Incorporating Florence Nightingale
Content
CLINICAL PRACTICE COLUMN
Column Editor: Maura MacPhee, PhD, RN
Incorporating Florence Nightingale’s Theory of Nursing into Teaching a Group of Preadolescent Children About Negative Peer Pressure
Loralee Sessanna, RN, MSN, CNS
Clinically based nurses often question the value of nursing theory, ultimately resulting in the reluctance to implement nursing theory into practice. This clinical practicum project successfully used Nightingale’s primary tenets, such as building trust, self-assessment, and group leadership, as a theoretical framework in a nursing practice group for the purpose of teaching a group of preadolescent children about negative peer pressure. Preadolescent children are particularly vulnerable to peer group culture. Proactive strategies, as demonstrated through this project, can be used to positively influence children’s behavior toward each other during the formative middle years. Group sessions addressed such topics as moral beliefs and values, bullying, and saying “no” to peer pressure and were structured using a variety of contemporary resources to develop interactive exercises that engaged the children and enhanced group communication. The children and their parents reported positive outcomes from the nurse-led group sessions. © 2004 Elsevier Inc. All rights reserved.
Editor’s introduction I recently read an article by Woodward (2003) advocating for theory-based nursing education and practice. Woodward outlined the myths that surround nursing theory. For instance, “nursing theory is just fluff that has no link to nursing activities” (p. 215). This statement caught my attention, because we (nurses) are becoming more accountable every day for what we do. Through theory, we can systematically derive or develop nursing care interventions that can be tested, evaluated, and linked to measurable outcomes. Nursing theory, therefore, helps us establish ‘what is best practice,’ and it helps us achieve public and professional accountability. Another myth about nursing theory described in Woodward’s article is: “Nursing theory is discussed at tables and in meetings rather than used with actual people” (p. 216). I did a literature search of ‘nursing theory and practice’ and was amazed at all the evidence for theory-based ‘best practice’ that indicates the opposite. The following article helps to further debunk these two myths about nursing theory. It demonstrates the importance of educating professional nurses about theorybased practice. This innovative application of Florence Nightingale’s theory was based on a student practicum. It also illustrates how theory can be used to enhance outcomes for actual people, pre-teens in this case. Nursing theory often becomes abandoned post-graduation, but it can contribute to evidence of what is ‘uniquely nursing’ about the care we give. Maura MacPhee, RN, PhD, Clinical Practice Editor Reference Woodward, W. (2003). Preparing a new workforce. Nursing Administration Quarterly, 27(3), 215-222.
Journal of Pediatric Nursing, Vol 19, No 3 (June), 2004
N
IGHTINGALE’S IDEAS and teachings have been an inspiration for many nurses throughout history, providing an invaluable foundation for the profession of nursing. Within the body of her work, Nightingale specifically addressed the importance of caring for children’s health stating, “money would be better spent in maintaining health in infancy and childhood than in building hospitals to cure disease” (Monteiro, 1991, p. 102). In her book Notes on Nursing, Nightingale (1860/ 1969) further disclosed the importance of caring for children, stating:
To revert to children. They are much more susceptible than grown people to all noxious influences. They are affected by the same things, but much more quickly and seriously, viz., by want of fresh air, of proper warmth, want of cleanliness in house, clothes, bedding, or body, by startling noises, improper food, or want of punctuality, by
From the Community Health Nursing masters program, D’Youville College, Buffalo, New York. The author is currently a student at the University of Buffalo in the Doctor of Nursing Science program. Address correspondence and reprint requests to Loralee Sessanna, RN, MSN, CNS, 3932 Eckhardt Road, Hamburg, NY 14075. E-mail: [email protected] 0882-5963/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2004.02.002
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dullness and by want of light, by too much or too little covering in bed, or when up, by want of the spirit of management generally of those in charge of them. One can, therefore, only press the importance, as being yet greater in the case of children, greatest in the case of sick children, of attending to these things (p. 128).
This paper is based on a clinical practicum project that successfully used Nightingale’s primary tenets, such as building trust, self-assessment, and group leadership, as a theoretical framework in a nursing practice group for the purpose of teaching a group of preadolescent children about negative peer pressure. ADOLESCENT STATISTICS Peer pressure is defined by Wikipedia (2003) as, “A set of group dynamics whereby a group in which one feels comfortable may override personal habits, individual moral inhibitions, or idiosyncratic desires to impose a group norm of attitudes and/or behaviors” (p.1). Peer influence plays a major role within the developmental shaping of children and youth. The importance of peer relationships builds throughout the school years, particularly influencing preadolescent and adolescent behavior. Peer group culture often affects decision-making among preadolescent children regarding such taboo topics as sex and drugs (Wong, 2003). From a national health care perspective, it has become imperative to examine the effects of negative peer pressure on American youth. From a pediatric nursing perspective, it has become challenging to find creative ways to assist youth in constructively addressing the multiple threats that peer pressure challenges them with to help them grow into healthy, caring, and responsible adults. Healthy Youth 2010 is the American Medical Association’s (AMA) (2001) national health care initiative that focuses on attaining 21 critical objectives aimed at improving the health of adolescents and young adults between the ages
of 10 and 24 years. The 21 critical objectives are based on 10 leading health indicators, including physical activity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunizations, and access to care. Based on statistics found within the American Medical Association’s Healthy Youth 2010, there are some alarming trends that require the attention of pediatric health care professionals. Refer to Table 1 for an overview of these statistical trends. PREADOLESCENT GROWTH AND DEVELOPMENT The preadolescent stage of growth and development, also referred to as the middle or school age years of growth and development, takes place between the ages of 10 to 12 years. According to Whaley and Wong (1987):
It has been found that this period makes an important contribution to children’s learning the fundamental skills of their culture and developing competence and self-esteem. It is a time of intellectual growth, investment in work, and the first real commitment to a social unit outside of and larger than the family (p. 704).
