Developmental Theories

Stage 1: Oral (Birth to 12 to 18 Months): Initially sucking and oral satisfaction are not only vital to life but also extremely pleasurable in their own rights. Late in this stage the infant begins to realize that the mother/parent is something separate from self. Disruption in the physical or emotional availability of the parent (e.g., inadequate bonding or chronic illness) could affect an infant’s development.

Stage 2: Anal (12 to 18 Months to 3 Years): The focus of pleasure changes to the anal zone. Children become increasingly aware of the pleasurable sensations of this body region with interest in the products of their effort. Through the toilet-training process the child delays gratification to meet parental and societal expectations.

Stage 3: Phallic or Oedipal (3 to 6 Years): The genital organs are the focus of pleasure during this stage. The boy becomes interested in the penis; the girl becomes aware of the absence of the penis, known as penis envy. This is a time of exploration and imagination as the child fantasizes about the parent of the opposite sex as his or her first love interest, known as the Oedipus or Electra complex. By the end of this stage the child attempts to reduce this conflict by identifying with the parent of the same sex as a way to win recognition and acceptance.

Stage 4: Latency (6 to 12 Years): In this stage Freud believed that sexual urges from the earlier oedipal stage are repressed and channeled into productive activities that are socially acceptable. Within the educational and social worlds of the child, there is much to learn and accomplish.

Stage 5: Genital (Puberty Through Adulthood): In this final stage sexual urges reawaken and are directed to an individual outside the family circle. Unresolved prior conflicts surface during adolescence. Once the individual resolves conflicts, he or she is then capable of having a mature adult sexual relationship.

Freud believed that the components of the human personality develop in stages and regulate behavior. These components are the id, the ego, and the superego. The id (i.e., basic instinctual impulses driven to achieve pleasure) is the most primitive part of the personality and originates in the infant. The ego represents the reality component, mediating conflicts between the environment and the forces of the id. The ego helps people judge reality accurately, regulate impulses, and make good decisions. The third component, the superego, performs regulating, restraining, and prohibiting actions. Often referred to as the conscience, the superego is influenced by the standards of outside social forces (e.g., parent or teacher).

Some of Freud’s critics contend that he based his analysis of personality development on biological determinants and ignored the influence of culture and experience. Other critics think that Freud’s basic assumptions such as the Oedipus complex are not applicable across different cultures. Psychoanalysts today believe that the role of conscious thought is much greater than Freud imagined (Santrock, 2008).

Trust versus Mistrust (Birth to 1 Year): Establishing a basic sense of trust is essential for the development of a healthy personality. The infant’s successful resolution of this stage requires a consistent caregiver who is available to meet his needs. From this basic trust in parents, the infant is able to trust in himself, in others, and in the world (Hockenberry and Wilson, 2011). The formation of trust results in faith and optimism. A nurse’s use of anticipatory guidance helps parents cope with the hospitalization of an infant and the infant’s behaviors when discharged to home.

Autonomy versus Sense of Shame and Doubt (1 to 3 Years): By this stage a growing child is more accomplished in some basic self-care activities, including walking, feeding, and toileting. This newfound independence is the result of maturation and imitation. The toddler develops his or her autonomy by making choices. Choices typical for the toddler age-group include activities related to relationships, desires, and playthings. There is also opportunity to learn that parents and society have expectations about these choices. Limiting choices and/or enacting harsh punishment leads to feelings of shame and doubt. The toddler who successfully masters this stage achieves self-control and willpower. The nurse models empathetic guidance that offers support for and understanding of the challenges of this stage.

Initiative versus Guilt (3 to 6 Years): Children like to pretend and try out new roles. Fantasy and imagination allow them to further explore their environment. Also at this time they are developing their superego, or conscience. Conflicts often occur between the child’s desire to explore and the limits placed on his or her behavior. These conflicts sometimes lead to feelings of frustration and guilt. Guilt also occurs if the caregiver’s responses are too harsh. Preschoolers are learning to maintain a sense of initiative without imposing on the freedoms of others. Successful resolution of this stage results in direction and purpose. Teaching the child impulse control and cooperative behaviors helps the family avoid the risks of altered growth and development.

