CH.

27 SELF-CONCEPT

• Self-Concept- An individual’s conceptualization of himself or herself. A subjective

sense of self and a complex mixture of conscious thoughts, attitudes, and
perceptions.

Scientific Knowledge Base

• Tendency of males to report higher self-esteem than females.
• Parents and other primary caregivers influence the development of a child’s self-
concept and self-esteem.
• Significant emphasis on fostering school-age children’s self-concept.
• In general, young children tend to rate themselves higher than other children,
suggesting that their view of themselves is positively inflated.
• Adolescent experience adversely affects self-concept and self-esteem. Important to
assess self-concept over time as it changes through the life span.
• Job satisfaction and job performance in adulthood are also linked to self-esteem.
Sense of self can diminish when people lose their jobs.
• Establishment of a sense of self that is stable and that transcends relationships and
situations is a developmental goal of adulthood.
• Sense of self is negatively affected in older adulthood because of the intensity of
emotional and physical changes associated with aging. As when older people lose a
spouse or has a change in health.
• There are ethnic and cultural differences in self-concept and self-esteem across the
lifespan
○ For boys, family income above the federal poverty level, positive family
communication, and involvement in a religious community are associated with
high self-esteem.
○ For girls, being of African American or Hispanic race/ethnicity, positive family
communication, and feeling safe are predictive of selfhigher self-esteem.
• Chronic illness often affects the ability to provide financial support, which then
affects an individual’s self-esteem and perceived roles in the family.
○ Chronic illness also affects identity and body image.
• What individuals think and how they feel about themselves affects the way in which
they care for themselves physically and emotionally, as well as the way in which
they care for others.

Nursing Knowledge Base

• Development of Self-Concept- a complex lifelong process that involves many
factors.
○ Erikson’s psychosocial theory of development remains helpful in understanding
key tasks that individuals face at various stages of development. Each stage
builds on the tasks of the previous stage. Successful mastery of each stage
leads to a solid sense of self.
○ Nurses learn to recognize an individual’s failure in achieving age-appropriate
goals or a patient’s regression into an earlier stage in a period of crises.
○ Self-concept is always changing and is reliant on:
 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
  Ethnic, racial, and spiritual identity
○ Self-esteem is usually highest in childhood, drops in adolescence, rises
gradually throughout adulthood, and declines again in old age.
○ For some adolescents, a decline in self-esteem results in increased risk-taking
behavior.
○ Erikson’s emphasis on the generativity stage explains the rise in self-esteem
and self-concept in adulthood.
 The individual focuses on being increasingly productive at work, while at
the same time promoting and guiding the next generation.
 Other than childhood, the mid-60’s seem to represent the highest level
of self-esteem across the life span.

