Chapter 23 Dimensions of self: pathways to self-identity

Anthony Welch

LEARNING OUTCOMES

Mastery of content will enable you to:

• Explain the five components of self: identity, body image, self-esteem, roles and spirituality.

• Define the components of what constitutes a healthy self as related to psychosocial and cognitive stages of development.

• Discuss the relationship of spirituality to an individual’s conception of self.

• Describe the relationship between faith, hope, trust and spiritual wellbeing.

• Identify most commonly recognised spiritual needs.

• Describe stressors that can affect a person’s perception of self.

• Describe behaviours indicating identity confusion, disturbed body image, low self-esteem, role conflict and spiritual distress.

• Identify and discuss ways in which nursing activities can affect the client’s perception of self.

• Discuss nursing interventions designed to promote spiritual healing and spiritual health.

• Identify important aspects of culture that affect nursing care in support of clients’ conception of self.

• Distinguish factors that promote a healthy self.

Relationship with oneself is the most intimate relationship and one of the most important aspects of life experience, yet it is one of the most difficult to define. What we think and feel about ourselves affects the way in which we care for ourselves and others physically, psychologically, emotionally and spiritually. People with a poor conception of self often do not feel a sense of personal worth, which influences whether they seek physical, emotional and spiritual help as the need arises.

Dimensions of the self

The ways in which a person comes to know and understand themself as a unique individual is primarily determined by two key elements: self-concept and a person’s spirituality. Self-concept is an individual’s awareness about the self (e.g. ‘I am good at maths’) (Stein-Parbury, 2005), while a person’s spirituality is concerned with a search for meaning, purpose and interconnectedness with self, others/nature and possibly an ultimate other.

A person’s conception of self as a unique individual has its origins in the psychic representation of an individual, the central core of ‘I’ around which all perceptions and experiences are organised. It is developed through a range of processes involving five key elements—identity, body image, self-esteem, role performance and one’s spirituality. The development of a person’s conception of self is a dynamic combination formulated over years and based on the following:

• reactions of others to one’s body

• ongoing perceptions of the reactions of others to the self

• relationships with self and others

• personality structure

• perceptions of stimuli that have an impact on the self

• prior and new experiences

• present feelings about the physical, emotional, social and spiritual self

• expectations about the self

• spiritual identity.

A positive conception of self gives a sense of continuity, wholeness and consistency to a person. A healthy conception of self has a high degree of stability despite the person experiencing either positive or negative feelings towards the self. Being ‘oneself’ is the crux of a healthy self in all its dimensions (Edward and others, 2011).

The five dimensions that constitute self—identity, body image, self-esteem, role performance and the spiritual self or a person’s spirituality—form the basis of an individual’s overall sense of who they are as a human being (see Figure 23-1).

FIGURE 23-1 Dimensions of the self.

Identity

Identity involves a person’s sense of individuality, wholeness and consistency in various life circumstances over time. The concept of identity thus includes constancy and continuity. Identity implies being distinct and separate from others—being able to view oneself as a unique individual.

Identity develops over time. A child learns culturally accepted values, behaviours and roles through identification. The child first identifies with parenting figures and later with teachers, peers and heroes. To form an identity, the child must be able to bring together learned behaviours and expectations into a coherent, consistent and unique whole (Erikson, 1963).

The achievement of identity is necessary for intimate relationships because one’s identity is expressed in relationships with others. Sexuality is a part of one’s identity. Sexual identity is a person’s image of the self as a man or a woman and the meaning of this image. This image and its meaning are influenced by sociocultural values that are learned through socialisation (see Chapter 24).

Body image

Body image is an individual’s mental picture of their physical appearance. It includes a person’s feelings and attitudes towards the body. These images are not necessarily consistent with the actual body structure or appearance. Body image may change within a few hours, days, weeks or months, depending on the impact of external stimuli on the body and actual changes in appearance, structure or function. Body image is also influenced by personal views of physical characteristics and abilities and by perceptions of others. For example, a controlling, violent husband might tell his wife that she is ugly and that no one else would want her. Over the years of marriage, she believes this image of herself and incorporates it into her self-concept.

Body image is affected by cognitive development and physical growth. Normal developmental changes such as physical growth and ageing have a more apparent effect on body image than on other aspects of self-concept (Saucier, 2004). Hormonal changes during adolescence and menopause influence body image. Changes associated with ageing (e.g. wrinkles, greying hair and decrease in visual acuity, hearing and mobility) may also affect body image.

Cultural and societal attitudes and values also influence body image (Cafri and others, 2005) (see Working with diversity). In Australian society, youth, beauty and wholeness are emphasised—a fact apparent in television programs, movies and advertisements. Western cultures have been socialised to accept the normal ageing process as a part of life, whereas in Eastern cultures ageing is viewed very positively and the older adult is respected.

WORKING WITH DIVERSITY FOCUS ON CULTURAL CARE

Culture influences what people tend to value in their lives. How people think about themselves, what motivates them and how they behave are all related to the culture within which people are socialised. In order to provide culturally safe care, healthcare professionals need to be aware of the significance of culture to a person’s health and wellbeing. This involves becoming culturally aware and responding to the cultural needs of individuals and their families. It is important to remember that a person’s cultural needs and spiritual needs are intertwined. This means that in providing culturally safe care, the spiritual needs of the person must be considered.

Body image depends only partly on the reality of the body. When physical changes occur, people may or may not incorporate these changes into their body image (Landa and Bybee, 2007). Often, for example, people who have experienced significant weight loss do not perceive themselves as thin. Older adults often report that they do not feel different despite such changes as wrinkled skin or greying hair.

Self-esteem

Self-esteem is an individual’s sense of self-worth. It is influenced by both self-evaluation and the responses of others. According to Erikson (1963), young children begin to develop a sense of usefulness or industry by learning to act on their own initiative. A child’s self-esteem is related to the child’s evaluation of their effectiveness at school or work, within the family and in social settings. The evaluation of others is also likely to have a profound influence on the child’s self-esteem. A person’s family and society in general set the standards by which individuals evaluate themselves. A child who excels in school and who is liked by peers is likely to have high self-esteem, whereas a child who has difficulty in school and is not liked by peers is likely to develop low self-esteem.

Understanding self-esteem can be enhanced by considering the relationship between a person’s self-concept and the ideal self. The ideal self consists of the aspirations, goals, values and standards of behaviour that a person considers ideal and strives to attain. The ideal self originates in the preschool years and develops throughout life. It is influenced by societal norms and the expectations and demands of parents and significant others. In general, a person whose self-concept comes close to matching the ideal self has high self-esteem, whereas a person whose self-concept varies widely from the ideal self has low self-esteem.

A person’s perception of self is based on gender, age, perceived health status, background, family roles, occupation, social roles and use of leisure time. Basic feelings about the self tend to be constant, even though there is some fluctuation, with good and bad days. An individual’s self-perception does not necessarily match the perceptions of others. Self-evaluation is an ongoing mental process. A positive sense of self-worth, or self-esteem, is a basic human need, according to Maslow’s hierarchy of needs (Maslow, 1954). People’s self-esteem affects their self-concept and how they function in the world.

A person’s ability to contribute in a meaningful way to society often affects their self-concept and self-esteem. Individuals who are sick and unable to be involved in society may feel a sense of worthlessness (Fung and others, 2006; Luxton and others, 2006). The nurse’s acceptance of a client as an individual with worth and dignity can be vital in maintaining and improving the client’s self-esteem.

Role performance

Role performance is concerned with the roles individuals assume or follow in given situations and involves expectations or standards of behaviour that they have developed over time. An individual develops role behaviour based on patterns established through socialisation. Socialisation begins just after birth, when an infant responds to adults and adults respond to the infant’s behaviours. The patterns of behaviour established in early life change only minimally during adulthood. A child learns behaviours that are approved by society through the following processes (Parsons, 1951):

• Reinforcement–extinction: certain behaviours become common or are avoided, depending on whether they are approved and reinforced or discouraged and punished.

• Inhibition: a child learns to refrain from behaviours, even when tempted to engage in them.

• Substitution: a child replaces one behaviour with another, which provides the same personal gratification.

• Imitation: a child acquires knowledge, skills or behaviours from members of the social or cultural group.

• Identification: a child internalises the beliefs, behaviour and values of role models into a personal, unique expression of self.

Through the process of socialisation, a child generally develops the skills necessary for functioning in many different roles. Unsuccessful socialisation is an inability to function according to society’s values.

Ideal societal role behaviours are often hard to live out in real life where individuals have multiple roles and individual needs. Successful adults learn to distinguish between ideal role expectations and realistic possibilities. To function effectively in roles, people must know the expected behaviour and values, must want to conform to them and must be able to meet the role requirements. Most individuals have more than one role. Common roles include mother or father, wife or husband, daughter or son, employee or employer, sister or brother, and friend. Each role involves meeting certain expectations. Fulfilment of these expectations leads to rewards. Difficulty or failure in meeting role expectations often contributes to decreased self-esteem.

Role performance is the way people perceive their competency in carrying out significant roles (Sargent, 2003). An individual’s perception of competency may or may not match the evaluation of others who relate to the person.

Spirituality

The word spirituality derives from the Latin word spiritus, which refers to breath or wind. The spirit gives life to, or animates, a person. It signifies whatever is at the centre of all aspects of a person’s life, including a sense of self (Elder and others, 2009). The human spirit is a powerful force that defines our existence, offers a source of hope and helps to achieve inner harmony (Edward and others, 2011).

