Future Health Care Professionals' Knowledge of Developmentally Appropriate Care with Children in the Health Care Setting

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Title:
Future Health Care Professionals' Knowledge of Developmentally Appropriate Care with Children in the Health Care Setting
Physical Description:
1 online resource (98 p.)
Language:
english
Creator:
Wente,Jessica N
Publisher:
University of Florida
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Gainesville, Fla.
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Thesis/Dissertation Information

Degree:
Master's ( M.S.)
Degree Grantor:
University of Florida
Degree Disciplines:
Family, Youth and Community Sciences
Committee Chair:
Diehl, David C.
Committee Members:
Forthun, Larry F.
Wiens, Brenda A

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Subjects / Keywords:
Family, Youth and Community Sciences -- Dissertations, Academic -- UF
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Family, Youth and Community Sciences thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

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Abstract:
Children experience significant anxiety and distress during procedures and other experiences in the health care setting (Brady, Avner, & Khine, 2011; Chorney & Kain, 2009; Hamilton, 1995; Kain, Mayes, O'Connor, & Cicchetti, 1996; MacLaren & Kain, 2009). Without intervention, this can interfere with children?s normal development (Child Life Council, 2008; Chorney & Kain, 2009; R. H. Thompson & Snow, 2009). Children want to know what they will experience in the health care setting (Fortier et al., 2009; Smith & Callery, 2005), and children have the right to be prepared for their health care experience and to have their desires, needs, and emotions considered (United Nations, 1989). It is the health care professionals? ethical responsibility to provide appropriate psychosocial care (Kuttner, 2010). This research evaluates future health care professionals? knowledge of developmentally appropriate care (DAC) with children in the health care setting. Participants include nursing, medical, physician assistant, physical therapy, and non-clinical health care students. The instrument utilizes subscales that measure knowledge of DAC, confidence in providing DAC, and interest in future training on DAC, which are informed by the Child Life Council?s child life professional certification exam and the Child Life Internship Program Self-Review. Knowledge of DAC significantly varied by field of study, with non-clinical health care professionals scoring significantly lower on the knowledge of DAC scale than other fields of study. Students who intend to work with children in their profession had the same level of knowledge of DAC as students who indicate that they do not plan to work with children. Patient-centered views significantly predict knowledge of DAC with children in the health care setting. As age increases, knowledge of DAC also increases for nursing and physical therapy students. However, personal and professional experience does not significantly predict knowledge of DAC within any of the fields of study. For non-clinical health care students, a course in child development significantly predicts more knowledge of DAC. Interest in future training on DAC varies significantly between the observed fields of study, with physician assistant students being the most interested. Students who intend to work with children in their profession indicate significantly more interest than students who indicate that they do not plan to work with children. Across all fields of study, students who are younger, more confident in their ability to provide DAC, had more personal and professional experience with children, had taken a course in child development, and who are more patient-centered are more interested in future training on DAC with children in the health care setting.
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In the series University of Florida Digital Collections.
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Includes vita.
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Includes bibliographical references.
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Description based on online resource; title from PDF title page.
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This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Jessica N Wente.
Thesis:
Thesis (M.S.)--University of Florida, 2011.
Local:
Adviser: Diehl, David C.

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UFRGP
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Applicable rights reserved.
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lcc - LD1780 2011
System ID:
UFE0043462:00001


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1 FUTURE HEALTH CARE PROFESSIO OF DEVELOPMENTALLY APPROPRIATE CARE WITH CHILDREN IN THE HEALTH CARE SETTING By JESSICA NICOLE WENTE A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2011

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2 2011 Jessica Nicole Wente

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3 To children: may this research contribute to a better health care experience for you and your families.

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4 ACKNOWLEDGMENTS I would like to take the opportunity to thank everyone who has contributed to my success as a graduate student. I thank my family for their dedication to my education, as none of this would be possible without their love and support. My parents have always taught me to follow my passion, and I have done just that. Additionally, my family has taught me a few life skills that have helped over the last few years. My m other exemplif ies o ptimism and resilience, and my father and s tep mother have taught me patience, a good sense of humor, and to pick my battles in life. My Grandpa Burger has taught me the value of a good education and to never take myself too seriously, and my Grandma Donna has taught me the value of family and faith (and good chocolate pie!). I thank you all for your dedication to my education and who I am as a I than k my committee for allowing me to pursue a research t opic that I am truly passionate about. It made my thesis work exciting and meaningful I am also thankful patient guidance on best practices for research. I thank m y committee chair, David Diehl, for going ab ove and be yond as a mentor to make sure I never settle for less than my best work. I am appreciative of t his investment in my development as a graduate student and as a young professional. L ast but certainly not least I would like to thank my friends who have helpe d me celebr ate milestones, accomplishments and have s imply made life enjoyable. I cherish you and am thankful for the opportunities you provide daily to laugh and to remember what is important in life.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 8 ABSTRACT ................................ ................................ ................................ ................... 10 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 12 ................................ ........ 12 Appropriate Interventions for Children in the Health Care Setting .......................... 14 Practice of Psychosocial Care ........... 15 Focus of Research ................................ ................................ ................................ .. 18 Research Questions ................................ ................................ ............................... 19 2 LITERATURE REVIEW ................................ ................................ .......................... 20 Health Care ............................ 20 ................................ ................................ .............................. 20 ................................ .................. 21 Children Want to Know ................................ ................................ ..................... 22 ................... 23 Patient Centered Communication ................................ ................................ .... 24 ................................ ................................ .. 26 ................................ 28 Training Needs of Health Care Professionals ................................ ......................... 29 Development and Behavior ................................ ................................ .............. 29 Communication ................................ ................................ ................................ 30 Theoretical Framework ................................ ................................ ........................... 32 Adult Lear ning Theory ................................ ................................ ...................... 32 Social Learning Theory ................................ ................................ ..................... 33 Hypotheses ................................ ................................ ................................ ............. 35 3 METHODOLOGY ................................ ................................ ................................ ... 38 Research Design ................................ ................................ ................................ .... 38 Data Collection ................................ ................................ ................................ ....... 39 Sample Selection ................................ ................................ ............................. 39 Instrumentation ................................ ................................ ................................ 39 Knowledge ................................ ................................ ................................ 40 Confidence in providing developmentally appropriate care ........................ 41 Experience with children: personal, professional, and educational ............ 42 Interest in future training ................................ ................................ ............ 42

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6 Patient practitioner orientation ................................ ................................ ... 43 Demographics ................................ ................................ ............................ 44 Pre Testing ................................ ................................ ................................ ....... 44 Procedure ................................ ................................ ................................ ......... 45 Analyzing the Data ................................ ................................ ................................ .. 46 Statistical Tests ................................ ................................ ................................ 46 Analysis of Hypotheses ................................ ................................ .................... 48 Hypothesis 1 ................................ ................................ .............................. 48 Hypothesis 2 ................................ ................................ .............................. 48 Hypothesis 3 ................................ ................................ .............................. 49 4 RESULTS ................................ ................................ ................................ ............... 50 Sample Statistics ................................ ................................ ................................ .... 50 Hypothesis 1 ................................ ................................ ................................ ........... 52 Knowledge of DAC by Field of Study ................................ ............................... 52 Post hoc analysis: knowledge of DAC by field of study ............................. 52 Additional analysis: professional experien ce with children by field of study ................................ ................................ ................................ ....... 53 Additional analysis: knowledge of DAC by clinical fields of study .............. 53 Knowledge of DAC by Intent to Work with Children ................................ ......... 54 Additional analysis: professional experience with children by intent to work with children ................................ ................................ ................... 54 Hypothes is 2 ................................ ................................ ................................ ........... 55 Nursing Students: Variables that Predict Knowledge of DAC ........................... 55 Medical Students: Variables that Predict Knowledge of DAC ........................... 56 Physician Assistant Students: Variables that Predict Knowledge of DAC ........ 56 Physical Therapy Students: Variables that Predict Knowledg e of DAC ............ 57 Non Clinical Health Care Students: Variables that Predict Knowledge of DAC ................................ ................................ ................................ .............. 57 Summary of Findings for Hypothesis 2 ................................ ............................. 58 Hypothesis 3 ................................ ................................ ................................ ........... 58 Interest in Future Training on DAC by Field of Study ................................ ....... 58 Post hoc analysis: interest in future training on DAC by field of study ....... 59 Interest in Future Training by Intent to Work with Children ............................... 59 Training ................................ ................................ ................................ ......... 59 5 DISCUSSION ................................ ................................ ................................ ......... 70 Discussion of Key Findings ................................ ................................ ..................... 70 Hypothesis 1 ................................ ................................ ................................ ..... 70 Hypothesis 2 ................................ ................................ ................................ ..... 71 Hypothesis 3 ................................ ................................ ................................ ..... 73 Implications for Practice ................................ ................................ .......................... 74 Study Limitations ................................ ................................ ................................ .... 78 Recommendations for Future Research ................................ ................................ 79

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7 APPENDIX A INFORMED CONSENT ................................ ................................ .......................... 81 B INSTRUMENT: DEVELOPMENTALLY APPROPRIATE PRACTICE WITH CHILDREN IN THE HOSPITAL SETTING ................................ .............................. 82 REFERENCES ................................ ................................ ................................ .............. 88 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 98

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8 LIST OF TABLES Table page 2 1 The r elationship between Concepts of Illness ................................ ................................ ............................. 37 4 1 Characteristics of students in the overall s ample ................................ ................ 61 4 2 Characteristics of student samples by field of s tudy ................................ ........... 61 4 3 Knowledge of DAC mean scores and standard deviations as a function of field of s tudy ................................ ................................ ................................ ....... 62 4 4 Analysis of covariance for knowledge of DAC as a function of field of study, with race, gender and age as c ovariates ................................ ............................ 62 4 5 Knowledge of DAC mean scores and standard deviations as a function of intent to work with children ................................ ................................ ................. 62 4 6 Analysis o f covariance for knowledge as a function of intent to work with children, with race, gender and age as covariates ................................ .............. 62 4 7 Means and standard deviations for knowledge of DAC within nursing student sample and predictor variables (N = 191) ................................ ........................... 63 4 8 Intercorrelations for of DAC and predictor variab les (N = 191) ................................ ................................ ............................. 63 4 9 Regression knowledge o f DAC (N = 191) ................................ ................................ .............. 63 4 10 Mean s and standard deviations for knowledge of DAC with in medical student sample and predictor variab les (N = 190) ................................ ........................... 64 4 11 Intercorrelatio edge of DAC an d predictor variabl es (N = 190) ................................ ................................ ............................. 64 4 12 Regress knowled ge of DAC (N = 190) ................................ ................................ .............. 64 4 13 Means a nd standard deviations for knowled ge of DAC wi thin physician assistant students and predictor var iables (N = 111) ................................ .......... 65 4 14 Intercorrela edge of DAC and predictor vari ables (N = 111) ................................ ................................ .............. 65 4 15 Regress ion analysis summary for variables predicting physician assistant of DAC (N = 111) ................................ ............................... 65

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9 4 16 Mea ns and standard deviations for knowle dge of DAC with in physical therapy student sample and predictor var iables (N = 52) ................................ ... 66 4 17 Intercorrela wledge of DAC and predictor varia bles (N = 52) ................................ ................................ ................ 66 4 18 Regressi on analysis summary for variables predicting physical therapy f DAC (N = 52) ................................ ................................ 66 4 19 Means an d standard deviations for knowledge of DAC with in non clinical health care student sample and predictor var iables (N = 83) ............................. 67 4 20 Intercor relations for non wledge of DAC and predictor varia bles (N = 83) ................................ ................................ ................ 67 4 21 Regressio n analysis summary for variables predicting non clinical health care DAC (N = 83) ................................ ................................ 67 4 22 Intere st in future training on DAC mean scores and standard deviations as a function of field of study ................................ ................................ ...................... 68 4 23 Analys is of covariance of interest in future training as a function of field of study, with race, gender and age as covari ates ................................ ................. 68 4 24 Interes t in future training mean scores and standard deviations as a function of intent to work with childr en ................................ ................................ ............. 68 4 25 Analysis o f covariance of interest in future training as a function of intent to work with children, with race, gender and age as co variates .............................. 68 4 26 Intercorrelations fo r interest in future training and variables of in terest .............. 69

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10 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science FUTURE HEALTH CARE DEVELOPMENTALLY APPROPRIATE CARE WITH CHILDREN IN THE HEALTH CARE SETTING By Jessica Nicole Wente August 2011 Chair: David Diehl Major: Family, Youth and Community Sciences Children experience significant anxiety and distress during procedures and other experie nces in the health care setting (Brady, Avne r, & Khine, 2011; Chorney & Kain, 2009; Hamilton, 1995; Kain, Mayes, O'Connor, & Cicchetti, 1996; MacLaren & Kain, 2009) (Child Life Council, 2008; Chorney & Kain, 2009; R. H. Thompson & Snow, 2009) C hildren want to know what they will experience in the health care setting (For tier et al., 2009; Smith & Callery, 2005) and c hildren have the right to be prepared for their health care experience and to have their desires, needs, and emo tions considered (United Nations, 1989) I t is the psychosocial care (Kuttner, 2010) This research evaluate s future health care of developmentally appropriate care (DAC) with children in the health care setting. Participants include nursing, medical, physician assistant, physical therapy, and non clinical health care students The instrument utilize s subscales that measure knowledge of DAC confidence in providing DA C and interest in future training on DAC, which are

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11 certification exam and the Child Life Internship Program Self Review Kn owledge of DAC significantly varied by field of study, with non clinic al health care professionals scoring significantly lower on the knowledge of DAC scale than other fields of study. Students who intend to work with children in their profession had the same level of knowledge of DAC as students who indicate that they do no t plan to work with children. Patient centered views significantly predict knowledge of DAC with children in the health care setting. As age increase s knowledge of DAC also increase s for nursing and physical therapy students. However, personal and profess ional experience d oes not significan tly predict knowledge of DAC within any of the fields of study. For non clinical health care students, a course in child development significantly predict s more knowledge of DAC. Interest in future training on DAC varie s significantly between the observed fields of study, with physician assistant students being the most interested. Students who intend to work with children in their profession indicate significantly more interest than students who indicate that they do not plan to work with children. Across all fie lds of study, students who are younger, more confident in their ability to provide DAC, had more personal and professional experience with children, had taken a course in child development, and who are more patien t centered are more interested in future training on DAC with children in the health care setting.

