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29 Nursing: A Concept-Based Approach to Learning Self MODULE
VOLUME TWO | SECOND EDITION 29 MODULE Self
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Self-Concept A subjective sense of self and a complex mixture of unconscious and conscious thoughts, attitudes, and perceptions Provides a positive sense of meaning, wholeness, and consistency to a person. Provides a high degree of stability and generates positive feelings toward the self. Self-esteem is an individual’s overall feeling of self-worth or the emotional appraisal of self-concept. Self-esteem comes from self-concept, and self-esteem influences self-concept.
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Healthy Self-Concept A clear sense of self and others Realistic
A separate individual Appropriate coping skills
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How individuals view themselves and their perception of their health are closely related.
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Normal Presentation, continued
Three major components of self Self-concept Self-esteem Self-awareness 5
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Self-Concept One's personal perception of self
Integral to psychosocial development Affects individual mentally, physically, spiritually Personal traits, characteristics, values, beliefs, behavior Effective nursing care Exploring, optimizing Own self-concept Client's self-concept 6
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Self-Concept, continued
Personal identity Ideal self, real self, public self Body image Perceptual Cognitive Behavioral Affective Subjective satisfaction Cultural influences: ideal body image 7
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Components of Self-Concept, continued
Role performance Role development Role ambiguity Role strain Role conflicts Interpersonal, interrole, person–role Role mastery 8
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Factors That Affect Self-Concept
Stage of development Family, culture Stressors Resources History of success, failure Illness, trauma 9
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Self-Esteem Individual's opinion of self Judgments about self-concept
Two categories Global Specific Development Early parent–child interactions Much remains a mystery 10
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Self-Awareness Formation of reality-based perception of self
Ongoing process Self-examination Connections between past experiences, present actions insight Introspection 11
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Psychosocial Development
Self theory Freud's Psychosexual Theory of Development is grounded in psychosexual elements and the human response to impulses. Erikson's Psychosocial Theory of Development incorporates social, cultural and interpersonal components. 12
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Psychosocial Development
Development of self-concept is a lifelong process. Erikson’s psychosocial theory: Each stage builds on tasks of the previous stage. Successful mastery leads to a sense of self. Each developmental stage involves factors that are important to the development of a healthy, positive self-concept. Self-concept is always changing and is based on the following: sense of competency, perceived reactions of others to one’s body, ongoing perceptions and interpretations of the thoughts and feelings of others, personal and professional relationships, academic and employment-related identity, personality characteristics that affect self-expectations, perceptions of events that have an impact on the self, mastery of prior and new experiences, and finally ethnic, racial, and spiritual identity. Self-esteem is usually highest in childhood, drops during adolescence, rises gradually throughout adulthood, and declines again in old age. Erikson’s stages are helpful in understanding key tasks. [Ask the class: What are the goals for adolescence; early, mid-, and late adulthood? Discuss.] [See Box 33-1 on text p. 659 Self-Concept: Developmental Tasks.] Identity versus role confusion (12 to 20 years) Adolescents’ participating in group activities can foster self-esteem. Identity is particularly vulnerable during adolescence. Intimacy versus isolation (mid-20s to mid-40s) Generativity versus self-absorption (mid-40s to mid-60s) Ego integrity versus despair (late 60s to death) [Photo is Figure 33-1 from text p. 659.]
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Stressors Affecting Self-Concept
Identity stressors Role performance stressors Body image stressors Self-esteem stressors Physical appearance and abilities Role ambiguity Affect appearance, structure or function of a body part Vary by develop-mental stage Role overload Role conflict Role strain These stressors can be real or perceived; they challenge a person’s adaptive capabilities. [See Figure 33-3 for examples—discuss.] Identity stressors can occur at any time during the life span, but particularly during adolescence. Role performance stressors can occur in relationship to situational transitions that occur when parents, children, spouses, family members, or close friends die, or when people move, marry, divorce, or change jobs. They can also occur when one moves from a place of wellness to illness. Role ambiguity involves unclear role expectations, which makes people unsure about what to do or how to do it. Role overload involves having roles or responsibilities that are unmanageable. This can occur when a person is ill. Role conflict results when a person has to assume two or more roles that are inconsistent, contradictory, or mutually exclusive. Role strain combines role conflict and role ambiguity. Body image stressors include those that occur in appearance, structure, or function of a body part. Self-esteem stressors can vary within developmental stages. Chronic illness, injuries, or surgeries change lifestyle and patterns, and this affects a person’s sense of self-worth.