Spirituality is a concept that is unique to each individual. People’s definitions of their own spirituality are influenced by their culture, development, life experiences, beliefs and ideas about life. A person’s spirituality enables the person to love, have faith and hope, seek meaning in life and to nurture relationships with others. Spirituality offers a sense of connectedness intrapersonally (connected within oneself), interpersonally (connected with others and the environment) and transpersonally (connected with what a person may perceive as a higher power). Elements of spirituality often found in the literature include spiritual health, spiritual needs and spiritual awareness. Berman and others (2010) describe spiritual wellbeing as a force that provides meaning and purpose in life and a sense of harmony between self, others/nature and an ‘Ultimate Other’, which exists throughout and beyond time and space. There are two important characteristics of spirituality about which most authors agree: it is a unifying theme in people’s lives, and it is a state of being.

There are people who either do not believe in the existence of a god (atheist) or who do not believe in any ultimate meaning for the way things are (agnostic). However, this does not mean that spirituality is not an important concept for the atheist or agnostic. Atheists often search for meaning in life through their work and their relationships with other people. They also tend to believe in a joint responsibility for others. In acting for themselves, they feel they should also act for all humankind. In the case of agnostics, it is important for them to discover or find meaning in what they do or how they live. Spirituality can be viewed from other perspectives, including faith, religion and hope.

Faith

The concept of faith has two definitions in the literature. In the first, faith is defined as a cultural or institutional religion, such as Judaism, Buddhism, Islamism or Christianity. (Faith as a religion is described in the next section.) The second deals with faith as a relationship with a divinity, higher power, authority or spirit that incorporates a reasoning and a trusting faith (Doucet, 2008). A reasoning faith deals with a person’s belief and confidence in something for which there is no proof. It is an acceptance of what reasoning cannot reach. However, faith is also manifest in the manner in which a person chooses to live life. Faith in this sense enables action. For example, a person might believe that having a positive outlook on life is the best way to achieve life’s goals. The belief that comes with faith involves transcendence, or an awareness of that which one cannot see or know in ordinary physical ways. It gives purpose and meaning to a person’s life. A trusting faith deals with the inner resources that allow a person to act. For example, clients with cancer who have faith in a positive outlook on life might search out more knowledge about their disease and continue to pursue daily activities rather than resign themselves to the disease’s symptoms.

Religion

Emblen (1992) defines religion as a system of organised beliefs and worship that a person practises to outwardly express spirituality. Many people hold a faith or belief in the doctrines and expressions of a specific religion or sect, such as the Anglican church within Christianity or the Orthodox Jewish faith. Religion serves different purposes in people’s lives. For some, religion is a set of rules and rituals used to worship a supreme being. For others, religion is a way of life providing nourishment and a connectedness to all life. In this latter context, religion is more directly associated with spiritual wellbeing. Religion is the system that may form the basis of and nurture some people’s spirituality. Many people are spiritual without being religious, and some people may be religious without being overtly spiritual. The writings and lives of leaders such as Gandhi are rich in spiritual material that may be influential for others in their spiritual quest. In the literature, spirituality and religiosity are often referred to as being synonymous, but for an accurate assessment of clients’ spiritual needs it is important for the nurse to realise that they are not the same and to be able to make that distinction (Baldacchino and Draper, 2001).

Hope

Spirituality is often identified as a key element in hope. When a person has the attitude of something to live for and look forward to, hope is present. Miller and Powers (1988) describe hope as a multidimensional concept consisting of anticipation of a continued good, an improvement or the lessening of something unpleasant. Hope is energising, giving people a motivation to achieve and the resources to use towards that achievement. It is an invaluable personal resource whenever someone is faced with a loss (Chapter 25) or a challenge that seems difficult to achieve. Hope has purpose and direction and gives reason for being (Berman and others, 2010). Loss of hope can give way to spiritual distress in which the person feels abandoned and left with no direction or sense of purpose.

WORKING WITH DIVERSITY FOCUS ON CULTURAL CARE

Spirituality is not limited to the concepts of faith, religion and hope from a religious perspective, but is also present within the context of culture. There are numerous cultural groups throughout the world whose sense of the spiritual is not aligned with religion but with their cultural heritage, identity, connection to the land and language group. Evidence of cultural alignment to a person’s sense of spirituality can be found in such cultural groups as the North American Indians, Māri, and Aboriginals and Torres Strait Islanders. Each of these cultural groups has a rich repository of spiritual beliefs that play a significant role in daily life, illness, health and healing. Premonitions, apparitions and visitations are points of connection with the spirit world—both past and present (Eckermann and others, 2006).

From the perspective of Māri culture, which embodies both a belief in a deity and a spiritual bonding with the earth, spirituality overarched both of these notions. Connection with a deity was achieved through the use of a godstick which was used by a priest or qualified person of the community for ritualistic occasions to speak to the spirit of a particular god. In relation to connecting with the land, many of New Zealand’s geographical features have spiritual meaning and are important anchors in defining self. Underpinning Māri culture is the belief that each human being has a spiritual essence which is connected to the person, nature, land, and objects made by man.

Eckermann AK, Dows T, Chong E and others 2006 Binan Goonj: bridging cultures in Aboriginal health, ed 2. Sydney: Elsevier.

RESEARCH HIGHLIGHT

Research focus

During the last few decades a large and growing body of research has emerged examining the relationship between spirituality and health. Williams and Sternthal (2007) provide a review of the empirical evidence linking measures of spirituality or religious involvement to health, with an emphasis on recent Australian research.

Research findings

• Levels of spirituality and religious beliefs and behaviour are relatively high in Australia, although lower than those in the United States.

• There is mounting scientific evidence of a positive association between religious involvement and multiple indicators of health.

• The strongest evidence exists for the association between religious attendance and mortality, with higher levels of attendance predictive of a strong, consistent and often graded reduction in mortality risk.

• Negative effects of religion on health have also been documented for some aspects of religious beliefs and behaviour and under certain conditions.

• Health practices and social ties are important pathways by which religion can affect health. Other potential pathways include the provision of systems of meaning and feelings of strength to cope with stress and adversity.

Reference

Williams DR, Sternthal MJ. Spirituality, religion and health: evidence and research directions. Med J Aust. 2007;186:S47–S50. © 2007 The Medical Journal of Australia; extract reproduced with permission.

Development of self-concept

Development of self-concept is a lifelong process. Each stage of development has specific tasks. Successful negotiation of these tasks tends to promote a positive self-concept (Box 23-1). Influential theorists who have considered various components of human development include Erikson (1963), Gilligan (1982), Kohlberg (1969) and Piaget (1963). The following is a brief discussion of the stages of development. For additional information, consult the chapter indicated with each section (Chapters 19–22 Chapter 20 Chapter 21 Chapter 22).

BOX 23-1 SELF-CONCEPT: DEVELOPMENTAL TASKS

0–1 YEAR

• Begins to trust

• Distinguishes self from environment

1–3 YEARS

• Has control of some language

• Begins to be autonomous in thoughts and actions

• Likes body

• Likes self

3–6 YEARS

• Takes initiative

• Identifies with a gender

• Increases self-awareness

• Increases language skills

6–12 YEARS

• Is industrious

• Interacts with peers

• Increases self-esteem with new skill mastery

• Is aware of strengths and limits

12–20 YEARS

• Accepts changed body

• Explores goals for future

• Feels positive about self

• Interacts with those whom they find sexually attractive

MID-20S TO MID-40S

• Has intimate relationships with family and significant others

• Has stable, positive feelings about self

MID-40S TO MID-60S

• Can accept changes in appearance and endurance

• Re-assesses life goals

• Shows contentment with ageing

LATE 60S ON

• Feels positive about their life and its meaning

• Is interested in providing a legacy for the next generation

Stages of development

Infant

What an infant needs initially is a primary caretaker and a relationship with that caretaker. This nurturing role can be filled by a mother, a father or someone responsible for taking care of the infant. When the infant has pleasant, nurturing interactions with the caregivers, these are remembered and internalised into the infant’s psyche. If the interactions are unsatisfying, painful or frustrating, this can result in difficulties in establishing a positive self-concept. When an infant’s needs are met with reasonable consistency, the infant develops a sense of trust in the world (see Chapter 20). During this phase of development, the infant begins to differentiate between self and others.

Toddler

Toddlers (1–3 years of age) are more mobile than infants and able to interact with others. Their major psychosocial task is the development of autonomy (see Chapter 20). Toddlers move from total dependence to a greater sense of independence and separateness of themselves from others. They also tend to view others and themselves in terms of ‘all good’ or ‘all bad’. They gain skills in feeding themselves and in performing basic hygiene tasks. Toddlers learn to coordinate movements and imitate others. They learn control of their bodies through locomotion, toilet training, speech and socialisation skills.

Preschooler

Body boundaries, sense of self and gender of preschoolers become more definite to them because of a developing sexual curiosity and awareness of differences from others of the same and opposite gender. Learning about the body—where it begins and ends, what it looks like and what it can do—is basic to self-concept and body-image formation. Growing self-awareness includes discovery of feelings. For example, preschoolers learn names for their feelings. They begin to learn how they affect others and how others respond to them. They also learn the rudiments of control over feelings and behaviour. The concept of body is reflected in the way children talk, move, draw pictures and play. Children begin to test roles and imitate people as they identify with the same-sex parent or a family member (see Chapter 20).