• Components and Interrelated Terms of Self-Concept- The components of self-

concept frequently considered by nurses are Identity, Body Image, and Role
Performance. Self-esteem comes from self-concept, and self-esteem influences self-
concept.
○ Identity- involves the internal sense of individuality, wholeness, and
consistency of a person over time and in different situations.
 Implies being distinct and separate from others.
 Children learn culturally accepted values, behaviors, and roles through
identification and modeling.
 An individual first identifies with parenting figures and later with other
role models such as teachers or peers.
 The achievement of identity is necessary for intimate relationships
because individuals express identity in relationships with others.
 Sexuality is a part of identity.
 Gender identity is a person’s private view of maleness or femaleness.
 Gender role is the masculine or feminine behavior exhibited.
 Cultural differences in identity exist. Racial or cultural identity develops
from an identification and socialization within an established group, as
well as through experiences of integrating the response of individual’s
outside the cultural or racial group into one’s self-concept.
 The more one identifies with social groups, the higher the self-esteem.
○ Body Image- involves attributes related to the body, including physical
appearance, structure, or function.
 Feelings about body image include those related to sexuality, femininity
and masculinity, youthfulness, health, and strength.
 Not always consistent with a person’s actual physical structure or
appearance.
 Alterations in body image can come from:
• A psychological component such as anorexia nervosa
• A situational component such as a loss or change in a body part.
• How others view our body also has an influence as in an abusive,
controlling relationship.
 Cognitive growth and physical development affect body image.
• Normal developmental changes such as puberty and aging have a
more apparent effect on body image than on other aspects of self-
concept.
• Hormonal changes during adolescence and menopause influence
body image.
• Development of secondary sex characteristics and changes in body
fat distribution has a tremendous impact on the self-concept of
adolescents.
• Physical changes common in older adults also has an affect on
body image.
  Cultural and societal attitudes also influence body image.
• Racial and ethnic background plays an integral role in body
satisfaction in adolescent girls as reflected in the higher incidence
of body satisfaction among African American girls compared to
white girls.
• Western culture dreads old age but Eastern cultures respect and
admire older adults.
○ Role Performance- is the way in which individuals perceive the ability to
carry out significant roles.
 Includes roles such as parent, supervisor, or close friend.
 Assuming a role involves socialization to expectations or standards of
behavior.
 Individuals develop and maintain behaviors that society approves
throught the following process:
• Reinforcement-extinction- Certain behaviors become common or
are avoided, depending on whether they are approved and
reinforced or discouraged and punished.
• Inhibition- An individual learns to refrain from behaviors , even
when tempted to engage in them.
• Substitution- An individual replaces one behavior with another,
which provides the same personal gratification.
• Imitation- An individual acquires knowledge, skills, or behaviors
from members of the social or cultural group.
• Identification- An individual internalizes the beliefs, behavior, and
values or role models into a personal, unique expression of self.
 Personal needs and multiple roles conflict at times and realistic
possibilities have to be distinguished from ideal role expectations.
• Stressors Affecting Self-Concept- A self-concept stressor is any real or perceived
change that threatens identity, body image, or role performance.
○ Perception of stressor is the most important factor in determining a person’s
response.
○ Adaptation to stressors leads to a positive sense of self, whereas failure to
adapt often leads to negative self-concept.
○ Stressors created as a result of a crises affect a person’s health: if identity
confusion, disturbed body image, low self-esteem or role conflict is not relieved
then illness is likely to occur.
○ Identity Stressors- Stressors affect an individual’s identity throughout life,
but individuals are particularly vulnerable during adolescence.
 Adults generally have a more stable identity and thus a more firmly
developed self-concept.
 Cultural and societal stressors have more impact on adults.
 Identity Confusion- results when people do not maintain a clear,
consistent, and continuous consciousness of personal identity.
○ Body Image Stressors- Changes in the appearance, structure, or function of
a body part requires an adjustment in body image.
 Changes such as pregnancy, amputations can lead to a negative body
image and lead to adverse health outcomes.
 Obesity epidemic in western culture requires a focus on weight
management without negatively affecting body image.
○ Role Performance Stressors- Situational transitions occur when parents,
spouses, children, or close friends die or people move, marry, divorce, or
change jobs.
 Role Conflict- results when a person has to simultaneously assume two
or more roles that are inconsistent, contradictory, or mutually exclusive.
  Sick role- Involves the expectations of others and society regarding how
an individual behaves when sick.
 Role Ambiguity- involves unclear role expectations, which makes
people unsure about what to do or how to do it, creating stress and
confusion. This is common in the adolescent years.
 Role Strain- combines role conflict and role ambiguity. Can be
expressed as a feeling of frustration when a person feels inadequate or
unsuited to a role.
 Role Overload- involves having more roles or responsibilities within a
role than are manageable.
○ Self-Esteem Stressors- Individuals with high self-esteem are generally more
resilient and are better able to cope with demands and stressors than those
with low self-esteem.
 The more a chronic illness interferes with the ability to engage in
activities contributing to feelings of worth or success, the more it affects
self-esteem.
 Self-esteem stressors vary with developmental stages. Children are
affected by factors such as perceived inability to meet parental
expectations, inconsistent discipline, and unresolved sibling rivalry. In
college-age age adolescents; low self-esteem and stressful life events
can be predictors for suicidal thoughts.
 Developmental milestones such as pregnancy introduce self-concept
stressors.
 Self-concept stressors in older adults include declining socio-economic
status, spousal loss or bereavement, loss of social support, and decline
in achievement experiences following retirement.
• Family Effect on Self-Concept Development- Family plays a key role in creating
and maintaining the self-concepts of its members. Children develop a basic sense of
who they are from their family caregivers.
○ Well-meaning parents can sometimes cultivate negative self-concepts in
children.
○ Parents are the most important influences on a child’s development, yet
variations on approach depend on culture.
○ Family and cultural factors sometimes influence negative health practice, such
as cigarette smokeing.
• The Nurse’s Effect on the Client’s Self-Concept- A nurse’s acceptance of a
client with an altered self-concept helps promote positive changes.
○ Nurses need to assess and clarify the following self-concept issues about
themselves:
 Thoughts and feelings about lifestyle, health, and illness
 Awareness of how own nonverbal communication affects clients and
families
 Personal values and expectations and how these affect clients
 Ability to convey a nonjudgmental attitude toward clients
 Preconceived attitudes toward cultural differences in self-concept and
self-esteem
○ A positive and matter-of-fact approach to care provides a model for the client
and family to follow.
○ Showing acceptance of altered body has a positive effect on body image; as
when a woman has a mastectomy and nurse shows acceptance instead of
having a shocked or disgusted look on the nurse’s face.
○ Self-esteem and HIV high-risk behavior practices were linked in a study of
predominantly urban African-American women. Researchers predicted self-
esteem levels in these women by race, religion, childhood experiences with
 emotional neglect, the number of money-related problems, and the number of
drug-related problems.
○ Tailoring interventions to a patient’s profile to incorporate self-esteem building
components and improve health outcomes is necessary.