Industry versus Inferiority (6 to 11 Years): School-age children are eager to apply themselves to learning socially productive skills and tools. They learn to work and play with their peers. They thrive on their accomplishments and praise. Without proper support for learning new skills or if skills are too difficult, they develop a sense of inadequacy and inferiority. Children at this age need to be able to experience real achievement to develop a sense of competency. Erikson believed that the adult’s attitudes toward work are traced to successful achievement of this task (Erikson, 1963). During hospitalization it is important for the school-age child to understand the routines and participate as actively as possible in his or her treatment. For example, some children enjoy keeping a record of their intake and output.

Identity versus Role Confusion (Puberty): Dramatic physiological changes associated with sexual maturation mark this stage. There is a marked preoccupation with appearance and body image. This stage, in which identity development begins with the goal of achieving some perspective or direction, answers the question, “Who am I?” Acquiring a sense of identity is essential for making adult decisions such as choice of a vocation or marriage partner. Each adolescent moves in his or her unique way into society as an interdependent member. There are also new social demands, opportunities, and conflicts that relate to the emergent identity and separation from family. Erikson held that successful mastery of this stage resulted in devotion and fidelity to others and to their own ideals (Hockenberry and Wilson, 2011). The nurse provides education and anticipatory guidance for the parent about the changes and challenges to the adolescent. Nurses also help hospitalized adolescents deal with their illness by giving them enough information to allow them to make decisions about their treatment plan.

Intimacy versus Isolation (Young Adult): Young adults, having developed a sense of identity, deepen their capacity to love others and care for them. They search for meaningful friendships and an intimate relationship with another person. Erikson portrayed intimacy as finding the self and then losing the self in another (Santrock, 2008). If the young adult is not able to establish companionship and intimacy, isolation results because he or she fears rejection and disappointment (Berger, 2007). Nurses must understand that hospitalization increases a young adults’ need for intimacy; thus young adults benefit from the support of their partner or significant other during this time.

Generativity versus Self-Absorption and Stagnation (Middle Age): Following the development of an intimate relationship, the adult focuses on supporting future generations. The ability to expand one’s personal and social involvement is critical to this stage of development. Middle-age adults achieve success in this stage by contributing to future generations through parenthood, teaching, and community involvement. Achieving generativity results in caring for others as a basic strength. Inability to play a role in the development of the next generation results in stagnation (Santrock, 2008). Nurses assist physically ill adults in choosing creative ways to foster social development. Middle-age persons often find a sense of fulfillment by volunteering in a local school, hospital, or church.

Integrity versus Despair (Old Age): Many older adults review their lives with a sense of satisfaction, even with their inevitable mistakes. Others see themselves as failures, with their lives marked by despair and regret. Older adults often engage in a retrospective appraisal of their lives. They interpret their lives as a meaningful whole or experience regret because of goals not achieved (Berger, 2007). Because the aging process creates physical and social losses, some adults also suffer loss of status and function (e.g., through retirement or illness). These external struggles are also met with internal struggles such as the search for meaning in life. Meeting these challenges creates the potential for growth and the basic strength of wisdom (Fig. 11-1).

Nurses are in positions of influence within their communities to help people feel valued, appreciated, and needed. Erikson stated, “Healthy children will not fear life, if their parents have integrity enough not to fear death” (Erikson, 1963). Although Erikson believed that problems in adult life resulted from unsuccessful resolution of earlier stages, his emphasis on family relationships and culture offered a broad, life-span view of development. As a nurse, you will use this knowledge of development as you deliver care in any health care setting.

• The easy child—Easygoing and even-tempered. This child is regular and predictable in his or her habits. An easy child is open and adaptable to change and displays a mild-to– moderately intense mood that is typically positive.

• The difficult child—Highly active, irritable, and irregular in habits. Negative withdrawal toward others is typical, and the child requires a more structured environment. A difficult child adapts slowly to new routines, people, or situations. Mood expressions are usually intense and primarily negative.

• The slow-to–warm up child—Typically reacts negatively and with mild intensity to new stimuli. The child adapts slowly with repeated contact unless pressured and responds with mild but passive resistance to novelty or changes in routine.