Appraisal by a family member becomes self-appraisal. If the family is critical of the child’s budding self-concept, this negative input creates a decreased self-esteem, which the person will have to work very hard to overcome as an adult.

School-age child

Until children attend school, self-concept and body image are based mainly on parental attitudes (see Chapter 20). At school, others contribute to the child’s self-concept and body image. This can have a counterbalancing effect for children whose families have been extremely critical, or it can be negative if the child experiences a negative educational environment.

As the child enters the school years, growth is steady, and more motor, social and intellectual skills are acquired. The child’s body changes and their sexual identity strengthens. The child’s attention span increases, and reading allows expansion of the child’s self-concept, through imagination, into other roles, behaviours and places. The child begins to reason in a more systematic way and is able to apply previous learning to current situations (Piaget, 1963). Through games, children interact with peers, develop additional motor and intellectual skills, and thereby expand their self-concept and body image (Figure 23-2). Children express feelings through games, literature, drawing and music. The nurse can use these to gain clues to children’s self-concepts. With increased problem-solving abilities, a greater self-awareness of personal strengths and limitations develops. Self-concept and body image can change at this time because the child is changing physically, emotionally, mentally and socially.

FIGURE 23-2 A child learns to define self partly though interactions with peers.

Image: iStockphoto/Christopher Futcher.

Adolescent

Adolescence brings physical, emotional and social upheaval. Throughout sexual maturation, new feelings, roles and values must be integrated into the self. Rapid growth, noticed by the adolescent and others, is an important factor in body image acceptance and revision (see Chapter 20).

Adolescents are forced to alter their mental pictures of themselves. Physical changes in size and appearance cause changes in self-perception and use of the body. Adolescents may spend a great deal of time in front of the mirror for hygiene, grooming and dressing, as they seek to improve their appearance as much as possible. Great distress is felt about perceived body imperfections.

Development of self-concept and body image is closely related to identity formation (Erikson, 1963). The ways in which adolescent males and females consider moral situations also demonstrate differences. Kohlberg (1969), whose research involved following boys over time to observe moral development, found them to have highly developed moral reasoning concerning equality, reciprocity, justice and rights. Being aware of these common gender differences when interacting with clients can help the nurse understand an individual’s perceptions of what is important and valued.

Young adult

Although physical growth has stopped by this stage, cognitive, social and behavioural changes continue for the rest of life. Young adulthood (early 20s to mid-40s) is a period of choice; it is a period of settling into responsibility, gaining stability in employment, and beginning intimate relationships. Self-concept and body image become relatively stable at this time. However, these are challenged by pregnancy and childbirth occurring within this developmental period. Self-concept and body image are social creations, and approval and acceptance are given for normal appearance and proper behaviour according to societal standards. Self-concept constantly evolves and can be identified in values, attitudes and feelings about the self (see Chapter 21).

Middle-aged adult

Physical changes such as additional fat deposits, baldness, grey hair, wrinkles and varicosities confront the middle-aged adult. People realise that they look older, and they may feel older as well. Work may be stressful if middle-aged people feel that they have less stamina, endurance and vigour to cope with the task at hand. This reduced energy level is often a result of lower basal metabolism and reduced muscle tone.

Often middle adulthood is a time of self-reflection and re-evaluation. Individuals are likely to re-examine their lives, considering whether they are satisfied with what they have accomplished and how they want to live the rest of their lives (Sheehy, 1995). This time of reflection may be difficult as people consider what is right and what is wrong in their lives. Even though this self-reflection may be difficult at times, it can foster growth and a more integrated self-concept.

Illness or death of loved ones can create concerns about personal health. The person may feel inferior to youth as the previous self-image of a strong and healthy body with boundless energy is replaced with a self-image reflecting the changes of ageing. Difficulties in accepting the loss of youth are also caused by fear of the effects of menopause, folklore about sexuality, and social and advertising pressures describing the virtues of youth.

The middle adult years are often the time for a re-assessment of life experiences and a redefinition of the self in life roles and values (see Chapter 21). This is called the ‘midlife crisis’ and might include a re-evaluation of career or marriage choices. Successful resolution involves the integration of new qualities into the self-concept. Most people gradually adjust to their slowly changing bodies and accept the changes as part of maturing. Emotionally mature people realise that they cannot return to youth and acknowledge that their own pasts and experiences are valid and valuable. Middle-aged people who are content with their age and have no desire to relive the youthful years exhibit a healthy self-concept.

Older adult

Physical changes in older adults can be seen as gradual reductions of structure and function (see Chapter 22). Loss of muscle strength and tone occurs. Osteoporosis, which is a loss of bone density and mass, may increase the risk of fractures and create changes to physical appearance (e.g. a dowager’s hump).

Loss of sensory acuity is a factor that influences older adults in interacting with the environment. The normal process of ageing causes decreased visual acuity. Hearing loss can cause negative personality changes, such as suspiciousness, irritability, impatience or withdrawal, as older people realise that they are less aware of what is happening around them. Many older adults view a hearing aid as another threat to body image. To many older adults, glasses are more socially acceptable because they are worn by all age groups, but a hearing aid is perceived as direct evidence of old age.

Loss of skin tone with accompanying wrinkles may affect self-esteem and cause older people to feel unattractive in a society that values youth and beauty. Western culture does not discriminate in terms of age and appearance against men as severely as it does against women.

Self-concept during older adulthood is influenced by experiences throughout life. It is a time when many people reflect on their lives, reviewing successes and disappointments and thereby creating a unified sense of meaning about themselves and the world (see Working with diversity). Helping the younger generation in a positive way often helps an older adult to develop a feeling of leaving a legacy. Self-concept is also influenced by people’s present perceived health status.

Stressors affecting self-concept

Stressors challenge a person’s adaptive capacities. Selye (1956) states that stress is the normal wear-and-tear of life, not the specific result of any one action or typical response to any one thing. The normal process of maturation and development itself is a stressor. Changes that occur in physical, spiritual, emotional, sexual, familial and sociocultural health are stressful. A self-concept stressor is any real or perceived change that threatens identity, body image, self-esteem or role behaviour (Figure 23-3).

FIGURE 23-3 Common stressors that can influence self-concept.

WORKING WITH DIVERSITY FOCUS ON OLDER ADULTS

Reminiscence has been found to support a positive self-concept in older adults. Suggestions for reminiscence include the following:

• Spend time reviewing old photographs and have the older adult tell their stories that relate to the pictures.

• Plan sessions where the older adult and a friend can talk about past shared experiences.

• Encourage the person to write about a positive past event.^*

• Ask a person to tell you about a memorable event and record their story (asking permission before you begin), then play the recording back for the person, either at that time or at another time.^*

• Encourage the person to write letters to old friends.^*

^*From Nugent E 1995 Try to remember … reminiscence as a nursing intervention. J Psychosoc Nurs 33(11):7.

Different people react to similar situations with varying degrees of stress. Perception of a stressor is an important factor that influences how people respond to it. People learn patterns of behaviour as a way of coping with or adapting to stressors. These patterns are often used when a person encounters a new stressor. Some of these patterns of responding to stressors are more adaptive than others. Being able to adapt to stressors is likely to lead to a positive sense of self, whereas failure to adapt often leads to a negative sense of self (Berge and Ranney, 2005). A person’s ability to adapt is related to numerous factors, including the number of stressors, duration of the stressor, and health status (see Chapter 42).

Any change in health can be a stressor that affects a person’s self-concept. A physical change in the body can lead to an altered body image, affecting identity and self-esteem. Chronic illnesses often alter role performance, which may alter one’s identity and self-esteem. The clinical example below illustrates the interrelationship of the components of self-concept.

A crisis occurs when a person cannot overcome obstacles with usual methods of problem solving and coping. Any crisis requires change and thus has the potential to threaten the person’s self-concept. Some crises, such as in the clinical example above, directly affect all four components of self-concept. During crises to self-concept, as with other kinds of crises, supportive resources can be valuable in helping a person learn new ways of coping with and responding to the event or situation to maintain a positive self-concept.

Identity stressors

One’s identity is affected by stressors throughout life. Adolescence is a time of great change, causing insecurity and anxiety. Adolescents are trying to adjust to the physical, emotional and mental changes of increasing maturity. Stressors may arise in any of these areas or as a result of conflicts among them. An adult generally has a more stable identity and thus a more firmly developed self-concept. Cultural and social stressors, rather than personal stressors, may have more impact on an adult’s identity. Developmental markers such as the initiation of menses, puberty, menopause, retirement, and decreasing physical abilities may affect identity. Identity, like body image, is closely related to appearance and abilities (Figure 23-4). Retirement may mean the loss of an important means of achievement and continued success. People at retirement may begin to question their identity and accomplishments. Loss of a significant other can lead the surviving person to re-explore aspects of their identity.

FIGURE 23-4 An individual’s appearance influences self-concept.

Image: iStockphoto/LifesizeImages.

