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LINICAL PRACTICE COLUMN

olumn Editor: Maura MacPhee, PhD, RN

ncorporating Florence Nightingale’s Theory ofursing into Teaching a Group of Preadolescenthildren About Negative Peer Pressure

oralee Sessanna, RN, MSN, CNS

linically based nurses often question the value of nursing theory, ultimately resulting in the reluctance to implement nursingheory into practice. This clinical practicum project successfully used Nightingale’s primary tenets, such as building trust,elf-assessment, and group leadership, as a theoretical framework in a nursing practice group for the purpose of teaching aroup of preadolescent children about negative peer pressure. Preadolescent children are particularly vulnerable to peer groupulture. Proactive strategies, as demonstrated through this project, can be used to positively influence children’s behavioroward each other during the formative middle years. Group sessions addressed such topics as moral beliefs and values,ullying, and saying “no” to peer pressure and were structured using a variety of contemporary resources to develop interactivexercises that engaged the children and enhanced group communication. The children and their parents reported positiveutcomes from the nurse-led group sessions.2004 Elsevier Inc. All rights reserved.

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Editor’s introductionI recently read an article by Woodward (2003) advo

ing for theory-based nursing education and pracWoodward outlined the myths that surround nursingory. For instance, “nursing theory is just fluff that haslink to nursing activities” (p. 215). This statement caumy attention, because we (nurses) are becomingaccountable every day for what we do. Through theorycan systematically derive or develop nursing care intertions that can be tested, evaluated, and linked to meable outcomes. Nursing theory, therefore, helps us elish ‘what is best practice,’ and it helps us achieve puand professional accountability. Another myth about ning theory described in Woodward’s article is: “Nurstheory is discussed at tables and in meetings ratherused with actual people” (p. 216). I did a literature seaof ‘nursing theory and practice’ and was amazed at alevidence for theory-based ‘best practice’ that indicateopposite. The following article helps to further debuthese two myths about nursing theory. It demonstrateimportance of educating professional nurses about thbased practice. This innovative application of FloreNightingale’s theory was based on a student practicualso illustrates how theory can be used to enhancecomes for actual people, pre-teens in this case. Nutheory often becomes abandoned post-graduation,can contribute to evidence of what is ‘uniquely nursiabout the care we give.Maura MacPhee, RN, PhD, Clinical Practice Editor

Reference Woodward, W. (2003). Preparing a nworkforce. Nursing Administration Quarterly, 27(3),215-222.

ournal of Pediatric Nursing, Vol 19, No 3 (June), 2004

IGHTINGALE’S IDEAS and teachings havbeen an inspiration for many nurses throu

ut history, providing an invaluable foundationhe profession of nursing. Within the body of hork, Nightingale specifically addressed theortance of caring for children’s health statimoney would be better spent in maintainealth in infancy and childhood than in buildiospitals to cure disease” (Monteiro, 1991, p. 102).

n her bookNotes on Nursing, Nightingale (1860/969) further disclosed the importance of car

or children, stating:

To revert to children. They are much more suscepthan grown people to all noxious influences. Theyaffected by the same things, but much more quicklyseriously, viz., by want of fresh air, of proper warmwant of cleanliness in house, clothes, bedding, or bodstartling noises, improper food, or want of punctuality,

From the Community Health Nursing masters program,’Youville College, Buffalo, New York. The author is currentlystudent at the University of Buffalo in the Doctor of Nursing

cience program.Address correspondence and reprint requests to Loralee Ses-

anna, RN, MSN, CNS, 3932 Eckhardt Road, Hamburg, NY4075. E-mail: todloralee@adelphia.net0882-5963/$ - 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 littlecovering in bed, or when up, by want of the spirit ofmanagement generally of those in charge of them. Onecan, therefore, only press the importance, as being yetgreater in the case of children, greatest in the case of sickchildren, of attending to these things (p. 128).