Children within this age group are acutely sensitive to peer group social pressures and begin to develop a concept of self-esteem that comprises their own self-evaluation in addition to the opinions of family members and outside contacts (Whaley & Wong, 1987). Peer groups establish standards for either group acceptance or group rejection with many children willing to modify their behavior to “fit in” (Wong, 2003). Although peer group identification is an essential developmental task, peer group pressure can force children into taking unnecessary risks such as unprotected sex, smoking, and alcohol and illicit drug consumption (Comerci, Fuller, & Morrison, 1993; Simons-Morton, Crump, Haynie, Saylor, Ei-
Table 1. Statistical Trends from Healthy People 2010
Health Indicator Trend Page Location
Physical Activity and Obesity Tobacco Use Substance Abuse Pregnancy Mental Health Suicide Homicide
1/10 adolescents (12–19 years) are overweight 3,000 adolescents Ͻ 18 years will become daily smokers 25% of 8th graders and 62% of seniors have been drunk at least once 900,000 female adolescents/year 78% unplanned 28% of adolescent students report “feeling so sad or hopeless almost every day for at least 2 weeks in a row . . .” 25% females and 14% males (grades 9–12) report “seriously considering or attempting suicide” Record highs for adolescents 15–19. Third leading cause of death for 5–14 year-olds
8–9 14 11 17 19 19 24
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tel, & Yu, 1999; Watts & Nagy, 2000). Children this age have a strong desire not to be different because any differences may set the child apart from the group and may make him a target for peer group criticism and ridicule (Whaley and Wong, 1987). For example, children who are too tall, too short, or overweight can become painfully stigmatized by peers (Neumark-Sztainer, Story, & Faibisch, 1998). Monsen (2000) provided suggestions for how pediatric nurses can raise community awareness of the harm imposed on children through negative peer pressure. In addition to informing parents and teachers of inherent peer pressure risks, Monsen proposed that nurses advocate for the development of community-based youth activity programs such as “service projects, mentoring programs, and cultural diversity explorations” that support and supervise children (Monsen, 2000, p. 392). A THEORETICALLY BASED PRACTICUM PROJECT This project was created for the purpose of fulfilling a clinical practicum requirement for a graduate course in a community health nursing program that focused on crisis in the community. The project consisted of six interactive group sessions designed to provide children with verbal and nonverbal skills to enhance self-esteem and to protect against negative peer pressure influence. Session plans, parental consent, and child assent were reviewed and approved by the Graduate Director of Nursing, a doctorally prepared nurse with holistic nursing expertise, and by the course instructor, a doctorally prepared nurse with pediatric expertise. A convenience sample of four preadolescent children aged 10 to 12 years old were recruited from a local middle school. Tenets from Nightingale’s teachings were used to structure the group sessions. In the following sections, Nightingale’s key components are highlighted (see Table 2). CONFIDENTIALITY AND TRUST Parents were called and verbal consent was obtained before each group session took place. Parental support was enhanced by giving them an opportunity to ask questions and voice any concerns prior to the sessions. In addition to parental consent, verbal assent was obtained from each child participating in the group before each session began. In order to build trusting relationships among the members in the group, the meaning and impor-
tance of confidentiality was reviewed with the children during their first group session. Throughout the sessions, group exercises were devoted to establishing trusting and confidential relationships, and the children grew increasingly comfortable with sharing experiences and offering advice. Nightingale (1860/1998) strongly believed in the importance of confidentiality, stating:
And remember every nurse should be one who is to be depended upon, in other words, capable of being a “confidential” nurse. She does not know how soon she may find herself placed in such a situation; she must be no gossip, no vain talker; she should never answer questions about her sick except to those who have a right to ask them (p.125).
Nightingale (1860/1998) also addressed the importance of building trusting relationships with her patients, stating:
If you go without his knowing it, and he finds it out, he never will feel secure again that the things which depend upon you will be done when you are away, and in nine cases out of ten he will be right (p.39).
LEADERSHIP AND COMMUNICATION The nurse, as a group facilitator/leader, must be able to sit back and listen to what is being said to plan and implement future sessions according to the group’s stated needs, while helping to promote healthy and positive group working skills. With reference to leadership, Nightingale (1860/1998) stated:
To be “in charge” is certainly not only to carry out the proper measures yourself but to see that everyone else does so too; to see that no one either wilfully (sic) or ignorantly thwarts or prevents such measures. It is neither to do everything yourself nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appointed (p.33).
Nightingale was also a strong advocate for the use of proper communication skills, which included eye-to-eye contact in addition to being at the patient’s side. With regard to communication techniques, Nightingale (1860/1998) stated:
Always sit within the patient’s view, so that when you speak to him he has not painfully to turn his head round in order to look at you. Everybody involuntarily looks at the person when speaking. . .So also by continuing to stand you make him continuously raise his eyes to see you . . . Never speak to an invalid from the behind, nor from the door, nor from any distance from him, nor when he is doing anything (p.38).
To enhance communication techniques with the children, group sessions were designed to take
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place with members either sitting in a circle or around a table to provide for optimal person-toperson communication. Several communication techniques were used within the group sessions and included the use of verbal communication skills such as reflection, deflection, exploratory questioning, and summarization (Clark, 1994). The use of verbal reflection provided group members with opportunities to describe how they felt during their experiences with
peer pressure. Using verbal deflection allowed opportunity for the other group members to express their thoughts and opinions regarding the issue at hand. Exploratory questioning gave the group leader opportunity to probe further into the group’s thoughts and feelings. Verbal summarization was done at the end of each group session regarding what had transpired during the session together. Using humor in a sensitive and appropriate manner with this age group was extremely effective in
Table 2. Nightingale’s Theory: Concept, Quotation, and Group Implementation
Concept Nightingale’s Quote Group Implementation
Nursing Skills 1. Confidentiality “And remember every nurse should be one who is depended upon, in other words, capable of being a “confidential nurse”. She does not know how soon she may find herself placed in such a situation; she must be no gossip, no vain talker; she should never answer questions about her sick except to those who have a right to ask them” (p. 125). “If you go without his knowing it, and he finds out, he never will feel secure again that the things which depend upon you will be done when you are away. And in nine cases out of ten he will be right” (p. 39). “The most important practical lesson that can be given to nurses is to teach them to observe-how to observe-what symptoms indicate improvementwhat the reverse-which which are of importance-which are of nonewhich are the evidence of neglect- and what kind of neglect. If you cannot get into the habit of observation one way or another, you had better give up the being (sic) a nurse” (p. 105). In dwelling upon the vital importance of sound observation, it must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort (p. 125). Review what confidentiality means and its important role among group members.
2. Building Trust
Review what trust means and its role with among group members. Observe group as a means of gathering information in order to better help the group according to its own individual, and unique needs.