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12 CHAPTER 1 INTRODUCTION The Health Care The U.S. Department of Health and Human Services (2010) reported that in 2009, 91.5% of children had contact with a health care professional The study also found that m ore than 9.5 million children in the United States were on prescription medication for at l east three months due to a health problem, and about 14 million children between the ages of 5 17 years missed school because of an illness or injury (U.S. Department of Health and Human Services, 2010) Further, t hree quarters of all children reported having interaction with their doctor or another health care professional in the previous 6 months (U.S. Department o f Health and Human Services, 2010) and f or emergency care 10.4 million children had visited an emergency room in the past 12 months, and 5 million children had two or mo re visits to the emergency room as of 2009 (U.S. Department of Health and Human Services, 2010) Without question, most children in the United States will interact with the health care setting. For example, i f recommendations from the Centers for Disease Control and the American Academy of Pediatrics are followed, children will receive at least at least 20 vaccinations by the age of 6 (Brady et al., 2011) I n addition to routine pediatric check ups, more than 5 million children will have surgery in the United States every year (Kain, Mayes, Caldwell Andrews, Karas, & McClain, 2006) Unfortunately, research shows that the needles and injections is well documented (Brady et al., 2011; Hamilton, 1995) ; and procedures such as anesthesia induction give children significant anxiety (Chorney & Kain, 2009; Kain, Mayes, O'Connor et al., 1996; MacLaren & Kain, 2009) This may lead

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13 to children resisting treatment and medical care (Chorney & Kain, 2009; Eldridge & Kennedy, 2010) which can cause schedule delays and increase the number of staff and resources required to provide pediatric care (Eldridge & Kennedy, 2010) Beyond regular doctor visits and outpatient care, children may also be hospitalized for a period of time. Hospitalization presents many challenges for children including separation from parents (Bell, Johnson, Desai, & McLeod, 2009; McCann & Kain, 2001) being in an unfamiliar environment, not knowing what to expect (Eldridge & Kennedy, 2010) disruption of routines, lack of choices and control, and difficulty in understanding complicated information (Bolig & Weddle, 1988) In a study of young children, Salmela, Salantera and Aronen (2009) found that 90% of children surveyed had at least one fear in the hospital setting. Children who are hospitalized may experience aggression (M. L. Thompson, 1994) attitudinal and affective changes (M. L. Thompson, 1994) significant distress (Chorney & Kain, 2009) anxiety (McCann & Kain, 2001; M. L. Thompson, 1994) disturbances in sleeping or eating (McCann & Kain, 2001; M. L. Thompson, 1994) apathy and withdrawal (McCann & Kain, 2001) and new onset enuresis (McCann & Kain, 2001) Various (Eiser, 1990; Kain, Mayes, O'Connor et al., 1996; Rennick, Johnston Dougherty, Platt, & Ritchie, 2002) gender (Brewer, Gleditsch, Syblik, Tietjens, & Vacik, 2006; Eiser, 1990; Hurtig, Koepke, & Park, 1989; R H. Thompson, 1985) parental anxiety and behaviors (Kain et al., 1996; Mahoney, Ayers, & Seddon, 2010) temperament of the child (Kain, Mayes, O'Connor et al., 1996) previous medical experiences (Dahlquist et al., 1986; Eiser, 1990; Kain, Mayes, O'Connor et al., 1996;

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14 Rennick et al., 200 2) (Rennick et al., 2002) St udies show that children who a re younger (typically between the ages of 7 months and 4 years ) (Chorney & Kain, 2009; King & Ziegler, 1981; Mabe, Treiber, & Riley, 1991; McClowry, 1988; R. H. Thompson, 1985) have had more invasive procedures (Rennick et al., 2002) and have had more severe illness (Rennick et al., 2002) may be most vulnerable to long term negative outcomes. shows lasting negative effects. Many children will continue to experience negative behavioral changes two weeks aft er a procedure (Kain, Mayes, O'Connor et al., 1996; R. H. Thompson & Vernon, 19 93) Rennick et al. (2002) found that some children continue to experience medical fears six months after being discharged from the hospital. Without intervention, (Child Life Council, 2008; Luthar, Cicchetti, & Becker, 2000) Appropriate Interventions for Children in the Health Care Setting Research shows that health care professionals can provide appropriate example, children with high anxiety during venepuncture tend to have very negative memories of the ex perience, which often also predicts children finding procedures of the same kind to be more painful in the future (Noel, McMurty, Chambers, & McGrath, 2010) However, children with medical staff present that promoted co ping behaviors were more capable of accurately framing the procedural experience two weeks later (Noel et al., 2010) Further, Mahoney, Ayers, & Seddon (2010) found that health care coping behaviors. Children often will engage in coping behaviors only after they are

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15 prompted to do so by adults (Chorney & Kain, 2009) Another important intervention on behalf of health care professionals is preparation for surgery, which can decrease anxiety levels in children significantly (Brewer et al., 2006) For emergent care, a recent study demonstrated that psychological i ntervention significantly decreased chest pain and somatization in children and adolescents (Lipsitz, Gur, Albano, & Sherman, 2011) appropriate and patient guided nonpharmacologic techniques to reduce patient distress improves the efficiency of emergency care delivery as well as improves patient, family, and health care staff Health care professionals can also learn how to make certain routin e treatments more bearable for children. For example, a study of young infants found that when health care professionals administered three immunizations simultaneously, as opposed to three separate immu distress were reduce d (Hanson et al., 2010) Health care professionals should work together to achieve optimal outcomes for pediatric patients (Goldberger, Mohl, & Thompson, 2009) Though each in terdisciplinary team member may offer different services to each patient and family, every health care professional medical and non medical health care experiences (Eldridge & Kennedy, 2010) This means that physicians, nurses, child life specialists, social w orkers, physical therapists, hospital administrators and others can all have a role in providing optimal psychosocial care to children in the health care setting. Knowledge and Practice of Psychosocial Care In order to improve health care providers must be competent in how child development

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16 illn ess (Perrin & Perrin, 1983) and how children may perceive situations in the hospital setting (Vacik, Nagy, & Jessee, 2001) and illness (Banks, 1990; Bibace & Walsh, 1980; Carson, Gravley, & Council, 1992; Crisp, Ungerer, & Goodnow, 1996; Harbeck & Peterson, 1992; Kalish, 1997; Kister & Patt erson, 1980; Koopman, Baars, Chaplin, & Zwinderman, 2004; Lipson, 1993; Perrin & Gerrity, 1981; Rushforth, 1999; L. R. Schmidt & Frohling, 2000; Siegal, 1988; Sigelman, Maddock, Epstein, & Carpenter, 1993; Springer & Ruckel, 1992) body parts and functi ons (Scolnik, Atkinson, Hadi, Caulfeild, & Young, 2003; Vessey & O'Sullivan, 2000) and management of illness (C. K. Schmidt, 2002) can assist health c are professionals in understanding how to communicate with children on various medical topics. By being competent in child development and how children perceive health related issues, health care professionals can provide developmentally appropriate care t o help children cope in the hospital setting. b y Perrin & Perrin (1983) r eported that when health care providers and students (pediatricians, nurses, and child development st udents) were given statements children made regarding illness, they were only accurate in estimating the age of the child less than 40% of the time. Health care professionals and students often overestimated what young children may be able to understand, a nd underestimated what older children may be able to understand (Perrin & Perrin, 1983) Perrin & Perrin (1983) concluded that communicatio n with children.

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17 Similarly Vacik et al (2001) assert that many problems children experience in the health care setting could be resolved if health care providers could understand the Vacik et al. (2001) performed a study assessing nursing, social work, child life, and counseling education students on their a s Perrin & Perrin (1983), they found that students were only know ledgeable of O ther research supports the need for more training for health care professionals in the areas of patient centered communication (Curley, 1998; Levinson, Lesser, & Epstein, 2010) ; such as patients (Haidet et al., 2002) and biopsy chosocial issues which consider physician relationship, ethics, clinical epidemiology, nutrition, b ehavioral science, and the like (H. Schmidt, 1998) There is much room for improvement in preparing health care professional s for the psychosocial aspect of working with patients and families (Hafferty, 1998; Levinson et al., 2010; H. Schmidt, 1998) In a study on how health care profe ssionals respond to pain in children postoperatively, Simons and Roberson (2002) knowledge deficits and poor communication with parents lead to poor pain management in children Simons and Roberson (2002) assert that understanding pain i n children is perceive and cope with their pain. Further, Brady et al. (2011) found that even though 90% of primary care providers were aware of the pain and anxiety for p ediatric patients surrounding their vaccine injections and believed that it was possible to allevia te that pain and anxiety, only 11% of primary care providers utilized the technique s to reduce

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18 pain and anxiety Schechter, Bernstein, Zempski, Bright & Will ard (2010) explain that despite strategies being available to relieve pain and anxiety associated with immunizations, pediatric providers often do not utilize these strategies. However, their study found that a small group, 1 hour teaching session at the site of care leads to reducing techniques at 1 and 6 months after the training (Schechter, Berns tein, Zempski, Bright, & Willard, 2010) In summary, research shows that effective intervention from health care There is a need for further training in the areas of child specific nee ds and other aspects of patient care for health care students (Hafferty, 1998; Haidet et al., 2001; Perrin & Perrin, 1983; H Schmidt, 1998; Vacik et al., 2001) and health care professionals (Levi, 2007; Rae, McKenzie, & Murray, 2010; Simons & Roberson, 2002) Focus of Research The purpose of this research is to u nderstand how well students who are in the health care field are prepared to work with children. Participants will include nursing, medical, physician assistant, physical therapy, and non clinical health care students. T he aim of this rese arch is to understand what factors predict more knowledge of developmentally appropriate care with children in the h ealth care settin g among health care students of DAC will be useful for guiding fu rther training. This information will be valuable for healthcare students, academic training programs healthcare professionals and policy makers

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19 Research Questions 1. How does knowledge of developmentally appropriate care with children and intent to work with children in the health care setting vary between the observed fields of study? 2. To what extent do confidence, experience, and patient practitioner orientation the health c are setting within the observed fields of study? 3. and demographic characteristics associated with interest in future training on developmentally appropriate care with childre n in the health care setting?

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20 CHAPTER 2 LITERATURE REVIEW You judge a society by how it trea ts its most vulnerable citizens (Bass, n.d.) Rights The United Nations Convention on the Rights of the Child set a foundation for (Goldhagen, 2003) Several articles are relevant to psychosocial aspects of care for children in the health care setting specifically, including articles related to non discrimination (2), best interests of the child (3) survival and development (6), respect for views of the child (12), freedom of expression (13), right to pr ivacy (16), access to information for health and well being (17), children with disabilities (23), health and health services (24), right to education (28), leisure, play and culture (31), other forms of exploitation (36), and knowledge of rights (42) (United Nations, 1989) This framework has been used to ad vocate for health care professio (Kuttner, 2010) and a s a framework for pediatricians in delivery of care (Goldhagen, 2007) he United Nations Convention on the Rights of the Child ( UNICEF, n.d. ). In response to the importance of care setting, the American Academy of Pediatrics, in conjunction w ith the Royal College of Paediatrics and Child Health, has put together a training referred to as the Rights Curriculum for health professionals. This course educates health professionals

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21 th policy, and practice (American Academy of Pediatrics, n.d.b) Organizations representing the best interest of children in health care have taken the articles from the UN Convention on the Right s of the Child and have operationalized those concepts into the framework for their practice. For example, Southall et al. (2000) used this to inform a m odel for Child Friendly Healthcare in Child Friendly Healt hcare Initiative (CFHI): Healthcare Provision in Accordance With the UN Convention on the Rights of the Child produced A Pediatric Bill of Rights in 1991. In 2002, the Child Life Council took over the production of the Bill of Rights to continue to make it available. The publication includes a Bill of rights for Children and Teens, a Bill of rights for Parents, and Family Responsibilities. The Bill of Rights for Children and Teens explains wha t can be expect ed from their health care experience. Health care professionals have a responsibility to deliver care in a way that is child and their family, expla ining information in a way that children understand, providing and learnin desire and ability to make informed choices regarding their care (I. Child Life Council, 2002; United Nations, 1989) A Child in Pain: What Health Professionals Can Do to Help professionals are held to codes of ethical responsibility by their professional certifying

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22 organ ization, as well as their place of employment (American Medical Association, n.d.; American Nurses Association, 2011; I. Child Life Council, 2002; National Association of Social Workers, 2008; Public Health Leadership Society, 2002) Additionally, the American Academy of Pediatrics has a Committee on Bioethics (COB) which specifically addresses issues central to provision of care in pediatrics (American Academy of Pediatrics, n. d.a) It is also important for health care professionals to consider the physician patient parent triad as it relates to the delivery of care (Cummings & Mercurio, 2010) from their parents, or adolescents may prefer to talk to their health care provider about issues that they are not comfortable discussing with their parents (Schaeuble, Haglund, & Vukovich, 2010) It is important for health care professionals to consider their own ethical obligations in cognitive processes. Children Want t o Know Children desire to know what they will experie nce, and it is important for health care professionals to provide this information in a developmentally appropriate way (Fortier et al., 2009) s of th e Child children have the right to be listened to and taken seriously (United Nations, 1989) Smith and Callery (2005) found that many children know very little about what to expect during their health car e exper ience, noting that identified 61 questions about their forthcoming admissions, including questions about: getting information; procedures; anesthesia; timing; hospital environment; family support; feelings/pain; th eir own co ndition; and concerns

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23 needs, patients may be provided little information prior to their visit. Fortier et al (2009) found that most ch ildren prefer comprehensive information about their surgery, particularly what kind of pain they will experience and how long it will last. They also found that children who were more anxious desired knowledge about the pain they would experience inste ad o f avoiding the information. P readolescents were particularly interested in what the perioperative environment would look like, and children who had surgery before were not any less inquisitive than children who were having surgery for the first time (Fortier et al., 2009) Additionally recent research on adolescent s health care preferences shows that respect and trust from their primary health care provider are extremely important (Schaeuble et al., 2010) Adolescents also desire to be involved in the planning and management of their care, and value confidentiality in health care providers (Schaeuble et al., 2010) We now know tha t children and adolescents desire information regarding their health care experience. It is also clear that children and adolescents want to be a part of the planning and management of their care. Therefore, it is important that providers understand how to share that information with children in a developmentally appropriate way that respects their personal preferences and values. Experiences Health care professionals can provide appropriate intervent ions to reduce can take place For example, v arious techniques have proven to be effective in reducing anxiety before, during, and after venepuncture R ing children

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24 to cough once, and then again, while on the second cough inserting the needle) can be an effective method for reducing pain in this procedure (Dustin, Allen, Lacroix, & Pitner, 2010) Another study foun d that when infants received three immunizations distress were reduced (Hanson et al., 2010) These ideas can be incorporated into procedural techniques during painful medical procedures (Brewer e t al., 2006; Noel et al., 2010) McMur t y et al (2010) explain that ore effective in promoting child coping (Noel et al., 2010) Further, children often engage in coping behaviors only after they are prompted to do so by adults (Chorney & Kain, 200 9) Children who receive psychological preparation for procedures will have significantly lower anxiety (Brewer et al., 2006) significantly decreased chest pain and somatization (Lipsitz et al., 2011) increased efficiency in emergency care (Eldridge & Kennedy, 2010) and improved satisfaction (Eldridge & Kennedy, 2010) Psychological prepara tion for procedures is a skill that requires knowledge of developmentally appropriate communication and how children respond to various adult behaviors and information. Patient Centered Communication (Levetown & the Committee on Bioethics, 2008) The Institute of Medicine (2001) defines patient care that is respec tful of and responsive to individual patient preferences, needs, and

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25 Patient centered communication has positive impacts on patient outcomes, including improved patient satisfac tion, adherence, and self management (Levinson et al., 2010) Patient centered communication skills are important for a successful health care setting (Levinson et al., 2010 ) Levin centered verbal (R. M. Epstein & Street, 2007; R. M. Epstein & Hundert, 2002; Levinson et al., 2010) A recent study by Tanner, Stein, Olson, Frintner and Radecki (2009) fo und that to establish an effective patient practitioner relationship, it was important for the clinician to have A report by the Institute of Medicine (2001) identified pati ent centered health care as one of the six aims for improvement in advancing quality care in the 21 st century. Further, the Institute of Medicine (2001) asserts that in order to change the environment of health care delivery, the workforce must be prepared accordingly: Health care is not just another service industry. Its fundamental nature is characterized by people taking care of other people in times of need and stress. Stable, trusting relationships between a patient and the people providing care can be critical to healing or managing an illness. Therefore, the importance of adequately preparing the workforce to make a smooth transition into a thoroughly revamped health care s ystem cannot be underestimated. (p. 6). The Na tional Cancer Institute provides a model that defines three elements of patient centered care: (1) informed, activated, participatory patient and family, (2) accessible, well organized, responsive health care team, and (3) patient centered communicative clinician (R. M. Epstein & Street, 2007) These elements work together to achieve improved communication and health outcomes. Epstein & Street (2007)

