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I": q A {54‘ ”'01-” 2' l 3 “I 'yg ‘ Warn" swam-Jaw? ll Tum; lllzllfllljllll in 11 mil IILI I'll u a 2.; This is to certify that the thesis entitled THE EXPRESSED CONCERNS OF MALE ADOLESCENTS WHEN PROVIDED THE INFORMATION THAT THEIR PHYSICAL EXAMINATION MAY BE CONDUCTED BY A FEMALE HEALTH CARE PROVIDER presented by Judith Rae Mitchell has been accepted towards fulfillment of the requirements for M.N. degree in NUT‘San / ,Q- G ‘ . // ” «jZCAQU ,_ ‘Tea/ Major professor Date October 13. 1978 0-7639 LIBRARY -~ Michigan State ' Univr' I ‘~' ' © 1978 JUDITH RAE MITCHELL ALL RIGHTS RESERVED THE EXPRESSED CONCERNS OF MALE ADOLESCENTS NHEN PROVIDED THE INFORMATION THAT THEIR PHYSICAL EXAMINATION MAY BE CONDUCTED BY A FEMALE HEALTH CARE PROVIDER By Judith Rae Mitchell A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF NURSING School of Nursing 1978 ABSTRACT THE EXPRESSED CONCERNS OF MALE ADOLESCENTS WHEN PROVIDED THE INFORMATION THAT THEIR PHYSICAL EXAMINATION MAY BE CONDUCTED BY A FEMALE HEALTH CARE PROVIDER By Judith Rae Mitchell In the present study the concerns of male adolescents are identified when provided the information that their complete physical examination might be conducted by a female health care provider instead of a male provider. Additionally the relationships between the Concerns of the participants and their Ages and Tanner Stages of development are determined. Finally the relationship between Tanner Stage and Concerns was identified while holding Age constant. To determine the relationships between the independent vari- ables Age and Tanner Stage and the dependent variables Concerns (Total), Body Image, Identity, Independence and Relatedness Concerns, Pearson Product-Moment and Partial Correlations were used. The find- ings show that as Age increased, Concerns (Total) decreased. The findings further showed that there was no significant relationship between Concerns (Total) and Tanner Stage. Additional data analysis revealed that as Age was held constant there was no significant relationship between Tanner Stage and Concerns. To My Family, Len, Geoff, and Steve ii ACKNOWLEDGMENTS I wish to convey my appreciation to The Michigan Department of Public Health for the Fellowship Grant which made my graduate education possible. A special note of thanks is extended to committee chairman, Dr. Barbara Given, my mentor, who gave me support, advice, and encouragement in this undertaking. She always knew how I felt. I am grateful to my thesis committee members, Bonnie Elmassian, Patricia Peek, Patricia Salisbury, and Jacqueline Wright for their guidance and counsel which proved to be invaluable through- out this study. I wish to thank LeAnn Slicer for helping me with the seemingly little things that were very big to me. She went beyond the usual limits of helpfulness. I greatly appreciate those people in the physician's offices who helped administer the questionnaires: Ann Avery, RN, P.N.P., Carol Phillip Bray, P.A., Linda Feighner, RN, P.N.P., Linda Jonites, RN, P.N.P. and office receptionists Betty Morse, Laura Little and Doris Trarey. A special note of appreciation is given to physicians, Walter Long, M.D., Paulino Chan, M.D., and Allen Dumont, M.D. These people gave me permission to conduct the research in their private offices when seemingly no others would offer such consent. iii I wish to thank Dr. William Crano for his kindness and help in developing the instrument and the data analysis. His interest in the study furthered its progress. Above all, I am especially grateful to my husband Len, and sons Geoffrey and Steven who gave me support, offered patience, were proud of me, and helped me withstand the vicissitudes of this part of my life. iv TABLE OF CONTENTS Page LIST OF TABLES ......................... viii LIST OF FIGURES ......................... ix Chapter I. THE PROBLEM ........................ l Introduction ...................... 1 Purpose ........................ 2 Statement of the Problem ................ 3 Conceptual Hypotheses ................. 3 Operational Definition of Concepts ........... 3 Delimitation of the Problem Area ............ 9 Limitations of the Study ................ lO Assumptions ...................... ll Overview of the Chapters ................ l2 II. CONCEPTUAL FRAMEWORK ................... 13 Introduction ...................... l3 Male-Female Relationships in Health Care ........ l3 Adolescent Developmental Characteristics ........ 17 Nursing Theory--Imogene King .............. 23 Summary ........................ 26 III. REVIEW OF THE LITERATURE ................. 30 Introduction ...................... 3O Adolescence ...................... 3] Physiological Development .............. 32 Body Image ..................... 36 Identity ...................... 40 Independence .................... 42 Relatedness ..................... 46 Summary ........................ 48 IV. METHODOLOGY AND PROCEDURE ................. 5l Overview ........................ 5l Chapter Page Population ...................... 53 Descriptions of Settings ............... 55 The Instrument .................... 57 Overview ...................... 57 Pre-Pilot Testing ................. 58 Pilot Testing ................... 62 Reliability .................... 65 Validity ...................... 67 Data Collection Procedure ............... 69 Scoring ........................ 72 Data Analysis ..................... 74 Operational Definitions of Concepts ........ 74 The Variables ..................... 80 The Hypotheses .................... 80 The Statistical Techniques .............. 8l Human Rights Protection ................ 85 V. DATA PRESENTATION AND ANALYSIS .............. 86 Overview ....................... 86 Descriptive Findings of the Popualtion ........ 87 Participants and Nonparticipants .......... 88 Previous Examinations by Female Health Care Providers ..................... 92 Summary ...................... 94 Data Presentation for Hypotheses ........... 95 Hypothesis l: Descriptive Findings of Concerns . . 95 Summary ...................... ll5 Hypothesis 2 .................... ll7 Hypothesis 3 .................... ll9 Hypothesis 4 .................... l22 Reliability of the Instrument ............. l23 Summary ........................ l26 VI. SUMMARY, IMPLICATIONS, AND RECOMMENDATIONS ....... l27 Summary and Interpretations of the Findings ...... l3O Hypothesis 1 .................... l30 Hypothesis 2 .................... l4O Hypothesis 3 .................... l43 Hypothesis 4 .................... 145 Additional Findings ................ l46 iProblems Encountered ................. T47 Implications for Nursing and Other Health Professions .................... l48 Recommendations for Future Study ........... 156 vi Page APPENDICES ........................... 160 A. Demographic Data ...................... lGl B. Letter to Adolescent and Parent and Consent Form ...... 163 C. Researcher Letter to the Adolescent ............. l67 D. The Instrument with Key for Scoring ............. 170 E. Pre-Pilot Instrument and Pilot Instrument with Key for Scoring ..................... 176 F. Directions to the Receptionists ............... l90 G. Physician Permission Letters ................ 194 H. Human Rights Protection ................... l98 BIBLIOGRAPHY .......................... 209 vii Table 10. ll. 12. 13. LIST OF TABLES Page Example Correlation Matrix for Seven Study Variables . . . 83 Age and Tanner Stages of the Study Population and Eighteen Year Olds ................... 90 Number Per Tanner Stage for Age of Study Population and 18 Year Olds .................... 