3. Observation
Peer Pressure 4. Self-Assessment “I knew a very clever physician, of a large dispensary and hospital practice, who invariably began his examination of of each patient with ’Put your finger where you be bad’. That man never wasted his time collecting accurate information (p. 109). “To be ’in charge’ is certainly not only to carry out the proper measures yourself but to see that everyone else does so too; to see that no one either wilfully (sic) or ignorantly thwarts or prevents such measures. It is neither to do everything yourself nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appointed” (p. 33). “Always sit within the patient’s view, so that when you speak to him he has not painfully to turn his head round in order to look at you. Everybody involuntarily looks at the person when speaking . . . so also by continuing to stand you make him continuously raise his eyes to see you . . . Never speak to an invalid from behind, nor from the door, nor from any distance from him, nor when he is doing anything” (p. 38). “A little needle work, a little writing, a little cleaning, would be the greatest relief the sick could have” (p. 63). Assess group members by allowing them to explain their individual needs. (Peer Pressure Questionnaire) Establish effective group leadership skills while encouraging positive group participation.
5. Group Leadership
6. Communication Skills
Establish effective group communication techniques by encouraging group participation, eye contact, respect for group members, etc. Provide group members with a variety of learning experiences (movies, discussion, etc) to help increase understanding. Hold group sessions in rooms with open windows for fresh air and abundant sunlight.
7. Varied Teaching Methodologies
8. Fresh Air and Bright Environment
“Where there is sun, there is thought” (p. 86). “It is the unqualified result of all my experience with the sick, that second only to their need of fresh air is their need of light; that, after a close (sic) room, what hurts most is a dark room. And it is not only light but sunlight they want” (p. 64).
References: Nightingale, F. (1860/1998).
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helping to discuss difficult issues. Humor helped to decrease group tension and provided the group with a different way of looking at difficult situations. Some excellent resources on effective communication with children include books by Faber & Mazlish (1980), Healy (1994), and Dinkmeyer & McKay (1997). OBSERVATION Nightingale (1860/1998) believed that observation was the single most important skill for nurses to acquire:
The most important practical lesson that can be given to nurses is to teach them what to observe-how to observewhat symptoms indicate improvement-what the reversewhich are of importance-which are of none-which are the evidence of neglect-and of what kind of neglect. If you cannot get the habit of observation one way or other, you had better give up the being (sic) a nurse (p.105).
according to Nightingale, meant that both the environment that patients were placed in and the activities that patients were allowed to do were important for the process of healing. Nightingale (1860/1998) wrote, “The effect in sickness of beautiful objects, of variety of objects, and especially of brilliancy of color, is hardly ever appreciated” (p.58). Nightingale continued to write, “a little needle work, a little writing, a little cleaning, would be the greatest relief the sick could have” (p. 63). Group sessions were held in different locations in rooms that were colorfully decorated and painted, having several windows where sunlight and fresh air were abundant. Group sessions were also planned using a variety of teaching methods and activities. SELF-ASSESSMENT During the first group session, a peer pressure baseline assessment was done to determine how members of the group felt about their social relationships with their peers and to learn about the negative peer pressure problems that the children felt they were experiencing. A self-assessment questionnaire was created by the author (see Table 3). The assessment tool consisted of 10 open-ended questions appropriate for a preadolescent level of understanding. The tool was reviewed by pediatric clinical experts to establish construct validity. The questionnaire acted as an excellent resource for ideas concerning topics related to negative peer pressure that could be discussed in future group sessions.
Table 3. The Preadolescent Peer Pressure Assessment Tool 1) What do you think peer pressure means? 2) Tell me about a time when you think you felt peer pressure. 3) Were there any bad or negative things you felt because of this peer pressure? If you did have any bad feelings because of this peer pressure, tell me about these feelings and why you felt this way. 4) Were there any good or positive things you felt because of this peer pressure? If there were any good feelings you felt about this peer pressure, tell me about these feelings and why you felt this way. 5) Do you feel that you made the right decisions on how you handled this peer pressure situation? 6) Do you like how you handled this situation? 7) Is there anything you think you could have done differently to make this situation better? 8) Did you learn any lessons from this experience? 9) What do you think is the most important thing to remember about this situation? 10) If you are faced with another peer pressure situation, what will you do?
Nightingale (1860/1998) further believed:
In dwelling upon the vital importance of sound observation, it must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort (p.125).
Observation was the most valuable nursing skill and intervention applied during the group sessions. Observation of both the children’s body language and the children’s verbal reactions during group discussion and group activities provided insight into the group’s comfort level, provided opportunity for gathering information on issues thought of as most important to the group regarding peer pressure, and revealed the development of a healthy peer support system over the time that the group sessions were held. ENVIRONMENT AND VARIED ACTIVITY Nightingale believed that the environment in which patients were placed had a profound affect on the patient’s recovery and believed that placing patients in clean and bright environments with access to fresh air was of crucial importance for healing. Nightingale (1860/1998) stated, “Where there is sun, there is thought” (p.86). Nightingale additionally stated:
It is the unqualified result of all my experience with the sick, that second only to their need of fresh air is their need of light; that, after a close (sic) room, what hurts most is a dark room. And it is not only light but sunlight they want (p.64).