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26 assert that all aspects of patient centered care are important, as any missing element can result i n patients receiving less than exceptional care. The medical community has recognized the need for more formal training on patient centered communication (Curley, 1998; Levinson et al., 2010) This means considering the patients feelings and preferences (Haidet et al., 2002) and biopsychosocial issues (H. Schmidt, 1998) Haidet et al. (2002) found that students who had more patient centered attitudes were female, Caucasian, had more children, were planning to go into primary care specialties, and had experience in the profession. Providing pa tient centered communication with children requires health care professionals to be knowledgeable of what children can reasonably understand (Perrin & Perrin, 1983; Vacik et al., 2001) M any st understanding of illness, in order to provide adults with information on how to more efficiently communicate with children in the health care setting (Banks, 1990; Bibace & Walsh, 1980; Carson et al., 1992; Crisp et al., 1996; Harbeck & Peterson, 1992; Kalish, 1997; Kister & Patterson, 1980; Koopman et al., 2004; Lipson, 1993; Myant & Willia ms, 2008; Perrin & Gerrity, 1981; Rushforth, 1999; L. R. Schmidt & Frohling, 2000; Siegal, 1988; Sigelman et al., 1993; Springer & Ruckel, 1992; Varkula, Resler, Schulze, & McCue, 2010) ed theoretical (Rushforth, 1999) Piaget proposes a cognitive the follow ing four stages: sensorimotor (birth 2 years) preoperational (2 7 years),

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27 concrete operational (7 11 ye ars), and formal operational (11 + years) (Koopman et al., 2004; Piaget, 1962; Tu rner, 2009) Building on developed a framework for h ow children understand illness. cognitive development, Bibace and Walsh (1980) have identified two phases of Phenomenism and Contagion are specific to children in the Preoperational Stage as children in this stage of development believe that illness is transmitted magically from an external object or person (Bibace & Walsh, 1980) concepts of Contamination and Internalization. Children in this phase are beginning to understand internal organs and will recog nize illness as harmful. Bibace and Walsh understanding of illness in the Formal Operational Stage. Children in this developmental stage understand that even though the cause of illness may still be external, there is a series of events inside the body that result in an illness. Bibace and Walsh (1980) explain that children in this stage are also able to understand the relationship between emotional health and overall wellness The relationship between of Illness is outlined in Table 2 1. Perrin & Perrin (1983) Cognitive Development to assess health care professionals and students on their found that when health care professionals were presente d wit h statements children made and then were asked to

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28 conducted a similar study with graduate students and found that partici pants assume d most children to have the understanding of a school age child, even if the child was older or younger. Both studies found that there were no statistically significant differences in the knowledge of participants based on their field (Perrin & Perrin, 1983; Vacik et al., 2001) Additionally, a ge, experience (stage of training, length of practice), and physician group (resident, faculty, practicing pediatricians), did not present st atistical differences in the analyses (Perrin & Perrin, 1983) Vacik, Nagy, & Jessee (2001) reported that even though 99% of their sample had taken a course in child development, overall most participants did not co Studies understanding of illness. Va rkula, Resler, Schulze & McCue ( 2010 ) found that some preschoolers were using They assert that children seemed to be presenting a more advanced, less concrete conception of cancer, not as easily explained by the theory of Bibace and Walsh. These understanding of illness at this age, at least in the case o f cancer Vacik Nagy & Jessee (2001) and that using a Piagetian knowledge may result in an inadequate assessment of their knowledge understanding of illness (Vacik et al., 2001) Gelman (2009) also asserts t construction of concepts goes beyond the self directed learning that Piaget describes.

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29 Children also learn from others (Gelman, 2009) It is important to understand the nature of the input, the nature of the human mind, and how the child and environmental cues facilitate learning the formation of concepts (Gelman, 2009) Rushforth (1999) also ass erts that Piaget presents a defi cits tive abilities rather than a strengths cognitive abilities surpassing what we might expect them to understand about illness (Rushforth, 1999) Training Needs of Health Care Professionals Goethe Development and Behavior Perrin & Perrin (1983) report typically inadequately trained in developmental processes and their assessment normal development and behavior is important for pediatricians, as they will use this to inform their detection of behavioral issues and devel opmental delays (Boreman, Thomasgard, Fernandez, & Coury, 2007) In addition, 47% of physicians report that the patients the y care for require expertise in developmental or behavioral pediatrics, and 51% reported c aring for patients who require subspecialties in adolescent medicine (Freed et al., 2009) Despite this prevalence, Boreman et al (2007) report that many pediatric ian s are not thoroughly trained in behavioral and developmental issues, resulting in pediatricians having lower perce ived competence Tanner et al. (2009) also found that pediatricians felt there was room for improvement in detecting developmental and behavio r al problems earlier; and that improving resident training and ongoing education for pediatricians in this area was necessary. Further, when Boreman et al. (2007) surveyed

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30 pediatricians, many felt less than comfortable providing primary care to patients re garding developmental or behavioral issues, as compared with general areas of pediatrics. In a study by Blum & Bearinger (1990) physicians, nurses, social workers, psychologists, and nutritionists felt inadequate in providing primary care to adolescents in the areas of development, prevention, sexual counseling, contraceptive services, substance abuse prevention, and family conflict. Blum & Bearinger (1990) assert that facilitating this care would require health care providers to have an understanding of de velopment. Excessive time demands and insufficient training were two main barriers health care providers identified in serving adolescents (Blum & Bearinger, 1990) Communication A recent study by Tanner et al. ( 2009) found that pediatricians felt training during residency was insufficient in the areas of interviewing and communication skills. Further, pediatricians felt that ongoing professional education would be important for improving their practices with well chil d visits (Tanner, Stein, Olson, Frintner, & Radecki, 2009) As a result, t here is much room for improvement in preparing health care professionals for the psychosocial aspect of working with patients and families (Hafferty, 1998; Levetown & the Committee on Bioethics, 2008; Levinson et al., 2010; H. Schmidt, 1998) Levetown et al (2008) assert that there is little education on communication in pediatric training, despite its tandem relationship with delivery of care. The Committee on Psychosocial Aspects of Child and Family Health (2001) also emphasizes the importance of conveying empathy to patients and their families. Health care professionals face barriers to the provision of patient centered care daily, and it is important that they are equipped to o vercome these challenges. For

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31 example, Curley et al. (1998) discuss the daily challenges that get in the way of nurses prov iding optimal care to patients asserting that to patient ratios, increased use of unlicensed assistive personnel, and s horter lengths of hospitalization, layered on a cumbersome healthcare system, challenge nurses ability to provide adequate care as tra ditionally defined for patients Curley et al. (1998) suggest that certification programs and recertification pro cesses should address and encourage further professional development. Levetown et al. (2008) report that empathy in the medical field has not improved in the last 15 years, which is certainly reflected in the quality of patient centered care. Further, L evetown & the Committee on Bioethics (2008) explain that current efforts to improve psychosocial competencies in physicians are not successful as it may not be seen as cost preferences. benefit to patients, physicians, and society effective communication is not rewarded by academic promotion or financial compe nsation Hafferty (1998) suggests that improving the quality of medical education is much more complex than simply adding a new course on the topic, as learning i n medical school encompasses the formal curriculum (courses and clinical experience), informal curriculum (the interpersonal educational interactions between the professors and students), and the hidden curriculum ( organizational and cultural influences); all of which must be addressed to effectively improve medical education. Levinson et al. (2010) also assert that a class, alone, cannot improve a phys centered care. D k,

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32 similar to learning to perform a medical procedure (Levinson et al., 2010) Further, understand how their own emotional responses may impact their communication and cognitive process (Levinson et al., 2010) T heoretical Framework ledge of developmentally approp riate care with children in the health care setting. This topic is important in the health care field, as it relates to training and practice, and is relevant to the overall purpose of bettering the health care experience for children. The predictors chose Though previous research does not present results on knowledge of DAC, interest in training on DAC, or confidence in providing DAC, this literature review has attempted to justify the need for such research. Additionally, c onstructs from Adult Learning Theory and Social Learning Theory will be discussed as a framework for the concepts measured in this study. Epstein & Hundert (2002) defined professional competence in the h and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and the community being served acknowledges effective methods of training to achieve these outcomes is necessary. Adult Learning Theory Adult learning theory has been presented for use in medical education (Abela, 2009; Kaufman, 2003) introduced to North America by Malcom Knowles (Kaufman, 2003) This theory assumes that the learner is self directed

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33 (Abela, 2009) Andragogy is grounded in the assumption that adults (1) are independent and self directing, (2) have experience that can be used as a resource for learning, (3) value learning that is useful for their everyday life, (4) are more interested in immedia te problem centered approaches than in subjected centered ones and (5) are more motivated by internal drives than external drives (Abela, 2009; Kaufman, 2003) Learners should feel comfortable i n the adult learn ing environment (Kaufman, 2003) and it is important to foster respect between the teacher and learner (Abela, 2009) Andragogy calls teachers to involve lear ners in curriculum planning and formulation of objectives when possible, engage learners in reflecting on their own needs (triggering internal motivation), encourage learners to develop plans and find resources, support learners in seeing their plans throu gh, and involve learners in critical reflection by having them evaluate themselves (Kaufman, 2003) Critics of andragogy feel that reflection is left out of this process of adult learning and does not consider indi viduals who are extrinsically motivated (Abela, 2009) Social Learning Theory also has a strong application to the medical education setting. Social learning theory (Bandura, 1977) supplement s constructs from adult learning theory by emphasizing the importance of self efficacy and external motivation. The social learning theory presents a framework for psychological functioning that assumes indiv iduals learn and model behavior by observing others. This theory assumes an ongoing interaction between the individual and his or her environment, acknowledging that learned behaviors are i mpacted by psychological and physiological develop ment, as well as biological factors (Bandura, 1977) Social learning theory asserts that individuals learn through the modeling of

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34 others (Bandura, 1977) Through modeling, in dividuals are able to observe the outcomes of specific behaviors, allowing them to assess whether or not to adapt the behavior based on the outcome observed. Bandura (1977) uses the examples of teaching children to swim, adolescents to drive, and medical s tudents to perform operations in explaining the importance of allowing individuals the opportunity to learn from another competent individual before trying it themselves for the first time. In Applying Educational Theory in Practice, Kaufman (2003) prese nts self efficacy as a n important concept for application to learning and teaching in the medical field. Self efficacy is and individual (Bandur a, 1977; Kaufman, 2003) When an individual believes that he or she can accomplish a certain behavior, and that the behavior will lead to a desired outcome, the individual is more likely to perform that behavior (Bandura, 1977) Kaufman (2003) explains that self attainments, observations of other people, verbal pers uasion, and physiological state (p. 214). efficacy, especially if failure occurs at the beginning of a learning process (Kaufman, 2003) Individuals feel mastery as a result of a success ful performance (Bandura, 1977) elf efficacy can be strengthened by verbal reinforcement and through observing other successful performances of similar individuals (Kaufman, 2003) In summary, constructs from adult learning theory and social learning theory can be applied to concepts studied in this research. Adult learning theory addresses the knowledge acquisition process as it relates to medical education, while social learning

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35 p rovides insight into the importance of self efficac y, mastery, and motivation for adults to continue learning. Adult learning theory and social learning theory collectively relate edge (competence), confidence (self efficacy), and desire (motivation) for fu ture training on the topic of developmentally appropriate care with children in the health care setting. By examining which variables are correlated with future health care knowledge of and interest in training on developmentally appropriate care with children in the health care field, this research will present valuable information for the education in the health care field Hypotheses RQ1: How does knowled ge of developmentally appropriate care with children and intent to work with children in the health care setting vary between the observed fields of study? H1 .1 : Knowledge of developmentally appropriate care with children in the health care setting will no t vary by field (Perrin & Perrin, 1983; Vacik et al., 2001) H 1.2 : Knowledge of developmentally appropriate care with children in the health care setting will not vary by s rk with children in their career (Blum & Bearinger, 1990; Boreman et al., 2007; Tanner et al., 2009) RQ2: To what extent do confidence, experience, and patient practiti oner children in the health care setting within the observed fields of study? H2: Students with more patient centered views, and who have more personal and professional experi ence with children (Abela, 2009; Bandura, 1977; Kaufman, 2003) will have more knowledge of developmentally appropriate care with children in the health care setting. Based on previous research by Perrin & Perrin (1983) and Vacik et al. (2001), it is predicted that a course in child development will not be a predictor variabl e for knowledge of DAC in this study. Additionally, d emographic characteristics, having taken a seminar on DAP, and confidence will not significantly predict knowledge children, and demographic characteristics associated with interest in future

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36 training on developmentally appropriate care with children in the health care setting? *** This hypothesis is exploratory in nature, and for that reason a specific hypothesis will not be in formed by previous research. H3.1 : Does i nterest in future training on developmentally appropr iate care with children in the health care setting vary by field of study? H3.2: Does i nterest in future training on developmentally appropriate care with children in the health care setting by s vary by intent to work with children in their career ? H3.3: How are s children, and demographic characteristics correlated with interest in future training on developmentally appropriate care with children in the health care setting

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37 Table 2 1. The r Cognitive Development *Examples from Bibace and Walsh (1980) pp. 914 915 0 2 years Sensorimotor 2 7 years Preoperational Phenomenism Children will perceive the cause of illness as something concrete and external, but will not be able to articulate how it occurred. *Example: How Contagion Children will perceive the cause of illness as objects or people near them. Transmission of illness is considered to be magical. 7 11 years Concrete Operational Contamination Children will perceive the cause of illness to be from making contact with someone who is sick, or from engaging in an action that results in illness. the cold would touch it Internalization Children will perceive illness as something external that they can internalize through breathing or swallowing. bacteria gets in by breathing. Then the lungs get too soft (child exhale), and it 11 + years Formal operational Physiological Children will perceive the illness as something that may be caused from something external, but ultimately results from internal processes ceasing to function properly. Psychophysiological Children will acknowledge that illness can come from an external source and may also be caused by internal physiologic factors. Children understand that being. wracked. You worry

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38 CHAPTER 3 METHODOLOGY (Rumrill & Bellini, 1999) Research Design This is a cross sectional study, a type of observational design that collects data at one point in time with a single instrument (Agresti & Finlay, 2009) De Vaus (2005) outlines four main c omponents of the cross sectional design. First, the design assumes that there are existing differences within the groups (de Vaus, 2005) In this study, all groups are currently students that plan to (or currently) work in the health care field. Second, there is a minimum of one independent variable and the presence of at least two categories (de Vaus, 2 005) In this study, the variables of interest in the study are race, gender, age, field of study, personal, professional, and educational experience with children, knowledge and confidence in working with children in the health care setting, intent to work with children and patient practitioner orientation. Third, data are collected at one point in time, typically in the form of a survey (Agresti & Finlay, 2009; de Vaus, 2005) There is no ti me dimension. This means that cross sectional designs are excellent for measuring the differences between groups; however, they are not able to measure change as a result of intervention (de Vaus, 2005) For this stu dy, data were collected in the time range of December 2010 April 2011. And finally, groups are not randomly allocated (de Vaus, 2005) The data for a cross variable is linked with group differences. That is, to what extent do those in different categories of the independent variable differ in relation to the (de

