1. Chapter 33
Self-Concept
Self-concept is an individual’s conceptualization of himself.
Nurses need to help patients adjust to alterations in self-concept and support components to promote successful coping.

2. Self-Concept
A subjective sense of self and a complex mixture of unconscious and conscious thoughts, attitudes, and perceptions
A positive self-concept gives a sense of meaning, wholeness, and consistency to a person.
A healthy self-concept has a high degree of stability and generates positive feelings toward the self.
Self-esteem is closely related.
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.

3. Case Study
Paul Taylor, a 58-year-old man, suffered an unexpected and sudden stroke. He did not know that he had hypertension because he did not get yearly checkups. He awoke in the hospital bed to find that he could not move his hand.
He was not able to care for himself or even turn himself for days. His body image has dramatically changed from that of a man of strength to that of a helpless individual.
[Ask the class: What stressors is Mr. Taylor experiencing? How does stroke affect self-concept? Discuss.]

4. Scientific Knowledge Base
Parents and primary caregivers have tremendous influence on the development of a child’s self-concept.
Individuals learn and internalize cultural influences on self-concept and self-esteem in childhood and adolescence.
In adulthood, job satisfaction and job performance are linked to self-esteem.
The sense of self is often negatively affected in older adulthood.
Many factors affect self-concept.
Ethnicity and cultural influences on self-concept and self-esteem exist across the life span. For example, for boys, a family income above poverty rate, positive family communication, and involvement within a religious community were associated with high self-esteem. For girls, being of African American or Hispanic ethnicity, having positive family communication, and feeling safe were predicators of high self-esteem.
It will be important for nurses to be knowledgeable about variables that affect self-concept and self-esteem.

5. Family Effect on Self-Concept Development
Family plays a key role.
Children develop a basic sense from family.
Strong parental support and parental monitoring create positive effects.
Family and cultural influences can be positive or negative.
Children develop a sense of who they are from their caregivers. Additionally, a child gains from family norms for thinking, feeling, and behaving.
Parents who respond in a firm, consistent, and warm manner have children who have good self-esteem and develop low-risk behaviors.
Positive communication and positive social support foster self-esteem, especially in adolescents.
A family who exhibits bad habits such as smoking, alcohol use, and/or drug usage may impact family members in a negative way.

6. Nursing Knowledge Base: Development of Self-Concept
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.]

7. Case Study (cont’d)
Mr. Taylor’s self-esteem lessens as his recovery and rehabilitation move slowly. His self-concept has changed from that of a strong laborer, one who did his own plumbing and car repairs, to a man who must rely on others.
Although Mrs. Taylor works, they have not saved enough money to meet monthly expenses or to educate their children without both incomes. Mr. Taylor’s role as primary breadwinner will change if he does not improve.
[Ask the class: How does an inability to work affect self-esteem?]

8. Components of Self-Concept
Identity
Involves the internal sense of individuality, wholeness, and consistency of self
Body image
Involves attitudes related to physical appearance, structure, or function
Role performance
How individuals carry out their significant roles
Identity includes the sense of a person over time and in different situations.
Feelings about body image include those related to sexuality, femininity and masculinity, youthfulness, health, and strength.
Body image is the mental picture of one’s body and is not necessarily consistent with a person’s actual body structure or physical appearance.
Role performance includes roles such as parent, supervisor, or close friend.
Identity is formed in childhood as children learn culturally acceptable values, behaviors, and roles through identification and modeling. Part of this identity includes gender awareness and sexual identity.
Feelings about body image include those also related to sexuality, femininity, masculinity, youthfulness, health, and strength. Racial and ethnic background can influence one’s ideas regarding body image. Values such as ideal body weight and shape, as well as ideas about body piercing and tattoos, youth, beauty, and Western culture’s ideas regarding aging, impact self-concept and self-esteem.
What are some roles we all occupy? [parent, spouse, partner, students, teacher, child, friend]. Societal roles oftentimes impact how we perceive role performance. Having difficulty living up to perceived societal or cultural standards can affect self-concept and self-esteem.
[Photo is Figure 33-2 from text p. 661.]

9. Case Study (cont’d)
Maria Kendal is a 27-year-old nursing student assigned to care for Mr. Taylor. She is divorced, has two school-aged children, and works part-time as a certified nurse assistant at a local long-term care facility while in school.
She recognizes that changes in health status often result in stressors that affect a person’s self-concept. Such stressors influence a person’s ability to interact with others and to function effectively.
Ms. Kendall’s knowledge of self-concept will aid in identifying stressors that affect Mr. Taylor and in promoting effective planning to support his growth and adaptation to change.
[Ask the class: What stressors would you identify that affect Mr. Taylor? How would you address those stressors?]