Nightingale also believed in the importance of using variety when caring for patients. Variety,
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Nightingale stressed the importance of letting the patient personally voice those problems that he or she felt that they were experiencing by giving them an opportunity to use his or her own words to describe the situation. Nightingale (1860/1998) stated, “I knew a very clever physician, of a large dispensary and hospital practice, who invariably began his examination of each patient with ‘Put your finger where you be bad’. That man never wasted his time with collecting inaccurate information” (p. 109). Having the group fill out the peer pressure questionnaire gave each child an opportunity to “point their finger where they be bad” regarding their negative peer pressure experiences. TEACHING Contemporary resources were used to operationalize group discussion topics and activities. The Book of Virtues for Young People (Bennett, 1997) and Kid Stories: Biographies of 20 Young People You’d like to Know (Delise, 1991) were excellent sources for stories dealing with peer pressure, morals, and values. Other resources written specifically on teen stressors and peer pressure include books by Cherniss & Sluke (2001), Covey (1998), and Carlson (2000). The primary educational/informational topics for group sessions were as follows: (a) the definition of peer pressure, (b) the differences between positive and negative peer pressure, (c) establishing and maintaining positive morals and values, (d) building healthy relationships, (e) managing bullying, and (f) saying “no” to negative peer pressure situations. A variety of teaching methods were used to engage the children emotionally, physically, and cognitively. All group sessions were held in an informal atmosphere to promote a relaxing environment where the children would feel comfortable expressing their thoughts and feelings (Spradley & Allender, 1997). The first group session was used to introduce group members to one another, to establish group rules, to discuss the meaning of confidentiality and trust, and to assess, with the use of the peer pressure questionnaire, both the meaning of peer pressure and the different negative peer pressure situations that the children felt they had experienced. At the end of the first session, one group member stated that it felt good to know that they were not the only one “who was having peer pressure problems,” and another member stated, “I never knew so many other kids were feeling the same way I am.“ The children in the group additionally commented that they liked knowing that their feelings
and experiences would be kept both “private and confidential.” The second group session involved watching the movie The Outsiders (Warner Home Video, Ltd., 1983). The children were asked to identify any negative peer pressure situations that they saw in the movie. The children then discussed what they thought were both the right and wrong ways in which each negative peer pressure situation was handled and what they would do if the same situation arose in their lives. The third group session involved watching several VeggieTale videos (Big Idea Productions), which addressed the topics of peer pressure, selfesteem, and the importance of being kind to others. During the fourth group session, together, both the movie and videos acted as a resource for role playing, incorporating situations picked out by the children where the children alternated acting out being both the “bully” and the “victim.” Role playing peer pressure situations allowed the children to safely explore different ways to manage difficult and embarrassing situations. The children became immersed in their role-play characters. The “observers” coached and provided positive suggestions on how to best handle negative peer pressure scenarios. One child told the group that they “did not like being the bully because it felt bad,” and another group member told the group, “I felt sorry for the person who played the victim and I kept wanting to help!” The remaining group sessions included working on projects to help build self-esteem and selfconfidence such as making “just say no” t-shirts and artistic posters promoting saying “no” to negative peer pressure situations. The children also made wooden wall plaques to hang in their rooms promoting positive messages such as, “Triumph is just ‘umph’ added to try” (author unknown) and “Do not just look at the stars, reach for them” (author unknown). OUTCOMES During the last group session, the children were asked to talk about what they had learned during their time together. The children agreed that the sessions were “fun,“ that they learned “a lot about themselves and a lot about negative peer pressure,” and that they were relieved to know that “they were not the only ones” who were experiencing negative peer pressure situations. Group members’ feedback indicated that they enjoyed the variety of teaching methods that were incorporated into the group sessions, such as role playing, movies, vid-
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eos, arts and crafts, and discussion. Several children stated that they “looked forward to learning something new each week.” A follow-up phone call was made to each parent after the group sessions were finished to thank them for allowing their children to participate and to get feedback regarding their thoughts and ideas about the effectiveness of the group sessions in relation to teaching their child about negative peer pressure. Feedback from the parents was both encouraging and positive, and the parents expressed how eager their children were each week to share with their families what they had learned from the group. CLINICAL IMPLICATIONS This clinical practicum pilot project was a successful demonstration of how Nightingale’s histor-
ical theory of nursing can be applied to teaching a group of contemporary children. By combining Nightingale’s theoretical framework with other resources, such as books, videos, and arts and crafts, the children involved in this project were able to share their innermost thoughts and feelings regarding preadolescent peer pressure despite the difficult nature and abstract topics used within group sessions. This project demonstrated the process of combining theory with different teaching methodologies to develop an educational curricula and support group for preadolescent and adolescent children. Although this clinical practicum pilot project lacked a formal evaluative component, the findings support the importance of future pediatric research related to the short-term and long-term outcomes of theory-based pediatric nursing interventions.
REFERENCES
American Medical Association. (2001). Healthy youth 2010: Supporting the 21 critical adolescent objectives. Retrieved July 26, 2003, from http://www.ama-assn.org/ama/upload/mm/39/ healthy2010.pdf. Bennett, W. (1997). The Book of Virtues for Young People. New York: Simon & Schuster. Carlson, R. Don’t Sweat the Small Stuff for Teens: Simple Ways to Keep Cool in Stressful Times. New York: Hyperion Press. Cherniss, H., & Sluke, S. (2001). The Complete Idiot’s Guide to Surviving Peer Pressure for Teens. Indianapolis, IN: Alpha Publishing. Clark, C.C. (1987). The Nurse as the Group Leader (2nd ed.). New York: Springer. (Original work published in 1978). Comerci, G., Fuller, P., & Morrison, S. (1997). Keeping adolescents healthy, part I: Cigarettes, drugs, alcohol and teens. Patient Care, 31, 56-60. Covey, S. (1998). The 7 Habits of Highly Effective Teens. New York: Simon & Schuster. Delise, J. (1991). Kid Stories: Biographies of 20 Young People You’d Like to Know. Minneapolis, MN: Free Spirit Publishing. Dinkmeyer, D., & McKay, G. (1998). Parenting Teenagers: Systematic Training for Effective Parenting of Teens (STEP). Circle Pines, MN: American Guidance Service. Falk Rafeal, A.R. (1999). The politics of health promotion: Influences on public health promoting nursing practice in Ontario, Canada from Nightingale to the nineties. Advances in Nursing Science, 22(1), 23-39. Halsall, P. (1997). Modern History Sourcebook: Florence Nightingale: Rural hygiene. Retrieved July 26, 2003, from http://www.fordham.edu/halsall/mod/nightingale-rural.html. Monsen, R. (2000). The child in the community: Nursing makes a difference. Journal of Pediatric Nursing, 15, 391-392. Monteiro, L.A. (1991). Florence Nightingale on public health nursing. In B.W. Spradely (Ed.), Readings in Community Health Nursing. Philadelphia, PA: Lippincott. Neumark-Sztainer, S., Story, M., & Faibisch, L. (1998). Perceived stigmatization among overweight African-American and Caucasian adolescent girls. Journal of Adolescent Health, 23, 264-270. Nightingale, F. (1969). Notes on Nursing (2nd ed.). New York: Dover Publications. (Original work published in 1860). Nightingale, F. (1860). Notes on Nursing: What It Is, and What It Is Not. Boston: William Carter. Simons-Morton, B., Crump, A., Haynie, D., Saylor, K., Eitel, P., & Yu, K. (1999). Psychosocial, school, and parent factors associated with recent smoking among early adolescent boys and girls. Preventive Medicine, 28, 138-148. Spradley, B.W., & Allender, J.A. (1997). Readings in Community Health Nursing (5th ed.). Philadelphia, PA: LippincottRaven. Watts, G., & Nagy, S. (2000). Sociodemographic factors, attitudes, and expectations toward adolescent coitus. American Journal of Health Behavior, 24, 309-317. Whaley, L.F., & Wong, D.L. (1987). Nursing Care of Infants and Children (3rd ed.). St. Louis, MO: Mosby. Wikipedia: The Free Encyclopedia. (2003). Peer pressure. Retrieved July 26, 2003, from http://www.wikipedia.org/wiki/ Peer-pressure. Wong, D.L., Hockenberry, M., Wilson, D., Winkelstein, M., & Kline, N. (2003). Wong’s Nursing Care of Infants and Children (7th ed.). St. Louis, MO: Mosby.