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39 Vaus, 2005) So instead of using random assignment to groups, a cross sectional design relies on statistical controls to identify causal relationships (de Vaus, 2005) The subsamples in this study (students from the five different a reas of study: medical, physician assistant, nursing, physical therapy, and non clinical health care professions) have not been randomly allocated into groups. Data Collect ion Sample Selection This study addresses which variables correlate with future health care professionals having more knowledge of DAC and a desire for future training regarding developmentally appropriate care with children in the health care setting. As a result, the study participants were students pursuing careers in the health care field. The survey was administered to nursing, medical, physician assistant, physical therapy, and non clinical health care students at the University of Florid a Only students who indicated that they plan to work in the health care field were considered. Further, only participants who are in their terminal degree program will be considered as future health care professionals For example, students in the College of M edicine who indicate that they will be a physician are included in the sample. However, students in the College of H ealth and Human Performance who have intentions of becoming a physician, but are not currently in the College of Medicine were not con sidered. Instrumentation Research shows that instrumentation based on a Piagetian framework has limitations (Vacik et al., 2001) cognitive capabilities (Rushforth, 1999) and fails to encompass all of the ways that children learn and form concepts (Gelman, 2009) Health care prof essionals and

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40 students may also struggle to answer p understanding of illness due to a lack of information with which to assess the age of the child. Knowledge This instrument measured knowledge using items from a retired Child Life Professional Certification Examination with express permission from the Child Life Council the nation al certifying organization for child life s pecialists (Child Life Council, n.d.a) Child life s promote effective coping through play, preparation, education, and self expression activities. They provide emotional support for families, and encourage optimum development of children facing a broad range of challenging experiences, particularly those r elated to healthcare and (Child Life Council, 2008) knowledge, understanding and practical application of professi (Child Life Council, n.d.b) T Certifica tion Examination is 150 multiple choice questions and eligible candidates are domains: assessment, intervention, and professional responsibility (Child Life Council, 2004) Only items from the intervention subscale were considered to be relevant to this study, and many items in this category assumed extensive knowledge of child development theory and practice. As a result, onl y 13 of 50 retired items were considered to be reasonable for health care professionals in fields other than child life to know and s ome items were altered for clarity for health care professionals other than

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41 child life specialists. For example, for the i child for health care experiences should fi health care providers may be thinking of medical preparation for a procedure. Also, particularly difficult questions that had answers with overla pping ages were made to be more specific e range of children most vulnerable to (a) Birth to two and one half years, (b) six months to four years, (c) two years to three years, or (d) three years to six years. The answers were changed to (a) birth to six months, (b) six months to four years, (c) five years to eleven years, and (d) twelve years to eighteen years. The correct answer was still accurate while making it less confusing for health care professionals t hat may not be as well versed in child development theory. Since these items have been altered and are not representative of all domains on the original exam, the items used i n this survey w ere not be an accurate assessment of what future health care performance would be on the Child Life Professional Certification Exam. The mean score of the knowledge of DAC section of the instrument was 7.17 (SD = 1.91). There were 13 items for this section, so the possible range was 0 13 correct. T he actual range was 10 with a minimum score of 2 and a maximum score of 12. Confidence in providing developmentally appropriate c are Confidence items were developed using a document from the Child Life Council called the Child Lif e Internship Program Self Review These competencies are taught

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42 and test ed in the field of child life, as relevant to developmentally appropriate care with children in the hospital setting. Using a 6 point L ikert scale ranging from strongly disagree to strongly agree participants were asked to assess their level of confidence in effectively explaining illness, procedures, surgeries, and medications to toddlers, preschoolers, school age childre n, and adolescents. There are also items designed to measure idence in their abilities to collaborate with families on developmental issues and stressful events, consider diversity and socio economic issues of patients and their families, and interact and coordinate with interdisciplinary team members. The mean sco re of the confidence in providing DAC section of the instrument was 4.35 (SD = 0.79). There range of possible scores for this section was 1 6 (strongly disagree to strongly agree) and the actual range was 5.00 with a minimum score of 1 and a maximum sc ore of 6 The confidence in providing DAC scale had a Experience with children: personal, professional, and e ducational Participants were asked how much experience the participants have had with children, both professiona lly and personally. This was measured on a 4 p oint Likert scale ranging from none to a lot The instrument also asked whether or not the student had taken a class or had an in service training on child development or deve lopmentally appropriate care with child ren in the health care se tting, and how long it had been since that class or in service training. Interest in future t raining Using a 4 p oint Likert scale ranging from very unlikely to very likely participants were asked how likely they were to attend trainings about explaining illness,

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43 procedures, surgeries, and medicals to children of various ages, collaborate with families on developmental issues and stressful events, consider diversity and soc io economic issues of patients and their families, and interact and coordinate with interdisciplinary team members. Similar to the confidence section, these items were inform Child Life Internship Program Self Review The mean score of the interest in future training on DAC section of the instrument was 2.93 (SD = 0.66). There range of possible scores for this section was 1 4 (very unlikely to very likely) and the actual range was 3.00 with a minimum score of 1 and a ma ximum score of 4 0.91. Patient practitioner o rientation The Patient Practitioner Orientation Sc ale (PPOS) is a valid and reliable instrument that measures how patients, practitioners, an d students perceive the patient practitioner relationship (Haidet et al., 2 001; E. Krupat, Hsu, Irish, Schmittdiel, & Selby, 2004; E. Krupat et al., 2000; E. Krupat et al., 2000; E. Krupat, Yeager, & Putnam, 2000; E. Krupat, Bell, Kravitz, Thom, & Azari, 2001; Street, Krupat, Bell, Kravitz, & Haidet, 2003) Previous research reports good reliability for the PPOS instrument 0.80) subscal es (E. Krupat, Putnam, & Yaeger, 1996; E. Krupat et al., 2000; E. Krupat, Yeager et al., 2000) The PPOS instrument has 18 items with a 6 point Likert scale ranging fro m strongly agree to strongly disagree In the instrument used for this resear ch, the scale was presented as strongly d isagree to strongly agree Higher scores indicate a more patient centered ( egalitarian ) attitude, while lower scores indicate a more doctor centered (paternalistic) attitude (Haidet et al., 2001) There are two subsca les on this instrument

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44 (sharing and caring), each consisting of 9 items The sharing subscale measures the degree to which the participant believes physicians should share information with the patient, and power and control are equal between the two (Haidet et al., 2001; E. Krupat et al., 2000) The caring subscale measures the degree to which the participant believes identified needs, and personal circumstances should inform the plan of care (Haidet et al., 2001; E. Krupat et al., 2000) For this study, the overall PPOS score was used, while the subscales were not The mean score of the PPOS section of the instrument was 4.42 (SD = 0.47). There range of possible scores for this section was 1 6 (increasing as p atient centeredness increased), and the actual range on this scale was 4.06 with a minimum score of 1.83 and a maximum score of 5.89 The Pa tient Practitioner Orientation Scale had a Demographics Participants were asked to identify their gender, age, marital status, how many children they have race, gr aduate / undergraduate status undergraduate major/minor whet her or not they plan to work in the health care field, college, year in current program, future career plans, and main area of interest or specialty. Pre T esting This instrument was pre tested with multiple phases First, the principal committee gave feedback on the instrument. Then, stu dents took the survey and gave feedback ; including a research methods class that gave feedback on its clarity, length, and ability to measure the main concepts. Students felt that the items were reasonabl e for health care professionals in various areas of study to understand, and that the instrument was applic able to the population of interest After refining the

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45 survey with feedback from students it was sent out to professors knowledgeable in the area of instrumentation and health care professions to receive their feedback. The survey was modified again and then was reviewed by current physicians and nurses. The survey was modified again. Finally, the survey was sent back to the principal thesis committee for review. After approval, it was submitted to the Medical studies (IRB 02). The instrument received approval from IRB 02. Procedure The principal investigator contacted professors currently teaching eligible participants. Despite the rigorous schedule of most students entering the health care field, many professors were happy to allocate 15 minutes of their class time for their student s to complete the survey. Another option for data collection also approved by IRB 02, was for students to take the survey online. This was mostly used by professors teaching online courses, distance courses, or who did not have available class time for survey administration As an incentive for professors to allocate time for the survey to be distributed in class, the principal investigator offered to present a workshop on developmentally appropriate care with children in the health care setting. Some pr ofessors did request this presentation, and the workshop was tailored to the specific curriculum interests Each time the survey was administered to students, the principal investigator briefly review ed the informed consent (Appendix B) with the participants The principal investigator explained the purpose of the study required. Participants were informed of the confidentiality of the survey, as their names would not be associated with their answers. Inst ead, surveys were assigned a code

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46 number for the purposes of double checking data entry. They were made aware that keep the data confidential. Participants were informed that the survey would in no way impact thei Participants were told that the survey was voluntary, that they could withdraw from the study at any time, and that they did not have to answer questions that they did not want to answer. Copies of the informed consent were made available to everyone, which committee, and the Institutional Review B oard Most students completed the survey in about 15 minutes. Analyzing the Data prespecified analysis plans should be viewed as a framework to ensure (Belin & Normand, 2009) Statistical Tests The data will be analyzed using ANCOVAs, correlations, and multiple regressions, as appropriate for each hypothesis. The analysis of v ariance (ANOVA), also referred to as an F test, measures the difference between two or more (usually multiple) means (Agresti & Finlay, 2009; Pyrczak, 2004) The ANOVA tests for independence bet ween a quantitative outcome (dependent) variable and a categorical predictor (independent) variable (Agresti & Finlay, 2009) An analysis of c ovariance (AN CO VA) test is a similar to the ANOVA, however the ANCOVA wil l control for other continuous variables that may differ between the groups (the covariates) as they may predict the outcome (dependent) variable (Leech, Barrett, & Morgan, 2008) The ANCOVA identifies the variance that may result from covariates by computing a regression analysis in each cell

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47 (StatSoft Inc., 2011) Through this process, the variance resulting from the covariance is separated out (StatSoft Inc., 2011) T hus, t he ANCOVA strengthens the statistical power of an analysis (Colliver & Markwell, 2006) by controlling for some variables and therefore explaining variability in the vari ables of interest (StatSoft Inc., 2011) The ANCOVA can be used to remove bias effects in observational studies, to fit regressions in multiple classification variables, and to analyze data when some observations a re missing (Belin & Normand, 2009; Cochran, 1957) A correlation measures the strength of association between two variables, with 1 representing a perfect negative correlation, +1 representing a perfect positive relationship, and 0 representing no relationship at all. Multiple correlation identifies the relationship between two or more independent variables and one dependent va riable (Pyrczak, 2004) Correlation can show a relationship between two variables, however it cannot show causation (Pyrczak, 2004) Multiple linear regression predicts the lin ear relationship between multipl e independent variables and one dependent variable (Agresti & Finlay, 2009) Multiple independent variables in a statistical model will better predict a dependent variable than one independent variable alone (Agresti & Finlay, 2009) Multivariate models are able to control for certain varia bles, allowing for interpretation of the relationship between the variables of interest (Agresti & Finlay, 2009) As a result, m ultiple linear regression is helpful for finding correlation between variables in non ex perimental studies (Field, 2008) Since multiple linear regression shows correlation as opposed to causation it is very useful for correlational studies which observe variables that were collected at

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48 one point in t ime (Field, 2008) It is assumed that variables in this type of study are not manipulated by an intervention (Field, 2008) Analysis of Hypotheses Hypothesis 1 H1: Knowledge of de velopmentally appropriate care with children in the health care setting will not vary by field (Perrin & Perrin, 1983; Vacik et al., 2001) intent to work with children in th eir career (Blum & Bearinger, 1990; Boreman et al., 2007; Tanner et al., 2009) To analyze H ypothesis 1, ANCOVA s were be used. Knowledge of developmentally appropriate care with children in the health care setting was the dependent variable field of study (nursing, medical, physician assistant, physical therapist, or non clinical health care professionals) was the independent variable. The covariates were race gender and age The race variable was dichotomized to represent two groups: White and non White. The second ANCOVA was parallel to the first one, with children in t heir career. Covariates were race, gender and age. Hypothesis 2 H2: Students with more patient centered views, and who have more personal and professional experience with children (Abela, 2009; Bandura, 1977; Kaufman, 2003) will have more knowledge of developmentally appropriate care with children in the health care setting. Demographic characteristics, having a course in child development or seminar on DAP, and confidence will not significantly predict knowledge (Perrin & Perrin, 1983; Vacik et al., 2001) To analyze H ypothesis 2, multiple linear regression s were used with knowledge of developmentally appropriate care with children in the health care setting as the dependent variable. Independent variables were personal experience, professional experience, course in child development, seminar on DAP, confidence in working w ith

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49 children in the health care setting and patient practitioner orientation. Covariates were race, gender and age. Hypothesis 3 H3: This hypothesis to work with children, and demographic cha racteristics are associated with interest in future training on DAC with children in the health care setting. It is exploratory in nature, and for that reason a specific hypothesis will not be formed by previous research. To analyze H ypothesis 3, ANCOVA s and a correlation were used. For the first ANCOVA, the dependent variable was interest in future training on developmentally appropriate care with children in the health care setting. The independent variable was field of study (nursing, medical, physician assistant, physical therapist, or non clin ical health care professionals). Covariates were race, gender and age. The second intent to work with children in their caree r. Covariates were race, gender and age Finally, a correlation was run with the following variables: age, interest on future training, knowledge and confidence in working with children in the health care setting, personal experience, professional experien ce, course in child development, seminar on DAP and patient practitioner orientation.

