As the age cohort of persons over 65 continues to grow, health-care professionals have focused attention on normal aging processes as well as on the health problems commonly encountered by older people. Although much of the literature emphasizes the losses of aging, Rowe and Kahn (1987) contended that the effects of the aging process itself have been exaggerated and that the beneficial effects of diet, exercise, personal habits, and psychosocial factors have been underestimated. As Atchley (1982) observed, ". . . it is not merely a matter of what aging does to people but also of what people do with aging."
Adapting to aging and preserving independence are espoused goals for most older adults. An understanding of the interplay between the social, psychological, and biological factors of aging is necessary for older people to achieve these goals. The purpose of this exploratory, correlational study was to investigate the relationship between self-concept and self-care among independent elderly individuals residing in the community. If self-concept and self-care are positively related to a meaningful degree, then nursing interventions that enhance either are warranted. Selected demographic attributes and functional health status were also examined for their relationship to self-care.
REVIEW OF THE LITERATURE
Morris (1985) defined self-concept as the person's total appraisal of appearance, background and origins, abilities and resources, and attitudes and feelings that culminate as a directing force for behavior. Investigations have found that physical alterations, whether from illness or normal aging processes, are integrated into self-concept with both positive and negative results (McCloskey, 1976; McGlashan, 1988; Roberts, 1986; Wright, 1987). Gaber (1984) suggested that changes occur in the self-concept of older people that provide them with unique ways of dealing with the challenges of aging. The apparent capacity of self-concept to evolve appropriately in response to new demands is consistent with Holtzclaws' (1985) view that self-concept is simultaneously ". . . permanent yet permeable."
Self-care may be an important explanatory and causal link between self-concept and the effects of aging processes. Connally (1987) stated that self-concept is the basic determinant of self-care both directly and indirectly through its impact on the perception of past, present, and future events. Lantz's (1985) findings lend support to the premise that selfworth and self-regard are important in a person's ability to assume an active self-care role. Alternatively, self-care may be a coping strategy that mediates the effects of age changes on self-concept.
The functional health status of individuals represents the physical capacity for role fulfillment and social involvement rather than a medical chronology of disease. As such, functional health would seem to be a component of both self-concept and self-care.
With aging, self-care demands increase in complexity and become more essential to the maintenance of health. Identifying factors that enhance self-concept and self-care would facilitate the accomplishment of the ultimate concerns of elderly persons: achieving greater selfactualization, living rewarding lives, and continuing to contribute to society. As the age span continues to lengthen, identifying factors that enhance self-care for elderly persons is of increasing societal as well as personal importance.
Orem's (1985) theory of self-care was the theoretical framework used for this study. The four essential components of the model are self-care agency, therapeutic self-care demands, self-care deficits, and nursing agency. Self-care agency is the ability of an individual to engage in those activities necessary to maintain and promote healthy patterns of behavior. To do so, individuals must use their resources, abilities, and experiences and seek any information needed to accomplish this objective.
Therapeutic self-care demands refer to the measures to be done by or for an individual to achieve better health. When therapeutic self-care demands exceed self-care agency, a selfcare deficit is the result. In this event, nursing agency is used to intervene in response to identified self-care deficits. Nursing agency is a set of qualities, knowledge, and skills that the nurse has acquired through specialized preparation and education. The concepts of self-care agency and therapeutic self-care demands are particularly appropriate for this study because they frame nursing interventions (nursing agency) that can be employed with community-residing elderly persons so that independence can be maintained.
Three hypotheses were investigated: that there would be a significant, positive relationship between self-concept and self-care; that there would be significant differences in self-concept by age, education, number of children, income, sex, and employment; and that there would be a significant, positive relationship between functional health status and self-care.
Sample and Procedures
The subjects for this study were a convenience sample of 48 independently living persons age 65 or older who volunteered to participate. Approximately half of the subjects resided in independent retirement complexes, about half were participants in senior citizen center activities, and a few (four) were contacted through personal referral. Data were collected at one of the meeting rooms in the various settings or in the subjects' homes.
The instrument consisted of separate scales to measure self-concept, self-care, functional health status, and a brief questionnaire to assess selected demographic characteristics of the sample.
The Tennessee Self-Concept Scale (TSCS) was used to measure selfconcept (Fitts, 1965). The TSCS is a standardized scale requiring about a sixth grade reading level It is relatively simple to administer and is a multidimensional measure of selfconcept. The dimensions include scales for the physical, moral-ethical, personal, family, and social selves, as well as items that measure the concepts of self-criticism, identity, self-satisfaction, and behavior. These nine subscale scores are added to yield a single indicator for total selfconcept. The scale consists of 100 selfdescriptive items with responses recorded on a five-point bipolar scale (Fitts, 1985; Roid, 1988). Split-half reliability of .91 foT the total score was reported by Nunnally (1978) and testretest reliability coefficients range from .60 to .92 (Fitts, 1965). Support for construct validity has been found (Vacchiano, 1968).