Column Editor: Maura MacPhee, PhD, RN
Incorporating Florence Nightingale’s Theory of Nursing into Teaching a Group of Preadolescent Children About Negative Peer Pressure
Loralee Sessanna, RN, MSN, CNS
Clinically based nurses often question the value of nursing theory, ultimately resulting in the reluctance to implement nursing theory into practice. This clinical practicum project successfully used Nightingale’s primary tenets, such as building trust, self-assessment, and group leadership, as a theoretical framework in a nursing practice group for the purpose of teaching a group of preadolescent children about negative peer pressure. Preadolescent children are particularly vulnerable to peer group culture. Proactive strategies, as demonstrated through this project, can be used to positively influence children’s behavior toward each other during the formative middle years. Group sessions addressed such topics as moral beliefs and values, bullying, and saying “no” to peer pressure and were structured using a variety of contemporary resources to develop interactive exercises that engaged the children and enhanced group communication. The children and their parents reported positive outcomes from the nurse-led group sessions. © 2004 Elsevier Inc. All rights reserved.
Editor’s introduction I recently read an article by Woodward (2003) advocating for theory-based nursing education and practice. Woodward outlined the myths that surround nursing theory. For instance, “nursing theory is just fluff that has no link to nursing activities” (p. 215). This statement caught my attention, because we (nurses) are becoming more accountable every day for what we do. Through theory, we can systematically derive or develop nursing care interventions that can be tested, evaluated, and linked to measurable outcomes. Nursing theory, therefore, helps us establish ‘what is best practice,’ and it helps us achieve public and professional accountability. Another myth about nursing theory described in Woodward’s article is: “Nursing theory is discussed at tables and in meetings rather than used with actual people” (p. 216). I did a literature search of ‘nursing theory and practice’ and was amazed at all the evidence for theory-based ‘best practice’ that indicates the opposite. The following article helps to further debunk these two myths about nursing theory. It demonstrates the importance of educating professional nurses about theorybased practice. This innovative application of Florence Nightingale’s theory was based on a student practicum. It also illustrates how theory can be used to enhance outcomes for actual people, pre-teens in this case. Nursing theory often becomes abandoned post-graduation, but it can contribute to evidence of what is ‘uniquely nursing’ about the care we give. Maura MacPhee, RN, PhD, Clinical Practice Editor Reference Woodward, W. (2003). Preparing a new workforce. Nursing Administration Quarterly, 27(3), 215-222.
Journal of Pediatric Nursing, Vol 19, No 3 (June), 2004
N
IGHTINGALE’S IDEAS and teachings have been an inspiration for many nurses throughout history, providing an invaluable foundation for the profession of nursing. Within the body of her work, Nightingale specifically addressed the importance of caring for children’s health stating, “money would be better spent in maintaining health in infancy and childhood than in building hospitals to cure disease” (Monteiro, 1991, p. 102). In her book Notes on Nursing, Nightingale (1860/ 1969) further disclosed the importance of caring for children, stating:
To revert to children. They are much more susceptible than grown people to all noxious influences. They are affected by the same things, but much more quickly and seriously, viz., by want of fresh air, of proper warmth, want of cleanliness in house, clothes, bedding, or body, by startling noises, improper food, or want of punctuality, by
From the Community Health Nursing masters program, D’Youville College, Buffalo, New York. The author is currently a student at the University of Buffalo in the Doctor of Nursing Science program. Address correspondence and reprint requests to Loralee Sessanna, RN, MSN, CNS, 3932 Eckhardt Road, Hamburg, NY 14075. E-mail: [email protected] 0882-5963/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2004.02.002
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dullness and by want of light, by too much or too little covering in bed, or when up, by want of the spirit of management generally of those in charge of them. One can, therefore, only press the importance, as being yet greater in the case of children, greatest in the case of sick children, of attending to these things (p. 128).
This paper is based on a clinical practicum project that successfully used Nightingale’s primary tenets, such as building trust, self-assessment, and group leadership, as a theoretical framework in a nursing practice group for the purpose of teaching a group of preadolescent children about negative peer pressure. ADOLESCENT STATISTICS Peer pressure is defined by Wikipedia (2003) as, “A set of group dynamics whereby a group in which one feels comfortable may override personal habits, individual moral inhibitions, or idiosyncratic desires to impose a group norm of attitudes and/or behaviors” (p.1). Peer influence plays a major role within the developmental shaping of children and youth. The importance of peer relationships builds throughout the school years, particularly influencing preadolescent and adolescent behavior. Peer group culture often affects decision-making among preadolescent children regarding such taboo topics as sex and drugs (Wong, 2003). From a national health care perspective, it has become imperative to examine the effects of negative peer pressure on American youth. From a pediatric nursing perspective, it has become challenging to find creative ways to assist youth in constructively addressing the multiple threats that peer pressure challenges them with to help them grow into healthy, caring, and responsible adults. Healthy Youth 2010 is the American Medical Association’s (AMA) (2001) national health care initiative that focuses on attaining 21 critical objectives aimed at improving the health of adolescents and young adults between the ages
of 10 and 24 years. The 21 critical objectives are based on 10 leading health indicators, including physical activity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunizations, and access to care. Based on statistics found within the American Medical Association’s Healthy Youth 2010, there are some alarming trends that require the attention of pediatric health care professionals. Refer to Table 1 for an overview of these statistical trends. PREADOLESCENT GROWTH AND DEVELOPMENT The preadolescent stage of growth and development, also referred to as the middle or school age years of growth and development, takes place between the ages of 10 to 12 years. According to Whaley and Wong (1987):
It has been found that this period makes an important contribution to children’s learning the fundamental skills of their culture and developing competence and self-esteem. It is a time of intellectual growth, investment in work, and the first real commitment to a social unit outside of and larger than the family (p. 704).