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50 CHAPTER 4 RESULTS Sample Statistics Surveys were completed by 705 graduate and undergraduate students Twen ty six students did not meet the criteria of planning to w ork in the health care field or being enrolled in the prog ram that qualifies them to work in the health care field and 30 surveys were missing too much data (several items and/or multiple scales) to use for analysis (3 paper surveys, 27 online surveys). After removing unusable surveys, 649 participant surveys (N = 649) remained for data analysis. Of the 649 participants who completed usable surveys ( Table 4 1) 481 ( 74.2% ) were female and 167 ( 25.7% ) were male. 55 with a mean of 25.1 (SD = 5.06) Of those who indicated their race, 466 (74.2%) were White/non Hispanic, 75 ( 11.6% ) were Asian/Pacific Islander, 45 (7.0 % ) were Hispanic/Latino, 33 ( 5.1% ) were Black/non Hispanic, 19 ( 2.9% ) were Mu lti racial, and 8 ( 1.2% ) indicated Other T he race variable was dichotomized into W hite non Hispanic/not W hite /non Hispanic for the analyses since most of the participants were W hite /non Hispanic Five fields of study were represented in the sample including 200 (30.8%) medical students 197 (30.4%) n ursing students 112 (17.3%) p hysician a ssistant students 86 (13.3%) non clini cal health care students and 54 (8.3%) physical t herapy students The only undergraduates included in the sample were nursing students, all others were gr aduate students. The entire sample contained 501 (77.4%) graduate students and 147 (22.7%) undergraduate students For H ypothesi s 2, the students were analyzed by field of study. In the nursing student sample ( Table 4 2 ) 190 (96.4%) were female and 7 (3.6%) were male Of those

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51 who indicated their race, 152 (77.2%) were White/non Hispanic 17 (8.6%) were Hispanic/Latino 12 (6.1%) w ere Asian/Pacific Islander 11 (5.6%) were Black/non Hispanic and 5 (2.5%) were Multi racial Forty nine nursing students were graduate students and 146 were undergraduate. The mean age was 24. 2 with a standard deviation of 7. 42 In the medical student sample ( Table 4 2 ) 102 (51.3%) were female and 97 (48.7%) were male Of those who indicated their ra ce, 121 (61.1%) were White/non Hispanic, 38 (19.2%) were Asian/Pacific Islander 14 (7.1%) were Black/non Hispanic, 12 (6.1%) were Hispanic/Latino, 8 (4.0%) were Multi racial and 5 (2.5%) were Othe r/ The mean age was 24.5 with a standard deviation of 1.94. In the physician assistant student sample ( Table 4 2 ) 94 (83.9%) were female and 18 (16.1%) were male. Of those who indicated their race, 99 (88.4%) were White/non Hispanic 6 (5.4%) were Asian/Pacific Islander, 6 (5.4%) were Hispanic/Latino, and 1 (0.9% ) was Black/non Hispanic The mean age was 26.3 with a standard deviation of 3.65 In the physical therapy student sample ( Table 4 2 ) 38 (70.4%) were female and 16 (29.6%) were male Of those who indicated their race, 42 (77.8%) were White/non Hispanic 8 (14.8%) wer e Asian/Pacific Islander 3 (5.6%) were Hispanic/Latino and 1 (1.9%) was Other The mean age was 26.4 with a standard deviation of 4.40. In the non clinical health care student sample ( Table 4 2 ) 57 (66.3%) were female and 29 (33.7%) were male Of those who indicated their race, 52 (61.2%) were White/non Hispanic 11 (12.9%) wer e Asian/Pacific Islander 7 (8.2%) were

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52 Hispanic/Latino 7 (8.2%) were Blac k/non Hispanic 6 (7.1%) were Multi racial and 2 (2.4%) were Other The mean age was 26. 1 with a standard deviation of 4. 95 Hypothesis 1 RQ1: How does knowledge of developmentally appropriate care with children and intent to work with children in the health care setting vary between the observed fields of study? H1: Knowledge of developmenta lly appropriate care with children in the health care setting will not vary by field (Perrin & Perrin, 1983; Vacik et al., 2001) intent to work with children in their career (Blum & Bearinger, 1990; Boreman et al., 2007; Tanner et al., 2009) Knowledge of DAC by Field of Study An analysis of covariance was used to assess whether or not know ledge of DAC varied by field of study after controlling for race, gender and age. Table 4 3 presents the means and standard deviations for know ledge of DAC by field of study. R esults of the ANCOVA presented in Table 4 4 indicate that after controlling for race, gender and age, knowledge of DAC was significantly different between the observed fields of study F (1, 634) = 4.32, p = .0 02 This contrasts with the proposed hypothesis that knowledge of DAC would not vary by fi eld. Non clinical health care students appear to have less knowledge of DAC than students in nursing, medical, physician assistant and physical therapy programs. Post hoc analysis: knowledge of DAC by field of study A post hoc analysis revealed that non cl inical health care students scored significantly lower than nursing (p < .001), medical (p = .001), physician assistant (p = .005), and physical therapy students (p = .023).

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53 Additional analysis: professional experience with children by field of study Beca use non clinical students scored lower on the knowledge items, an analysis was conducted to see if non clinical health care students had less professional experience with children in the health care setting, a post hoc analysis of covariance was used to as sess whether or not professional experience with children varied by field of study after controlling for race, gender and age. The means and standard deviations for professional experience with children by field of study were M = 2.38 (SD = .94 ) for nursing students M = 2.49 (SD = .77 ) for medical students, M = 2.53(SD = .81 ) for physician assistant students, M = 2.25 (SD = .62 ) for physical therapy students and M = 2.15 (SD = 1.07) for non clinical health care students Results indicate that after c ontrolling for race, gender and age, professional experience with children was significantly different between the observed fields of study F (4, 633) = 2.84, p = .024 Non clinical health care students had the least amount of experience with children in the professional setting, and physician assistant students had the most. Additional analysis: knowledge of DAC by clinical fields of study Because non clinical students scored lower on the knowledge items, an analysis was conducted only with clinical stud ents to see significantly vary by field, a post hoc analysis of covariance was used to assess whether or not knowledge of DAC var ied by field of study among nursing, medical, physician assistant, and physical therapy students after controlling for race, gender and age. Nursing, medical, physician assistant and physical therapy students were included in the analysis. Non clinical hea lth care students were not included in this analysis The means and standard deviations for knowledge of DAC by clinical fields of study were: M

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54 = 7.47 (SD = 1.84) for nursing students, M = 7.11 (SD = 1.95) for medical students, M = 7.35 (SD = 1.79) for ph ysician assistant students and M = 7.30 (SD = 1.86) for physical therapy students. Results indicate that after controllin g for race, gender and age, knowledge of DAC was not significantly different between clinical ( nursing, medical, physician assistant, a nd physical therapy ) fields of study F (3, 551) = .56, p = .644 Knowledge of DAC by Intent to Work with Children An analysis of covariance was used to assess whether or not knowledge of DAC ng for rac e, gender and age. Table 4 5 presents the means and standard deviations for knowledge of DAC by students who plan to work with children, and those who do not. As hypothesized, results presented in T able 4 6 indicate s that after controlling for race, gender and age, knowledge of DAC wa s not significantly different between students who plan to work with children and those who do not plan to work with children F (1, 631) = .18, p = 676 Additional analysis: professional experience with children by intent to work with children Because students knowledge did not vary among students who intend to work with children and those who intend to work with children, an analysis was conducted to see if students who intend to work with children we re engaged in more professional experience with children, a post hoc analysis of covariance was used to assess whether or not professional experience with children varied by students who intend to work with children and those who do not aft er controlling for race, gender and age. The means and standard deviations for professional experience with children by intent to work with children wer e M = 2.07 (SD = .81) for those who do not intend to work with children, and M = 2.57 (SD = .855) for th ose who do intend to work with children. Results indicate that

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55 after controlling for race, gender and age, professional experience was significantly different between the two groups F (1, 630) = 56.67, p < .001 ; with students who intend to work with child ren having significantly more professional experience with children than those who do not plan to work with children. Hypothesis 2 RQ2: To what extent do confidence, experience, and patient practitioner orientation developmentally appropriate care with children in the health care setting within the observed fields of study? H2: Students with more patient centered views, and who have more personal and professional experience with children (Abela, 2009; Bandura, 1977; Kaufman, 2003) will have more knowledge of developmentally appropriate care with children in the health care setting. Demographic characteristics, having a course in child development or seminar on DAP, and confidence will not significantly predict knowledge (Perrin & Perrin, 1983; Vacik et al., 2001) To a nswer H ypothesis 2, separate regression analyses were ru n to see wh ich variables predict knowledge of DAC within each field. A regression was run for each field to avoid utilizing confusing dummy variables to code for field of study in one regression with each field. Knowledge of DAC was the dependent variable, and personal and professional experience with children, educational experience ( course in child development or seminar on DAC ) confidence in providing DAC, and patient practitioner orientation were independent variables. Race, gender and age were covaria tes. Nursing Students: Variables that Predict Knowledge of DAC Demographic variables of the nursing student s ample are presented in Table 4 2 The means and standard deviations for knowledge of DAC within the nursing student sample and predictor vari ables are presented in Table 4 7 The intercorrelations for ables are presented in Table 4 8

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56 Results from the regression analysis for the n ursing student sample (Table 4 9 ) k nowledge of DAC wa s predicted by age p = 0 02 ) and patient practitioner orientation = .0 03 ) Specifically, as age and patient centeredness increased, knowledge of DAC among nursing students also increased. Medical Students: Variable s that Predict Knowledge of DAC Demographic variables of the medical student sample are presen ted in Table 4 2 The means and standard deviations for knowledge of DAC within the medical student sample and predictor vari a bles are presented in Table 4 10 T he intercorrelations for s are presented in Table 4 11 Results from the regression analysis for the m e dical student sample (Table 4 12 ) indicate that medical s signific antly predicted by patient practitioner orientation p = .0 09 ) Medical students who were more patient centered had more knowledge of DAC. Physician Assistant Students: Variables that Predict Knowledge of DAC Demographic variables of the physici an assistant student sample are presented in Table 4 2 The means and standard deviations for knowledge of DAC within the physician assistant student sample and predictor vari a bles are presented in Table 4 13 The intercorrelations for physician assistant vari a bles are presented in Table 4 14 Results from the regression analysis for the physi c ian assistant sample (Table 4 15 wledge of DAC wa s not significantly predicted by any of the variables in the model

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57 Physical Therapy Students: Variables that Predict Knowledge of DAC Demographic variables of the physical therapy student sample are presented in Table 4 2 The means and standard deviations for knowledge of DAC within the physical therapy student sample and predictor variables are presented in Table 4 16 vari a bles are presented in Table 4 17 Results from the regression anal ysis for the physical therapy sample ( Ta ble 4 18 ) indicate that physical therapy knowledge of DAC wa s significantly predicted by age p = .0 1 1) of DAC. Non Clinical Health C are Students: Variables that Predict Knowledge of DAC Demographic variables of the non clinical health care student sample are presented in Table 4 2 The means and standard deviations for knowledge of DAC within the non clinical health care student sampl e and predictor variables are presented in Table 4 19 The intercorrelations for non DAC and predictor vari a bles are presented in Table 4 20 Results from the regression analysis for the non clinical healt h care student sample (Table 4 21 ) indicate that non clinical health care wa s significantly predicted by having taken a course in child development = .0 34 ) and patient practitioner orientation p = .01 7 ) Students who had taken a course in child development and who were more patient centered had more knowledge of DAC.

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58 Summary of Findings for Hypothesis 2 The hypothesis that students with more patient centered views would be more knowledgeable of DAC held true for nursing students, medical students, and non clinical health care students. For these groups, the patient centered views significantly predicted knowledge of DAC with children in the health care setting. As age increased, knowledge of DAC also inc reased for nursing and physical therapy students. For nursing students, age was significantly ( p = .001) correlated with professional experience. Specifically, as age increased, so did professional experience. This was not the case for physical therapy stu dents. Age and personal experience were not significantly correlated for nursing or physical therapy students. For the regressions, personal and professional experience did not significantly predict knowledge of DAC in any of the fields, contrasting with t he hypothesized outcome. For non clinical health care students, a course in child development significantly predicted more knowledge of DAC, contrasting with the hypothesized outcome Hypothesis 3 intent to work with children, and demographic characteristics associated with interest in future training on developmentally appropriate care with children in the health care setting? H3: This hypothesis is exploratory in nature, and for that reason a spec ific hypothesis will not be formed by previous research. Interest in F uture Training on DAC by Field of Study An analysis of covariance was used to assess whether or not interest in future training on DAC varied by field of study after controlling for race, gender and age. Table 4 22 presents the means and standard deviations for interest in future training on DAC by field of study. The r esults in Table 4 23 indicate that after controlling for race, gender

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59 and age, interest in future training on DAC wa s significantly different between the observed fields of study F (4, 635) = 2.87, p = .023 P hysician assistants students were the most interested in future training on DAC. Post hoc analysis: interest in future training on DAC by field of study A post hoc analysis revealed that physician assistant students were significantly more interested in future training on DAC than nursing students (p = .034) and medical students ( p = .001). Interest in Future Training by Intent to Work with Children An analysis of covariance was used to assess whether or not interest in f uture training on DAC varied by intent to work with children after controlling for race, gender and age. Table 4 24 presents the means and standard deviations for interest in future training according to students who plan to work with children and those who do not plan to work with children. Results presented in Table 4 25 indicate that after controlling for race, gen der and age, interes t in future training on DAC wa s significantly different between students who plan to work with children, and those who do not plan to work with children F (1, 632) = 53.42, p < .00 1 Students who indicated that they intend to work with children were more interested in future training on DAC. Future Training es associated with future health care professionals who are interested in future training on DAC. Variables in the correlation included age, confidence in providing DAC, knowledge of DAC, personal and professional experience with children, educational expe riences such as a course in child development or seminar on DAC and patient practitioner orientation.

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60 Results from this analysis presented in Table 4 26 indicate that interest was significantly associated with age (r = .09, p = .026 ), confidence in provid ing DAC (r = .18, p < .00 1 ), personal experience with children (r = .19, p < .00 1 ), and professional experience with children (r = .16, p < .00 1 ) having taken a course in child development (r = .11, p = .007 ) and patient practitioner orientation (r = .08, p = .048 ) Specifically, students who were younger, more confident in their ability to provide DAC, had more personal and professional experience with children, had taken a course in child development, and who were more patient centered were more interested in future training on DAC with children in the health care setting.

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61 Table 4 1. Characteris tics of S tudents in the Overall Sample Frequency Percent Mean Standard Deviation Field of Study Nursing Medical Physician Assistant Physical Therapy Non Clinical Health Care 197 200 112 54 86 30.4 30.8 17.3 8.3 13.3 Gender Female Male 481 167 74.2 25.8 Race White/non Hispanic Black/non Hispanic Hispanic/Latino Asian/Pacific Islander Native American Multi racial Other 466 33 45 75 0 19 8 72.1 5.1 7.0 11.6 0.0 2.9 1.2 Graduate/Undergraduate Graduate Undergraduate 501 147 77.3 22.7 Age 25. 1 5.06 Table 4 2 Characteristics of Student Samples by Field of Study Nursing Medical Physician Assistant Physical Therapy Non Clinical Health Care Gender Female Male 190 (96.4) 7 (3.6) 102 (51.3) 97 (48.7) 94 (83.9) 18 (16.1) 38 (70.4) 16 (29.6) 57 (66.3) 29 (33.7) Race White/non Hispanic Black/non Hispanic Hispanic/Latino Asian/Pacific Islander Multi racial Other 152 (77.2) 11 (5.6) 17 (8.6) 12 (6.1) 5 (2.5) 0 (0.0) 121 (61.1) 14 (7.1) 12 (6.1) 38 (19.2) 8 (4.0) 5 (2.5) 99 (88.4) 1 (.9) 6 (5.4) 6 (5.4) 0 (0.0) 0 (0.0) 42 (77.8) 0 (0.0) 3 (5.6) 8 (14.8) 0 (0.0) 1 (1.9) 52 (61.2) 7 (8.2) 7 (8.2) 11 (12.9) 6 (7.1) 2 (2.4) Year in Program Graduate 1 st Year 2 nd Year 3 rd Year 4 th Year Other Undergraduate 1 st Year 2 nd Year 23 (46.9) 15 (30.6) 3 (6.1) 1 (2.0) 7 (14.3) 131 (89.7) 15 (10.3) 74 (37.2) 50 (25.1) 6 (3.0) 69 (34.7) 54 (48.2) 58 (51.8) 54 (100.0) 41 (47.7) 32 (37.2) 9 (10.5) Age M = 24.2 SD = 7.42 M = 24.5 SD = 1.94 M = 26.3 SD = 3.65 M = 26.4 SD = 4.40 M = 26.1 SD = 4.95

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62 Table 4 3 Knowledge of DAC mean scores and standard deviations as a function of field of study Source M SD Nursing Students 7.4 7 1.84 Medical Students 7.1 1 1.95 Physician Assistant Students 7.3 5 1.7 9 Physical Therapy Students 7.26 1.86 Non clinical Students 6.4 3 2.0 4 Total 7.18 1.9 2 Table 4 4 Analysis of covariance for knowledge of DAC as a function of field of study, with race, gender and age as covariates Source df SS MS F Race 1 8.80 8.80 2.54 Gender 1 12.30 12.30 3.55 Age 1 70.00 70.00 20.20*** Field of Study 4 59.8 5 14.96 4.32** Error 634 2196.8 9 3.4 7 Total 642 35488.00 Corrected Total 641 2356.31 p < .05. ** p < .01. *** p < .001. Table 4 5 Knowledge of DAC mean scores and standard deviations as a function of intent to work with children Source M SD No 7.1 4 1.96 Yes 7.2 3 1.90 Total 7.19 1.92 Table 4 6 Analysis of covariance for knowledge as a function of intent to work with children, with race, gender and age as covariates Source df SS MS F Race 1 14.21 14.21 3.99* Gender 1 21.81 21.81 6.12** Age 1 58.67 58.67 16.47** Intent to Work w/Children 1 .62 .62 .1 8 Error 631 2248.17 3.56 Total 63 6 35229.00 Corrected Total 635 2347.98 p < .05. ** p < .01. *** p < .001.