91 Previously Examined by Females and Mean Scores on Concerns for Mean Age and Mean Tanner Stage ...... 93 Total Number and Percentage of Individuals Identifying Body Image Concerns for Age According to Item Number ...................... 97 Total Number and Percentage of Individuals Identifying Identity Concerns for Age According to Item Number ......................... 99 Total Number and Percentage of Individuals Identifying Independence Concerns for Age According to Item Number ......................... 104 Total Number and Percentage of Individuals Identifying Relatedness Concerns for Age According to Item Number ......................... 108 Mean Concern Scores for Age and Tanner Stage ....... 112 Correlation Matrix Presenting the Pearson Product- Moment Correlation Coefficients for the Seven Study Variables .................... 117 Pearson Product-Moment Correlation Coefficients (r) Between Concerns and Tanner Stage with Partial Correlations Holding Age Constant ........... 123 Summary of Hypotheses 2 Through 4 with Variables, Results and Interpretations .............. 124 Scores for Pilot Testing ................. 189 viii LIST OF FIGURES Figure Page 1. Developmental Stages of Secondary Sex Characteristics. . . . 5 2. Model of King's Theory of Nursing .............. 25 3. Operational Model of King's Theory Applied to Male Adolescent Concerns ................... 27 4. Criteria for Selection of Participants in the Study ..... 54 5. Grid of Physiological Development for Tanner Staging, Part B of the Instrument ................. 64 ix CHAPTER I THE PROBLEM Introduction Currently in the United States there are an increasing number of women who are performing in health care provider roles. These professional women are physicians, nurse practitioners, nurse clin- icians, or physician's assistants. With the increase in numbers of female professional health care providers, the likelihood of being examined for health or illness care by such women is therefore greater. In practice many professional women notice and discuss their apparent effects on their patients, particularly the males. They attribute the effect of male patient embarrassment, to being a female health care provider instead of a male (Chard, 1976). Many profes- sional women examine all ages of female patients, but the examination of male patients is limited to children. The male provider, however, examines all the male patients from adolescence to old age plus female patients of all ages. In my own experience when examining male adolescents I have seen numerous instances of the patient beginning to tremble during the examination. The trembling continues throughout the examination and usually stops at the conclusion of the exam. Invariably the male patient says, "It's cold in here." Since the room temperature is controlled and sometimes overheated to protect against cold, I began to suspect that possibly the patients, instead of being cold, are in fact embarrassed to be examined by a woman. Such embarrassment might be difficult to express for a male adolescent. Many adolescent males exhibit trembling, while some walk out of the office when they discover their examination is to be conducted by a female. Therefore there is a need to study the combined issues of the male adolescent and his concerns when he is provided the information that he may be examined by a female health care provider. Purpose A review of the literature revealed that no research has been done concerning male patients examined by female health care pro- viders. Some researchers would therefore suggest that an experimental study be designed to measure the effects of females on male patients before and after a health care encounter. It would appear to be more appropriate to start with a descriptive study identifying the concerns of male patients when examined by female health care pro- viders. Since adolescence has been the age at which many health care providers have noted embarrassment in male patients (Chard, 1976) this study is delimited to male adolescents. The purpose of this research is to identify and describe the concerns of male adolescents when they are provided the information that their physical examination may be conducted by a female health care provider. When concerns are identified, further nursing research can be conducted measuring the effects of examination on male adoles- cents and determining how best to manage their concerns. Statement of the Problem In this study the following questions are addressed: 1. What are the concerns of male adolescents if provided with information that a female health care provider might conduct their physical examination? 2. Is there a relationship between their expressed concerns and age? 3. Is there a relationship between their expressed concerns and Tanner Stage of development? 4. What is the relationship between Tanner Stage, Age, and expressed concerns? The answers to the above questions provide a beginning to studies related to male adolescents as patients and females as health care providers. From the questions hypotheses are developed depicting the concepts in the present study. Conceptual Hypotheses 1. Concerns of male adolescents who might have a complete physical exam by a female health care provider can be identified. 2. The concerns expressed by the male adolescents will be related to age, 3. The concerns expressed by the male adolescents will be related to Tanner Stage. 4. Controlling for age, the concerns expressed by the male adolescents will be related to Tanner Stage. Operational Definition of Concepts 1. Adolescence is defined as a stage in the process of human maturation. This stage occurs between the ages of 10 and 20 in the life cycle of Man (Brown and Murphy, 1975). It is an "in-between" age meaning that the person in this stage of development is neither a child nor is he yet an adult (Oremland and Oremland, 1974). For the purpose of this study adolescence is defined by age of the male patient and includes ages 13, 14, 15, 16, 17 as designated on the instrument in the demographic section under Age. 2. Tanner Stage for males is the stage of physical develop- ment of the penis, scrotum, pubic hair, axillary hair, facial hair, voice and height. The Stages are designated as I, II, III, IV, V with Stage I being prepubescence increasing to Stage V which is adult level of physical development (Tanner, 1973). For the purposes of this study Tanner Stage is determined by the male participant checking all the characteristics of his current development (see Appendix D). Each characteristic listed pertains to a Tanner Stage(s) (see Figure l). The Stages checked are then scored by the researcher to obtain the current Tanner Stage of the male participant. 3. Concerns are defined as expressed feelings of anxiety or worry when given the information that the physical exam may be conducted by female health care providers. The feelings are expressed on a written instrument by the male adolescent immediately after he is given the information that his complete physical examination might be conducted by a female. Expressed concerns or feelings of anxiety are measured using a Likert scale prior to the physical examination. For the purposes of this study the measured areas of concerns are categorized according to Body Image, Identity, Independence, Related- ness, and Total Concerns. An additionally listed category "Other" is not measured quantitatively, but instead is an open ended statement a»mmucm»um »_m:¥ua_m .3ogm o» mgwmmg swag xgm»—»x< .mxog so» a»»oo»m> »gm»mg mama mo mew» pmama .mxdg so» mgmgmmu mu»o> gem zogm o» mgwmmg L_mg memmm .go»»m -3L»mcme mo »mmgo mo »g»oa pmamz .m»g_m com »»»oopm> »gm»mg gem; mo mE»» Faun: .mm»»m»cm»omgmgu xmm xgmggoumm mo mmmm»m pm»gmsao»m>mouu._ mg:o»a .Lao»com »mmmeg pmgmgmm mg» o»:» mmpomgm mg» we cc»mmmomg “xpco mm—pwama mg» mo cow» -umnogg g»»z .»»