Children within this age group are acutely sensitive to peer group social pressures and begin to develop a concept of self-esteem that comprises their own self-evaluation in addition to the opinions of family members and outside contacts (Whaley & Wong, 1987). Peer groups establish standards for either group acceptance or group rejection with many children willing to modify their behavior to “fit in” (Wong, 2003). Although peer group identification is an essential developmental task, peer group pressure can force children into taking unnecessary risks such as unprotected sex, smoking, and alcohol and illicit drug consumption (Comerci, Fuller, & Morrison, 1993; Simons-Morton, Crump, Haynie, Saylor, Ei-
Table 1. Statistical Trends from Healthy People 2010
Health Indicator Trend Page Location
Physical Activity and Obesity Tobacco Use Substance Abuse Pregnancy Mental Health Suicide Homicide
1/10 adolescents (12–19 years) are overweight 3,000 adolescents Ͻ 18 years will become daily smokers 25% of 8th graders and 62% of seniors have been drunk at least once 900,000 female adolescents/year 78% unplanned 28% of adolescent students report “feeling so sad or hopeless almost every day for at least 2 weeks in a row . . .” 25% females and 14% males (grades 9–12) report “seriously considering or attempting suicide” Record highs for adolescents 15–19. Third leading cause of death for 5–14 year-olds
8–9 14 11 17 19 19 24
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tel, & Yu, 1999; Watts & Nagy, 2000). Children this age have a strong desire not to be different because any differences may set the child apart from the group and may make him a target for peer group criticism and ridicule (Whaley and Wong, 1987). For example, children who are too tall, too short, or overweight can become painfully stigmatized by peers (Neumark-Sztainer, Story, & Faibisch, 1998). Monsen (2000) provided suggestions for how pediatric nurses can raise community awareness of the harm imposed on children through negative peer pressure. In addition to informing parents and teachers of inherent peer pressure risks, Monsen proposed that nurses advocate for the development of community-based youth activity programs such as “service projects, mentoring programs, and cultural diversity explorations” that support and supervise children (Monsen, 2000, p. 392). A THEORETICALLY BASED PRACTICUM PROJECT This project was created for the purpose of fulfilling a clinical practicum requirement for a graduate course in a community health nursing program that focused on crisis in the community. The project consisted of six interactive group sessions designed to provide children with verbal and nonverbal skills to enhance self-esteem and to protect against negative peer pressure influence. Session plans, parental consent, and child assent were reviewed and approved by the Graduate Director of Nursing, a doctorally prepared nurse with holistic nursing expertise, and by the course instructor, a doctorally prepared nurse with pediatric expertise. A convenience sample of four preadolescent children aged 10 to 12 years old were recruited from a local middle school. Tenets from Nightingale’s teachings were used to structure the group sessions. In the following sections, Nightingale’s key components are highlighted (see Table 2). CONFIDENTIALITY AND TRUST Parents were called and verbal consent was obtained before each group session took place. Parental support was enhanced by giving them an opportunity to ask questions and voice any concerns prior to the sessions. In addition to parental consent, verbal assent was obtained from each child participating in the group before each session began. In order to build trusting relationships among the members in the group, the meaning and impor-
tance of confidentiality was reviewed with the children during their first group session. Throughout the sessions, group exercises were devoted to establishing trusting and confidential relationships, and the children grew increasingly comfortable with sharing experiences and offering advice. Nightingale (1860/1998) strongly believed in the importance of confidentiality, stating:
And remember every nurse should be one who is to be depended upon, in other words, capable of being a “confidential” nurse. She does not know how soon she may find herself placed in such a situation; she must be no gossip, no vain talker; she should never answer questions about her sick except to those who have a right to ask them (p.125).
Nightingale (1860/1998) also addressed the importance of building trusting relationships with her patients, stating:
If you go without his knowing it, and he finds it out, he never will feel secure again that the things which depend upon you will be done when you are away, and in nine cases out of ten he will be right (p.39).
LEADERSHIP AND COMMUNICATION The nurse, as a group facilitator/leader, must be able to sit back and listen to what is being said to plan and implement future sessions according to the group’s stated needs, while helping to promote healthy and positive group working skills. With reference to leadership, Nightingale (1860/1998) stated:
To be “in charge” is certainly not only to carry out the proper measures yourself but to see that everyone else does so too; to see that no one either wilfully (sic) or ignorantly thwarts or prevents such measures. It is neither to do everything yourself nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appointed (p.33).
Nightingale was also a strong advocate for the use of proper communication skills, which included eye-to-eye contact in addition to being at the patient’s side. With regard to communication techniques, Nightingale (1860/1998) stated:
Always sit within the patient’s view, so that when you speak to him he has not painfully to turn his head round in order to look at you. Everybody involuntarily looks at the person when speaking. . .So also by continuing to stand you make him continuously raise his eyes to see you . . . Never speak to an invalid from the behind, nor from the door, nor from any distance from him, nor when he is doing anything (p.38).
To enhance communication techniques with the children, group sessions were designed to take
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place with members either sitting in a circle or around a table to provide for optimal person-toperson communication. Several communication techniques were used within the group sessions and included the use of verbal communication skills such as reflection, deflection, exploratory questioning, and summarization (Clark, 1994). The use of verbal reflection provided group members with opportunities to describe how they felt during their experiences with
peer pressure. Using verbal deflection allowed opportunity for the other group members to express their thoughts and opinions regarding the issue at hand. Exploratory questioning gave the group leader opportunity to probe further into the group’s thoughts and feelings. Verbal summarization was done at the end of each group session regarding what had transpired during the session together. Using humor in a sensitive and appropriate manner with this age group was extremely effective in
Table 2. Nightingale’s Theory: Concept, Quotation, and Group Implementation
Concept Nightingale’s Quote Group Implementation
Nursing Skills 1. Confidentiality “And remember every nurse should be one who is depended upon, in other words, capable of being a “confidential nurse”. She does not know how soon she may find herself placed in such a situation; she must be no gossip, no vain talker; she should never answer questions about her sick except to those who have a right to ask them” (p. 125). “If you go without his knowing it, and he finds out, he never will feel secure again that the things which depend upon you will be done when you are away. And in nine cases out of ten he will be right” (p. 39). “The most important practical lesson that can be given to nurses is to teach them to observe-how to observe-what symptoms indicate improvementwhat the reverse-which which are of importance-which are of nonewhich are the evidence of neglect- and what kind of neglect. If you cannot get into the habit of observation one way or another, you had better give up the being (sic) a nurse” (p. 105). In dwelling upon the vital importance of sound observation, it must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort (p. 125). Review what confidentiality means and its important role among group members.
2. Building Trust
Review what trust means and its role with among group members. Observe group as a means of gathering information in order to better help the group according to its own individual, and unique needs.