10. Factors Affecting Self-Concept
Any real or perceived change that threatens identity, body image, or role performance can affect self-concept.
Changes that occur in physical, spiritual, emotional, sexual, familial, and sociocultural health affect self-concept.
Change in health
Other crises
An individual’s perception of the stressor is the most important factor in determining his or her response.
The ability to re-establish balance following a stressor is related to numerous factors, including the number of stressors, the duration of the stressors, and health status.
During self-concept crises, supportive and educative resources are valuable in helping a person learn new ways of coping with and responding to the stressful event or situation to maintain or enhance self-concept.

11. Stressors Affecting Self-Concept
Identity stressors
Role performance stressors
Body image stressors
Self-esteem stressors
Especially during adoles-cence
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.

12. Case Study (cont’d)
Maria realizes that Mr. Taylor’s stroke resulted in neurological deficits, which are significant stressors. Mr. Taylor’s independence is threatened because he is in the hospital and is dependent upon the nurses for most of his care.
He may never be able to go back to work again, and he does not consider himself a strong man anymore. Therefore, his family role as provider is threatened.
Maria’s father experienced a stroke 2 years ago. Maria remembers the struggle her father went through as he coped with the physical and emotional changes the stroke created. Maria’s experience as a single mother also provides insight into what it is like to assume a new role within a family.
[Ask the class: What does Maria need to do to care for Mr. Taylor?]

13. Quick Quiz!
1. You are assigned to care for a patient who has just undergone a mastectomy for a malignant tumor. You would most appropriately classify this self-concept component as A. Identity stressor. B. Sexuality stressor. C. Body image stressor. D. Role performance stressor.
Answer: C

14. The Nurse’s Effect on the Patient’s Self-Concept
Nurses need to remain aware of their own feelings, ideas, values, expectations, and judgments:
Use a positive and matter of fact approach.
Build a trusting relationship.
Be aware of facial and body expressions.
When caring for patients, nurses need to take a personal inventory of their own feelings, expectations, and attitudes.
Your nursing care significantly affects a patient’s body image. Be aware that both your nonverbal behavior and the words you use can have a direct positive or negative effect on a patient’s self-perception.

15. Adolescent Self-Concept
Identity confusion
Disturbed body image
Self-esteem
Role conflict
For some adolescents, a decline in self-esteem results in increased risk-taking behavior or unsafe behaviors, such as premature sexual activity, unprotected sex, risky driving, or substance abuse.
Changing physical appearance can disturb body image.
In addition, low self-esteem and stressful life events significantly predict suicidal ideations in older adolescents.
Nurses in all health care settings need to initiate suicide screening for early detection for suicide risk and to implement nursing interventions directed toward suicide prevention.
[See Box 33-4 (on text p. 664) Evidence-Based Practice: Self-Concept and the Impact of Body Image, Self-Esteem, and Stress on Adolescent Smoking Behaviors.]

16. Older-Adult Self-Concept
Can be negatively affected in older adulthood because of a number of life changes.
However, in some individuals, aging promotes improved coping strategies that protect against declining feelings of self-esteem, despite the physical and emotional changes associated with aging.
Nursing interventions aimed at enhancing self-concept and self-esteem in older adults are essential.
Nursing implications for practice in the older adult include:
•Clarify what the life changes mean and the effect on self-concept. Discuss health problems, declining socioeconomic status, spousal loss or bereavement, and loss of social support following retirement.
•Be alert to preoccupation with physical complaints. Assess complaints thoroughly, and if no physical explanation exists, encourage older adults to verbalize needs (fear, insecurity, loneliness) in a nonphysical way.
•Identify positive and negative coping mechanisms. Support effective strategies.
•Encourage the use of storytelling and review of old photographs.
•Communicate that the older adult is worthwhile by actively listening to and accepting the person’s feelings, being respectful, and praising healthy behaviors.
•Allow additional time to complete tasks. Reinforce the older adult’s efforts at independence.
[See Box 33-3 (on text p. 663) Focus on Older Adults: Enhancing Self-Concept in Older Adults.]

17. Quick Quiz!
2. You are caring for an adolescent patient who has undergone a gastric banding procedure 6 months previously. This adolescent tells you, “There is still a fat person inside of me.” This type of statement illustrates a flaw in the self-concept of A. Identity. B. Self-esteem. C. Body image. D. Role performance.
Answer: C

18. Cultural Considerations
Develop an open, nonrestrictive attitude for assessing and encouraging cultural practices to improve patients’ self-concept.
Ask patients what they think is important to help them feel better or gain a stronger sense of self.
Encourage cultural identity by individualizing self-care practices and offering treatment choices to meet patients’ self-concept needs.
Facilitate culturally sensitive health promotion activities that address at-risk behaviors identified through evidence-based practice.
Racial and cultural identity are important components of a person’s self-concept.
Early in growth and development, an individual develops this identity within the context of family. As the individual grows, the cultural aspects of his or her self-concept are reinforced through social, family, or cultural experiences.
In addition, a person’s self-concept is strengthened or questioned through political, social, or cultural influences experienced in school and workplace environments.
Positive or negative cultural role modeling or past experiences influence self-concept.
[See Box 33-2 (on text p. 660) Cultural Aspects of Care: Promoting Self-Concept and Self-Esteem in Culturally Diverse Patients.]