CLINICAL EXAMPLE

Paul, a 48-year-old man, suffers a stroke. The stroke is unexpected and sudden; he was not even aware that he had hypertension, because he had not been having annual checkups. Paul wakes up in a hospital bed to find that he cannot move even his hand. He cannot care for himself. He cannot even turn himself for days. Finally, he is able to pull himself out of bed and into a chair with the nurse’s help. He wonders what lies in store for him. Paul’s body image has dramatically changed from that of a man of strength and endurance to that of a helpless individual. Paul worries about his family and what will happen. His daughter, the older child, is away at university, and his son is still in secondary school. Paul and his wife, Meredith, are terrified. Although Meredith works, they have not saved enough money to be able to educate their children without Paul’s wages. Paul’s role as chief financial provider for the family may be drastically changed if his condition does not change.

Paul’s self-esteem wanes as his recovery and rehabilitation move slowly. His self-concept changes from that of a strong labourer, one who did his own plumbing and car repairs, to a man who has to tell his son what to do because he does not have the strength to do these tasks. Although he is now at home in the rehabilitation process, Paul is not able to perform tasks for the family and must wait until his wife and son get home to help him with things that require strength. Paul’s adaptation capabilities are stretched to the maximum, although his neurologist tells him that he is very fortunate to be alive. His life is now changed—for how long he does not know. Paul’s identity is not clear to him any more, he has no clear role within the family, his body image has been drastically altered and his self-esteem is spiralling lower and lower.

Paul continues in outpatient physical therapy. It takes much time and hard work even on simple tasks, but he begins to gain some strength. Paul continues to make gains. He is able to return to work. He has some diminished mental quickness and some muscle weakening, but he is able to perform his job. His self-esteem recovers, and his body image is enhanced. Although he still feels somewhat altered, his capabilities closely resemble his capabilities before the stroke.

Identity confusion results when people do not maintain a clear, consistent and continuous consciousness of who they are as a person. It may occur at any stage of life if a person is unable to adapt to identity stressors. Under extreme stress an individual may experience depersonalisation, a state in which internal and external realities or the differences between the self and others cannot be determined.

Body image stressors

Changes in the appearance, structure or function of a body part will require a change in body image. Changes in the appearance of the body, such as an amputation or facial disfigurement, are obvious stressors affecting body image. Mastectomy, colostomy and ileostomy are surgical procedures that alter the appearance and function of the body, although the changes may not be apparent when people are clothed. Even though they are not apparent to others, these changes have a significant effect on the individual. Chronic illnesses such as heart and renal disease involve a change in function, in which the body no longer functions at an optimal level. Even body changes resulting from the normal developmental process of ageing can affect body image. In addition, the effects of pregnancy, significant weight gain or loss, chemotherapy or radiation therapy change body image.

An individual’s perception of body changes may be affected by how the changes came about. For example, paralysis caused by war injuries may be considered acceptable to the individual. A veteran may be treated as a hero and praised for bravery by society as a result of injuries sustained during war; government resources will be available for rehabilitation. However, people who have car accidents while under the influence of alcohol or drugs and sustain significant injuries may receive a very different response from society.

The significance of a loss of function or a change in appearance is affected by the individual’s perception of the alteration. Body image consists of ideal and real elements. For example, if a woman’s body image incorporates breasts as the ideal, the loss of a breast by mastectomy may be a very significant alteration. The greater the importance of the body or a specific body part, the greater the threat felt by a change in body image.

Many people associate success with a specific body part or function. For example, athletes may consider their bodies and physical activities to be the focus of personal success. If they can never again participate in physical activities because of an accident, their adaptation and rehabilitation may be affected. To regain a positive self-concept, and to maintain good health, they need to face the challenge of revising long-standing assumptions and learn to adapt to their body image stressors.

There is a trend towards positive social changes with regard to illness and altered body image. The media now frequently present positive stories about people with serious disabilities or who have had major body-altering surgery. These stories provide positive role models for individuals undergoing similar life stressors, as well as for their families, friends and society as a whole.

Self-esteem stressors

Positive or high self-esteem involves seeing oneself as being a good person, worthy of respect and love. A person with low self-esteem tends to feel unloved and may experience depression and/or anxiety as a consequence. Self-esteem fluctuates somewhat with surrounding conditions, although a basic core of positive or negative self-esteem generally remains constant even with changing circumstances. Most people experience ‘bad days’, when they feel less worthy and competent, but these feelings pass relatively quickly for someone with positive self-esteem.

Self-esteem stressors vary at different stages of the developmental life cycle. For example, inability to meet parental expectations, harsh criticism, inconsistent punishment, sibling rivalry and repeated defeats may reduce the level of self-worth of children. Stressors affecting the self-esteem of an adult include failure in work and failures in relationships.

Illness, surgery or accidents that change life patterns may also have impacts on a person’s feelings of self-worth. Chronic illnesses such as diabetes, arthritis and cardiac disease require changes in accepted and long-assumed behavioural patterns. The more the chronic illness interferes with the ability of the person to engage in activities contributing to feelings of worth or success, the more it affects the individual’s self-esteem.

Critical thinking synthesis

Critical thinking requires synthesis of knowledge, experience, information gathered from clients, critical thinking attitudes, and intellectual and professional standards. Clinical judgment requires the nurse to anticipate the information necessary for making a sound evaluation, to analyse the data and to make informed decisions regarding client care. During assessment the nurse must consider all critical thinking elements that contribute to making appropriate nursing diagnoses.

In the case of dimensions of self (self-concept and spirituality), the nurse must integrate knowledge from nursing and other disciplines, including self-concept theory, spirituality theory, communication principles and a consideration of cultural and developmental factors. Previous experience in caring for clients with self-concept alterations and associated spiritual wellbeing/distress helps the nurse adapt care for each new client. Critical thinking attitudes such as integrity ensure that the client receives professional and respectful care. Ethical standards of supporting clients’ autonomy and intellectual standards such as relevance ensure that the nurse respects the clients’ uniqueness. The way in which people view themselves and their relationships to others and the world profoundly influences a person’s response to illness. A critical thinking approach to care is therefore essential.

DIMENSIONS OF SELF AND THE NURSING PROCESS

ASSESSMENT

In assessing the various dimensions of the self, the nurse should focus on each component (identity, body image, self-esteem and role performance, and a person’s spirituality), behaviours suggestive of alterations to self-concept (Box 23-2), actual and potential stressors (see Figure 23-3), and coping patterns. Gathering comprehensive assessment data requires the nurse to critically synthesise information from multiple sources. Much of the data regarding self-concept and spiritual needs are most effectively gathered through observation of the client’s non-verbal behaviour and by paying attention to the content of the client’s conversation rather than through direct questioning. The nurse should take note of the manner in which clients talk about the people in their lives, since this can provide clues to both stressful and supportive relationships and to key roles.

BOX 23-2 BEHAVIOURS SUGGESTIVE OF ALTERED SELF-CONCEPT

Avoidance of eye contact

Overly apologetic

Hesitant speech

Overly critical

Excessive anger

Frequent or inappropriate crying

Puts self down

Excessively dependent

Hesitant to express views or opinions

Lack of interest in what is happening

Passive attitude

Difficulty in making choices

Slumped posture

Unkempt appearance

Self-harming

Disordered eating

Using knowledge of human development to determine what areas are likely to be important to the client, the nurse should inquire about these aspects of the person’s life. For example, the nurse might ask a 65-year-old client about their life and what has been important. This is the stage in life during which people examine their lives and consider the impact they have had in the world. The person’s conversation is likely to provide data relating to role performance, identity, self-esteem, stressors and coping patterns. At times, specific questions may be useful (Table 23-1).

TABLE 23-1 NURSING ASSESSMENT OF CLIENT’S SELF-CONCEPT

ASSESSMENT QUESTIONS^*	RESPONSES REFLECTING DIFFICULTIES WITH SELF-CONCEPT
IDENTITY
‘How would you describe yourself?’	Derogatory answers (e.g. ‘I don’t know; there’s not much that is very exciting about me’ or ‘I’m not good at much of anything’) should raise concern
BODY IMAGE
‘What aspects of your appearance do you like?’ ‘Are there any aspects of your appearance that you would like to change? If yes, describe the changes you would make.’	Most people can identify something about their appearance that they like (e.g. ‘People have always told me I have nice eyes’). If a person cannot identify any appreciated characteristic, this is suggestive of a negative body image and self-esteem. Most people have one or two areas that they would like to change (e.g. ‘My nose is too big’ or ‘My hips are too big’), but a long list of problem areas should lead the nurse to consider difficulties with self-concept
SELF-ESTEEM
‘Tell me about the things you do well.’	Statements about not having any strengths or not being able to do anything well should raise concern
ROLE PERFORMANCE
‘What are your primary roles (e.g. partner, parent, friend, sister, professional role)? How do you see yourself carrying out each of these roles?’	The nurse should listen for the number of primary roles identified. A large number of primary roles will put the client at risk of role conflicts and role overload. As with questions above, if the client indicates that they do not feel that these roles are adequately covered, the person may be experiencing alterations in self-concept. Although in Western cultures most people carry out many roles and often feel as though some of them are not adequately covered, listen for the person’s perception about their overall role competency.

^*In addition to the verbal content of the client’s answer, the nurse should note the client’s non-verbal behaviours. Hesitant speech, poor eye contact and hunched posture suggest alterations in self-concept.