This paper is based on a clinical practicumroject that successfully used Nightingale’s pri-ary tenets, such as building trust, self-assess-ent, and group leadership, as a theoretical frame-ork in a nursing practice group for the purpose of

eaching a group of preadolescent children aboutegative peer pressure.

ADOLESCENT STATISTICS

Peer pressure is defined by Wikipedia (2003)s, “A set of group dynamics whereby a group inhich one feels comfortable may override per-

onal habits, individual moral inhibitions, or id-osyncratic desires to impose a group norm ofttitudes and/or behaviors” (p.1). Peer influencelays a major role within the developmentalhaping of children and youth. The importancef peer relationships builds throughout thechool years, particularly influencing preadoles-ent and adolescent behavior. Peer group cultureften affects decision-making among preadoles-ent children regarding such taboo topics as sexnd drugs (Wong, 2003). From a national healthare perspective, it has become imperative toxamine the effects of negative peer pressure onmerican youth. From a pediatric nursing per-

pective, it has become challenging to find cre-tive ways to assist youth in constructively ad-ressing the multiple threats that peer pressurehallenges them with to help them grow intoealthy, caring, and responsible adults.Healthy Youth 2010 is the American Medical

ssociation’ s (AMA) (2001) national healthare initiative that focuses on attaining 21 criti-al objectives aimed at improving the health ofdolescents and young adults between the ages

Table 1. Statistical Tren

Health Indicator

Physical Activity and Obesity 1/10 adolescents (12–19 yearsTobacco Use 3,000 adolescents � 18 yearsSubstance Abuse 25% of 8th graders and 62% oPregnancy 900,000 female adolescents/yeMental Health 28% of adolescent students repo

least 2 weeks in a row . . .”Suicide 25% females and 14% males (g

attempting suicide”Homicide Record highs for adolescents 15

f 10 and 24 years. The 21 critical objectives areased on 10 leading health indicators, includinghysical activity, overweight and obesity, to-acco use, substance abuse, responsible sexualehavior, mental health, injury and violence,nvironmental quality, immunizations, and ac-ess to care. Based on statistics found within themerican Medical Association’ s Healthy Youth010, there are some alarming trends that requirehe attention of pediatric health care profession-ls. Refer to Table 1 for an overview of thesetatistical trends.

PREADOLESCENT GROWTH ANDDEVELOPMENT

The preadolescent stage of growth and develop-ent, also referred to as the middle or school age

ears of growth and development, takes place be-ween the ages of 10 to 12 years. According to

haley and Wong (1987):

It has been found that this period makes an importantcontribution to children’s learning the fundamental skillsof their culture and developing competence and self-es-teem. It is a time of intellectual growth, investment inwork, and the first real commitment to a social unit outsideof and larger than the family (p. 704).

Children within this age group are acutelyensitive to peer group social pressures and be-in to develop a concept of self-esteem thatomprises their own self-evaluation in additiono the opinions of family members and outsideontacts (Whaley & Wong, 1987). Peer groupsstablish standards for either group acceptancer group rejection with many children willing toodify their behavior to “fi t in” (Wong, 2003).lthough peer group identification is an essentialevelopmental task, peer group pressure canorce children into taking unnecessary risks suchs unprotected sex, smoking, and alcohol and illicitrug consumption (Comerci, Fuller, & Morrison,993; Simons-Morton, Crump, Haynie, Saylor, Ei-

Healthy People 2010

Trend Page Location

erweight 8–9me daily smokers 14have been drunk at least once 11unplanned 17ng so sad or hopeless almost every day for at 19

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el, & Yu, 1999; Watts & Nagy, 2000). Childrenhis age have a strong desire not to be differentecause any differences may set the child apartrom the group and may make him a target for peerroup criticism and ridicule (Whaley and Wong,987). For example, children who are too tall, toohort, or overweight can become painfully stigma-ized by peers (Neumark-Sztainer, Story, &aibisch, 1998).Monsen (2000) provided suggestions for how

ediatric nurses can raise community awarenessf the harm imposed on children through nega-ive peer pressure. In addition to informing par-nts and teachers of inherent peer pressure risks,onsen proposed that nurses advocate for the

evelopment of community-based youth activityrograms such as “ service projects, mentoringrograms, and cultural diversity explorations”hat support and supervise children (Monsen,000, p. 392).