Period I: Sensorimotor (Birth to 2 Years): Infants develop a schema or action pattern for dealing with the environment. These schemas include hitting, looking, grasping, or kicking. Schemas become self-initiated activities (e.g., the infant learning that sucking achieves a pleasing result generalizes the action to suck fingers, blanket, or clothing). Successful achievement leads to greater exploration. During this stage the child learns about himself and his environment through motor and reflex actions. He or she learns that he or she is separate from the environment and that aspects of the environment (e.g., parents or favorite toy) continue to exist even though they cannot always be seen. Piaget termed this understanding that objects continue to exist even when they cannot be seen, heard, or touched object permanence and considered it one of the child’s most important accomplishments.

Period II: Preoperational (2 to 7 Years): During this time children learn to think with the use of symbols and mental images. They exhibit “egocentrism” in that they see objects and persons from only one point of view, their own. They believe that everyone experiences the world exactly as they do. Early in this stage children demonstrate “animism” in which they personify objects. They believe that inanimate objects have lifelike thought, wishes, and feelings. Their thinking is influenced greatly by fantasy and magical thinking. Children at this stage have difficulty conceptualizing time. Play becomes a primary means by which they foster their cognitive development and learn about the world (Fig. 11-2). Nursing interventions during this period recognize the use of play as the way the child understands the events taking place.

Period III: Concrete Operations (7 to 11 Years): Children now are able to perform mental operations. For example, the child thinks about an action that before was performed physically. Children are now able to describe a process without actually doing it. At this time they are able to coordinate two concrete perspectives in social and scientific thinking so they are able to appreciate the difference between their perspective and that of a friend. Reversibility is one of the primary characteristics of concrete operational thought. Children can now mentally picture a series of steps and reverse the steps to get back to the starting point. The ability to mentally classify objects according to their quantitative dimensions, known as seriation, is achieved. They are able to correctly order or sort objects by length, weight, or other characteristics. Another major accomplishment of this stage is conservation, or the ability to see objects or quantities as remaining the same despite a change in their physical appearance (Santrock, 2009).

Period IV: Formal Operations (11 Years to Adulthood): The transition from concrete to formal operational thinking occurs in stages during which there is a prevalence of egocentric thought. This egocentricity leads adolescents to demonstrate feelings and behaviors characterized by self-consciousness, a belief that their actions and appearance are constantly being scrutinized (an “imaginary audience”), that their thoughts and feelings are unique (the “personal fable”), and that they are invulnerable (Santrock, 2008). These feelings of invulnerability frequently lead to risk-taking behaviors, especially in early adolescence. As adolescents share experiences with peers, they learn that many of their thoughts and feelings are shared by almost everyone, helping them to know that they are not so different. As adolescents mature, their thinking moves to abstract and theoretical subjects. They have the capacity to reason with respect to possibilities. For Piaget this stage marked the end of cognitive development.

Piaget’s work has been challenged over the years as researchers have continued to study cognitive development. For example, some aspects of objective performance emerge earlier than Piaget believed, and other cognitive abilities can surface later than he predicted. We now know that many adults may not become formal operational thinkers and others have cognitive development that goes beyond the stages that Piaget proposed (Santrock, 2009). Assessment of cognitive ability becomes critical as the nurse engages in health care teaching for patients and families.

Level I: Preconventional Reasoning: This is the premoral level, in which there is limited cognitive thinking and the individual’s thinking is primarily egocentric. At this stage thinking is mostly based on likes and pleasures. This stage progresses toward having punishment guide behavior. The person’s moral reason for acting, the “why,” eventually relates to the consequences that the person believes will occur. These consequences come in the form of punishment or reward. It is at this level that children view illness as a punishment for fighting with their siblings or disobeying their parents. Nurses need to be aware of this egocentric thinking and reinforce that the child does not become ill because of wrongdoing.

Level II: Conventional Reasoning: At level II, conventional reasoning, the person sees moral reasoning based on his or her own personal internalization of societal and others’ expectations. A person wants to fulfill the expectations of the family, group, or nation and also develop a loyalty to and actively maintain, support, and justify the order. Moral decision making at this level moves from, “What’s in it for me?” to “How will it affect my relationships with others?” Emphasis now is on social rules and a community-centered approach (Berger, 2007). Nurses observe this when family members make end-of-life decisions for their loved ones. Individual members often struggle with this type of moral dilemma. Grief support involves an understanding of the level of moral decision making of each family member (see Chapter 36).