=u< .ugaoe xgmucoomm m Ego» o» »mmmcg mg» soc» »omnoca mappwama mam mmpomc< .mgso»coo mg» mo :o_»mcmamm o: g»»: .mmpomgm gem m»mmmgg mo »gmsmmempcm new go»»m>m»m ng»e=m .mm»»»amn mg» ccaogm go»»m>m»m mo mmcm ppmsm mem»mEm»n gm— -omLm mo »:mEmmLm»gu .apgo mPFPQma mg» mo co»»m»gm2m_a cmmmmgug» nx»cmg=amgm .max» new »g:osm g» »P=c< .mgm»g» mg» o» mg_ugm»xm »og co»»=g»g»m»c swag mo ummgam ng»eam .mmgm u_g:a mg_»cm mg» Lm>o xpmmgmam mummgam mapgau vgm mmgmou meoe .nggmu mmsoumg Ewe: .m_gmp mg» agopm go mwcma mg» mo mmmg mg» »m swag xgzcu .»gm»mg»m .mgo» mo g»:ogm mmgmnm .gmsougm mg» go »mg» o» empwewm mmgm owgza gm>o cwmgmx»emg=amea .gmm-Nm .aa .mom. .meowuaumpgaa ”ccowxo ..um ucm .mogmomm—ou< »m g»:¢gc .megm» .2 mmsma "mmcaom .g:o»:ou use mnmm g» »»=u< > .mgmpm mg» mo »gmsao»m>mu gem g»nameg a» g»:otm "E:»ogom new mm»mm» .mwgma mg» mo »gmsmmcmpcm cmg»g:m >H .E=»ogmm new mm»mm» mo g»3ogm ng»gsm wm_cma mg» mo »gmsmmcm»:m Pm»»»gH HHH .E=»ogum mg» mo mmmcmgo mg:»xm» new mngmuumL “mm»mm» ago 5:» -ogom mg» mo »gms -mmaa.=m _a»»»=~ Hg zugmgsamgm H mmmgmgu ng»o I‘ll." I »:mEQo—m>mo »mmmgm mpmsmu »gm5no»m>mo me: owgag mpmsmm new mpmz I TWMIHIHRIIWU " 1| »em5go»m>mo _~»_=mm m_a: omega emcee» gaunt”... III.‘ allowing the participant the freedom to write any other concern he may have (see Appendix D, Part A). a. Body Imagg is the "image of our body which we form in our mind--the way in which our body appears to ourselves“ (Schilder, 1935, p. 11). The body image of the adolescent is his perception of his physical body. It is how he views his body at any point in time. For the purposes of this study, Body Image is one of the categories of concerns in the instrument and pertains to the adolescent's percep- tion of his physical body. His perception of his body may partially cause concern or lack of concern relative to the examiner being a female. The items included in the Body Image category contain the words "scrotum," "erection," or "body" (see Appendix D, item numbers 1, 6, 7, l4 and 20). b. Identity is "the psychological awareness of self-sameness over time with the reciprocal awareness of others' perceptions of self-sameness" (Erikson, 1968, p. 50). "Identity refers to the adolescent's awareness of who he is as well as his perception of the assessment of others regarding who he is. As such, identity is partly self-defined and partly socially conferred" (Sider and Kreider, 1977, p. 844). Identity is defined as one's philosophy of self, or the self-image of who the person is in relation to his behavior, values, work, life style and environment. It is how he views himself as a person, how he defines himself, his values, habits, personality as opposed to those of other people. For the purpose of this study, Identity is one of the categories of concerns in the instrument and pertains to the philosophy of self as defined by the adolescent. The philosophy of self may partially determine the level of concern or lack of concern relative to the examiner being a woman. The items included in the Identity category contain the words "child," "feelings," "manners," "habits," or "we." See Appendix D, item numbers 2, 9, 13, 15 and 19. c. Independence is the freedom of the adolescent from a feeling of control by others (Sider and Kreider, 1977). It is a sense of autonomy and refers to the separation of physical and mental control of parents, other adults, and the environment with a move toward bonding with peers and self control. For the purpose of this study, Independence is one of the categories of concerns in the instrument and pertains to the adolescent need or desire for control of both himself and his environment. The need for control may precipitate concern or lack of concern if the examiner is a female. The items included in the Independence category contain the words "let me," "parents," "my word," "my choice," or "control" within their structure. See Appendix D, item numbers 3, 5, 8, 10 and 16. d. Relatedness refers to developing relationships and inter- actions with peers and members of the opposite sex (Sider and Kreider, 1977). For the purpose of this study, Relatedness is one of the categories of concerns in the instrument. The items considered as the Relatedness category contain the words "sexual," "make a pass,“ or "woman" within their struc- ture, and all imply a relationship or interaction with fear or anxiety concerning this relationship between the adolescent and the female examiner. See Appendix D, item numbers 4, ll, 12, 17 and 18. e. chgr_is an area of concern in the instrument in which the adolescent may write an answer to the open-ended statement: "Someting that hasn't been mentioned so far that rgglly_con- cerns me if a woman examines me is ." This item is placed as the final item in Part A of the instrument. (See Appendix D.) The sum of the scores of concerns in the categories of Body Image, Identity, Independence and Relatedness on the instrument is computed for each male adolescent participant. The sum is referred to as "Total Concerns." 4. Complete physical examination is defined as assessment of all body systems of the male adolescent using the methods of inspection, palpation, percussion, and auscultation where appropriate. Such systems assessed are the skeletel, muscular, central nervous, peripheral nervous, sensory, cardiovascular, lymph, respiratory, digestive, excretory, reproductive, endocrine and integumentary (Bates, 1974). For the purposes of the study the complete physical examination is conducted for health maintenance or screening purposes, i.e., school sports physical examinations, and is not related to illness. 5. Female health care_provider is defined as women who are: a. Registered nurses who are also students currently enrolled in programs preparing nurses to function in expanded roles such as Nurse Practitioners and Nurse Clinicians, or b. Certified, or uncertified Nurse Practitioners such as Pediatric Nurse Practitioners, Family Nurse Practitioners or c. Nurse Clinicians with a master's degree in nursing such as Family Nurse Clinicians and Clinical Special- ists, or d. Practicing physicians, or e. Medical students, or f. Physician's Assistants. The term "female health care provider" is not defined for the par— ticipating adolescents other than that the examiner may be a female. The tygg_of female provider is not the critical issue in the study. The issue is that the provider may be a female. Delimitation of the Problem Area The problem area is delimited in nature to the following extent: the population researched is male adolescents between the ages 13—17. The adolescents have appointments at physician offices specifically for receiving complete physical examinations for sports entry, camp, school entry. The male adolescents have not been l0 frequent health care users as evidenced by diagnoses of illnesses such as diabetes, hypertension, kidney disease, cancer, heart disease, respiratory disease. Limitations of the Study The limitations of the study are: 1. Changes in body structure, view point, and perception occur rapidly in the adolescent age group. Therefore the findings in this study may not reflect the concerns of the same participating adolescents at another point in time. 2. The study does not analyze specifically male adolescent perceptions of or previous experience with women, socio-economic background, racial status or cultural status. Such concepts as these could greatly influence their concerns or lack of concerns if women examine them. 3. Another limitation of the study is the instrument itself. Some of the topics in the items responded to by the adolescents may be of concern to the participant if the examiner is a woman gr_a man, however, each item is worded to call attention to the female examiner. 