A THEORETICALLY BASED PRACTICUMPROJECT

This project was created for the purpose of ful-lling a clinical practicum requirement for a grad-ate course in a community health nursing pro-ram that focused on crisis in the community. Theroject consisted of six interactive group sessionsesigned to provide children with verbal and non-erbal skills to enhance self-esteem and to protectgainst negative peer pressure influence. Sessionlans, parental consent, and child assent were re-iewed and approved by the Graduate Director ofursing, a doctorally prepared nurse with holisticursing expertise, and by the course instructor, aoctorally prepared nurse with pediatric expertise.

convenience sample of four preadolescent chil-ren aged 10 to 12 years old were recruited from aocal middle school. Tenets from Nightingale’seachings were used to structure the group ses-ions. In the following sections, Nightingale’s keyomponents are highlighted (see Table 2).

CONFIDENTIALITY AND TRUST

Parents were called and verbal consent was ob-ained before each group session took place. Pa-ental support was enhanced by giving them anpportunity to ask questions and voice any con-erns prior to the sessions. In addition to parentalonsent, verbal assent was obtained from eachhild participating in the group before each sessionegan.In order to build trusting relationships among

he members in the group, the meaning and impor- c

ance of confidentiality was reviewed with the chil-ren during their first group session. Throughouthe sessions, group exercises were devoted to es-ablishing trusting and confidential relationships,nd the children grew increasingly comfortableith sharing experiences and offering advice.ightingale (1860/1998) strongly believed in the

mportance of confidentiality, stating:

And remember every nurse should be one who is to bedepended upon, in other words, capable of being a “con-fidential” nurse. She does not know how soon she may findherself placed in such a situation; she must be no gossip,no vain talker; she should never answer questions abouther sick except to those who have a right to ask them(p.125).

Nightingale (1860/1998) also addressed the im-ortance of building trusting relationships with heratients, stating:

If you go without his knowing it, and he finds it out, henever will feel secure again that the things which dependupon you will be done when you are away, and in ninecases out of ten he will be right (p.39).

LEADERSHIP AND COMMUNICATION

The nurse, as a group facilitator/leader, must beble to sit back and listen to what is being said tolan and implement future sessions according tohe group’s stated needs, while helping to promoteealthy and positive group working skills. Witheference to leadership, Nightingale (1860/1998)tated:

To be “ in charge” is certainly not only to carry out theproper measures yourself but to see that everyone else doesso too; to see that no one either wilfully (sic) or ignorantlythwarts or prevents such measures. It is neither to doeverything yourself nor to appoint a number of people toeach duty, but to ensure that each does that duty to whichhe is appointed (p.33).

Nightingale was also a strong advocate for these of proper communication skills, which in-luded eye-to-eye contact in addition to being athe patient’s side. With regard to communicationechniques, Nightingale (1860/1998) stated:

Always sit within the patient’s view, so that when youspeak to him he has not painfully to turn his head round inorder to look at you. Everybody involuntarily looks at theperson when speaking. . .So also by continuing to standyou make him continuously raise his eyes to see you . . .Never speak to an invalid from the behind, nor from thedoor, nor from any distance from him, nor when he isdoing anything (p.38).