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63 Table 4 7 Means and standard deviations for knowledge of DAC within nursing student sample and predictor variables (N = 191) Variable M SD Knowledge 7.4 7 1.85 Personal experience with children 3.42 .74 Professional experience with children 2.40 .94 Course in child development .91 .2 9 Seminar or in service on DAP .30 .4 6 Confidence 4.3 5 .84 Patient Practitioner Orientation 4.4 9 .5 1 T able 4 8 Interco rrelations DAC and predictor variables (N = 191) Variable 1 2 3 4 5 6 7 8 9 10 1. Knowledge -2. Race .19 ** -3. Gender .1 3 .0 3 -4. Age 30 *** .1 6 ** .06 -5. Pers onal exp .13 .0 2 .02 .0 8 -6. Prof essional exp. .1 2 .0 1 .04 .2 4 *** .31 *** -7. Course .09 .0 5 .0 6 .05 .0 3 .15 ** -8. Seminar .0 1 .0 8 .0 8 .02 .0 5 .16 ** .08 -9. Confidence .00 .01 .02 .1 9 ** .21 *** .4 2 *** .14 .23 *** -10. PPOS 3 4 *** .2 4 *** 19 ** 25 *** .0 5 .01 .0 9 .11 .03 -* p < .05. ** p < .01. *** p < .001. Table 4 9 Regression knowledge of DAC (N = 191) Variable B SEB 95% CI Race .45 .30 .10 [ .15, 1.05 ] Gender 1.15 .73 .11 [ 2.58, .29 ] Age .06 .02 .24 ** [ .02, .09 ] Personal exp. .25 .18 .10 [ .10, .59 ] Professional exp. .10 .15 05 [ .20, .41 ] Course .55 .45 08 [ .33, 1.43 ] Seminar or in service .19 .28 .49 [ .36, .74 ] Confidence .23 .17 .10 [ .56, .10 ] PPOS .82 .27 .22 ** [ .29, 1.35 ] p < .05. ** p < .01. *** p < .001.

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64 Table 4 10 Means and standard deviations for knowledge of DAC within medical student sample and predictor variables (N = 190) Variable M SD Knowledge 7.15 1.94 Personal experience with children 3.04 .81 Professional experience with children 2.39 .77 Course in child development .37 .49 Seminar or in service on DAP .11 .31 Confidence 4.11 .74 Patient Practitioner Orientation 4.36 .46 Table 4 11 Intercorrelations variables (N = 190) Variable 1 2 3 4 5 6 7 8 9 10 1. Knowledge -2. Race .06 -3. Gender .07 .08 -4. Age .05 .14 .14 -5. Personal exp. .02 .04 .01 .10 -6. Professional exp. .03 .11 .04 .19 ** .26 ** -7. Course .02 .06 .15 .08 .18 ** .08 -8. Seminar .03 .10 .03 .11 .00 .23 *** .02 -9. Confidence .09 .01 .05 .13 .28 *** .29 *** .21 ** .03 -10. PPOS .19 ** .05 .23 *** .14 .15 .09 .05 .14 .03 -* p < .05. ** p < .01. *** p < .001. Table 4 12 Regression knowledge of DAC (N = 190) Variable B SEB 95% CI Race .25 .29 .06 [ .33, .83 ] Gender .16 .30 .04 [ .75, .42 ] Age .10 08 .10 [ .05, .25] Personal exp. 01 .19 .01 [ .36, .39] Professional exp. .13 .21 .05 [ .53, .28] Course .01 .30 .00 [ .59, .61] Seminar or in service .01 .48 .00 [ .96 .93] Confidence .24 .21 .09 [ .65, .17] PPOS .86 .33 .20 ** [.21, 1.50] p < .05. ** p < .01. *** p < .001.

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65 Table 4 13 Means and standard deviations for knowledge of DAC within physician assistant students and predictor variables (N = 111) Variable M SD Knowledge 7.34 1.80 Personal experience with children 3.05 .86 Professional experience with children 2.53 .81 Course in child development .58 .50 Seminar or in service on DAP .06 .24 Confidence 4.75 .64 Patient Practitioner Orientation 4.39 .43 Table 4 14 Intercorrelations DAC and predictor variables (N = 111) Variable 1 2 3 4 5 6 7 8 9 10 1. Knowledge -2. Race .09 -3. Gender .10 .08 -4. Age .02 .12 .30 *** -5. Personal exp. .00 .09 .06 .05 -6. Professional exp. .01 .07 .04 .05 .24 ** -7. Course .01 .20 ** .03 .02 .20 ** .02 -8. Seminar .07 .02 .01 .19 .07 .01 .22 ** -9. Confidence .01 .08 .07 .03 .37 *** .37 *** .16 .00 -10. PPOS .11 .02 .13 .06 .16 .08 .03 .05 .01 -* p < .05. ** p < .01. *** p < .001. Table 4 1 5 Regression analysis summary for variables predicting physician assistant DAC (N = 111 ) Variable B SEB 95% CI Race .48 .57 .09 [ .65, 1.61] Gender .54 .51 .11 [ 1.55, .47] Age .02 .05 .0 5 [ .08, .13] Personal exp. .05 .23 .03 [ .40, .51] Professional exp. .03 .24 .02 [ .44, .51] Course .00 .38 .00 [ .76, .76] Seminar or in service .63 .76 .09 [ 2.14, .88] Confidence .08 .32 .03 [ .71, .55] PPOS .41 .42 .10 [ .42, 1.24] p < .05. ** p < .01. *** p < .001.

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66 Table 4 16 Means a nd standard deviations for knowledge of DAC within physical therapy student sample and predictor variables (N = 52) Variable M SD Knowledge 7.31 1.85 Personal experience with children 2.98 .87 Professional experience with children 2.25 .62 Course in child development .90 .30 Seminar or in service on DAP .10 .30 Confidence 4.42 .53 Patient Practitioner Orientation 4.54 .38 Table 4 17 Intercorrelations predictor variables (N = 52) Variable 1 2 3 4 5 6 7 8 9 10 1. Knowledge -2. Race .09 -3. Gender .09 .37 ** -4. Age .37** .04 .24 -5. Personal exp. .11 .21 .03 .17 -6. Professional exp. .00 .17 .07 .05 .26 -7. Course .23* .17 .07 .05 .08 .03 -8. Seminar .09 .31 ** .07 .12 .16 .19 .11 -9. Confidence .07 .02 .18 .16 .12 .30 ** .08 .25 -10. PPOS .26 .21 .06 .22 .03 .30 ** .00 .03 .04 -* p < .05. ** p < .01. *** p < .001. Table 4 1 8 Regression analysis summary for variables predicting physical therapy DAC (N = 52) Variable B SEB 95% CI Race .42 .72 .09 [ 1. 86, 1.03] Gender .15 .59 .04 [ 1.34, 1.05] Age .16 .06 .39 ** [.04, .28] Personal exp. .32 .31 .15 [ .94, .30] Professional exp. .56 .45 .19 [ .35, 1.47] Course 1.30 .83 .21 [ .36, 2.97] Seminar or in service 1.04 .91 .17 [ 2.87, .79] Confidence .50 .51 .14 [ 1.53, .53] PPOS 1.23 .69 .26 [ .15, 2.61] p < .05. ** p < .01. *** p < .001.

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67 Table 4 19 Means and standard deviations for knowledge of DAC within non clinical health care student sample and predictor variables (N = 83) Medical Students M SD Knowledge 6.42 2.05 Personal experience with children 3.11 .95 Professional experience with children 2.16 1.08 Course in child development .51 .50 Seminar or in service on DAP .12 .33 Confidence 4.29 .83 Patient Practitioner Orientation 4.41 .51 Table 4 20 Intercorrelations for non of DAC and predictor variables (N = 83) Variable 1 2 3 4 5 6 7 8 9 10 1. Knowledge -2. Race .02 -3. Gender .03 .01 -4. Age .06 .10 .26 ** -5. Personal exp. .04 .01 .08 .01 -6. Professional exp. .14 .12 .27 ** .10 .50 *** -7. Course .32 *** .01 .06 .09 .09 .33 *** -8. Seminar .06 .16 .13 .04 .08 .12 .07 -9. Confidence .06 .22 .04 .18 .38 ** .35 *** .05 .16 -10. PPOS .29 ** .20 .30 ** .02 .08 .12 .19 .13 .01 -* p < .05. ** p < .01. *** p < .001. Table 4 21 Regression analysis summary for variables predicting non clinical health DAC (N = 83) Variable B SEB 95% CI Race .41 .47 .10 [ 1.34 .53] Gender .66 .52 .15 [ .39 1.70] Age .02 .05 .04 [ 08 .11] Personal exp. .01 .27 .00 [ .55, .54] Professional exp. .19 .27 .10 [ .34, .72] Course 1.02 .47 .25 [.08, 1.97] Seminar or in service .43 .69 .07 [ 1.80, .94] Confidence .22 .31 .09 [ .84, .40] PPOS 1.13 .46 .28 ** [.21, 2.05] p < .05. ** p < .01. *** p < .001.

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68 Table 4 22 Interest in future training on DAC mean scores and standard deviations as a function of field of study Source M SD Nursing Students 2.99 .63 Medical Students 2.79 .71 Physician Assistant Students 3.09 .58 Physical Therapy Students 2.92 .60 Non clinical Students 2.9 5 .67 Total 2.93 .66 Table 4 23 Analysis of covariance of interest in future training as a function of field of study, with race, gender and age as covariates Source df SS MS F Race 1 2.2 5 2.25 5.51 ** Gender 1 5.84 5.84 14.32 *** Age 1 1.44 1.44 3.53 Field of Study 4 4.67 1.17 2.87 Error 635 258.82 .41 Total 643 5814 .87 Corrected Total 642 276.93 p < .05. ** p < .01. *** p < .001. Table 4 2 4 Interest in future training mean scores and standard deviations as a function of intent to work with children Source M SD No 2.70 .62 Yes 3.09 .63 Total 2.94 .6 6 Tab le 4 2 5 Analysis of covariance of interest in future training as a function of intent to work with children, with race, gender and age as covariates Source d f SS MS F Race 1 2.02 2.02 5.29 Gender 1 7.01 7.01 18.38 *** Age 1 .36 .36 .94 Intent to Work w/Children 1 20.37 20.37 53.42 *** Error 632 241.03 .3 8 Total 637 5763.73 Corrected Total 636 274.73 p < .05. ** p < .01. *** p < .001.

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69 Table 4 26 Intercorrelations for interest in future training and variables of interest Variable 1 2 3 4 5 6 7 8 9 1. Interest -2. Age .09 -3. Confidence .18 *** .12 ** -4. Knowledge .00 .16 *** .02 -5. Personal exp. .19 *** .02 .26 *** .05 -6. Professional exp. .16 *** .12 ** .35 *** .07 .31 *** -7. Course .11 ** .05 .16 *** .11 ** .18 *** .12 ** -8. Seminar .01 .00 .13 *** .01 .09 .13 *** .16 *** -9. PPOS .08 .13 *** .01 .25 *** .06 .00 .11 ** .07 -* p < .05. ** p < .01. *** p < .001.

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70 CHAPTER 5 DISCUSSION Discussion of Key Findings Hypothesis 1 Hypothesis 1 predicted that knowledge of DAC with children in the health care setting would not vary by field of study or health significant in predicting knowledge of DAC. A post hoc analysis revealed that non clinical health care students had significantly les s knowledge of DAC than nursing, medical, physician assistant, and physical therapy students. Means for knowledge of DAC by field indicate that clinical health care professionals were answering 55 57% of DAC items correctly, and that non clinical health care students were only answering 49% of DAC items correctly. Overall, it seems that there is much room to grow with all Non clinical health care students may not have di rect exposure to the clinical setting, which may result in having less of a framework for answering the knowledge items on the questionnaire. Additional analyses revealed that professional experience with children does significantly vary by field of study. Non clinical health care professionals had the least amount of professional experience with children, which may be a contributing factor to non unique, and therefore it is challenging to support these results with previous research Comparable studies were concepts of illness (Perrin & Perrin, 1983; Vacik et al., 2001) ; and they found that

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71 knowledge was similar across fields. However, their studies did not include non clinical health care students. The inclusion of non clinical health care students contri butes an interesting finding that clinical health care students know significantly more than non clinical health care students. Additional analyses showed that when clinical (nursing, medical physician assistant, and physical therapy) students were analyze d without the inclusion of non clinical health care students knowledge of DAC did not significantly vary by field. This supports previous research that knowledge of DAC does not vary among future clinical health care professionals. Knowledge of DAC did no t vary by intent to work with children. Additional analyses conveyed that students who intend to work with children did have more profes sional experience with children; however these experiences did not seem to translate into more knowledge of DAC. This w professional experience with children, these experiences are not helping future health care professionals learn more about how to provide developmentally appropriate care in the health care setting. While it may be argued this education will take place in residency, r esearch has found that this has not always been effective. Students who go into pediatrics and primary care often feel that their training does not prepare them to understand their patien (Blum & Bearinger, 1990; Boreman et al., 2007; Haf ferty, 1998; Levetown & the Committee on Bioethics, 2008; Levinson et al., 2010; H. Schmidt, 1998; Tanner et al., 2009) Hypothesis 2 Hypothesis 2 predicted that within the observed fields of study, students with more patient centered views and those wh o have more personal and professional experience with children would have more knowledge of DAC with children in the health care

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72 setting. It was also predicted that demographic characteristics, having a course in child development or seminar on DAP, and co nfidence would not significantly predict knowledge. This study presents evidence that for nursing students, medical students, and non clinical health care professionals, individuals who were more patient centered also had more knowledge of DAC. This may in dicate that individuals who take the time to share information with their patients, balance power and control in the relationship, and value (Haidet et al., 2001; E. Krupat et al., 2000) needs and can respond appropriately. Additionally, students who are more patient c rsonal needs, and as a result have either studied or taken the time to learn ho w DAC can be provided. As age increased, knowledge of DAC also increased in nursing and physical therapy students. Results from the nursi ng regression suggest that as nursing st age increased, so did their professional experience. However, personal experience was significantly correlated with age for nursing or physical therapy students, and professional experience was not significantly correlated with age for physical the rapy students. Thus, even though older nursing and physical therapy students may seem to have more knowledge of DAC as a result of more personal and professional experience tly support this notion. Additionally, the regressions measuring knowledge of DAC within the observed fields of study conveyed that personal and professional experience did not significantly predict knowledge of DAC in any of the fields, contrasting with t he hypothesized outcome. This may convey a weakness in the measurement power of the