4. The subjects who agree to participate in the study may be different from those who refuse. Therefore, it is possible that the research findings are not representative of the adolescent age group. 5. The study depends not only on the adolescent knowing his own physical sexual developmental status, but also on his willingness to honestly choose the items in the instrument which reflect such 11 development. For personal reasons the participant may not be able to select such items, thus distorting the findings. Pilot testing for professionally confirmed accuracy of the sexual development was unable to be conducted due to logistic problems. Assumptions In this study the researcher is making the following assumptions: 1. It is assumed that all male adolescents have ggmg_con- cerns when they are provided the information that they may possibly receive a complete physical exam by a female examiner. 2. It is assumed that the concerns expressed on the instru- ment by the male adolescents are rggl_and honest concerns to the patient. 3. It is assumed that the male adolescents can express their concerns on the given instrument. 4. It is assumed the male adolescents can read and understand the instrument. 5. It is assumed that the male adolescents know their own physical sexual development and can accurately choose the stages of development pertaining to them on the instrument. 6. It is assumed that the age group selected for the study is representative of adolescents in Tanner Stages I-V. 7. It is assumed that the concerns will be the same regard- less of the type of female health care provider. 12 Overview of the Chapters The study is organized into six chapters. Chapter I provides an introduction, statement of the problem, hypotheses, limitations, operational definitions and the assumptions underlying this study. In Chapter II the conceptual framework is presented drawing on related adolescent and nursing theory. In Chapter III the pertinent literature and research in the problem are reviewed. In Chapter IV methodology and procedures of the research are described. In Chapter V data presentation and analysis of the results of the research are given and discussed. In Chapter VI the research findings are summarized and conclusions and recommendations are presented. CHAPTER II CONCEPTUAL FRAMEWORK Introduction The framework presented in this chapter evolves from concepts in two areas: Adolescence and Nursing. The topics presented are: male-female relationships in health care, adolescent developmental characteristics, and nursing theory as depicted by King (1971). According to King the nursing perceptions are partially formed by experience and a clinical knowledge base. The results of the present study add to the knowledge base of the nurse. The judgments made and actions taken by the nurse reflect his/her understanding and acknowledgment of the expressed concerns of male adolescents when their complete physical examination may be conducted by a female health care provider. Male-Female Relationships in Health Care Currently there are an increasing number of female health care providers in the United States due to changes in the needs of, and the attitudes toward, professional women. Such changes in atti- tudes primarily address the issue of acceptance of women, as well as men, in health care provider roles. As a result of changes in attitudes toward females as professional health care providers, the public has also increased their awareness of potential resources 13 14 that women have to offer in health care. Women are now seeking careers in medicine and in the expanded professional nurse roles such as Nurse Practitioners and Nurse Clinicians. Presently women in the expanded nurse roles function in independent/interdependent and collaborative relationships with physicians and/or other health team members. They establish and maintain their own case-load of patients and provide care through history taking, physical examination, psychosocial counseling, coordination of health care, patient education, health maintenance, screening, and child care. The nurse in the expanded role provides continuous Patient care with follow-up as needed. She is primarily concerned with the patient/family as a total person/group, and does not single out parts of the patient, i.e. disease of an organ, as her ‘focus of care. The nurse provides care to the patient and his family in the context of his/their social, biological, psychological, spiritual and cultural aspects of health and illness. ‘Prior to the movement of nurses into expanded roles, the health care providers who examined patients were primarily male physicians. The role of Nurse Practitioners and Nurse Clinicians -did not exist. Due to the lack of female providers (female physicians, 'Nurse Practitioners, and Nurse Clinicians), many women patients did not have any choice except to be examined by male physicians (Roland, 1977). Therefore in a physical examination, many women experienced sexual embarrassment especially during the breast and pelvic exam. Great care was taken to reduce this embarrassment. Such care included draping, gaining trust and rapport, and relaxation techniques. 15 However, measures generally are not taken to reduce mglg embarrassment when they are the patients examined by female providers. An exception is Chard (1976) who provides an approach to reduce embarrassment in male adolescents during an examination by Nurse Practitioners. Chard assumes the male adolescent is embarrassed and that the embarrassment is sexual in nature. Roland presents the male point of view: "Many men reject the thought of having their genitalia examined by a woman . . ." (Roland, 1977, p. 55). Some men flatly refuse a physical examination if they find that the examination is to be completed by a woman (Chard, 1976). Some male adolescents assume a mask of indifference allowing the examination to proceed, but carefully concealing their feelings of embarrassment (Oremland and Oremland, 1974). When a female patient is examined by a male health care pro- vider, the female is carefully draped exposing only the area to be examined. Then the area is quickly covered as the next area is examined. Medical and nursing textbooks, when discussing the pro- cedures for examination of the female, point out to the reader the necessity of first gaining rapport and trust before conducting the examination. The texts then discuss the modesty of the female patient, draping of the female and keeping eye contact throughout the examination (Bates, 1974). Some texts have entire chapters on the pelvic examination for women, complete with sections on how to reduce the anxiety and embarrassment of the woman (Settlage, 1975). In the above textbook Settlage does not present any section on genital examination of the male patient, his anxieties, fears or l6 embarrassment. Statements concerning female patients are usually made with emphasis placed on the male examiner having "confidence, gentleness, and reasonable alacrity" (Vaughn and McKay, 1975, p. 1371). When the patient is a male examined by a female health care provider, nothing is mentioned in the textbooks concerning