To enhance communication techniques with the

hildren, group sessions were designed to take

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228 LORALEE SESSANNA

lace with members either sitting in a circle orround a table to provide for optimal person-to-erson communication.Several communication techniques were used

ithin the group sessions and included the use oferbal communication skills such as reflection, de-ection, exploratory questioning, and summariza-

ion (Clark, 1994). The use of verbal reflectionrovided group members with opportunities to de-cribe how they felt during their experiences with

Table 2. Nightingale’s Theory: Conc

Concept Nightingale’s

Nursing Skills

1. Confidentiality “And remember every nurse should be owords, capable of being a “confidentiasoon she may find herself placed in sugossip, no vain talker; she should neveexcept to those who have a right to as

2. Building Trust “If you go without his knowing it, and heagain that the things which depend upaway. And in nine cases out of ten he

3. Observation “The most important practical lesson thatthem to observe-how to observe-whatwhat the reverse-which which are of imwhich are the evidence of neglect- andcannot get into the habit of observatiobetter give up the being (sic) a nurse”

In dwelling upon the vital importance ofbe lost sight of what observation is formiscellaneous information or curious faand increasing health and comfort (p.

Peer Pressure

4. Self-Assessment “I knew a very clever physician, of a largpractice, who invariably began his exa’Put your finger where you be bad’. Thcollecting accurate information (p. 109

5. Group Leadership “To be ’in charge’ is certainly not only toyourself but to see that everyone else deither wilfully (sic) or ignorantly thwartneither to do everything yourself nor toeach duty, but to ensure that each doeappointed” (p. 33).

6. Communication Skills “Always sit within the patient’s view, so tnot painfully to turn his head round ininvoluntarily looks at the person whencontinuing to stand you make him cont. . . Never speak to an invalid from beany distance from him, nor when he is

7. Varied TeachingMethodologies

“A little needle work, a little writing, a litrelief the sick could have” (p. 63).

8. Fresh Air and BrightEnvironment

“Where there is sun, there is thought” (p“It is the unqualified result of all my expe

only to their need of fresh air is their nroom, what hurts most is a dark room.sunlight they want” (p. 64).

References: Nightingale, F. (1860/1998).

eer pressure. Using verbal deflection allowed op-ortunity for the other group members to expressheir thoughts and opinions regarding the issue atand. Exploratory questioning gave the groupeader opportunity to probe further into the group’shoughts and feelings. Verbal summarization wasone at the end of each group session regardinghat had transpired during the session together.sing humor in a sensitive and appropriate mannerith this age group was extremely effective in

otation, and Group Implementation

Group Implementation

is depended upon, in other. She does not know howation; she must be nor questions about her sick(p. 125).

Review what confidentiality meansand its important role amonggroup members.

ut, he never will feel securewill be done when you areright” (p. 39).

Review what trust means and its rolewith among group members.

given to nurses is to teachs indicate improvement-e-which are of none-ind of neglect. If youay or another, you had).bservation, it must nevert for the sake of piling upfor the sake of saving life

Observe group as a means ofgathering information in order tobetter help the group according toits own individual, and uniqueneeds.

nsary and hospitaln of of each patient withnever wasted his time

Assess group members by allowingthem to explain their individualneeds. (Peer PressureQuestionnaire)

ut the proper measuresoo; to see that no onevents such measures. It ist a number of people toty to which he is

Establish effective group leadershipskills while encouraging positivegroup participation.

n you speak to him he haslook at you. Everybody

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r from the door, nor fromnything” (p. 38).

Establish effective groupcommunication techniques byencouraging group participation,eye contact, respect for groupmembers, etc.

ing, would be the greatest Provide group members with avariety of learning experiences(movies, discussion, etc) to helpincrease understanding.

ith the sick, that secondight; that, after a close (sic)is not only light but

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elping to discuss difficult issues. Humor helped toecrease group tension and provided the groupith a different way of looking at difficult situa-

ions. Some excellent resources on effective com-unication with children include books by FaberMazlish (1980), Healy (1994), and DinkmeyerMcKay (1997).

OBSERVATION

Nightingale (1860/1998) believed that observa-ion was the single most important skill for nurseso acquire:

The most important practical lesson that can be given tonurses is to teach them what to observe-how to observe-what symptoms indicate improvement-what the reverse-which are of importance-which are of none-which are theevidence of neglect-and of what kind of neglect. If youcannot get the habit of observation one way or other, youhad better give up the being (sic) a nurse (p.105).