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73 experience variables. The experience variables may have been too vague by only with chi ldren on a likert scale from 1 (none) to 4 (a lot). These items did not convey whether or not these experiences were parenting, working at a camp, volunteering wit h children, internships, or working at a hospital A more comprehensive scale measuring specific experiences might be more effective in measuring this variable in the future. For non clinical health care students, a course in child development significantly predicted more knowledge of DAC, contrasting w ith the hypothesized outcome. Since non clinical health care students lack exposure to the clinical setting in their curriculum, a course in child development seems to have better prepared them for understanding children's needs in the health care setting. Interestingly, none of the variables were significant predictors for physician between their knowledge of DAC and the variables measured in this study. Further research with this population may provide further conclusions. Hypothesis 3 knowledge, confidence, experience, intent to work with children, and demographic characteristics were associated with interest in future training on DAC with children in the health care setting. Interest in future training on DAC with children in the health care setting did significantly vary by field. A post hoc analysis revealed that physician assistant students w ere significantly more interested in future training on DAC than nursing and medical students. This suggests that even though this study did not identify which variables predict physician assistants' knowledge of DAC, they are indeed

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74 interested in learning how to provide DAC. It would appear that physician assistants seem to take more of an interest in learning about DAC with children in the health care setting than the other fields. Students who intend to wor k with children were significantly more intere sted in future training on DAC with children in the health care setting. Additionally, students who were younger, more confident in their ability to provide DAC, had more personal and professional experience with children, had taken a course in child devel opment, and who were more patient centered, were more interested in future training on DAC with children in the health care setting. Implications for Practice According to this study, future health care professionals were only able to accurately answer ab out half of the items correctly relating to knowledge of DAC with children in the health care setting. However, future health care professionals do desire to learn about DAC. Thus, it is important to provide opportunities for in service training, health ca re curriculum courses, and experience based trainings on how to provide developmentally appropriate care. Some topics for these trainings may include learning techniques to reduce pain children experience from procedures and how to consider Further studies should be done to address non knowledge, confidence, and interest in further training on developmentally appropriate care with children in the health care setting. It is imp ortant to include them in this research as they will influence the clinical aspects of health care through teaching, research, and policy. For example, the field of public health is encouraged to consider m implementation and

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75 epidemiological research (Avan & Kirkwood, 2010) Similarly, hospital administrators may not directly communicate with children in the clinical setting, but they ought to be knowledgeable of child decisions, such as creating child life positions, providing training opportunities for DAC with children in the health care setting, and aligning incentives for medical teams that consider their pat that non clinical health care students were the least knowledgeable of DAC among the health care student samples, and that a course in child development was significantly correlated with thei r knowledge of DAC. Training on DAC with children in the health care setting may be best targeted toward health care students who plan to work with children, as these students are more interested in training on DAC and appear to have room for improvement in their understanding of DAC. Students may also benefit from learning how to be patient centered, as this strongly predicts knowledge of DAC with children in the health care setting among nursing, medical, and non clinical health care students. Physician assistants were the most interested in training on DAC. Individuals facilitating training might benefit from knowing that health care students who are younger, have more confidence in their ability to provide DAC, have more personal and professional experi ence with children, have taken a course in child development, and who are more patient centered seem to be the most interested in future training on DAC with children in the health care setting. These individuals may be invested in learning more about DAC and may be helpful in arranging and attending in service or seminar opportunities to learn more about providing DAC. These individuals may also help champion new

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76 concepts and ideas to help translate DAC into practice. For example, they may be most supporti ve of introducing a parental presence for induction (PPI) program to the pre surgery unit or help in advocating for a more child friendly play room. According to Adult Learning Theory, training should be directly applicable to centered approaches to learning (Abela, 2009; Kaufman, 2003) Additionally, though a class in child development was significantly related to non cli knowledge of DAC, Hafferty (1998) recomm ends going beyond improving the formal curriculum (courses and clinical experience), to also considering the informal curriculum (the interpersonal educational interactions between the pro fessors and students), and the hidden curriculum (organizational and cultural influences). The same philosophy might be an excellent foundation for improving knowledge and practice of DAC in nursing, medical, physician assistant, physical therapy and non c linical health care programs. In addition to offering an elective on developmentally appropriate care with children in the health care setting, professors might convey the importance of developmentally appropriate care through examples in lecture and mode ling developmentally appropriate care during clinical rotations. Additionally, student s learn the importance of providing DAC through organizational and cultural influences, such as g DAC. Thus, training should not be limited to in services and courses. Developmentally appropriate should be given to health care students on their interactions with child ren, including positive feedback and a discussion on areas of improvement.

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77 Medicine has incorporated a rotation for medical students to have direct experience with the psychos ocial aspects of patients in the clinical setting (Sexton & Massey, 2011) Medical students can observe procedural preparation and support, medical play, and can engage with children in the hospital under the observat ion of child life specialists at Riley Hospital for Children. During their bedside visits and playroom activities, medical students learn more about what it is like for children to be hospitalized and experience an illness. The Pediatric Clerkship Director Assistant Clerkship Director, Chief Medical Officer, Clinical Director, medical students, and child life specialists had very positive feedback about the program. Medical students reflected upon their experience, noting that they learned about child life family centered care, humanism, resiliency and self awareness. For professionals already in the field Levetown and the Committee on Bioethics (2008) note that it is difficult to engage physicians in further training due to lac k of time and monetary reward for doing so. As a result, appropriate incentives should be aligned to help health care professionals see the value in such training. For some health care professionals, external motivation such as a fun name badge clip or their name posted Additionally, training should be an appropriate length and at a ti me that the staff can attend (e.g a lunch and learn or at the b eginning or end of the day when health care professionals are not seeing patients). Some programs have found a one hour training to be successful in improving pediatric pain management in their practice (Schechter e t al., 2010)

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78 Study Limitations This study does have limitations. First, t he cross sectional design of this study makes only one observation, limiting the tim e dimension of the data (de Vaus, 2005) As a result, outside influences on the partici pants, such as having a bad day or not being focused, could influence their answers on the survey. Some studies overcome this limitation by using a repeated cross sectional design. This method would survey different, but co mparable, students in these colleges (as opposed to the same students over and over again) at different points in time (de Vaus, 2005) Additionally, the methods used to anal yze the hypothesis were powerful for pres enting correlations and relationships, but not for presenting causation. For example, it would be interesting to know whether or not a class on child development le a d s to more knowledge of developmentally appropriate care with children in the health care s etting, or whethe r or not patient centeredness leads to DAC, or if DAC leads to patient centeredness. Another limitation of this study is that not all of th e items on the instrument have been validated. The items measuring knowledge of DAC, confidence in providing DAC, and interest in future training on DAC we re considered to be strong, as much of the s. However, other than the Patient Practitioner Orientation Scale, most of the items have not been tested for validity and reliability. Also, as mentioned in previous chapters, items were modified from their original phrasing on the Child Life Council Prof essional Certifying exam. This was to improve clarity and understanding for individuals in fields of study other than child development, while still measuring the same concept.

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79 Also, despite the large number of students in this sample, this study is not g eneralizable to all nursing, medical, physician assistant, physical therapy, and no n clinical health care students. T his data was collected from one university, so results may differ if implemented at other universities due to variances in curriculum and l earning opportunities. Further, the knowledge scores for this instrument did not have a large range. In general, students performed to predict knowledg e because without a sample that perform s will on the DAC items, it is difficult to accurately assess which variables predict knowledge. Additionally this study utilized self reporting. When participants self report, they may rush through the study for various reasons. Participants may also try to appease the principal investigator by answering in favor of this topic (for example, with more interest in further training in DAC). This concept is called social desirability. To try to minimize social desirability, the principal investigator did not discuss her profession and interest in advocacy for children in the health care setting before the participant s took the survey. Finally, there was a small sample size for physical therapy students (n = 53). As a result, more participants ought to be utilized for similar regression analyses (or less variables for the same number of participants). Recommendations f or Future Research Future researchers that use this instrument might conside r updating the instrument revised core competencies that were released after this study was in progress However, the older competencies informed item s instrument that proved to have excellent reliability for the confide nce and interest

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80 scales, so the older Child Life Council competencies should not be ruled out as effective for informing future measures Also, the Child Life Council has since updated their Child Life Professional Certification Ex am items, and future instrument development should consider using the newer items. Future research should utilize stronger measures of experience, such as a scale with several factors indicat ing experience that includes personal, professional, and educational experience. As mentioned earlier, the e xperience variables might also be improved if they helped specify the type of personal and professional experience the participants are referring to (internships, paid experience, parenting, volunteering at a camp, etc.). The experience variables used in this study did not significantly predict knowledge, though i t seems intuitive that older students would have more knowledge of DAC as a result of mor e life experience with children. If this were true, they would have ds in the health care setting; h owever, the experience variables did not capture that. Future research should investigate the relationship between DAC and patient centered care, whether or not more knowledge of DAC translates into better practice of DAC, and what type of training on DAC is most effective for health care students and professionals.

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81 APPENDIX A INFORMED CONSENT Informed Consent Pro tocol Title: Developmentally Appropriate Practice with Children in the Hospital Setting Please read this consent document carefully before you decide to participate in this study. Purpose of the research study: developmentally appropriate practice with children in the health care setting and to understand what factors correlate with that knowledge. Results may be published and presente d at relevant conferences. What you will be asked to do in the study: Students in the College of Medicine, College of Nursing, College of Health and Human Performance, and Public Health and Health Professions will be asked to complete a survey responding to items regarding your demographic information, knowledge of developmentally appropriate practice with children in the hospital setting, and items from the patient provider orientation scale. This survey will be administered at the beginning of class and, in some cases, online. If you take the survey in class, you will not miss class and it will not negatively impact your grades. If you choose not to complete this questionnaire while it is being distributed in class, you can engage in another quiet activit y until participants have completed the questionnaire. Time required: 15 20 minutes Risks and Benefits: There are no risks involved with this study. We do not anticipate that you will benefit directly by participating in this experiment. You will not be compensated for participating in this study. Confidentiality: Your identity will not be recorded or associated with your responses. Your information will be assigned a code number. The list connecting your name to this number will be kept in a locked file in the principal Voluntary participat ion: Your participation in this study is completely voluntary. There is no penalty for not participating. Right to withdraw from the study: You have the right to withdraw from the study at anytime without consequence. Further, you do not have to answer a ny question that you do not wish to answer on this questionnaire. Whom to contact if you have questions about the study: Jessica Wente, BS, CCLS, Principal Investigator, Questionnaire Administrator, Graduate Student Department of Family, Youth and Commun ity Sciences University of Florida, P.O. BOX 110310, Gainesville, FL, 32611 David Diehl, PhD, Faculty Supervisor, Department of Family Youth and Community Sciences Whom to contact about your rights as a research participant in the study: IRB02 Office, Box 112250, University of Florida, Gainesville, FL 32611 2250 Agreement: I have read the procedure described above. I voluntarily agree to participate in the procedure and I have received a copy of this description. Participant: _______________________ _____________________ Date: _________________ Principal Investigator: ___________________________________ Date: _________________

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82 APPENDIX B INSTRUMENT: DEVELOPMENTALLY APPROPRIATE PRACTICE WITH CHILDREN IN THE HOSPITAL SETTING Developmentally Appropriate Practice with Children in the Hospital Setting Thank you for taking time to complete this questionnaire! Please read instructions for each section carefully and complete to the best of your ability. Each page has a front and back portion to com plete. Part I This portion of the questionnaire will test your knowledge of developmentally appropriate practice with children in the hospital setting. These items have been developed using material from a retired Child Life Professional Certification Ex am. These items are not representative of each domain that is tested on the exam and many items have been altered for clarity for individuals in fields other than child life. As a result, your performance on this survey is not an accurate assessment of wha t your performance would be on the Child Life Professional Certification Exam. The Child Life Council has given the principal investigator of this study express permission to use these retired exam items that are protected under copyright law. Directions : Please circle the answer that you believe to be correct. Throughout the questionnaire, assume the following ages for each developmental stage unless otherwise specified in the question: Infants (Under 1 year) Toddlers (1 2) Preschoolers (3 5) School Age (6 11) Adolescent (12 18) 1. Which of the following is the GREATEST stressor for most hospitalized preschool children? a. Painful procedures b. The hospital environment c. Separation from parents d. The lack of apparent routines 2. Fundamental to an ad a. Mastery and control b. Physical limitations c. Humor d. Family support 3. a. During the pre admission assessment to visit the hospital b. Through a private phone call to the parents initiated by a designated pediatric staff member c. During a scheduled pre admission tour which includes the entire family d.

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83 4. The MOST beneficial play act ivities for children in health care settings are: a. Emotionally charged b. Highly structured c. Open ended d. Passive 5. Preparation of a preschool child for a medical procedure is MOST effective when performed: a. Immediately before the procedure b. A few hours before the p rocedure c. A few days before the procedure d. A few weeks before the procedure 6. Which age group is MOST likely to believe that death is reversible? a. Infants (Under 1 year) b. Toddlers (1 2) c. Preschoolers (3 5) d. School Age (6 9) 7. Which of the following will BEST facil itate coping in a preschool child who is intubated and in an intensive care unit? a. Regular multidisciplinary teaching rounds b. Opportunities for dramatic play c. Practices that increase environmental predictability d. Visitations by volunteers and peers 8. Coping strategies employed by hospitalized children: a. Can be acquired, changed, or eliminated through personal experiences b. Are innate and stimulated by traumatic events c. Have limited value for preschool children d. Remain constant from infancy through pre adolescence 9. The BEST method for preventing separation anxiety during a procedure is: a. Having the parents present b. Having a child life specialist present c. Consistently having the same physician perform all procedures d. Having the parents leave a transitional object with th e child 10. Health care providers who are psychologically preparing a child for health care experiences should first and foremost consider: a. Family structure b. Developmental level c. Medical condition d. Personality

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84 11. Which of the following activities would be MOST effective in helping a toddler address the issues of autonomy and separation? a. Reading a book on separation b. Discussing separation c. and d. The following questions are not specific to a developmental stage and therefore do no t apply to the age ranges listed at the beginning of this subsection. Rather, research on this topic has identified specific age ranges for each topic. 12. The age range of children most vulnerable to psychological upset related to hospitalization is: a. Birth t o six months b. Six months to four years c. Five years to eleven years d. Twelve years to eighteen years 13. A child is being prepared for a hernia repair. Which age group would MOST likely need to be assured that their condition is not the result of their thoughts or actions? a. 1 3 year olds b. 3 7 year olds c. 7 9 year olds d. 9 11 year olds Part II Directions: For each of the following items, please circle one answer that you most identify e Internship Program Self http://www.childlife.org/files/InternshipProgramSelfReview.pdf ). Strongly Disagree Disagree Somewhat Disagree Somewhat Agree Agree Strongly Agree effectively explain illness, procedures, surgeries, and medications to toddlers (1 2) 1 2 3 4 5 6 effectively explain illness, procedures, surgeries, and medications to preschoolers (3 5) 1 2 3 4 5 6 effectively explain illness, procedures, surgeries, and medications to school age children (6 11) 1 2 3 4 5 6 effectively explain illness, procedures, surgeries, and medications to adolescents (12 18) 1 2 3 4 5 6 collaborate with families regarding developmental issues and impact of stressful events. 1 2 3 4 5 6 consider diversity and socio economic issues of patients and their families. 1 2 3 4 5 6 interact and coordinate with interdisciplinary team members. 1 2 3 4 5 6