his modesty or emotional preparation for the examination. There is no mention of draping. The reader is immediately referred to inspection and palpation for key abnormality assessment. The extent of discussion is confined to, "It would seem easier to skip this part of the exam- ination [genital] for some boys because they are so upset by it" (Alexander and Brown, 1974, p. 166). In practice many times the male patient is not given a draping sheet and is allowed to wear his undershorts only, while possible embarrassment or fear due to exposure of his arms, legs and trunk seems to be of no consideration to the examiner. The dilemma is that many examiners assume, by avoidance of the subject, that male patients have no concerns or that their concerns are not that paramount when given a physical examination by a female health care provider. In summary, a change has occurred in the attitudes of pro- fessionals and the public concerning women in professional health care roles. As a result, an increasing number of female professional nurses are seeking careers in expanded roles such as the health care provider role. Traditionally the relationship between provider and patient has involved the provider as a male physician. Physicians are 17 generally educated to examine the female patient with gentleness and alacrity in order to reduce female patient embarrassment. When the patient is a male examined by either a male or female provider, there is very little mentioned in health care textbooks concerning the topic of male patient embarrassment. As a result, there are no existing published methods to manage male embarrassment. As increasing numbers of females become health care providers who examine male patients, it appears that a study is needed to begin to determine if male patients have concerns and if they do, the nature of their concerns if women examine them. One such study should be delimited to the male patient who is at the age of adolescence, because, as noted by many female health care providers, adolescence is the age at which male patient embarrassment is observed in the male-female encounter. Adolescent Developmental Characteristics How can we be so sure that male adolescents have no concerns when examined by female health care providers? If they do have con- cerns, what are they? An ideal age at which to test these questions is adolescence because the adolescent male is at his peak in sexual awareness and physical functioning; yet he is not an adult male who has learned appropriate male-female social interactions (Woods, 1975). Adult males usually have learned appropriate behavior related to interactions with females (Group for the Advancement of Psychiatry, 1968). In addition, grown men have already reached their ultimate growth and development and do not have a rapidly changing body 18 structure. Adult males have become accustomed to their body and its functions. Most men have usually defined themselves in society (Diekelmann, 1977). Identity has been established with self con- fidence in the majority of cases (Erikson, 1968). Adult males are more likely to have become independent physically and emotionally from their parents, and have found that absolute personal control of their bodies and their environment is not as crucial as it was in their adolescent years (Diekelmann, 1977 and Erikson, 1968). Rarely has the adolescent male reached these adult levels. The adolescent is not yet physically, sexually, mentally, nor emotionally mature. (Therefore he is likely to have more concern about his body, his self as a person, his need for control and his ability to relate to women when told that his physical examination may be conducted by a female health care provider. The adolescent male is different from the adult male (Bruggen and Pitt-Aikens, 1975). The adolescent, according to adolescent theorists, is absorbed in the here and now developmental tasks of (l) reaching physical maturation, (2) establishing a personal identity, (3) gaining a comfortable independence from his parents and (4) establishing relationships with peers and members of the opposite sex (Sider and Kreider, 1977; Goethals and K105, 1976; Erikson, 1968; and 8105, 1962). During the process of physical maturation, there is an increased production of gonadotropic hormones which influence rapid development of the genitals and secondary sex characteristics such as axillary and facial hair. Tanner (1973) has characterized the 19 development of the genitals and secondary sex characteristics into five stages starting at prepubescence and ending with adult develop- ment. See Figure 1. In addition growth hormone from the pituitary gland causes rapid growth in the skeletal structure. Together, the gonadotropic and growth hormones in adolescence cause a rapidly changing body structure (Sider and Kreider, 1977). The perception of the male adolescent or image of his body development may therefore influence the amount and type of concerns he presents if examined by a female health care provider. He may feel concern if his image of his body is one that is overdeveloped or underdeveloped. The concern may take the form of "what would she [the female examiner] think if my body is underdeveloped [or overdeveloped1." In establishing a personal identity, the adolescent seems to be trying to define "Who am I" as opposed to his family members and peers (Keniston, 1975). Freud (1905) first posited the term "identity,'I but he did not mean or use the term as it is currently employed. Erikson (1963, 1968) is generally credited for the concept "identity" development during adolescence. He compares identity to the opposite end of the pole--role diffusion or, as he sometimes states, "identity confusion" (Erikson, 1968). In establishing an identity, the adolescent defines his personal views and roles in society concerning vocational issues (Erikson, 1968), i.e. "When I get out of school I will go to college to learn to be an engineer," or "I'm not smart enough to be an engineer. I'm more interested in being a garage mechanic." The 20 above comments are a reflection of adolescent views of the self in vocational aspects. The adolescent also establishes his identity vis-a-vis ideological spheres-~what he believes in, his philosophy of life, and what is important to him as a person (Erikson, 1968), i.e. "Friend- ship is important to me." "The world is a nice place to be in for me." "It seems to me that there are a lot of problems, but I also see a lot of solutions, and I'm going to work om them" (above quotes are from researcher experiences with adolescents). "To me this is what politics is all about: getting people to think critically about themselves and others in such a way that they become willing to change" (Goethals and K105, 1976, p. 207). The adolescent further establishes an identity in social and ggxggl_spheres, or his beliefs concerning peers, members of the opposite sex, and himself as a sexual being (Erikson, 1968), i.e. "Girls are an important part of my life and I do expect to marry one someday and have children." "I think it's important to treat other people just like you'd like to be treated. That's my way of making friends." "I think I'm very masculine, but sometimes it worries me that the other guys don't think so, because I stick up for girls sometimes" (above quotes are from researcher experiences with adoles- cents). "During those six months, I was more conqued than I had ever been before. Intellectually I had worked out, partly as a result of my relation with Tom in high school, my feeling toward homosexuality. But emotionally I was incredibly ambivalent. I 21 knew I wanted to relate as fully as possible to Paul, but I could hardly even relax and simply touch him" (Goethals and K105, 1976, p. 173). In establishing their personal identity or personality, the adolescent is influenced by his social community, family beliefs and values (Erikson, 1968). The people in his life and their beliefs and values help him establish his own identity. As he grows older, the adolescent identity becomes more abstract in nature as opposed to the concreteness of his earlier years (Montemayor and Eisen, 1977). For example, the 13 year old may state: "I am John Doe. I live at 3447 Ocean Drive. I am 13 years old. I have a dog. I have a lot of friends." The 17 year old may state his identity in a more abstract manner: “I sometimes think that I am a miserable person. Yet I know that I'm not. I have many sincere friends and I feel a strong happiness when I'm with them. I feel that I am a very deep person, that I have a lot of insight in myself and in others.