Situational low self-esteem nursing diagnosis in people with an ostomy: a diagnostic accuracy study*

Objective: To verify the accuracy of the defining characteristics of the situational low self-esteem nursing diagnosis in people with an ostomy. Method: A cross-sectional and descriptive study developed in two stages. The first stage was performed with 90 people with an ostomy, and a descriptive analysis of the collected data was performed. In the second phase, diagnostic inference was verified with nursing judges. Results: The situational low self-esteem nursing diagnosis frequency was low (23.3%). Among the defining characteristics, self-deprecating verbalizations (33.3%), indecisive behavior (28.8%) and non-assertive behavior (26.1%) prevailed. The most sensitive were indecisive behavior (71.0%) and expressing feelings of worthlessness (71.0%). Conclusion: It was observed that the situational low self-esteem nursing diagnosis can be identified in people with an ostomy, and that there are defining characteristics in this diagnosis which better predict and increase the chance of its occurrence. In this sense, the importance of nursing care in the adaptation process and self-esteem is emphasized.


INTRODUCTION
The term ostomy is used to designate surgical exteriorization of a viscera in order to divert its usual course (1) . As the performance of an ostomy imposes a new condition on being and a need to adapt to the current situation, people in this condition may present negative feelings and diminished levels of self-esteem (2) .
The concept of self-esteem is defined as the individual's perception of their own value (3) , and this perception is derived from their own body image, from society's acceptance of being, from their physical and emotional well-being and from their ability to adapt (4) .
In view of the problems presented after performing the ostomy, the importance of qualified professionals is emphasized, especially nurses, for clarifying questions and helping people with an ostomy in the adaptation process. As a way to facilitate the performance of this process, authors have pointed to the use of the Systematization of Nursing Care (SNC) as a scientific method of organizing patient care (5) . SNC is used by the nursing team to organize and scientifically support care, using the Nursing Process (NP) as a tool to develop it. The NP assists in detecting problems, in determining a nursing diagnosis, in choosing the interventions, in implementing actions and in evaluating the results (5) .
In order to perform the diagnostic inference, nursing uses specific literature, especially the North American Nursing Diagnosis Association International (NANDA I), which enables detecting nursing diagnoses which guide scientifically informed and standardized decision-making, free from the common sense perception of the professional (6) .
However, in order for a diagnosis to be inferred for a given population, it must be recognized how its defining characteristics are demonstrated by the patient, and from that point on identify the real presence or absence of the tracked diagnosis. Thus, the importance of studies on the accuracy of clinical indicators of nursing diagnoses is important, since these indicators are observed through subjective human responses, and for this reason they are not always adequate for the individual (7) .
Despite the scarcity of studies developed in the area, the relevance of studies on the accuracy of direction care and its contribution to producing specific knowledge for clinical practice is recognized. Studies carried out with other populations highlight the benefits of accurate diagnostic inference, with their results pointing out the importance of studies of this nature in determining sensitive results, which guide the selection of effective interventions to the desired result (8) . Other evidence emphasizes the relevance of planning and performing activities centered on clinical indicators to assist in problem resolution (9) .
Thus, a convenient investigation to be made regarding the self-esteem of people with an ostomy is assessing the accuracy of the situational low self-esteem nursing diagnosis, conceptualized as "developing a negative perception about one's own value in response to a current situation" (6) .
Such a study will help the nurse in identifying the defining characteristics that actually predict the existence of the diagnosis, facilitating differentiation of patients which have the diagnosis from the patients who only manifest some defining characteristics.
Thus, we sought to answer the following research question: are there defining characteristics with a higher degree of accuracy for the situational low self-esteem nursing diagnosis in people with an ostomy? In view of the above, the objective was to verify the accuracy of the defining characteristics of the situational low self-esteem nursing diagnosis in people with an ostomy.

Study deSign
A diagnostic, cross-sectional and descriptive accuracy study developed in two stages. The first was the research involving people with an ostomy to identify the characteristics of the situational low self-esteem nursing diagnosis in this clientele.
The second stage was performed with nursing judges for the diagnostic inference of the "Situational low self-esteem" nursing diagnosis in people with an ostomy.

PoPulation
The study population in the first stage was composed of 687 people with an ostomy attended at the Adult Rehabilitation Center of Rio Grande do Norte (CERHRN -Centro de Reabilitação de adultos do Rio Grande do Norte). After the calculation by Barbetta (10) with a sample error of 0.1, a sample of 87 people with an ostomy was obtained. The sample was expanded to 90 people in predicting possible losses. After calculation for the quantitative definition of experts (11) and considering the confidence level (95%), expected proportion (95%) and acceptable error (20%), the sample in the second step consisted of five nurses with expertise in Stomal Therapy and Nursing Diagnosis, members of the Nursing Procedures Incubator research group.