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85 Part III Directions: Please check yes or no in response to the following: 1. Do you plan to work with children in your profession? Yes No 2. Have you taken a course in child development? Yes No 3. If you have taken a course in child development, how long has it been since you completed the course? (please provide your best estimate in months): _______________ 4. Have you had a seminar or in service training on developmentally appropriate practice in the hospital setti ng? Yes No 5. If you have participated in a seminar or in service training on developmentally appropriate practice in the hospital setting, how long has it been since the seminar or training? (please provide your best estimate in months): __________ __ Directions: Please circle the answer that you most identify with: None A little Some A lot How much experience have you had with children in your personal life? 1 2 3 4 How much experience have you had with children as a professional? 1 2 3 4 Directions: Please circle the response that you most identify with: Program Self http://www.childlife.org/files/InternshipProgramSelfReview.pdf ). If the opportunity arises, how likely are you to attend a seminar or in Very unlikely U nlikely Likely Very likely effectively explain illness, procedures, surgeries, and medications to toddlers (1 2) ? 1 2 3 4 effectively explain illness, procedures, surgeries, and medications to preschoolers (3 5) ? 1 2 3 4 effectively explain illness, procedures, surgeries, and medications to school age children (6 11) ? 1 2 3 4 effectively explain illness, procedures, surgeries, and medications to adolescents (12 18) ? 1 2 3 4 collaborate with families regarding developmental issues and impact of stressful events? 1 2 3 4 consider diversity and socio economic issues of patients and their families? 1 2 3 4 interact and coordinate with interdisciplinary team members? 1 2 3 4

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86 Part IV Directions: Please circle the response that you most identify with: Questionnaire continues Strongly Disagree Disagree Somewhat Disagree Somewhat Agree Agree Strongly Agree The doctor is the one who should decide what gets talked about during a visit. 1 2 3 4 5 6 Although health care is less personal these days, this is a small price to pay for medical advances. 1 2 3 4 5 6 The most important part of the standard medical visit is the physical exam. 1 2 3 4 5 6 It is often best for patients if they do not have a full explanation of their medical condition. 1 2 3 4 5 6 and not try to find out about their conditions on their own. 1 2 3 4 5 6 When doctors ask a lot of questions about a into personal matters. 1 2 3 4 5 6 If doctors are truly good at diagnosis and treatment, the way they relate to patients is not that important. 1 2 3 4 5 6 Many patients continue asking questions even though they are not learning anything new. 1 2 3 4 5 6 Patients should be treated as if they were partners with the doctor, equal in power and status. 1 2 3 4 5 6 Patients generally want reassurance rather than information about their health. 1 2 3 4 5 6 warm, the doctor will not have a lot of success. 1 2 3 4 5 6 When patients disagree with their doctor, this is a respect and trust. 1 2 3 4 5 6 A treatment plan cannot succeed if it is in 1 2 3 4 5 6 Most patients want to get in and out of the 1 2 3 4 5 6 The patient must always be aware that the doctor is in charge. 1 2 3 4 5 6 illness. 1 2 3 4 5 6 treatment of the patient. 1 2 3 4 5 6 When patients look up medical information on their own, this usually confuses more than it helps. 1 2 3 4 5 6

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87 Descriptive and Background Information 1. I am: Female Male 2. What is your age? ________ 3. Are you married? Yes No 4. Do you have any children? Yes No If so, how many? _________ 5. I consider myself to be: White/non Hispanic Black/non Hispanic Hispanic/Latino Asian/Pacific Islander Native American Multi racial Other: ___________________ 6. I am a(n): undergraduate student graduate/professional student 7. If you are a graduate student, what was your undergraduate area of concentration? Major: _____________________________ Mi nor (if applicable): _________________ 8. Do you plan to (or do you currently) work in the health care field? Yes No 9. College within the University of Florida: Medicine Nursing Health & Human Performance Public Health & Health Professions Other: ___________________ 10. Year in current program: 1 st 2 nd 3 rd 4 th Other: ___________________ 11. Future career plans: Nurse Nurse Practitioner Physician Physician Assistant Physical Therapist Hospital Administrator Other: ___________________ 12. If applicable, what is your main area of interest or specialty? Pediatrics Cardiology Emergency Medicine Hematology/Oncology PICU NICU Family Medicine Pathology or Immunology Psychiatry Urology Radiology Surgery Aging/Geriatrics Anesthesiology Obstetrics and Gynecology Neurology Orthopaedics and Rehabilitation Not Applicable Other: ___________________ Thank you for taking the time to take this questionnaire!

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88 REFERENCES Abela, J. (2009). Adult learning theories and medical education: A review. Malta Medical Journal, 21 (1), 11 18. Agresti, A., & Finlay, B. (2009). Statistical methods for the social sciences (4th ed.). United States of America: Prentice Hall, Inc. American Academy of Pediatrics. (n.d.a). About the committee on bioethics (COB). Retrieved 2011, March 28, from http:// www.aap.org/sections/bioethics/Committee.cfm American Academy of Pediatrics. (n.d.b). Community pediatrics: Children's rights curriculum. Retrieved March 28, 2011, from http://www.aap.org/commpeds/resources/childrensrights.htm American Medical Association. (n.d.). AMA's code of medical ethics. Retrieved March 28, 2011, from http://www.ama assn.org/ama/pub/physician resources/medical ethics/code medical ethics.page American Nurses Association. (2011). Code of ethics for nurses. Retrieved March 28, 2011, from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsf orNurses.aspx Avan, B. I., & Kirkwood, B. R. (2010). Review of theoretical frameworks for the study of child de velopment within public health and epidemiology. Journal of Epidemiology & Community Health, 64 388 393. doi:10.1136/jech.2008.084046 Bandura, A. (1977). Social learning theory Englewood Cliffs, N.J.: Prentice Hall, Inc. Banks, E. (1990). Concepts of h ealth and sickness of preschool and school aged children. Child Health Care, 19 (1), 43 48. Bass, K. (n.d.). Great quotes.com. Retrieved March 28, 2011, from http://www.great quotes.com/qu ote/847151 Belin, T. R., & Normand, S. T. (2009). The role of ANCOVA in analyzing experimental data. Psychiatric Annals, 39 (7), 753 760. Bell, J. L., Johnson, B. H., Desai, P. P., & McLeod, S. M. (2009). Family centered care and the implications for chil d life practice. In R. H. Thompson (Ed.), The handbook of child life (pp. 95 115). Springfield, Illinois: Charles C Thomas, Publisher, LTD. Bibace, R., & Walsh, M. E. (1980). Development of children's concepts of illness. Pediatrics, 66 912 917.

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93 Krupat, E., Rosenkranz, S. L., Yeage r, C. M., Barnard, K., Putnam, S. M., & Inui, T. S. (2000). The practice orientations of physicians and patients: The effect of doctor patient congruence on satisfaction. Patient Education and Counseling, 39 (1), 49 59. doi:DOI: 10.1016/S0738 3991(99)00090 7 Krupat, E., Yeager, C. M., & Putnam, S. (2000). Patient role orientations, doctor patient fit, and visit satisfaction. Psychology & Health, 15 (5), 707 719. Kuttner, L. (2010). A child in pain: What health professionals can do to help UK: Crown House P ublishing. Leech, N. L., Barrett, K. C., & Morgan, G. A. (2008). Data coding and explanatory analysis (EDA). In SPSS for intermediate statistics (3rd ed., pp. 23 45). United States of America: Taylor & Francis Group, LLC. Levetown, M., & the Committee on Bioethics. (2008). Communicating with children and families: From everyday interactions to skill in conveying distressing information. Pediatrics, 121 (5), e1441 e1460. Levi, B. H. (2007). Addressing parents' concerns about childhood immunizations: A tutorial for primary care providers. Pediatrics, 120 18 26. doi:10.1542/peds.2006 2627 Levinson, W., Lesser, C. S., & Epstein, R. M. (2010). Developing physician communication skills for patient centered care. Health Affairs, 29 (7), 1310 1318. doi:10.137 7/hlthaff.2009.0450 Lipsitz, J. D., Gur, M., Albano, A. M., & Sherman, B. (2011). A psychological intervention for pediatric chest pain: Development and open trial. Journal of Developmental & Behavioral Pediatrics, 32 (2), 153 157. Lipson, M. (1993). What do you say to a child with AIDS? Hastings Center Report, 23 (2), 6 12. Luthar, S. S., Cicchetti, D., & Becker, B. (2000). The construct of resilience: A critical evaluation and guidelines for future work. Child Development, 71 (3), 543 562. Mabe, P. A., T reiber, F. A., & Riley, W. T. (1991). Examining emotional distress during pediatric hospitalization for school aged children. Children's Health Care, 20 (3), 162. MacLaren, J., & Kain, Z. N. (2009). Behavioral analysis of children's response to induction o f anesthesia. Anesthesia & Analgesia, 109 1434 1440. venepuncture. Journal of Pediatric Psychol ogy, 35 (9), 985 995. doi:10.1093/jpepsy/jsq009

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95 Rumrill, P. D., & Bellini, J. L. (1999). The logic of experimental design. Journal of Vocational Rehabilit ation, 13 (1), 65. Rushforth, H. (1999). Practitioner review: Communicating with hospitalised children: Review and application of research pertaining to children's understanding of health and illness. Journal of Child Psychology and Psychiatry, 40 (5), 683 691. Salmela, M., Salanter, S., & Aronen, E. (2009). Child reported hospital fears in 4 to 6 year old children. Pediatric Nursing, 35 (5), 269 276, 303. Schaeuble, K., Haglund, K., & Vukovich, M. (2010). Adolescents' preferences for primary care provider interactions. Journal for Specialists in Pediatric Nursing, 15 (3), 202 210. doi:10.1111/j.1744 6155.2010.00232.x Schechter, N. L., Bernstein, B. A., Zempski, W. T., Bright, N. S., & Willard, A. K. (2010). Educational outreach to reduce immunization pain in office settings. Pediatrics, 126 e1514 e1521. doi:10.1542/peds.2010 1597 Schmidt, C. K. (2002). Comparison of three teaching methods on 4 through 7 year old management of a sthma: A pilot study. Journal of Asthma, 39 (7), 641 648. Schmidt, H. (1998). Integrating the teaching of basic sciences, clinical sciences, and biopsychosocial issues. Academic Medicine, 73 (9), S24 S31. Schmidt, L. R., & Frohling, H. (2000). Lay concepts of health and illness from a developmental perspective. Psychology and Healt, 15 229 238. Scolnik, D., Atkinson, V., Hadi, M., Caulfeild, J., & Young, N. L. (2003). Words used by children and their primary caregiver for private body parts and functions. Canadian Medical Association Journal, 169 (12), 1275 1279. Sexton, M., & Massey, B. (2011). Humanism in medicine: Incorporating child life into medical student curriculum 29th Annual Child Life Council Conference on Professional Issues: Child Life Counci l, Inc. Siegal, M. (1988). Children's knowledge of contagion and contamination as causes of illness. Child Development, 59 (5), 1353 1359. Sigelman, C., Maddock, A., Epstein, J., & Carpenter, W. (1993). Age differences in understanding of disease causalit y: AIDS, colds, and cancer. Child Development, 64 (1), 272 284. Simons, J., & Roberson, E. (2002). Poor communication and knowledge deficits: Journal of Advanced Nursing, 40 (1), 78 86.

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96 Sm ith, L., & Callery, P. (2005). Children's accounts of their preoperative information needs. Journal of Clinical Nursing, 14 230 238. Southall, D. P., Burr, S., Smith, R. D., Bull, D. N., Radford, A., Williams, A., & Nicholson, S. (2000). The child friend ly healthcare initiative (CFHI): Healthcare provision in accordance with the UN convention on the rights of the child. Pediatrics, 106 1054 1064. doi:10.1542/peds.106.5.1054 Springer, K., & Ruckel, J. (1992). Early beliefs about the cause of illness: Evi dence against immanent justice. Cognitive Development, 7 429 443. StatSoft Inc. (2011). ANOVA/MANOVA. In Electronic statistics textbook Tulsa, OK: StatSoft. Street, R. L., Krupat, E., Bell, R. A., Kravitz, R. L., & Haidet, P. (2003). Beliefs about cont rol in the physician patient relationship. Journal of General Internal Medicine, 18 (8), 609 616. doi:10.1046/j.1525 1497.2003.20749.x Tanner, J. L., Stein, M. T., Olson, L. M., Frintner, M. P., & Radecki, L. (2009). Reflections on well child care practic e: A national study of pediatric clinicians. Pediatrics, 124 (3), 849 857. Thompson, M. L. (1994). Information seeking coping and anxiety in school age children anticipating surgery. Children's Health Care, 23 (2), 87. Thompson, R. H. (1985). Psychosocial research on pediatric hospitalization and health care: A review of the literature. Springfiled, IL: Charles C. Thomas. Thompson, R. H., & Snow, C. W. (2009). Research in child life. In R. H. Thompson (Ed.), The handbook of child life (pp. 36 56). Springfi eld, Illinois: Charles C. Thomas. Thompson, R. H., & Vernon, D. T. A. (1993). Research on children's behavior after hospitalization: A review and synthesis. Developmental and Behavioral Pediatrics, 14 28 35. Turner, J. C. (2009). Theoretical foundations of child life practice. In R. H. Thompson (Ed.), The handbook of child life: A guide for pediatric psychosocial care (pp. 23 35). Springfield, Illinois: Charles C. Thomas Publisher, Ltd. U.S. Department of Health and Human Services. (2010). Summary health statistics for U.S. children: National health interview survey, 2009. No. 247). Hyattsville, Maryland: United Nations. (1989). Convention on the rights of the child. No. 1577).UN General Assembly.

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97 Vacik, H. W., Nagy, M. C., & Jessee, P. O. (2001). Children's understanding of illness: Students' assessments. Journal of Pediatric Nursing, 16 (6), 429 437. Varkula, L. C., Resler, R. M., Schulze, P. A., & McCue, K. (2010). Pre school children's understanding of cancer: The impact of parental teaching an d life experience. Journal of Child Health Care, 14 (1), 24 34. doi:10.1177/1367493509347115 Vessey, J. A., & O'Sullivan, P. (2000). A study of children's concepts of their internal bodies: A comparison of children with and without congenital heart disease Journal of Pediatric Nursing, 15 (5), 292 298.

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98 BIOGRAPHICAL SKETCH Jessica Wente received her Bachelor of Science at Florida State University in Family and Child Sciences, minoring in Chemistry. After traveling as a consultant for a non profit organ ization, Jessica attended Johns Hopkins Child Life Training Program, certifying as a child life specialist shortly after. She received her Master of Science from the University of Florida in Family, Youth, and Community Sciences. In her time at the Univer sity of Florida, Jessica continued clinical experience as a student and then as a professional at in the pediatric hematology oncology clinic of Shands at UF, a private, non for profit hospital. Upon graduation, Jessica accepted a child life specialist pos ition with Florida Hospital for Children.