Coping strategies

The nursing assessment should also include consideration of previous coping behaviours; the nature, number and intensity of the stressors; and the client’s internal and external resources. Knowledge of how a client has dealt with stressors in the past can provide insight into the client’s style of coping. Not all issues are faced in the same way by clients, but often one uses a familiar coping pattern for newly encountered stressors. As the nurse identifies previous coping patterns, it is useful to determine whether these patterns have contributed to healthy functioning or created more problems. For example, the use of drugs or alcohol during times of stress often creates additional stressors.

Exploring resources and strengths, such as helpful significant others or previous use of community resources, can be important in formulating a realistic and effective plan. Also pertinent in assessment is determining how the client views the situation. What is viewed as a crisis by one client may be seen as less significant by another client. For example, one client might express great fear and distress over needing to have a colonoscopy and biopsy, whereas another client may see the need for the diagnostic testing as a manageable outgrowth of growing older, and take the attitude that if there is something to be concerned about, the client will know about it soon enough.

Significant others

Valuable data may also evolve out of conversations with family and significant others. Significant others may have insights into the person’s way of dealing with stressors and what is supportive to the person. The way in which the person talks about the client and the non-verbal behaviours of the significant others may provide information about what kind of support is available for the client.

Client expectations

Also important in the assessment process is the person’s expectations. Asking the client how they believe interventions will make a difference in their situation can provide useful information regarding the client’s expectations and an opportunity to discuss the client’s goals. For example, a nurse working with a client who is experiencing anxiety related to an upcoming diagnostic study might ask the client about their expectations of the relaxation exercise that they have been practising together. The client’s response will give the nurse valuable information about the client’s beliefs and attitudes regarding the efficacy of the interventions.

• CRITICAL THINKING

A 51-year-old man has been transferred to the rehabilitation unit following two weeks of hospitalisation resulting from an industrial accident in which his pelvis was crushed by a hydraulic press. His pelvis was stabilised with external fixation. Initially he was paralysed from T12 down. During the two weeks since the accident, feeling and movement have begun to return to his lower extremities. With the return of function, there have also been spasms that occur with movement and increase in severity if movement is continued. With the gradual return of functioning, medical staff have been hesitant to give the client a prognosis and have told him that waiting and seeing is what will reveal his returning functioning. The client seems satisfied with this explanation at this point. His main focus is on directing his personal care to minimise risk of infection and to ensure that whoever is caring for him understands the importance of waiting for a muscle spasm to subside before continuing with care.

You are a student nurse assigned to care for the client during a 4-week rotation. How might you establish trust and assess the client’s concerns about the future?

NURSING DIAGNOSIS

Assessment data need careful consideration by the nurse to identify a client’s actual or potential problem areas. The nurse will rely on knowledge and experience, apply appropriate standards and attitudes and look for clusters of defining characteristics that indicate a nursing diagnosis (Box 23-3).

BOX 23-3 SAMPLE NURSING DIAGNOSTIC PROCESS

DISTURBED SELF-CONCEPT
ASSESSMENT ACTIVITIES	DEFINING CHARACTERISTICS	NURSING DIAGNOSIS
Observe client’s behaviour during conversation.	Client demonstrates restlessness, glancing about, facial tension, increased perspiration and focus on self.	Anxiety related to accidental injury, pain, uncertainty of outcome of upcoming surgery.
Ask client, ‘How are you going?’ or ‘How do you feel about tomorrow’s procedure?’	Client replies, ‘I’m feeling really scared. You know there is a possibility they may amputate my leg tomorrow. I just don’t know how I will manage if it comes to that. I just couldn’t sleep last night. There was the pain, and I just keptthinking about all that is happening.’

Making nursing diagnoses in the realm of self-concept and spirituality is complex. Often, isolated data could be defining characteristics for more than one nursing diagnosis (Box 23-4). For example, a client might express feelings of regret and inadequacy. These are defining characteristics for anxiety, spiritual distress and situational low self-esteem. To make the most appropriate nursing diagnoses in this situation, the nurse must be open to seeing the possibilities of different yet interrelated nursing diagnoses. In fact, the awareness that the client is demonstrating defining characteristics of more than one nursing diagnosis can guide the nurse in gathering specific data to validate and differentiate the underlying problem. To further assess the possibility (for instance) of anxiety as the nursing diagnosis, the nurse might consider whether the person has any of the following defining characteristics: increased muscle tension, shakiness or restlessness. These symptoms suggest that anxiety may be the more appropriate diagnosis.

BOX 23-4 NURSING DIAGNOSES

ALTERATIONS IN SELF-CONCEPT

Adjustment, impaired

Anxiety

Body image disturbance

Caregiver role strain

Coping, ineffective individual

Denial, ineffective

Fear

Hopelessness

Loneliness, risk of

Parental role conflict

Parenting, altered

Personal identity disturbance

Powerlessness

Rape-trauma syndrome

Role performance, altered

Self-esteem, chronic low

Self-esteem, situational low

Self-esteem disturbance

Self-mutilation, risk of

Spiritual distress (distress of the human spirit)

Violence, risk of: self-directed

However, defining characteristics relating to patterns that reflect a person’s dispiritedness may indicate that a person is in a spiritual crisis. For example, expressing concern with the meaning of life and belief systems, anger towards a god, verbalising conflicts about personal beliefs or asking for spiritual assistance are consistent with a loss of spirit which suggests a diagnosis of spiritual distress. Examples of nursing diagnoses for clients in need of spiritual support are given in Box 23-5.

BOX 23-5 NURSING DIAGNOSES

CLIENTS IN NEED OF SPIRITUAL SUPPORT

Spiritual wellbeing, potential for enhanced wellbeing

Spiritual distress

Coping, ineffective individual

Coping, ineffective family: compromised

Coping, family; potential for growth

Family processes, altered

Dysfunctional grieving

Anxiety

Fear

Hopelessness

Powerlessness

Self-esteem disturbance

On the other hand, if the person expresses a predominantly negative self-appraisal, including inability to handle situations or events and difficulty making decisions, these characteristics would suggest that the more appropriate nursing diagnosis might be situational low self-esteem. To further help the nurse differentiate between the three demonstrated diagnoses, information regarding recent events in the person’s life and how the person has viewed themself and their life circumstances in the past would provide insight into the most appropriate nursing diagnosis. In this example, the three nursing diagnoses are closely related. Often in practice the nurse will have to differentiate between several diagnoses. The client may demonstrate several defining characteristics from different diagnoses; but as additional data are gathered, the most appropriate or predominant nursing diagnosis usually becomes evident.

It is also important for the nurse to have sufficient data to correctly identify the factors that have contributed to the nursing diagnosis. These factors will be reflected in the ‘related to’ component of the nursing diagnostic statement. If a thorough database is not gathered before formulating the nursing diagnosis, diagnostic errors are likely. For example, a nurse is caring for a 62-year-old woman who was admitted because of chronic back pain. The client demonstrated signs of anxiety (inattentiveness, frequent starting, self-report of poor sleep, diminished appetite and increased muscle tension). The nurse knew that the client had undergone diagnostic testing to rule out cancer as the cause of the pain. The nurse made the following nursing diagnosis: anxiety related to the possibility of cancer. The nurse later learned that the woman was anxious because her grandson had been in a serious motor vehicle accident and was in intensive care.

The above example illustrates the danger in making a diagnosis without sufficient data. Even though the anxiety component of the nursing diagnosis was correct, the cause was incorrect. Failure to be accurate and precise regarding the aetiology of the anxiety will result in inappropriate nursing interventions. In order to avoid a similar situation when making a diagnosis of, for example, spiritual distress, critical thinking is required which involves a review of concrete data (e.g. religious rituals and sources of fellowship) as well as an assessment of previous client experiences, the nurse’s own spirituality and the appraisal of the client’s spiritual wellbeing. Defining characteristics must be validated and clarified with the client before a diagnosis and plan of care are made.

With spiritual care, the importance of the nurse’s own spiritual wellbeing and perceptions cannot be overemphasised. Nurses should avoid imposing their personal beliefs on the client. Each diagnosis must have an accurate related factor so that the resulting interventions can be purposeful and goal-directed.

One way to develop an accurate nursing diagnosis is to discuss the problem with the client and the family. Before involving the family, however, the nurse needs to consider the client’s wishes for their involvement, and cultural norms regarding who most often makes decisions in the family.

To validate critical thinking regarding a nursing diagnosis, the nurse can share observations with the client and allow the client to verify the nurse’s perception. This approach often results in the client providing additional data, which further clarifies the situation. In the example above, the nurse might say to the client, ‘I notice you haven’t eaten much of your breakfast or lunch and that you jumped when I came up behind you. Are you feeling uneasy today?’ This could allow the client to verify whether she is, in fact, anxious and to tell the nurse about her concerns.

• CRITICAL THINKING

A client with a progressive neurological disease tells you he is afraid he will soon be unable to walk. His affect is blunted and he often looks away into the distance. His wife tells you that difficulty walking and getting to the toilet in time prevents him from going out much, such as going to church. At one point both of them were very active in church activities.

What might you want to learn about the client during your assessment?

PLANNING

During planning, the nurse again synthesises knowledge, experience, critical thinking attitudes and standards. Critical thinking ensures that the client’s plan of care integrates all that the nurse knows about the individual, as well as key critical-thinking elements. Professional standards are especially important to consider when the nurse develops a plan of care (Australian College of Mental Health Nurses, 2010; Australian Nursing and Midwifery Council, 2006). These standards often establish ethical or scientifically proven guidelines for selecting effective nursing interventions.