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Assessment Create safe environment for client, nurse
Establish trust, working relationship 15
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Nursing Assessment Psychosocial assessment Personal identity
Physical history Communication skills, behaviors Body image Role performance Self-esteem
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Nursing Assessment: Objective Data
Avoidance of eye contact Slumped posture Unkempt appearance Overly apologetic Hesitant speech Overly critical or angry Frequent or inappropriate crying Negative self-evaluation Excessively dependent Hesitant to express views or opinions Lack of interest in what is happening Passive attitude Difficulty in making decisions When assessing, observe for behaviors that suggest an alteration in the patient’s self-concept. Make sure to assess the patient’s coping skills and resources, support from significant others, and patient expectations. Assess the patient’s cultural background. Determine the patient’s feelings and perceptions about changes in body image, self-esteem, or role. Assess the quality of the patient’s relationships. [From Box 33-5 (on text p. 665), Behaviors Suggestive of Altered Self-Concept.] [See also Box 33-6 (on text p. 665) Nursing Assessment Questions, and Figure 33-4 (on text p. 666) Critical thinking model for self-concept assessment.]
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Nursing Assessment: Subjective Data
How would you describe yourself? Tell me about the things you do that make you feel good about yourself? How do you feel about yourself? Are you satisfied with your life? How do you get along at your work? Do you feel different or inferior to others? Does it bother you if you think someone doesn’t like you? What could you change about yourself if you could?
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Diagnostic Tests No specific laboratory diagnostics that can be used to conclusively confirm a diagnosis Testing may be used to assess for additional impairments that occur as a result of the primary disorder 19
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Interventions and Therapies
Identify areas of strength, weakness Framework for identifying personality strengths Specific strategies to reinforce strengths Work with mental health professional 20
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Interventions and Therapies, continued
Enhancing self-esteem Therapeutic relationship requires: Self-awareness Communication skills Developmental considerations 21
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Independent Nurse should exercise authenticity
Remain committed to promoting the client's health and well-being Specific strategies to reinforce strengths Building a therapeutic relationship can be challenging. Promotion of adequate nutrition is difficult but critical. 22
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Implementation-Children
Security and trust Identity Belonging Purpose Personal competence Key Ingredients: Love, acceptance, firmness, consistency, expectations, and a predictable world to live in
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Implementation-Adolescents
Responsibility Appreciation Participation Realistic goals
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Implementation-Adults
Positive qualities Positive contributions Assess internal and external forces Avoid comparisions
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Implementation-Elders
Participation Listening Stay connected with memories Respect and dignity Small goals Weaving the tapestry of life: self-esteem, love of life, closeness to the Godlife in oneself and others…
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Collaborative Cognitive behavioral therapy (CBT)
Focus on immediate problems Developing solutions through activities such as repatterning Dialectual behavioral therapy (DBT) Schema-focused therapy (SFT) Antidepressants Anxiolytics 27
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Evaluation Frequent evaluation of patient progress is necessary.
Expected outcomes for a patient with a self-concept disturbance: Nonverbal behaviors showing positive self-concept Statements of self-acceptance Acceptance of change Evaluation is the last link in the process. This step determines whether patient outcomes have been met. Use critical thinking to evaluate the patient’s success in meeting each goal and the established expected outcomes. Key indicators of a patient’s self-concept are nonverbal behaviors. Observe the patient’s nonverbal behaviors, looking for whether they indicate a positive self-concept. Ask the patient to share opinions and ideas. Note whether they include statements of self-acceptance or acceptance of change in appearance or function. Observe the patient’s appearance. [See Fig (on text p. 671) Critical thinking model for self-concept evaluation.]
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