3. Observation
Peer Pressure 4. Self-Assessment “I knew a very clever physician, of a large dispensary and hospital practice, who invariably began his examination of of each patient with ’Put your finger where you be bad’. That man never wasted his time collecting accurate information (p. 109). “To be ’in charge’ is certainly not only to carry out the proper measures yourself but to see that everyone else does so too; to see that no one either wilfully (sic) or ignorantly thwarts or prevents such measures. It is neither to do everything yourself nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appointed” (p. 33). “Always sit within the patient’s view, so that when you speak to him he has not painfully to turn his head round in order to look at you. Everybody involuntarily looks at the person when speaking . . . so also by continuing to stand you make him continuously raise his eyes to see you . . . Never speak to an invalid from behind, nor from the door, nor from any distance from him, nor when he is doing anything” (p. 38). “A little needle work, a little writing, a little cleaning, would be the greatest relief the sick could have” (p. 63). Assess group members by allowing them to explain their individual needs. (Peer Pressure Questionnaire) Establish effective group leadership skills while encouraging positive group participation.
5. Group Leadership
6. Communication Skills
Establish effective group communication techniques by encouraging group participation, eye contact, respect for group members, etc. Provide group members with a variety of learning experiences (movies, discussion, etc) to help increase understanding. Hold group sessions in rooms with open windows for fresh air and abundant sunlight.
7. Varied Teaching Methodologies
8. Fresh Air and Bright Environment
“Where there is sun, there is thought” (p. 86). “It is the unqualified result of all my experience with the sick, that second only to their need of fresh air is their need of light; that, after a close (sic) room, what hurts most is a dark room. And it is not only light but sunlight they want” (p. 64).
References: Nightingale, F. (1860/1998).
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helping to discuss difficult issues. Humor helped to decrease group tension and provided the group with a different way of looking at difficult situations. Some excellent resources on effective communication with children include books by Faber & Mazlish (1980), Healy (1994), and Dinkmeyer & McKay (1997). OBSERVATION Nightingale (1860/1998) believed that observation was the single most important skill for nurses to acquire:
The most important practical lesson that can be given to nurses is to teach them what to observe-how to observewhat symptoms indicate improvement-what the reversewhich are of importance-which are of none-which are the evidence of neglect-and of what kind of neglect. If you cannot get the habit of observation one way or other, you had better give up the being (sic) a nurse (p.105).
according to Nightingale, meant that both the environment that patients were placed in and the activities that patients were allowed to do were important for the process of healing. Nightingale (1860/1998) wrote, “The effect in sickness of beautiful objects, of variety of objects, and especially of brilliancy of color, is hardly ever appreciated” (p.58). Nightingale continued to write, “a little needle work, a little writing, a little cleaning, would be the greatest relief the sick could have” (p. 63). Group sessions were held in different locations in rooms that were colorfully decorated and painted, having several windows where sunlight and fresh air were abundant. Group sessions were also planned using a variety of teaching methods and activities. SELF-ASSESSMENT During the first group session, a peer pressure baseline assessment was done to determine how members of the group felt about their social relationships with their peers and to learn about the negative peer pressure problems that the children felt they were experiencing. A self-assessment questionnaire was created by the author (see Table 3). The assessment tool consisted of 10 open-ended questions appropriate for a preadolescent level of understanding. The tool was reviewed by pediatric clinical experts to establish construct validity. The questionnaire acted as an excellent resource for ideas concerning topics related to negative peer pressure that could be discussed in future group sessions.
Table 3. The Preadolescent Peer Pressure Assessment Tool 1) What do you think peer pressure means? 2) Tell me about a time when you think you felt peer pressure. 3) Were there any bad or negative things you felt because of this peer pressure? If you did have any bad feelings because of this peer pressure, tell me about these feelings and why you felt this way. 4) Were there any good or positive things you felt because of this peer pressure? If there were any good feelings you felt about this peer pressure, tell me about these feelings and why you felt this way. 5) Do you feel that you made the right decisions on how you handled this peer pressure situation? 6) Do you like how you handled this situation? 7) Is there anything you think you could have done differently to make this situation better? 8) Did you learn any lessons from this experience? 9) What do you think is the most important thing to remember about this situation? 10) If you are faced with another peer pressure situation, what will you do?
Nightingale (1860/1998) further believed:
In dwelling upon the vital importance of sound observation, it must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort (p.125).
Observation was the most valuable nursing skill and intervention applied during the group sessions. Observation of both the children’s body language and the children’s verbal reactions during group discussion and group activities provided insight into the group’s comfort level, provided opportunity for gathering information on issues thought of as most important to the group regarding peer pressure, and revealed the development of a healthy peer support system over the time that the group sessions were held. ENVIRONMENT AND VARIED ACTIVITY Nightingale believed that the environment in which patients were placed had a profound affect on the patient’s recovery and believed that placing patients in clean and bright environments with access to fresh air was of crucial importance for healing. Nightingale (1860/1998) stated, “Where there is sun, there is thought” (p.86). Nightingale additionally stated:
It is the unqualified result of all my experience with the sick, that second only to their need of fresh air is their need of light; that, after a close (sic) room, what hurts most is a dark room. And it is not only light but sunlight they want (p.64).