Level III: Postconventional Reasoning: The person finds a balance between basic human rights and obligations and societal rules and regulations in the level of postconventional reasoning. Individuals move away from moral decisions based on authority or conformity to groups to define their own moral values and principles. Individuals at this stage start to look at what an ideal society would be like. Moral principles and ideals come into prominence at this level (Berger, 2007).

1. Mrs. Banks is an 84-year-old woman who has recently been diagnosed with breast cancer. She also has severe cardiovascular disease that limits her choices of treatment. She has completed a series of radiation treatments that have left her exhausted and unable to participate in her usual activities. Her oncologist now recommends a cycle of chemotherapy treatments that her cardiologist believes would be fatal. Her family is urging her to do all that is recommended. The patient, who is in good spirits despite her diagnosis, decides against further medical treatment.

2. Amanda Peters, 9 years old, was admitted to the unit yesterday with a new diagnosis of type I diabetes. Her mother has spent the night with her and is arranging the food on Amanda’s breakfast tray when you enter the room to check her blood sugar and administer her insulin. Although the diabetes educator will be meeting with Amanda and her family, as part of her care today you want to begin her discharge teaching.

3. You have been assigned to care for Daniel Jackson, a 17-year-old male who was in an automobile accident several days ago and sustained a fractured pelvis. He has had a surgical repair and remains on bed rest. School is starting next month and he was scheduled to begin football practice next week. During bedside report he refuses to make eye contact with the nursing staff or respond to any questions to help direct his care.

1. The nurse is aware that preschoolers often display a developmental characteristic that makes them treat dolls or stuffed animals as if they have thoughts and feelings. This is an example of:

2. An 18-month-old child is noted by the parents to be “angry” about any change in routine. This child’s temperament is most likely to be described as:

3. Nine-year-old Brian has a difficult time making friends at school and being chosen to play on the team. He also has trouble completing his homework and, as a result, receives little positive feedback from his parents or teacher. According to Erikson’s theory, failure at this stage of development results in:

4. The nurse teaches parents how to have their children learn impulse control and cooperative behaviors. This would be during which of Erickson’s stages of development?

5. When Ryan was 3 months old, he had a toy train; when his view of the train was blocked, he did not search for it. Now that he is 9 months old, he looks for it, reflecting the presence of:

6. When preparing a 4-year-old child for a procedure, which method is developmentally most appropriate for the nurse to use?

7. A 35-year-old woman is speaking with you about her recent diagnosis of a chronic illness. She is concerned about her treatment options in relation to her ability to continue to care for her family. As she considers the options and alternatives, she incorporates information, her values, and emotions to decide which plan will be the best fit for her. She is using which form of cognitive development?

8. You are caring for a recently retired man who appears withdrawn and says he is “bored with life.” Applying the work of Havinghurst, you would help this individual find meaning in life by:

9. Place the following stages of Freud’s psychosexual development in the proper order by age progression.

    10. According to Piaget’s cognitive theory, a 12-year-old child is most likely to engage in which of the following activities?

    11. Allison, age 15 years, calls her best friend Laura and is crying. She has a date with John, someone she has been hoping to date for months, but now she has a pimple on her forehead. Laura firmly believes that John and everyone else will notice the blemish right away. This is an example of the:

    12. Elizabeth, who is having unprotected sex with her boyfriend, comments to her friends, “Did you hear about Kathy? You know, she fools around so much; I heard she was pregnant. That would never happen to me!” This is an example of adolescent:

    13. Teaching an older adult how to use e-mail to communicate with a grandchild who lives in another state is an example of ____________, which aids cognitive performance by using new approaches.

    14. Dave reports being happy and satisfied with his life. What do we know about Dave?

    15. You are working in a clinic that provides services for homeless people. The current local regulations prohibit providing a service that you believe is needed by your patients. You adhere to the regulations but at the same time are involved in influencing authorities to change the regulation. This action represents which stage of moral development?