Initial use of this instrument on elderly subjects revealed more variation in scores than for the normative (and younger) sample (Fitts, 1972), reflecting the known diversity and heterogeneity of older people. Similar results were found in this study; although elderly sample subjects had significantly lower physical selfconcepts when compared with the normative subjects, scores were significantly higher for moral-ethical and personal selves as well as for self-criticism.
Self-care was measured through the Exercise of Self-Care Agency (ESCA) scale (Kearney, 1979). The ESCA is a global measure of Orem's self-care agency using 43 items in a five-point Likert scale format. Testretest reliability is .77 (Kearney, 1979; McBride, 1987); split-half reliability has been reported to range from .77 to .81 (McBride, 1987). Evidence for construct validity has been found (Gough, 1965; McBride, 1987; Riesch, 1988).
Roscow and Breslau's Guttman Health Scale for the Aged was employed to measure functional health (Roscow, 1966). This scale was developed from a self-assessment interview of 25 health-related questions administered to 1,200 subjects. Three questions with six response categories were produced with a coefficient of reproducibility of .91 and a 9% level of error. Similar results have been found in other elderly samples (Fuller, 1980; Kee, 1984).
Ages of the 48 subjects ranged from 65 to 97 years, with the median age being approximately 79 years. As expected in elderly subjects, women (42) outnumbered men (6), 87.5% and 12.5% respectively. Widows composed 60.4% of the sample, 10.4% were never married, 14.4% were currently married, and 14.6% were separated or divorced. The number of children varied from none to nine with a mean of 1.9.
Twelve subjects (25%) had a high school education, whereas 19 (34.9%) had some college experience. Five subjects (10.4%) had an eighth grade education in contrast to six subjects (12.5%) who had graduate school preparation. Nearly 94% of the subjects were retired with only three (6.3%) working part time. Before retirement, 30 subjects (62.5%) were in white-collar occupations and six (12.5%) were blue-collar. Another 12 subjects reported no employment or did not state the type of employment. In terms of income, 40 subjects (83.3%) were receiving Social Security benefits, 22 subjects (45.8%) had private pensions, 19 subjects (39.6%) had investment income, the 3 (6.3%) who were employed part-time received a salary, and almost 1 in 5 (18.8%) had additional income from other sources.
The first hypothesis, positing a relationship between self-concept and self-care, was tested using Pearson's product-moment correlation. Subscale and total scores on the TSCS (self-concept) were correlated in turn with the score attained on the ESCA (self-care). As shown in Table 1, a strong, significant relationship was found between the self-care and the total self-concept scores. Of almost equal strength was the significant relationship between the self-care score and the self-concept subscale score for the social self. Self-care was also related to three other self-concept subscales (physical self, self-satisfaction, and behavior) at the .001 level of confidence. A moderate, significant relationship existed between the selfcare and the self-concept subscale scores of moral-ethical self, personal self, family self, and identity.
The mean score achieved by the subjects on the self-care scale was 122 points, with scores ranging from 87 to 148 points (total possible score is 172). Total scores on the selfconcept scale ranged from 278 to 412 (total possible score is 500). The mean score for the total self-concept score was 347, slightly above the mean score obtained by Roid and Fitts (1988) in their normative sample.
Correlation Coefficients Between Self-Concept* and Sett-Care†*
Correlation Coefficients Between Sett-Concept*, Sett-Care†, and functional Health Status*
The second hypothesis, that there would be differences in self-care scores on the ESCA according to selected demographic variables, was not supported. When grouped in turn by the categories of age, income, sex, and employment, no differences were found using i-test procedures in self-care scores. The variables of education and number of children approached significance (p = .058 for each), however, indicating that subjects who had attained a higher level of education or subjects with children tended to have higher self-care scores.
The third hypothesis, exploring the relationship between self-care and functional health status, was also rejected. As shown in Table 2, a significant correlation was found between functional health status and selfconcept (the total TSCS score) but not between functional health status and self-care.
The findings from this study must be interpreted with caution due to the small number of subjects and to the fact that the sample was one of convenience.
The major result found was the relationship between self-concept and self-care. As discussed below, this finding has implications for nurses as they strive to maximize self-care agency for older individuals. Self-care scores were not affected by demographic differences among the subjects in this study.
Although functional health status was not significantly correlated with self-care, it was related to selfconcept, suggesting that functional health has a role in the maintenance of self-concept among elderly persons. Because the ESCA scale assesses self-reported attitudes and behaviors, and because healthy attitudes and behaviors may exist even in the presence of disability, the absence of a significant relationship between self-care and functional health was not surprising.