Nightingale also believed in the importance of using variety when caring for patients. Variety,
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Nightingale stressed the importance of letting the patient personally voice those problems that he or she felt that they were experiencing by giving them an opportunity to use his or her own words to describe the situation. Nightingale (1860/1998) stated, “I knew a very clever physician, of a large dispensary and hospital practice, who invariably began his examination of each patient with ‘Put your finger where you be bad’. That man never wasted his time with collecting inaccurate information” (p. 109). Having the group fill out the peer pressure questionnaire gave each child an opportunity to “point their finger where they be bad” regarding their negative peer pressure experiences. TEACHING Contemporary resources were used to operationalize group discussion topics and activities. The Book of Virtues for Young People (Bennett, 1997) and Kid Stories: Biographies of 20 Young People You’d like to Know (Delise, 1991) were excellent sources for stories dealing with peer pressure, morals, and values. Other resources written specifically on teen stressors and peer pressure include books by Cherniss & Sluke (2001), Covey (1998), and Carlson (2000). The primary educational/informational topics for group sessions were as follows: (a) the definition of peer pressure, (b) the differences between positive and negative peer pressure, (c) establishing and maintaining positive morals and values, (d) building healthy relationships, (e) managing bullying, and (f) saying “no” to negative peer pressure situations. A variety of teaching methods were used to engage the children emotionally, physically, and cognitively. All group sessions were held in an informal atmosphere to promote a relaxing environment where the children would feel comfortable expressing their thoughts and feelings (Spradley & Allender, 1997). The first group session was used to introduce group members to one another, to establish group rules, to discuss the meaning of confidentiality and trust, and to assess, with the use of the peer pressure questionnaire, both the meaning of peer pressure and the different negative peer pressure situations that the children felt they had experienced. At the end of the first session, one group member stated that it felt good to know that they were not the only one “who was having peer pressure problems,” and another member stated, “I never knew so many other kids were feeling the same way I am.“ The children in the group additionally commented that they liked knowing that their feelings
and experiences would be kept both “private and confidential.” The second group session involved watching the movie The Outsiders (Warner Home Video, Ltd., 1983). The children were asked to identify any negative peer pressure situations that they saw in the movie. The children then discussed what they thought were both the right and wrong ways in which each negative peer pressure situation was handled and what they would do if the same situation arose in their lives. The third group session involved watching several VeggieTale videos (Big Idea Productions), which addressed the topics of peer pressure, selfesteem, and the importance of being kind to others. During the fourth group session, together, both the movie and videos acted as a resource for role playing, incorporating situations picked out by the children where the children alternated acting out being both the “bully” and the “victim.” Role playing peer pressure situations allowed the children to safely explore different ways to manage difficult and embarrassing situations. The children became immersed in their role-play characters. The “observers” coached and provided positive suggestions on how to best handle negative peer pressure scenarios. One child told the group that they “did not like being the bully because it felt bad,” and another group member told the group, “I felt sorry for the person who played the victim and I kept wanting to help!” The remaining group sessions included working on projects to help build self-esteem and selfconfidence such as making “just say no” t-shirts and artistic posters promoting saying “no” to negative peer pressure situations. The children also made wooden wall plaques to hang in their rooms promoting positive messages such as, “Triumph is just ‘umph’ added to try” (author unknown) and “Do not just look at the stars, reach for them” (author unknown). OUTCOMES During the last group session, the children were asked to talk about what they had learned during their time together. The children agreed that the sessions were “fun,“ that they learned “a lot about themselves and a lot about negative peer pressure,” and that they were relieved to know that “they were not the only ones” who were experiencing negative peer pressure situations. Group members’ feedback indicated that they enjoyed the variety of teaching methods that were incorporated into the group sessions, such as role playing, movies, vid-
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eos, arts and crafts, and discussion. Several children stated that they “looked forward to learning something new each week.” A follow-up phone call was made to each parent after the group sessions were finished to thank them for allowing their children to participate and to get feedback regarding their thoughts and ideas about the effectiveness of the group sessions in relation to teaching their child about negative peer pressure. Feedback from the parents was both encouraging and positive, and the parents expressed how eager their children were each week to share with their families what they had learned from the group. CLINICAL IMPLICATIONS This clinical practicum pilot project was a successful demonstration of how Nightingale’s histor-
ical theory of nursing can be applied to teaching a group of contemporary children. By combining Nightingale’s theoretical framework with other resources, such as books, videos, and arts and crafts, the children involved in this project were able to share their innermost thoughts and feelings regarding preadolescent peer pressure despite the difficult nature and abstract topics used within group sessions. This project demonstrated the process of combining theory with different teaching methodologies to develop an educational curricula and support group for preadolescent and adolescent children. Although this clinical practicum pilot project lacked a formal evaluative component, the findings support the importance of future pediatric research related to the short-term and long-term outcomes of theory-based pediatric nursing interventions.
REFERENCES
American Medical Association. (2001). Healthy youth 2010: Supporting the 21 critical adolescent objectives. Retrieved July 26, 2003, from http://www.ama-assn.org/ama/upload/mm/39/ healthy2010.pdf. Bennett, W. (1997). The Book of Virtues for Young People. New York: Simon & Schuster. Carlson, R. Don’t Sweat the Small Stuff for Teens: Simple Ways to Keep Cool in Stressful Times. New York: Hyperion Press. Cherniss, H., & Sluke, S. (2001). The Complete Idiot’s Guide to Surviving Peer Pressure for Teens. Indianapolis, IN: Alpha Publishing. Clark, C.C. (1987). The Nurse as the Group Leader (2nd ed.). New York: Springer. (Original work published in 1978). Comerci, G., Fuller, P., & Morrison, S. (1997). Keeping adolescents healthy, part I: Cigarettes, drugs, alcohol and teens. Patient Care, 31, 56-60. Covey, S. (1998). The 7 Habits of Highly Effective Teens. New York: Simon & Schuster. Delise, J. (1991). Kid Stories: Biographies of 20 Young People You’d Like to Know. Minneapolis, MN: Free Spirit Publishing. Dinkmeyer, D., & McKay, G. (1998). Parenting Teenagers: Systematic Training for Effective Parenting of Teens (STEP). Circle Pines, MN: American Guidance Service. Falk Rafeal, A.R. (1999). The politics of health promotion: Influences on public health promoting nursing practice in Ontario, Canada from Nightingale to the nineties. Advances in Nursing Science, 22(1), 23-39. Halsall, P. (1997). Modern History Sourcebook: Florence Nightingale: Rural hygiene. Retrieved July 26, 2003, from http://www.fordham.edu/halsall/mod/nightingale-rural.html. Monsen, R. (2000). The child in the community: Nursing makes a difference. Journal of Pediatric Nursing, 15, 391-392. Monteiro, L.A. (1991). Florence Nightingale on public health nursing. In B.W. Spradely (Ed.), Readings in Community Health Nursing. Philadelphia, PA: Lippincott. Neumark-Sztainer, S., Story, M., & Faibisch, L. (1998). Perceived stigmatization among overweight African-American and Caucasian adolescent girls. Journal of Adolescent Health, 23, 264-270. Nightingale, F. (1969). Notes on Nursing (2nd ed.). New York: Dover Publications. (Original work published in 1860). Nightingale, F. (1860). Notes on Nursing: What It Is, and What It Is Not. Boston: William Carter. Simons-Morton, B., Crump, A., Haynie, D., Saylor, K., Eitel, P., & Yu, K. (1999). Psychosocial, school, and parent factors associated with recent smoking among early adolescent boys and girls. Preventive Medicine, 28, 138-148. Spradley, B.W., & Allender, J.A. (1997). Readings in Community Health Nursing (5th ed.). Philadelphia, PA: LippincottRaven. Watts, G., & Nagy, S. (2000). Sociodemographic factors, attitudes, and expectations toward adolescent coitus. American Journal of Health Behavior, 24, 309-317. Whaley, L.F., & Wong, D.L. (1987). Nursing Care of Infants and Children (3rd ed.). St. Louis, MO: Mosby. Wikipedia: The Free Encyclopedia. (2003). Peer pressure. Retrieved July 26, 2003, from http://www.wikipedia.org/wiki/ Peer-pressure. Wong, D.L., Hockenberry, M., Wilson, D., Winkelstein, M., & Kline, N. (2003). Wong’s Nursing Care of Infants and Children (7th ed.). St. Louis, MO: Mosby.
