet, references which are available on loan from the RNABC are indicated. DIRECTIONS A. Introduction: The emotional needs of children and the ways in which nurses and hospitals can help to meet them vary with each age. The infant, the one and two year old, the preschool child ( 3 - 5 years), the elementary school aged child, and the adolescent a l l require different approaches according to the stage of growth and development and the ability to cope with hospitalization. This independent learning packet focusses on the emotional needs of the hospitalized three to five year old child. However, i t must be remembered that the chronological age of an individual child does not necessarily mean that his emotional, physical, or mental development is equivalent to the average for his age. For example, there ar two year olds who are more mature than some three year olds, and. six year olds who are not as mature as the average five year old. Therefore, one must be careful not to rely on chronological age alone when judging the emotional or physical maturity of an indiv-idual child. The need of preschool children for a close and continuous relation-ship with one person is the most important concept underlying the study of this topic. In most instances, this person is the child's natural mother, but "mother" should be interpreted as the person who usually cares for the child or with whom the child has the most continuous and close relationship. It may be the adoptive or foster mother, the father a housekeeper, a grandmother, or other relative. Occasionally, there may be not only one, but two or three people who seem equally important to the child. Keep in mind, then, that references to a child's "mother" may not, in individual cases, mean his natural mother. B. .  Study the resource materials included with this packet. They have been selected from a multitude of references related to this topic on the basis of their quality and suitability in helping you learn the ideas and concepts involved. C. When you feel you have achieved the objectives on page 2, complete the test without referring to the reference materials or any notes you may have made. D. F i l l in the evaluation form. E. If you wish to study this topic further, please refer to pages 20-23. Make a l i s t of the starred items that you would like copies of. Please enclose ten cents per page to cover the cost of Xeroxing Articles The audiotapes are also available on loan. F. Please return a l l the materials in this packet in the package you received them in. A return address label in enclosed for you to attach over your address on the envelope. INDEPENDENT- LEARNING PACKET 80 EVALUATION FORM Please complete this form after you finish your study and return i t with the independent learning packet in the envelope provided. A. General Information 1. What is the highest formal nursing education you have attained? technical institute or school community college hospital school some university credits university diploma or certificate Baccalaureate degree •  some graduate credits Master's degree Other (please specify) 2. Where do you work?-3. What is your position? 4.- If you are employed in a hospital, in what clinical area are you working? 5. How many years have you practised as a nurse since graduation? 6 . How ir.any years have you not practised as a nurse since graduation? 7. How old are you? 3. Rate the following statements according to how much you agree or disagree with each one. Circle the number which best represents your feeling about each statement. 2. I feel I achieved the stated objectives. 3. The resource materials were interesting and helpful. 4. The packet required too many hours of study. 5. I feel that more information should have been included in the packet. 1 2 3 4 5 co > a CO cJ- cm o r" cr H i-s r; !7> hi O CO c-r Q) o —< o r-i P C*» d5 !-i p j H CD h-1 << CD pj p. Cft H' hi 01 ro P CD o CD 1 2 3 5 1 2 3 5 1 2 3 5 1 2 3 5 1 2 3 4 5 81 C. Please answer the following questions. 1. Was a tape recorder available for you to l i s t e n to the enclosed audiotape? Yes No 2. How many hours did you spend studying this packet? 3. Would you l i k e to study other topics using independent learning packets? Yes No Why? • 4. What other topics would you lik e to study using independent learning packets? 5 . Are there any changes you would propose for improving this independent learning packet? 6. Have you further comments or suggestions? 2 APPENDIX III Chi Square Contingency Tables Group A and B versus C. TABLE 11.-Distribution of Age Age • Group A&B Group C Total 21 - 25 years 4 13 17 26 - 30 years 10 5 15 over 30 years 21 3 24 Total 35 21 56 x 2 = 17.5266, df = 2, p<.001 TABLE 12.-Distribution of educational preparation Educational Preparation Group A&B Group C Total Hospital school only 17 16 33 Further formal education (includes post graduate hospital diplomas, university credits, diplomas and degrees) 18 5 23 Total 35 21 56 x z = 4.1360, df = 1, p<.05 TABLE 13.-Distribution of the number of years of nursing practice No. of Years Nursing Practice Group A&B Group C Total 0 - 5 years 13 17 30 over 5 years 22 4 26 Total 35 21 56 x 2 = 10.1272, df = 1, p<.01 TABLE 14.-Distribution of the number of years not practised since graduation No. of Years Not Practised Since Graduation Group A&B Group C Total 0 14 17 31 1 - 5 years 13 4 17 over 5 years 8 0 8 Total 35 21 56 x 2 = 10.3577, df = 2, p<.01 TABLE 15.-Distribution of the place of employment Place of Employment Group A&B Group C Total Hospital 19 21 40 Outside hospital (includes public health, mental health center, occupational health, physician's office, children's group home) 9 0 9 Unemployed 7 0 7 Total 35 21 56 x 2 = 13.4396, df = 2, p<.01 TABLE 16.-Distribution of involvement : in pediatric nursing Extent of Involvement In Pediatric Nursing Group A&B Group C Total Nursing in hospital pediatric unit 18 21 39 Pediatric involvement outside hospital 6 0 6 No pediatric nursing (inside and outside hospital) 11 0 11 Total 35 21 56 x 2 = 14.6459, df = 2, p<.001 Group A versus Group B TABLE 17.-Distribution of educational preparation between Groups A and B Educational Preparation Group A Group B Total Hospital school only 8 9 17 Further education 10 8 18 Total 18 17 35 x z = .0269, df = 1, p>.80 TABLE 18.-Distribution of place of employment between Groups A and B Place of Employment Group A Group B Total Hospital 8 11 19 Outside hospital 6 3 9 Unemployed 4 3 7 Total 18 17 35 x 2 = 1.5892, df = 2, p>.30 TABLE 19.-Distribution of involvement in pediatric nursing between Groups A and B Extent of Involvement in Pediatric Nursing Group A Group B Total Nursing in hospital pediatric unit 7 11 18 Pediatric involvement outside hospital 4 2 6 No pediatric nursing 7 4 11 Total 18 17 35 x 2 = 2.3470, df = 2, p>.30 

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