IMPLICATIONS FOR NURSING PRACTICE
The finding that self-concept is significantly related to self-care has implications for nurses as they attempt to maximize self-care agency for older persons. Before an adequate level of self-care can be anticipated, psychosocial interventions to enhance self-concept may be necessary. Thus, cognitive restructuring may affect self-care behaviors. The converse may also follow in that active participation in self-care behaviors could ultimately strengthen the individual's self-concept. Nurses might want to consider the following strategies for enhancing the well-being of their older patients:
* Reinforcing positive health behaviors through acknowledgment and praise so that the moral-ethical component of self-concept is strengthened further.
* Avoiding emphasis on self-care deficits so that the tendency for heightened self-criticism and lowered physical self-concept is not accentuated.
* Ensuring that the older patient possesses the knowledge and competence necessary to engage in health-promoting self-care activities. This includes information on diet and nutrition, exercise, sleep, medications, and other disease management protocols so that a sense of control and personal responsibility is conveyed.
* Encouraging the older person to engage in those activities of daily living that contribute to achieving a reasonable level of independent functioning so that a sense of independence is maintained through self-care.
* Maintaining professional behaviors in interacting with older persons so that respect and caring are communicated.
By focusing on psychosocial needs as well as physical interventions, nurses can assist elderly persons to exercise self-care agency and to successfully meet therapeutic self-care demands. If, as the literature and the results of this study suggest, beliefs and feelings regarding the self are reflected in behavior, then older persons who possess relatively high selfconcepts and who engage in selfcare activities may have enhanced capacities for physical and psychological well-being.
- Atchley, R.C. The aging self. Psychotherapy, Theory, Research, and Practice 1982; 19:3883%.
- Connelly, CE. Self-care and the chronically ill patient. Nurs Clin North Am 1987; 22:621629.
- Fitts, W.H. Manual for the Tennessee SelfConcept Scale. Nashville, TN: Counselor Recordings and Tests, 1965.
- Fitts, W.H. The self-concept and behavior: Overview and supplement. Nashville, TN: Dede Wallace Center, 1972.
- Fuller, S.S., Larson, S.B. Life events, emotional support, and health of older people. Res Nurs Health 1980; 3:81-89.
- Gaber, L.B. Structural dimensions in aged selfconcept: A Tennessee self-concept study. Br J Psychol 1984; 75:207-212.
- Gough, H. G., Heilburn, A.B. The adjective check list manual. Palo Alto, CA: Consulting Psychologists Press, 1965.
- Holtzclaw, L. R. The importance of selfconcept for the older adult. Journal of Religion and Aging 1985; l(3):23-29.
- Kearney, B., Fleischer, B. Development of an instrument to measure exercise of self-care agency. Res Nurs Health 1979; 2:25-34.
- Kee, CC. Stressful life events, functional health status, and social support in the elderly Atlanta: Georgia State University. Unpublished dissertation, 1984.
- Lantz, J.M. In search of agents for self-care. Journal of Gerontological Nursing 1985; 11(7):10-14.
- McBride, S. Validation of an instrument to measure exercise of self-care agency. Res Nurs Health 1987; 10:311-318.
- McCloskey, J.C How to make the most of body image theory in nursing practice. Nursing76 1976; 6(5):68-72.
- McGlashan, R. Strategies for rebuilding selfesteem for the cardiac patient. Dimensions of Critical Care Nursing 1988; 7(1):28~38.
- Morris, CA. Self-concept as altered by the diagnosis of cancer. Nurs Clin North Am 1985;20:611-630.
- Nunnally, J.C. Psychometric theory, 2nd ed. New York: McGraw-Hill, 1978.
- Orem, D. Nursing: Concepts of practice, 3rd ed. New York: McGraw-Hill, 1985.
- Riesch, S.K., Hauck, M.R. The exercise of selfcare agency: An analysis of construct and discriminant validity. Res Nurs Health 1988; 11:245-255.
- Roberts, S.L. Behavioral concepts and the critically ill patient, 2nd ed. Norwalk, CT: Appleton-Century-Crofts, 1986.
- Roid, G.H., Fitts, W.H. Tennessee Self-Concept Scale. Los Angeles: Western Psychological Services, 1988.
Roscow, I., Breslau, N. A Guttman health scale for the aged. J Gerontol 1966; 21:556-559.
- Rowe, J. W-, Kahn, R.L. Human aging: Usual and successful. Science 1987; 237:143-149.
- Vaccchiano, R.B., Strauss, RS. The construct validity of the Tennessee Self-Concept Scale. J Clin Psychol 1968; 24:323-326.
- Wright, J.E. Self-perception alterations with coronary artery bypass surgery. Heart Lung 1987; 16:483-490.
Correlation Coefficients Between Self-Concept* and Sett-Care†*
Correlation Coefficients Between Sett-Concept*, Sett-Care†, and functional Health Status*