“ Therefore, the differences in levels of identity achievement during adolescence may influence the type and amount of concerns the young man presents if he is examined by a female health care provider. In gaining independence from his parents, the adolescent begins to separate emotionally from his parents, thus causing a strain in the family communication system (Sider and Kreider, 1977 and Keniston, 1975). He is noted for his lack of communication and rebelliousness with adults. The young person changes from day to day in his ability to agree or disagree with any adult. He is 22 inconsistent in his behavior and communication patterns. Throughout his need for seeking independence is the need to control himself, his life, and his environment (Oremland and Oremland, 1974). Therefore, the concerns of the male adolescent if examined by a female health care provider, may be influenced by his level of achievement in gaining control of his life and independence from his parents. The ability to establish and maintain long term relationships with peers and the opposite sex is the ultimate task during adoles- cence (Sider and Kreider, 1977). In establishing relationships with peers and members of the opposite sex, the adolescent learns to initiate contact with peers and the opposite sex. He must appear to "give" to the relationship as well as be gratified for it. Thus reciprocity is the unwritten rule. Some adolescents consciously do this by saying "Hi" with a smile to everyone they see in the halls at school. Initiating contact with peers as above means, "I am a friendly person." Not every adolescent feels comfortable in relation- ships with peers ggg_the opposite sex (Sider and Kreider, 1977). The ability to feel comfort in relationships especially with the opposite sex is a developmental process (Erikson, 1963) and is some- times never achieved (Erikson, 1968). Therefore the level of achieve- ment in the ability to establish comfortable relationships with members of the opposite sex--relatedness--may influence the concerns of the male adolescent if told that he may be examined by a jgmglg health care provider. With greater numbers of females in the health care profes- sions (Nurse Practitioners, Nurse Clinicians) whose roles partially 23 entail giving complete physical examinations, the probability of male adolescents being examined by females is increasing. The context of physical examinations therefore takes on greater signifi- cance if seen from the aspect of role reversal. Now the female is likely to be the health care provider, and the male is not the physician but the patient. It would seem helpful, therefore, knowing what is happening to the adolescent male during this period, vis-a-vis the adolescent characteristics described above, that the nursing profession (pri- marily females) determine specifically what concerns the male adoles- cent when he is examined by the female Nurse Clinician or Nurse Practitioner in a primary care setting. A general awareness of these concerns might then precipitate nursing measures and strategies related to these concerns as well as to the physical care of the patient. Nursing Theor --Imogene King The value of King's (1971) Theory as it applies to this study is that the findings from the study become part of nursing's knowledge base affecting nursing pgrceptions and clinical judgments which, in turn, determine nursing actions. King states that Man reacts to his environment and experiences as a total organism. Part of the role of nursing in interacting with Man utilizes the Nursing Process involving the skills of observation and communication as techniques in assess- ing patient behavior and physical condition. King further states that in the Nursing Process the two techniques of observation and 24 communication are then used to plan nursing actions based on the interpretation and evaluation of data gained by the use of the tech- niques. Many of the physical skills which nurses perform, i.e. taking blood pressures, temperature, etc., can be taught to other health care workers such as nurse aides, but according to King, one of the things that makes professional nursing unique is that nurses take action using the data that they have received from performing these physical skills. In nurse-patient interactions and transactions the nurse, through the use of the above two techniques, observation and communication, together with a substantial knowledge-base, develops a (1) general perceptjon of the patient and his circumstances which leads to (2) nursing clinical judgments and finally to (3) nursing action. In the theory of nursing, as proposed by King, these three steps are taken by the nurse. The patient also progresses along these same lines. He forms a perception of general circumstances from both within himself and from experiences within his environment. He forms judgments concerning these perceptions and he also takes ggtjgg, Perhaps his action would be to ask the nurse questions concerning his perception of unfamiliar circumstances. In all cases, according to King, the patient reacts as a total organism. The nurse and the patient then simultaneously perceive a reaction from the other related to the actions each took. They interact with each other and a transaction occurs. See Figure 2. As stated previously, Nurse Clinicians and Nurse Practitioners focus their care on the total patient. Male adolescent concerns 25 I -------- Feedback ------- Perception Nurse + Judgment , Agtion ‘ ‘TTRegbtion + Interaction + Transaction ' Action Patient + Judgment l Perception ' -------- Feedback ------- --h-- Source: Imogene M. King, Toward a Theory of Nursing, New York: John Wiley and Sons, 1971. Figure 2.