The nurse develops an individualised plan of care for each nursing diagnosis (see Sample nursing care plan). The nurse and the client set realistic expectations for care. Goals must be individualised and realistic, with measurable outcomes. In establishing goals, the nurse should consult with the client about whether the goals are realistic. Consultation with significant others, mental health workers and community resources (Box 23-6) can result in a more comprehensive and workable plan. Once a goal has been formulated, the nurse should consider how the clues that alerted them to the problem would change if the problem were diminished. These changes should be reflected in the outcome criteria. For example, a client is diagnosed with situational low self-esteem related to a recent job loss. The defining characteristics that she demonstrates are complaints of not being able to do anything right lately and expression of shame about losing her job. The nurse formulates the goal that the client’s self-esteem will improve within 1 week. Appropriate expected outcomes might include that the client will discuss a minimum of three areas of her life where she is functioning well and voice the recognition that losing her job is not reflective of her worth as a person.

BOX 23-6 RESOURCES IN THE COMMUNITY FOR SUPPORTING SELF-CONCEPT

Alcoholics Anonymous (AA)—www.aa.org.au, www.aa.org.nz

Al-Anon, for relatives of alcoholics—www.al-anon.org/australia, www.al-anon.org.nz

Beyond Blue—www.beyondblue.org.au

Community health centres

Eating disorders support networks

Gay and lesbian counselling services—www.glccs.org.au, various services in New Zealand

Grief support groups

Lifeline—www.lifeline.org.au, www.lifeline.co.nz

Rape crisis centres

Relationship advice/counselling—Relationships Australia, www.relationships.org.au; Relationships Aotearoa, www.relationshipsaotearoa.org.nz

SAMPLE NURSING CARE PLAN

Elder R, Evans K, Nizette D 2009 Psychiatric and mental health nursing. Sydney, Mosby.

ALTERATIONS IN SELF-CONCEPT

ASSESSMENT^*

Mr Johnson is a 45-year-old man who was involved in a car accident in which he sustained a crushing blow to his femur. On admission, an open reduction and internal fixation (ORIF) of the femur was done. Since then, he has developed an infection, and the most current X-ray film shows misalignment of the bone fragments. The chart reveals that Mr Johnson has been in essentially good health up until the time of the accident.

When Ian, the student nurse, first goes in to meet Mr Johnson, he finds that although Mr Johnson makes eye contact and answers questions, his answers are brief and to the point without elaboration. As Ian spends more time with Mr Johnson, his eye contact increases, but his answers to questions remain brief. He is restless and shifts frequently in the bed. Mr Johnson tells Ian that before the accident he had a nearly ideal life. He describes his family as a source of pleasure and satisfaction. He tells him briefly about a recent trip the family took and the adventures of his two teenagers. He describes his work as okay. He states, ‘I have been at the factory for 25 years. I know my job. Sometimes it gets boring, but it pays the bills, and I will be able to retire with good benefits if I can just work a few more years.’

In gathering the nursing history, Ian learns that Mr Johnson has had trouble sleeping since admission. He says that in addition to the pain, there is just so much to think about. Specifically, he says, ’You know, they may not be able to save my leg.’

In reviewing the progress notes since admission, Ian notes that Mr Johnson’s appetite has been recorded as poor and he usually eats only a quarter to a half of his meals.

NURSING DIAGNOSIS: Anxiety related to accidental injury, pain and uncertainty of outcome of upcoming surgery and treatment.

PLANNING

GOALS	EXPECTED OUTCOMES
Client’s anxiety will be diminished within 1 week.	Client will state that his anxiety/worry is less within 3 days. Client will discuss his concerns openly with a staff person within 3 days. Client will perform progressive relaxation exercises within 3 days. Client’s restlessness will decrease within 1 week.
Client will regain normal sleep pattern in 1 week.	Client will report having slept for 4 consecutive hours during the night within 1 week.
Client’s weight will remain stable for next month.	Client will report an increased appetite and eat at least three-quarters of his meals within 1 week.

INTERVENTIONS^†	RATIONALE
Coping enhancement
• Help client to define his level of anxiety (use terminology the client is comfortable with, e.g. worry, nervous).	Anxiety is highly individualised, and different clients manifest anxiety in varying degrees.
• Empathise with client that worry is a normal response to what has happened.	Anxiety is a normal response to an actual or perceived danger.
• Explore coping skills the client has used in the past. Encourage and support adaptive coping skills used in the past.	Most clients have developed effective coping skills during their lives. Supporting these coping skills in currently stressful situations can aid adaptation.
• Encourage client to express concerns verbally.	Verbalising a concern can allow the client to be more objective about what is happening.
Calming techniques
• Decrease the number of new stressors (e.g. answer client’s call bell promptly, explain procedures, decrease unnecessary noise).	The number of stressors affects the stress experience.
Pain management
• Treat pain before it becomes moderate to severe.	Pain is a stressor that can increase anxiety.
• Teach client the importance of seeking pain relief before the pain reaches a rating of 5.	Increasing the client’s ability to control his experiences and environment will help to decrease anxiety.
Alterations in self-concept
Pain management:	Relaxation is psychophysiologically in opposition to
• Teach client progressive relaxation techniques. Progressive muscle relaxation	anxiety. Relaxation is energy conserving and nurturing (Elder and others 2009).

^†Intervention classification labels from McCloskey JC, Bulechek GM 2000 Nursing interventions classification (NIC), ed 3. St Louis, Mosby.

EVALUATION

Explore with client what his current level of anxiety is.

Ask client how he slept the night before.

Inquire regarding client’s appetite and monitor the amount of food eaten from meal trays.

Weigh client weekly.

Explore with client his concerns and note areas he discusses.

Observe non-verbal clues regarding eye contact and degree of restlessness during discussion.

^*Defining characteristics are shown in bold type.

The care plan presents the goals, expected outcomes and interventions for a client with an alteration in self-concept. Interventions focus on helping the client adapt to the stressors that led to the self-concept disturbance and on supporting and reinforcing the development of coping methods. Often, a client perceives a situation as overwhelming and may feel hopeless about returning to the level of previous functioning. The client may need time to adapt to physical changes. The nurse should look for strengths in both the individual and the family and provide resources and education to turn limitations into strengths. Client teaching creates understanding of why certain events have happened (e.g. nature of a chronic disease, change in relationships, effect of a loss) and, often, once this is understood, the sense of hopelessness and helplessness can be lessened.

Often alterations in self-concept are not simple problems to resolve. The nurse should consider referral to mental health professionals and community resources that may be able to help the client work through complex problems (see Box 23-6).

As is the case in developing any plan of care, a spiritual care plan must include realistic and individualised goals along with relevant outcomes. It is important for both nurse and client to collaborate closely in setting goals and choosing related interventions. Setting realistic goals will require the nurse to know the client well. In cases where spiritual care requires helping clients adjust to loss or stressful life situations, goals may be long-term (see Sample nursing care plan). Short-term outcomes can also be established so that, progressively, the client reaches a more spiritually healthy situation.

IMPLEMENTATION

Once the goals and outcome criteria have been developed, the nurse considers nursing interventions that would help move the client towards the goals. To develop effective nursing interventions, the nurse should consider the nursing diagnosis and broad interventions that relate to the diagnosis. These broad, standard interventions should be tailored to the individual client. The nurse develops additional nursing interventions based on the ‘related to’ component of the nursing diagnosis. Developing interventions that affect the aetiological or ‘related to’ factors will often decrease the problem reflected in the nursing diagnosis.

SAMPLE NURSING CARE PLAN

Hall BA 1998 Patterns of spirituality in persons with advanced HIV disease. Res Nurs Health 21:143.

SPIRITUAL WELLBEING

ASSESSMENT

James is a 24-year-old who has recently been diagnosed with HIV. The clinic registered nurse (RN) has been talking to James during his last three visits. During that time James expresses a fear of dying and anger with God: ‘How can God do this to me? This just can’t be happening!’ The RN attempts to learn more about James’s faith and sources of spiritual support. James begins to cry and admits that he feels very alone. ‘I just don’t know what to believe in any more, this has happened so suddenly. It is as though God and everyone else has abandoned me. I am so afraid. Life isn’t making sense.’ In further discussion, James says has been unable to sleep, has little desire for food and is having difficulty finding ways to talk to his friends.

NURSING DIAGNOSIS: Spiritual distress related to fear and uncertainty of advanced illness.

PLANNING

GOALS	EXPECTED OUTCOMES
Client will express a sense of purpose.	Client will discuss how the experience of having AIDS may have a positive influence in life.
Client gains a sense of hope.	Client expresses a sense of confidence in treatments available for AIDS.
Client gains a sense of hope.	Client begins to talk of the future.

INTERVENTIONS	RATIONALE
Instilling hope
• Plan a session to discuss typical course of HIV, emphasising the typical pattern of remissions with drug therapy. Review therapies available for treatment.	Knowledge about disease will help client think as a person living with HIV rather than dying with HIV (Hall, 1998). Reality of disease course will help instil hope.
Spiritual support
• Encourage client’s expression of loneliness through establishing a caring presence.	Presence reflects being in tune with the client and displays caring. It is an effective technique that makes a topic of discussion more approachable.
• Listen to client’s feelings and concerns.
• Have client discuss his ability to cope with HIV and the meaning it has spiritually. Use spiritual resources.	People question and become open to discovering their unique spiritual meaning after a crisis that threatens health (Hall, 1998). Provides client with a resource from his community of faith to share concerns.