19. Quick Quiz!
3. You are assigned to care for a patient who retired 6 months ago. While providing care, you identify that this patient is struggling emotionally with change. This situation is most likely associated with the self-concept component of A. Identity stressor. B. Sexuality stressor. C. Body image stressor. D. Role performance stressor.
Answer: D

20. Self-Concept and the Nursing Process: Assessment
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.]

21. Self-Concept and the Nursing Process: Nursing Diagnosis and Planning
Goals and outcomes
Be realistic.
Setting priorities
Focus on adaptations to stressors.
Collaborative care
Consider additional resources.
When selecting an appropriate nursing diagnosis, use the North American Nursing Diagnosis Association (NANDA)-approved nursing diagnoses and make sure to incorporate aspects of cultural diversity.
Develop an individualized plan of care for each nursing diagnosis. Work collaboratively with the patient to set realistic expectations for care.
The care plan presents the goals, expected outcomes, and interventions for a patient with an alteration in self-concept.
Interventions help the patient adapt to the stressors that led to the self-concept disturbance and support and reinforce the development of coping methods.
When planning care for the patient who is experiencing problems with self-concept, you will use both critical thinking and the nursing process.
The perceptions of significant others are important to incorporate into the plan of care. Individuals who have experienced deficits in self-concept before the current episode of treatment have often established a system of support that includes mental health clinicians, clergy, and other community resources.
[See Box 33-7 (on text p. 666) Nursing Diagnostic Process: Situational Low Self-Esteem, Figure 33-5 Critical thinking model for self-concept planning, and Nursing Care Plan on text pp Situational Low Self-Esteem.]

22. Case Study (cont’d)
If you were Maria, what goal would you write for Mr. Taylor? Be sure to include observable behaviors.
What interventions would you suggest that Maria consider?
[Discuss questions.]
Suggested goal: Mr. Taylor will experience fewer alterations in self-concept, including low self-esteem, disturbed body image, and altered role performance, and will discuss concerns with staff members and significant others before discharge.
Possible interventions include
Facilitate an environment and activities (such as journal writing) that will increase self-esteem.
Monitor Mr. Taylor’s statements of self-worth.
Encourage increased responsibility for self, and assist patient with accepting dependence on others as appropriate.
Help Mr. Taylor identify specific role changes brought on by the stroke.
Discuss changes in function and physical appearance caused by changes in medical condition.

23. Self-Concept and the Nursing Process: Implementation
Goal: reduce situational low self-esteem
Target the level of care:
Health promotion
Acute care
Restorative care
Encourage self-care
Elicit patient’s perceptions of strengths and weaknesses
Explore coping responses
Reinforce strengths and successes
Nurses can use touch and eye contact to enhance a patient’s self-esteem.
Implementation needs to be targeted to the patient at the specific level of care. Consider whether implementation will occur as health promotion, in the acute care setting, or in the restorative care setting.
Work with patients to help them develop healthy lifestyle behaviors that contribute to a positive self-concept.
Measures that support adaptation to stress, such as proper nutrition, regular exercise within the patient’s capabilities, adequate sleep and rest, and stress-reducing practices, contribute to a healthy self-concept.
In the acute care setting, some patients experience potential threats to their self-concept because of the nature of the treatment and diagnostic procedures.
Interventions designed to help a patient reach the goal of adapting to changes in self-concept or attaining a positive self-concept are based on the premise that the patient first develops insight and self-awareness regarding problems and stressors and then acts to solve the problems and cope with the stressors.
[See Box 33-8 (on text p. 670) Patient Teaching: Alterations in Self-Concept.]

24. Self-Concept and the Nursing Process: Evaluation
Frequent evaluation of patient progress is necessary.
Apply knowledge of behaviors and characteristics of a healthy self-concept when reviewing the actual behaviors patients display.
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.]

25. Case Study (cont’d)
On the last day Maria cared for Mr. Taylor, he reported that he was going to a rehabilitation center that specializes in helping people who have had strokes.
Mr. Taylor is able to complete most of his bath independently. Although his gait is unsteady, he is able to walk short distances with a walker. During his bath, he jokes, “I think my new haircut makes me look a lot younger!” Mr. Taylor also states, “I can’t wait to get better. I have a lot of things to do, and I have a lot to live for.”
This improvement in function and acceptance of self has helped Mr. Taylor become more satisfied with himself and his progress in therapy. He is hopeful that he will be able to return to work after he leaves the rehabilitation center.
[Ask the class: What nursing actions would you take in evaluating Mr. Taylor’s progress? Discuss.]