--Mode1 of King's Theory of Nursing. in the categories of body image, identity, independence and related- ness if professional females examine them, are part of the total adolescent, and should be considered in their nursing care. For instance, from the viewpoint of the adolescent, his perceptions (of his body development, his self as a person, his need for inde- pendence and control of his life, his ability to relate to females) are based on experience and knowledge about himself, life and people. Therefore in any encounter with the female nurse the perceptions the adolescent has acquired form a basis for his judgments and ultimately his actions and reactions. It is necessary, therefore, for the female health care provider to not only be aware of her own perceptions in the encounter with the male adolescent, but also to be aware of the perceptions or concerns of the adolescent if he is examined by females, rather than males. The present study findings 26 provide an additional knowledge base to female nurses examing male adolescents. The knowledge base influences nursing perceptions. See Figure 3. One of the ways in which a nurse might utilize the findings of this study would be to observe the secondary sex characteristics of the male adolescent while not yet undressed. She would look for facial hair, lengthening of the mandibles, broadening of the shoulders. If she then related his chronological ggg_to her observa- tions of these secondary sex characteristics, and her knowledge of general adolescent concerns from this study, she might then be able to predict some of his concerns related to examinations by females. Her nursing actions then would center on reducing these areas of concern. See Figure 3. Strategies for managing the concerns involve another research project and thus are not within the scope of this study. Summar With greater numbers of females in roles of health care pro- viders, the likelihood also increases that adolescent males will be examined by such professional women. Traditionally the examiner has been a male physician with the patient being a female. Now the trend may reverse these roles of patients and examiners. 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CHAN. M.D. INTERNAL MEDICINE mos N Jerrensow STREET MARSHALL. mcmona noose TELEfiHONE. 781'2250 Foe PPOFESSIONA. SERVICES TO WHOM IT MAY CONCERN: I give my persmission to Judy Mitchell to do her research in my office. 197 ALLEN D. DUMONT. M.D.. F.A.A.P. 911 BROWN STREET ANN ARBOR. MICHIGAN 48104 TELEPHONI 769-3702 August 3, 1978 To Whom it May Concern: I give my express permission to Judy Mitchell, School of Nursing, Michigan State University, to distribute questionnaires to my patients. These will be distributed in the office only, to male patients age thirteen through seventeen. The purpose is to obtain information pertinent to a Masters Thesis. Sincerely, (ii/6% u. Mum Allen D. Dumont, M.D. APPENDIX H Human Rights Protection 198 Human Rights Protection Potential Risks to the Adolescents in the sample: There are no physical risks to those involved in this study. While there is the psychological risk of embarrassment in filling out the questionnaire, prior preparation to ensure the least embarrassment is provided by: l. The letter to the adolescent expressing the sincerity of the research and concern for young men having physical exams by women; 2. Providing the adolescent the written freedom to discuss his concerns and physical development with the physician, nurse, or physician's assistant prior to and after filling out the questionnaire: 3. Providing privacy while filling out the questionnaire either in the examining room or corner of the waiting room; 4. Providing the freedom to refuse to participate in the study and this refusal not altering the quality of health care received; 5. Providing a stamped, addressed envelope in which the adolescent seals his completed questionnaire while still in privacy; 6. Providing the information that the adolescent is not to write his name on the questionnaire and so is not iden- tified. Consent Procedures: (Copy Enclosed) Participation in the study is voluntary. Written consent is obtained by the adolescent and also his parents if available. The physician's office receptionist provides the adolescent with the letter from the researcher explaining the study and consent form. 199 200 He then either agrees to participate by signing the consent form, or he refuses. All physicians sign a letter giving consent to the research being conducted in their offices. Protecting Respondents: The identity and responses of all participating adolescents remains confidential. The subject's name will never be discussed nor displayed with data. The subjects are assigned an identification letter and number (.e. A20, 831). The letter corresponds to the physician's office administering the questionnaires, and the number corresponds to the adolescent. The participants are further protected by (1) providing pri- vacy while filling out the questionnaire, (2) by providing written consent, (3) by providing data in aggregate rather than individual form. Potential Benefits to Participants: Participants can feel a greater freedom to discuss their concerns and physical development with the physician, nurse, or physician's assistant since the subject is already broached for them by theiact of filling out the questionnaire. The greater benefit is to the group of adolescents as a whole, since this study provides background information on concerns of male adolescents if examined by female health care providers. MICHIGAN SENT! UNIVERSITY SCHOOLTOP NURSING "MN SUBJECTS REVIEW COMITTEE'APPLICATION Data for. completed: 8728731 Please type; use supplemt aheeta as needed. Submit dune copies to LeAnn Slim, A217 Li‘e Seance. Lech copy should have all aetevawt "acclaim, e. 9., consent semis), questionnaae, “cams, ante» aflxmue specified or I. II. III. IV. V. VI. Mamuwtéon 50m. Principal Investigator: Judith R. Mitchell Graduate Student (name) (position) 644 East Dr. ,Marshall,MI 49068 616-781-2515 (address) (telephone) ASSOClltES: None Names of other persons responsible for performing or supervising procedures. Barbara Given Patricia Salisbury Bonnie Elmassian A Jacqueline Wright Patricia Peek Title of DFOPOSGI or activity: "The Expressed Concerns of Male Adolescents .Ehen Their Physical Examination May Be Conducted By a Female Health Care Provider" Beginning date of prOposed activity: July 21. 1978 Anticipated coupletion date: September 15. 1978 Is this activity related to a grant or contract? Yes___ No L. If yes, complete A-I. ' A. Is it related to a training grant? Yes __ No __ B. Is it related to a fellowship? Yes _ No __ C. Has proposal been submitted? Yes __ No _ 0. Has award been made? Yes __ No _ E. Name of Principal Investigator shown (or to be shown) on proposal: F. Name of agency to whfch proposal was (or wilT be) submitted: 201 0'2 G. If continuation (or already awarded).;what is the agency's grant or contract number? H. Inclusive dates of grant or contract? From , through I. Will activity be perfOrmed ififfinding is not received? Yes No ___ VII. Checklist to be completed by investigator: A. Hill another organization or agency be involved (hospitals, Department of Public Health, others)? Yes 3;_. No flame of other organization(s) or agency: Physicians Private Offices Name and titles of person(s) in agency from whom permission to do study must be obtained: Robert Long, M.D., Homer, MI Paulino Chan, M.D., Marshall, MI Allen Dumont, M.D., Ann Arbor, MI B. Will an investigational new drug (IND) be used? Yes No 3' If yes, name, proposed dosage. status with Food and Drug Administration and IMO number. Enclose one copy of available toxicity data. C. Will other drugs be used? If yes, names and. Yes No ____ dosages. 202 Will a written consent form(s) be used? (Required in most cases.) 1. If no, explain why a written consent form will not be used. 2. If no, is a statement attached describing what participants will be told? Participants must be informed of all elements of VII-E, below. A.wn£tten senipt 06 the venbal expzanation must be attached to this newest. Does (Do) the consent form(s) include: "Michigan State University" heading? Name, position, department and telephone number of investigator? Date? Copy for subject? Signature and date lines to be completed by subject (and legal guardian, if subject is a minor or is legally incompetent), and investi- gator? The following elements of consent expressed in lay terms: Purpose--benefits to be expected of knowledge hoped to be gained? Procedures to be followed only for the pur- pose of this activity, and time involved? Nature and amount of risk, or substantial stress or discomfbrt involved? Appropriate alternate procedures that might be advantageous or available to subject? (Show N/A, not applicable, when there are none.) Costs the subject may immediately or ulti- mately be forced to bear and what reim- bursement of costs or other compensation the subject will receive as the result of participation in this activity? 