EVALUATION

Ask client to discuss what meaning he has gained from experiencing HIV.

Have client discuss how he plans to adjust to the disease in the future (including continuing work, social activities, and so on).

Promoting a healthy self-concept

Nursing interventions are designed to promote a client’s health and sense of wellbeing. Strategies help clients regain or restore the elements that contribute to a strong and secure sense of self and purpose in life. The approaches that nurses choose to use will vary according to the level of care clients require.

The nurse may have the opportunity to work with clients to help them develop healthy lifestyle measures that contribute to a healthy self-concept and spiritual wellbeing. Measures that support adaptation to stress, such as sound nutrition, regular exercise within the client’s capabilities, measures that facilitate adequate sleep and rest, and stress-reducing practices, may contribute to a healthy self-concept. Spiritual care should be a central theme in promoting an individual’s overall wellbeing. Spirituality is one personal resource that affects the balance between health and illness. In settings where health promotion activities occur, clients are often in need of information, counselling and guidance to make the necessary choices to remain healthy. Dietary observances, food and nutrition are important aspects of client care. Food is also an important component of some religious observances (Table 23-2). As with many aspects of a particular culture or religion, food and the rituals surrounding the preparation and serving of food can be important to a person’s spirituality. The nurse can consult with the dietitian to integrate the client’s dietary preferences into daily care.

TABLE 23-2 RELIGIOUS DIETARY REGULATIONS AFFECTING HEALTHCARE

RELIGION	DIETARY PRACTICES
Hinduism	Some sects are vegetarian. The belief is not to kill any living creature
Buddhism	Some are vegetarians, and many will not use alcohol or tobacco and may hesitate to use drugs Many will fast on holy days
Islam	Eating pork and consuming alcohol are prohibited Fasting occurs during the month of Ramadan
Judaism	Some observe the kosher dietary restrictions of avoiding pork and shellfish and not preparing and eating milk and meat at the same time
Christianity	Some faiths discourage the use of alcohol, caffeine and tobacco Some Roman Catholics may fast during Lent, Ash Wednesday, Good Friday and 1 hour before receiving Communion
Jehovah’s Witnesses	Members may avoid food prepared with or containing blood
Mormonism	Members abstain from alcohol, caffeine and tobacco
Baha’i	Members abstain from alcohol, caffeine and tobacco
Russian Orthodox Church	Followers must observe fast days as well as a ‘no meat’ rule on Wednesdays and Fridays. During Lent all animal products, including dairy products and butter, are forbidden

Nurses are in a unique position to identify lifestyle practices that put a person’s self-concept at risk or that suggest altered self-concepts. For example, a young teacher visits a clinic with complaints of being unable to sleep and having difficulty with anxiety attacks. In gathering the nursing history, the nurse may learn of lifestyle practices such as too little rest, a large number of life changes occurring simultaneously or excessive use of alcohol, which are suggestive of either self-concept disturbances or spiritual distress. The nurse in this situation talks with the client to determine how she views the various lifestyle elements, to help the client see the behaviours as potentially problematic and to make appropriate referrals or provide needed health teaching (Box 23-7).

BOX 23-7 CLIENT TEACHING FOR ANXIETY REDUCTION

OBJECTIVES

• Client will identify physical sensations associated with anxiety.

• Client will describe the location, size and shape of physical sensations associated with uncomfortable emotional feelings.

• Client will, while maintaining awareness of the size and shape of physical sensations associated with uncomfortable emotional feelings, verbalise whether the size and shape remain constant or change in some way.

• Client’s voice will become soft and slower in pacing as the experience unfolds.

• Client will voice feeling more relaxed.

• Client will explain how they could use the technique by themself when experiencing anxiety.

TEACHING STRATEGIES

• Explain to the client that often our habitual way of coping with emotional discomfort/anxiety is to ignore it or try to get away from it in some way (e.g. eating, use of substances). Suggest other ways of working with anxiety, paying attention to physical sensations and allowing them to move and change. This way of being with physical manifestations of anxiety can allow one to experience anxiety in a more accepting way. This acceptance can allow one to notice that all experience is constantly changing and that in fact what one sees as unbearable has periods of time when it is intense but also periods when the sensations are less intense.

• To guide the client in using this technique, have the client find a comfortable position. This could be lying in bed with arms at the sides and legs uncrossed or sitting with good body alignment.

• Ask the client to take in several deep breaths and let them go, relaxing onto the chair or bed.

• Ask the client to make contact with the physical sensation experienced in touching the chair or bed.

• Ask the client to describe the location, size and shape of the sensation. Ask them to stay with the physical sensation and every 5 or 10 seconds voice whether the sensation is the same, saying ‘same’ or, if changing, ‘changing’. If the client is quiet for 30–60 seconds, you can say ‘And now?’ to remind the client to stay with their sensations. If the client notes the sensation changing, ask if it is getting larger or smaller. If larger, have the client note ‘expanding’; if smaller, note ‘contracting’; if no change, note ‘same’.

• Continue in this way for 20–60 minutes. At the end of this time, ask the person to take in a deep breath, let it go and then gently open their eyes.

• At the completion of this experience, if a person has been able to focus on their sensations, they are likely to experience a sense of relaxation and a sense of peacefulness.

• Review the steps of the process as outlined above.

EVALUATION

• Ask the client to describe their physical sensations at the beginning of the experience.

• Ask the client to describe the location, size and shape of a physical sensation.

• Ask the client to voice the ongoing characteristic of the physical sensation as either changing or remaining the same. If changing, describe whether it is expanding or contracting.

• Note whether the client’s voice quality and speed of speaking change as the experience unfolds.

• Ask the client how they are feeling and note their response.

• Ask the client if they could use this technique when anxiety arises.

• If you have continuing contact with the client, inquire if they have used the technique since practising it with you, and how it went.

Acute care

In the acute care setting, the nurse is likely to encounter clients who are experiencing threats to their self-concept and/or spirituality because of the nature of the treatment and diagnostic procedures. Threats to a person’s sense of self and meaning attached to the experience can result in anxiety and/or fear. Numerous stressors, including unknown diagnoses, the need to make changes in lifestyle, and change in functioning, may be present and need to be dealt with. In the acute care setting there is often more than one stressor, thus increasing the overall stress level for the client and their family.

Nurses in the acute care setting also encounter clients who are faced with the need to adapt to an altered body image as a result of surgery or other physical change. Often a visit by someone who has experienced similar changes and adapted to them (e.g. someone who has had a laryngectomy) may be helpful. The timing of such a visit is important. The nurse needs to be sensitive to the client’s level of acceptance of the change. Forcing confrontation with the change before the client is ready could delay the person’s acceptance. Signs that a person may be receptive to such a visit include the client asking questions relating to how to manage a particular aspect of what has happened, or looking at the changed area. As the client expresses readiness to integrate the body change into their self-concept as part of making life-change adjustments, the nurse can either let the client know about groups able to help or ask the client whether they would like the nurse to make the contact. Another way in which the nurse can facilitate adjustment to a change in physical appearance and associated psychospiritual alterations is through their own response to the change. As the nurse responds with acceptance, this models acceptance for both the client and the family.

• CRITICAL THINKING

Mrs Stills has been hospitalised with cancer of the ovaries. Her disease has progressed but she expresses a satisfaction with her life and a faith that God will guide and protect her. She asks you about meditation exercises. In the acute care environment, how might you arrange a teaching session on meditation?

Restorative care

It is often in a long-term nurse–client relationship in a home-health or restorative-care environment that a nurse has the opportunity to work with a client to reach their identified health goals. Interventions designed to help a client reach the goal of adapting to life changes are based on the premise that the client first develops insight or self-awareness concerning problems and stressors and then acts to solve the problems and associated stressors. This approach, outlined by Stuart and Laraia (2001), involves the following levels of intervention: expanded self-awareness, self-exploration, self-evaluation, planning of realistic goals and commitment to action (Table 23-3).