Nightingale (1860/1998) further believed:

In dwelling upon the vital importance of sound obser-vation, it must never be lost sight of what observation isfor. It is not for the sake of piling up miscellaneousinformation or curious facts, but for the sake of saving lifeand increasing health and comfort (p.125).

Observation was the most valuable nursing skillnd intervention applied during the group sessions.bservation of both the children’s body language

nd the children’s verbal reactions during groupiscussion and group activities provided insightnto the group’s comfort level, provided opportu-ity for gathering information on issues thought ofs most important to the group regarding peerressure, and revealed the development of aealthy peer support system over the time that theroup sessions were held.

ENVIRONMENT AND VARIED ACTIVITY

Nightingale believed that the environment inhich patients were placed had a profound affectn the patient’s recovery and believed that placingatients in clean and bright environments withccess to fresh air was of crucial importance forealing. Nightingale (1860/1998) stated, “Wherehere is sun, there is thought” (p.86). Nightingaledditionally stated:

It is the unqualified result of all my experience with thesick, that second only to their need of fresh air is their needof light; that, after a close (sic) room, what hurts most is adark room. And it is not only light but sunlight they want(p.64).

Nightingale also believed in the importance of

sing variety when caring for patients. Variety,

ccording to Nightingale, meant that both the en-ironment that patients were placed in and thectivities that patients were allowed to do weremportant for the process of healing. Nightingale1860/1998) wrote, “The effect in sickness ofeautiful objects, of variety of objects, and espe-ially of brilliancy of color, is hardly ever appre-iated” (p.58). Nightingale continued to write, “aittle needle work, a little writing, a little cleaning,ould be the greatest relief the sick could have” (p.3).Group sessions were held in different locations

n rooms that were colorfully decorated andainted, having several windows where sunlightnd fresh air were abundant. Group sessions werelso planned using a variety of teaching methodsnd activities.

SELF-ASSESSMENT

During the first group session, a peer pressureaseline assessment was done to determine howembers of the group felt about their social rela-

ionships with their peers and to learn about theegative peer pressure problems that the childrenelt they were experiencing. A self-assessmentuestionnaire was created by the author (see Table). The assessment tool consisted of 10 open-endeduestions appropriate for a preadolescent level ofnderstanding. The tool was reviewed by pediatriclinical experts to establish construct validity. Theuestionnaire acted as an excellent resource fordeas concerning topics related to negative peerressure that could be discussed in future groupessions.

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 thispeer pressure?If there were any good feelings you felt about this peerpressure, tell me about these feelings and why you felt this way.

5) Do you feel that you made the right decisions on how youhandled 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?0) If you are faced with another peer pressure situation, what will

you do?

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230 LORALEE SESSANNA

Nightingale stressed the importance of lettinghe patient personally voice those problems that her she felt that they were experiencing by givinghem an opportunity to use his or her own words toescribe the situation. Nightingale (1860/1998)tated, “ I knew a very clever physician, of a largeispensary and hospital practice, who invariablyegan his examination of each patient with ‘Putour finger where you be bad’ . That man neverasted his time with collecting inaccurate infor-ation” (p. 109). Having the group fill out the peer

ressure questionnaire gave each child an oppor-unity to “point their finger where they be bad”egarding their negative peer pressure experiences.

TEACHING

Contemporary resources were used to operation-lize group discussion topics and activities. Theook of Virtues for Young People (Bennett, 1997)nd Kid Stories: Biographies of 20 Young Peopleou’d like to Know (Delise, 1991) were excellentources for stories dealing with peer pressure, mor-ls, and values. Other resources written specificallyn teen stressors and peer pressure include booksy Cherniss & Sluke (2001), Covey (1998), andarlson (2000). The primary educational/informa-

ional topics for group sessions were as follows: (a)he definition of peer pressure, (b) the differencesetween positive and negative peer pressure, (c)stablishing and maintaining positive morals andalues, (d) building healthy relationships, (e) man-ging bullying, and (f) saying “no” to negative peerressure situations.A variety of teaching methods were used to