203 0-4 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes lllrlr Ir Ir Ir No No No No No No No No No No No No Voluntary nature of participation and free- dam to withdraw at any point without penalty? Yes _3;_ No Opportunity to ask questions before con- senting? ' Yes __}_<_ No Assurance that subject's identity will remain confidential? Yes _3g_ No Describe how, by whom, and where consent will be obtained. Written consent will be obtained by the adolescent and his parents if available.Consent will be obtained by the physician's office receptionist when brought into the examining room. VIII. Subjects A. Approximate number and ages: Normal, patient, either. Approximate Number: SO; Ages 13-17. Normally healthy with the purpose of their office visit to obtain a physical examination for sports, camp, or school entry. 8. Criteria for selection and exclusion. Physically healthy -- no chronic illnesses. Males Age 13-17 Living in Michigan Purpose of office visit: physical examination. 204 D-S C. Source of subjects (including patients), and how they will be approached. Private physician's patients who are visiting his office for the purpose of having a physical examination.. Participants will be approached by receptionist explaining study, will be given letter with consent form, questionnaire, envelope. 0. Will subjects be paid or otherwise compensated? If so, what amount? And, what is the reason and payment? No E. Location where procedures will be carried out. e.g.. patient's bedside. conference room, etc. Physicians Office -- examining rooms or waiting room. IX. Confidentiality and Anonymity A. Steps to ensure that participation by subject will be kept confidential. 1) Assigning an ID number -- no names. 2) Envelope for sealing questionnaire inside. 3) Providing privacy while filling out questionnaire. 4) Sending consent form separetely to researchers, not along with questionnaire. 5) Data in aggregate form. 8. Provisions to ensure anonymity of documents and data. ID number assignment. Sending questionnaire and consent form separately. C. Provisions for controls over access to documents and data. Questionnaire data accessible only to researcher and Thesis Committee. 205 D-6 X. What publications might be helpful to the conmittee in consideration of this application? (Answer only if these might expedite review.) XI. Outline of Activity. (Circle option you will use in responding.) Fillet Option: Provide answers in spaces following A-B below (add sheets. when needed) . Second Option: Provide answers in attached summary statement. A. Background or rationale for this activity. Based on my experience in conducting physical exams on male adolescents who start to tremble during the examination or who refuse an examination altogether if they know the exam will be conducted by a female. In addition finding no research or literature pertinent to examination of males by females. Concise statement of objectives, including therapeutic intent, if any. Objective is to determine c6ncerns of male adolescents when provided the information that their examination may be conducted by a female. Further objectives are to determine if these concerns are related to age, or Tanner Stage of development and what is the relationship between Tanner Stage, Age, and Concerns? Potential significance of the results, e.g.. to patient, to society, to nursing, etc. This study can provide nursing with background information on concerns of male adolescents when examined by a female. Knowing these concerns nursing can then provide treatments (by using further research) to reduce these concerns. Review of methads.-materials. experimental design, including medications if applicable. Attach a copy 06 cu WWW. See proposal. 206 D-7 Identify alternate procedures, if any, not proposed fOr this activity that might be advantageous to the subject. If any deception (withholding complete information) is required far the validity of this activity, explain why this is necessary and attach debriefing statement. No deceptions. Potential benefit to the individual or benefits in general, including the relation of the project to the care of the subject, if the subject is a patient. He will be allowed more freedom to discuss his physical development and any concerns he may have about this with the M.D., nurse, or P.A. since the subject will have already been broached by filling out the questionnaire. Nature and degree of risk (include side effects), or substantial stress or discomfort involved. (Risk refers to all risks--physical, psycho- logical, social, legal, etc.) Include an assessment of the likelihood and seriousness of such risks. There will be no physical risks. There will be a psychological risk of embarrassment for some subjects. This will be more likely to involve younger subjects. 1. What safety precautions or counter-measures are planned to minimize risks in order to protect the rights and welfare of the individuals? a) Letter to adolescent explaining sincere concern for young men when examined by females. b) Provision in writing for permission to ask questions. c) Written consent form. d) Providing privacy and confidentiality. e) Freedom to refuse to participate. 2. Follow-up planned for procedures and possible adverse effects. None 3. Arrangements for financial responsibility for adverse effects. None 207 XII. Briefly outline the qualifications of the responsible investigator(s). I have been practicing nursing for the past 12 years, and now in the Master's program I have as my cognate -- Adolescent Health. Throughout my past experience and also in the program I have conducted hundreds of physical examinations of adolescents both male and female. APPROVAL BY THE COMMITTEE DOES NOT CONSTITUTE ANY ACCEPTANCE OR RESPONSIBILITY FOR THE CONDUCT OF THE INVESTIGATION. RESPONSIBILITY FOR CONDUCTING THE INVESTI- GATION MUST REMAIN WITH THE INVESTIGATORIS). THE COMMITTEE RESERVES THE RIGHT TO REVIEW AND/OR.WITHDRAW ITS APPROVAL AT ANY TIME. , l . Judith R. Mitchell 90.10% I, Wail/cat! 5495/14 Name of Principal Investigator ."T'SZgnatune Date ‘- .. , ‘i/ /- Isabel Payne tn, ££\&‘[./ lyny (I /A Director, School of Nursing Signatune —Tr Date OR Assistant Director, Graduate Program Barbara Given éA‘ Aw Adviser - Signatune Date Appnoved by the Ghaduate.AduLsony Committee 2/18/77. 208 D-9 BIBLIOGRAPHY 209 BIBLIOGRAPHY Books Alexander, Mary M., and Brown, Marie Scott. Pediatric Physical Diagnosis for Nurses. New York: McGrawéfiilTfiBook Company, 1974. Baggaley, Andrew R. Intermediate Correlational Methods. New York: John Wiley and Sons, Inc., 1964. Bates, Barbara. A Guide to Physical Examination. Philadelphia: J.B. Lippincott Company, 1974. 8105, Peter. 0n Adolescence: A Psychoanalytic Interpretation. New York: Eree Press, l962) Borg, Walter R., and Gall, Meredith D. Educational Research: An Introduction. New York: David MCKay Cbmpany,7Inc., 1971. Brown, Marie Scott and Murphy, Mary Alexander. Ambulatory Pediatrics for Nurses. 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