TABLE 23-3 LEVELS OF NURSING INTERVENTIONS FOR SELF-CONCEPT DISTURBANCE

PRINCIPLE	RATIONALE	NURSING ACTIONS
GOAL: EXPAND CLIENT’S SELF-AWARENESS
Work with resources client possesses	Some resources, such as self-control and self-perception, are needed as foundations for later nursing care	Confirm identity Provide support measures to reduce anxiety Approach client in an undemanding way Accept and attempt to clarify any verbal or non-verbal communication Prevent client isolation Help establish simple routine Help set limits on inappropriate behaviour Orient client to reality Reinforce appropriate behaviour Gradually increase activities and tasks that provide positive experiences Help with personal hygiene and grooming Encourage client to care for self
Maximise client’s participation in therapeutic relationship	Mutuality is necessary for client to assume ultimate responsibility for behaviour and coping responses	Gradually increase client’s participation in decisions that affect care Convey that client is a responsible individual
GOAL: ENCOURAGE CLIENT’S SELF-EXPLORATION
Show interest in and accept client’s feelings and thoughts	When nurse shows interest in and accepts client’s feelings and thoughts, the nurse helps client to do so also	Attend to and encourage client’s expression of emotions, beliefs, behaviour and thoughts—verbally, non-verbally, symbolically or directly Use therapeutic communication skills and empathetic responses Note use of logical and illogical thinking and reported and observed emotional responses
Help client clarify self-concept and relationships to others through self-disclosure	Self-disclosure and understanding self-perceptions are prerequisites to bringing about future change; this may in itself reduce anxiety	Elicit client’s perceptions of strengths and weaknesses Help describe ideal self Identify self-criticisms Help describe how client perceives relationships to other people and events Be open to your own feelings
Be aware and have control of your own feelings	Self-awareness allows nurse to model authentic behaviour	Accept your positive and negative feelings Practise therapeutic use of self: share your feelings with client, describe how another might have felt and mirror your perception of client’s feelings
Respond empathetically, not sympathetically, emphasising that power to change lies with client	Sympathy can reinforce client’s self-pity; rather, nurse should communicate that client’s life situation is subject to one’s own control	Use empathetic responses and monitor yourself for feelings of sympathy or pity Reaffirm that client is not helpless or powerless when dealing with problems Convey verbally and behaviourally that client is responsible for behaviour, including choice of maladaptive or adaptive coping responses Discuss with client scope of choices, areas of strength and coping resources available
GOAL: ASSIST CLIENT IN SELF-EVALUATION
Help client to clearly define problem	Only after problem is accurately defined can alternative choices be proposed	Identify relevant stressors with client and ask for appraisal of them Clarify that client’s beliefs influence feelings and behaviours Mutually identify faulty beliefs, misperceptions, distortions, delusions and unrealistic goals Mutually identify areas of strength
Explore client’s adaptive and maladaptive coping responses to problem	Examination of client’s choices made during coping will help define successful and unsuccessful responses	Place concepts of success and failure in proper perspective Explore use of coping resources Describe how coping responses are chosen and have positive and negative consequences Contrast adaptive and maladaptive responses Mutually identify disadvantages of client’s maladaptive coping responses Mutually identify advantages or ‘payoffs’ of client’s maladaptive coping responses
GOAL: ASSIST CLIENT IN FORMING REALISTIC GOALS
Help client identify alternative solutions	Only when all possible alternatives have been evaluated can change be effected	Help client understand that one can change only oneself, not others If client holds inconsistent perceptions, show that the following can change: beliefs or ideals to bring them closer to reality, and environment to make it consistent with beliefs. If self-concept is not consistent with behaviour, client can change the following: behaviour to conform to self-concept, beliefs underlying self-concept to include behaviour and ideal self Mutually review use of coping resources
Help client conceptualise realistic goals	Goal-setting that includes clear definition of expected change is necessary	Encourage client to form personal (not nurse’s) goals Mutually discuss emotional and practical consequences of each goal Help client define concrete change to be made Encourage client to enter new experiences for growth potential Use role-modelling and role-playing when appropriate
GOAL: ASSIST CLIENT IN BECOMING COMMITTED TO DECISION AND IN ACHIEVING GOALS
Help client take necessary action to change maladaptive coping responses and maintain adaptive ones	Ultimate objective in promoting client’s insight is to replace maladaptive coping responses with more adaptive ones	Provide opportunity for success Reinforce strengths, skills and healthy aspects of client’s personality Help client gain assistance (e.g. vocational, financial, social services) Use family and groups to enhance client’s self-esteem Allow client sufficient time to change Provide support and positive reinforcement to maintain progress
GOAL: ASSIST CLIENT IN ACKNOWLEDGING GOALS ACHIEVED AND EVALUATING THOSE NOT ACHIEVED
Help client to purposefully review achievements and explore reasons for any problems or setbacks	Reinforcement of gains made in strengthening self-concept will motivate continued change	Mutually review progress made Affirm achievements with client and family or significant others Evaluate what contributed most to success Help client discuss feelings regarding goals not achieved
GOAL: ASSIST CLIENT TO RE-FORM PLAN FOR ACHIEVING GOALS
Support client in reviewing goals Identify alternatives not tried previously	Insight gained from attempts to change will support further progress Different approaches may be necessary to achieve desired outcomes	Review with client the need for further self-evaluation Encourage client to continue those experiences that were successful Explore how new coping resources can be applied to continued change Redefine changes in adaptive behaviours to be made Continue to reinforce strengths and successes

Modified from: Stuart GW, Laraia MT 2005 Principles and practice of psychiatric nursing, ed 8. St Louis, Mosby.

Increasing the client’s self-awareness is achieved through establishing a trusting relationship that allows the client to openly explore feelings. Open exploration can make the situation less threatening for the client and encourages behaviours that expands a person’s awareness of self. Encouraging the client’s self-exploration is achieved by respecting the client’s feelings and thoughts, by helping the client to clarify interactions with others and by being empathetic. The nurse encourages self-expression and stresses the client’s self-responsibility. Helping the client to evaluate themselves involves working with the client to define problems clearly and to identify positive and negative coping mechanisms. The nurse works closely with the client in analysing adaptive and maladaptive responses, exploring different alternatives and discussing outcomes.

Helping the client establish realistic goals involves encouraging the client to identify appropriate alternative solutions and develop realistic goals. This facilitates real change and encourages further goal-setting behaviours. The nurse designs opportunities that result in success, reinforces the client’s skills and strengths and helps the client get needed assistance. Helping the client become committed to decisions and actions to achieve goals involves teaching the client to move away from ineffective coping mechanisms and develop successful coping strategies. Supporting adaptive, flexible, health-promoting activities in addressing threats to or alterations in self-concept and a person’s spirituality is critical for health and healing.

Clients who experience threats to or alterations in self-concept and spirituality often benefit from collaboration with mental health and community resources to promote increased awareness. Knowledge of available community resources, such as counselling, allows the nurse to make appropriate referrals. Establishing a therapeutic environment and relationship (see Chapter 12) and increasing self-awareness are important to successfully intervening with clients, whether care is focused on health promotion, dealing with an acute process or restorative care.

EVALUATION

Client care

Evaluating success in meeting each client’s goal and the established expected outcomes requires critical thinking. Frequent evaluation of client progress is recommended so that changes can be instituted if necessary. The nurse applies knowledge of behaviours and characteristics of a healthy self-concept and spiritual wellbeing when reviewing the actual behaviours clients display. This determines whether outcomes have been met.

Expected outcomes for a client with a self-concept disturbance or alterations to a person’s spirituality may include non-verbal behaviours indicating a positive sense of self, statements of self-acceptance, acceptance of change in appearance or function, and reconfiguring in a positive way life’s purpose and meaning. Key indicators of a client’s self-concept can be their non-verbal behaviours. For example, a client who has had difficulty making eye contact may demonstrate a more positive self-concept by making more-frequent eye contact during conversation. Social interaction, adequate self-care, acceptance of the use of prosthetic devices, and statements indicating understanding of teaching all indicate progress at both self-concept and spiritual levels. A positive attitude towards rehabilitation and increased movement towards independence facilitate a return to pre-existing roles at work or at home. The goals of care may be unrealistic or inappropriate as the client’s condition changes. The nurse may need to revise the plan, reflecting on successful experiences with other clients. Client adaptation to major changes may take a year or longer, but the fact that this period is long does not signify maladaptation. The nurse should look for signs that the client has reduced some stressors and that some behaviours have become more adaptive. Life changes, whether these be of self-concept or one’s spirituality, take time. A person’s sense of self and meaning and purpose in life is a dynamic process formed over years—it should not be discouraging that changes in the way a person views themselves also requires time.

Client expectations

If the nurse has developed a good rapport with clients, they may well be able to share how things are from their perspective. The nurse may be able to facilitate this sharing by initiating a review of what has happened over time. This offers the nurse the opportunity to share perceptions and encourages clients to consider and voice how they have experienced any changes.

Dimensions of the self

Identity

Body image

Self-esteem

Role performance

Spirituality

Faith

Religion

Hope

Research focus

Research findings

Development of self-concept

0–1 YEAR

1–3 YEARS

3–6 YEARS

6–12 YEARS

12–20 YEARS

MID-20S TO MID-40S

MID-40S TO MID-60S

LATE 60S ON

Stages of development

Infant

Toddler

Preschooler

School-age child

Adolescent

Young adult

Middle-aged adult

Older adult

Stressors affecting self-concept

Identity stressors

Body image stressors

Self-esteem stressors

Role stressors

The family’s effect on self-concept development

The nurse’s effect on the client’s self-concept

Altered self-concept

Stressors affecting a person’s spirituality

Acute illness

Chronic illness

Ageing

Advanced illness

Near-death experience

Spiritual healing

Critical thinking synthesis

DIMENSIONS OF SELF AND THE NURSING PROCESS

ASSESSMENT

Coping strategies

Significant others

Client expectations

NURSING DIAGNOSIS

ALTERATIONS IN SELF-CONCEPT

CLIENTS IN NEED OF SPIRITUAL SUPPORT

PLANNING

ALTERATIONS IN SELF-CONCEPT

ASSESSMENT*

PLANNING

EVALUATION

IMPLEMENTATION

SPIRITUAL WELLBEING

ASSESSMENT

PLANNING

EVALUATION

Promoting a healthy self-concept

OBJECTIVES

TEACHING STRATEGIES

EVALUATION

Acute care

Restorative care

EVALUATION

Client care

Client expectations

ONLINE RESOURCES

ASSESSMENT^*