ngage the children emotionally, physically, andognitively. All group sessions were held in annformal atmosphere to promote a relaxing envi-onment where the children would feel comfort-ble expressing their thoughts and feelings (Spra-ley & Allender, 1997).The first group session was used to introduce

roup members to one another, to establish groupules, to discuss the meaning of confidentiality andrust, and to assess, with the use of the peer pres-ure questionnaire, both the meaning of peer pres-ure and the different negative peer pressure situ-tions that the children felt they had experienced.t the end of the first session, one group member

tated that it felt good to know that they were nothe only one “who was having peer pressure prob-ems,” and another member stated, “ I never knewo many other kids were feeling the same way Im.“ The children in the group additionally com-

ented that they liked knowing that their feelings g

nd experiences would be kept both “private andonfidential.”

The second group session involved watching theovie The Outsiders (Warner Home Video, Ltd.,

983). The children were asked to identify anyegative peer pressure situations that they saw inhe movie. The children then discussed what theyhought were both the right and wrong ways inhich each negative peer pressure situation wasandled and what they would do if the same situ-tion arose in their lives.

The third group session involved watching sev-ral VeggieTale videos (Big Idea Productions),hich addressed the topics of peer pressure, self-

steem, and the importance of being kind to others.uring the fourth group session, together, both theovie and videos acted as a resource for role

laying, incorporating situations picked out by thehildren where the children alternated acting outeing both the “bully” and the “victim.” Role play-ng peer pressure situations allowed the children toafely explore different ways to manage difficultnd embarrassing situations. The children becamemmersed in their role-play characters. The “ob-ervers” coached and provided positive sugges-ions on how to best handle negative peer pressurecenarios. One child told the group that they “didot like being the bully because it felt bad,” andnother group member told the group, “ I felt sorryor the person who played the victim and I keptanting to help!”The remaining group sessions included working

n projects to help build self-esteem and self-onfidence such as making “ just say no” t-shirtsnd artistic posters promoting saying “no” to neg-tive peer pressure situations. The children alsoade wooden wall plaques to hang in their rooms

romoting positive messages such as, “Triumph isust ‘umph’ added to try” (author unknown) andDo not just look at the stars, reach for them”author unknown).

OUTCOMES

During the last group session, the children weresked to talk about what they had learned duringheir time together. The children agreed that theessions were “ fun,“ that they learned “a lot abouthemselves and a lot about negative peer pressure,”nd that they were relieved to know that “ theyere not the only ones” who were experiencingegative peer pressure situations. Group members’eedback indicated that they enjoyed the variety ofeaching methods that were incorporated into the

roup sessions, such as role playing, movies, vid-

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os, arts and crafts, and discussion. Several chil-ren stated that they “ looked forward to learningomething new each week.”

A follow-up phone call was made to each parentfter the group sessions were finished to thankhem for allowing their children to participate ando get feedback regarding their thoughts and ideasbout the effectiveness of the group sessions inelation to teaching their child about negative peerressure. Feedback from the parents was both en-ouraging and positive, and the parents expressedow eager their children were each week to shareith their families what they had learned from theroup.

CLINICAL IMPLICATIONS

This clinical practicum pilot project was a suc-

essful demonstration of how Nightingale’s histor- v

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ttp://www.fordham.edu/halsall/mod/nightingale-rural.html.

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cal theory of nursing can be applied to teaching aroup of contemporary children. By combiningightingale’s theoretical framework with other re-

ources, such as books, videos, and arts and crafts,he children involved in this project were able tohare their innermost thoughts and feelings regardingreadolescent peer pressure despite the difficult na-ure and abstract topics used within group sessions.

This project demonstrated the process of com-ining theory with different teaching method-logies to develop an educational curricula andupport group for preadolescent and adolescenthildren. Although this clinical practicum pilotroject lacked a formal evaluative component, thendings support the importance of future pediatricesearch related to the short-term and long-termutcomes of theory-based pediatric nursing inter-

entions.

ES

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