Critical Thinking

Assessment
• In assessing self-concept and self-esteem, first focus on each component of self-
concept (identity, body image, and role performance).

• Coping Behaviors- Nursing assessment also includes considerations to previous

coping behaviors; the nature, number, and intensity of the stressors; and the client’s
internal and external resources.
○ Identify previous coping strategies to determine whether these patterns have
contributed to healthy functioning or created more problems.
• Significant Others- Exploring resources and strengths, such as availability of
significant other or prior use of community resources, is important in formulating a
realistic and effective plan of care.
○ Significant others often have insight into the person’s way of dealing with
stressors.
○ The way in which a client talks about their significant others and the significant
other’s nonverbal behaviors provide information about what kind of support is
available for the client.
• Client Expectations- Another important factor in assessing self-concept is the
person’s expectations.
○ Asking a client how interventions will make a difference provides useful
information regarding the client’s expectations and provides an opportunity to
discuss the client’s goals.

Nursing Diagnosis
• Carefully consider the assessment data to identify a client’s actual or potential
problem areas.
• Although there are four nursing diagnostic labels for altered self-concept, the
following NANDA list also provides examples of self-concept-related nursing
diagnoses:
○ Disturbed body image
○ Caregiver role strain
○ Disturbed personal identity
○ Ineffective role performance
○ Readiness for enhanced self-concept
○ Chronic low self-esteem
○ Situational low self-esteem
○ Risk for situational low self-esteem

Planning
• During planning, synthesize knowledge, experience, critical thinking attitudes, and
standards.
• The note above is the same shit you see for “Planning” in every other chapter in this
book, fuck this book.
• Goals and Outcomes- Develop an individualized plan of care for each nursing
diagnosis.
○ Make sure goals are individualized, realistic, and have measurable outcomes.
 ○ In the goal, “Client’s self-esteem and self-concept will begin to improve in 1
week,” related to the nursing diagnosis of; situational low self-esteem related
to a recent job layoff, examples of expected outcomes include:
 The client will discuss a minimum of three areas of her life where she is
functioning well
 The client will be able to voice the recognition that losing her job is not
reflective of her worth as a person
 The client will attend a support group for out-of-work professionals
• Setting Priorities- Establishing priorities includes using therapeutic communication
to address self-concept issues, which ensures that the client’s ability to address
physical needs is maximized.
○ Look for strengths in both the individual and the family, and provide resources
and education to turn limitations into strengths. Often, once clients understand
their situations, their sense of hopelessness and helplessness is lessened.
• Collaborative Care- Before including the family, consider the client’s desires for
their involvement and cultural norms regarding who most frequently makes
decisions in the family. Individuals who have experienced self-concept deficits in the
past have often established a system of support including mental health clinicians,
clergy, and other community resources.
○ Additional resources include physical therapy, occupational therapy,
behavioral health, social services, and pastoral care.

Implementation
• Health Promotion- Work with clients to help them develop healthy lifestyle behaviors
that contribute to a positive self-concept.
○ Measures that show adaptation to stress such as proper nutrition, regular
exercise within the client’s capabilities, adequate sleep and rest, and stress-
reducing practices contribute to a healthy self-concept.
○ Nurse’s are in a unique position to identify lifestyle practices that put a person’s
self-concept at risk or are suggestive of altered self-concepts.
• Acute Care- In the acute-care setting, some clients experience potential threats to
self-concept because of the nature of the treatment and diagnostic procedures.
○ Threats to a person’s self-concept can lead to a person developing anxiety and/or
fear.
○ Stressors such as unknown diagnoses, the need to modify lifestyle, and change in
functioning, are often present, and the nurse needs to address them.
○ Nurses in the acute care setting also encounter clients who face the need to
adapt to an altered body image as a result of surgery or other physical change. In
acute care, addressing this is difficult so appropriate follow-up and referrals,
including home care, are essential.
○ Remain sensitive to the level of client’s acceptance to change.
○ Restorative and Continuing Care- nurse often has more of an opportunity to
work with a client to obtain the goal of attaining a more positive self-concept in
the home-health setting.
 increase the client’s self-awareness by allowing the client to openly explore
thoughts and feelings.
 A priority nursing intervention is the expert use of communication skills to
clarify the expectations of the client and family.
 Help the client to define problems clearly and to identify positive and
negative coping mechanisms.
 Supporting attempts at positive coping is essential, because with each
success the client is able to make another attempt.

Evaluation
• Frequent evaluation of client progress is necessary.
• Look for behaviors that indicate a healthy self-concept, this determines whether
outcomes have been met.
• Goals of care often become unrealistic or inappropriate as the client’s condition
changes; revise plan if needed reflecting on successful experiences with other clients.
• Changes in self-concept take time, major changes can take up to a year to adjust to.

Information Boxes To Review

• Box 27-1- Self-Concept: Development Tasks (Pg.412)

• Box 27-5- Behaviors Suggestive of Altered Self-Concept (Pg.418)