Selection criteria
Those who met the following inclusion criteria were recruited by convenience in the first stage: a permanent or temporary ostomy, being at least 3 months since creation, of both genders, over 18 years of age, attending an outpatient nursing service in Stomal Therapy during the data collection period. Data collection at this stage was carried out between January and March 2015. The selected individuals were clarified about the objectives of the study and signed the Clear and Informed Consent Form (ICF).
In the second stage, nurses with expertise in Stomal Therapy and Nursing Diagnostics were recruited according to the criteria by Fehring (12) , who considers nurses who obtain a minimum score of five in his scoring system as a judge. Data collection for the first stage was performed through an interview in a private room by a group of properly trained researchers between January and March 2015. The interviewers explained the purpose and importance of the study. A sociodemographic questionnaire was applied, constituting an instrument which shows the correlation between the Rosenberg scale items and the defining characteristics of the situational low self-esteem diagnosis developed in the study by Cavalcante, Sousa and Lopes (7) and the Rosenberg self-esteem scale (RSES) (3) .
The RSES is composed of 10 items, with content related to feelings of respect and acceptance of oneself. Half of the items are stated positively, and the other half negatively. There are four hypotheses of answers for each statement: I totally agree = 4, I agree = 3, I disagree = 2 and totally disagree = 1. For the self-esteem evaluation, all items that total a single value for the scale are added together. According to the sum, self-esteem can be evaluated as satisfactory or high (score greater than 31 points), average (score between 21 and 30 points), or unsatisfactory or low (scores lower than 20 points). In this way, the greater the sum, the greater the Self-esteem.
In the study (7) which correlated the defining characteristics with the assertive characteristics by the Rosenberg Self-esteem Scale, five affirmations were selected which had greater correlation with the characteristics defined by the NANDA-I for the diagnosis of interest, correlating each characteristic to an affirmation on the scale, with the exception of "Indecisive Behavior" and "Expressions of helplessness", which were analyzed in isolation through the questions "Do you have difficulty making decisions lately?" and "Do you feel helpless or without anyone to support you in difficulties?", respectively, because they have no correlation with assertions of the RSES.
The defining characteristics were considered to be present when the respondent agreed or fully agreed with the respective Rosenberg scale statement, with the exception of "verbally reports current situational challenge of their own value", which was categorized as present in cases of disagreement or total disagreement in relation to the corresponding affirmative.
Regarding the second stage of the study for diagnostic inference, training was conducted with the judges during the month of November 2016 to minimize possible diagnostic inference errors (13)(14) . After the training, the diagnosticians received spreadsheets containing the seven defining characteristics of the nursing diagnosis under study, as identified in the first stage of this study. From this, each expert judged whether the studied nursing diagnosis was present or absent in each of the worksheets by reading a brief history of the patient and the result from the Rosenberg self-esteem scale score.
These inferences were organized and synthesized in spreadsheets so that the diagnosis was considered present or absent when there was agreement by three or more diagnosticians regarding such inferences.

data analySiS and ProceSSing
The collected data were organized and analyzed in a statistical program, codified, tabulated and presented in the form of tables, charts and graphs. Descriptive analyzes and inferential analyzes were performed on crosses of the variables with a p-value significance level of ≤0.05. After checking the normality of the quantitative variables, the Mann-Whitney test and the Spearman correlation test were applied to evaluate the associations and correlations.
The Pearson's Chi-squared test and Fisher's exact test were used to verify the association between the defining characteristics and the diagnosis studied (p <0.05). The prevalence ratios of each defining characteristic were also calculated, with confidence interval of 95%.
Subsequently, the accuracy of the diagnostic characteristics of the low situational self-esteem diagnosis was assessed by sensitivity, specificity, negative and positive predictive values (15) . The positive and negative likelihood ratio plus the Diagnostic Odds Ratio (DOR) were also calculated to identify the statistical significance of the defining characteristics. For the analysis, the defining characteristics that presented statistical significance <0.2 were selected. After the analysis, data were organized into tables and discussed in relation to the scientific literature.

ethical aSPectS
The study fulfilled all the requirements of Resolution no. 466/12 of the National Health Council on research involving human beings and obtained a favorable opinion through process no. 421.342 from the Ethics and Research Committee of the Universidade Federal do Rio Grande do Norte. The respondents signed the Free and Informed Consent Form (ICF) and were informed of the possibility of refusing and interrupting their participation in any phase of the study if they deemed it convenient, with no impairment in following the treatment.

RESULTS
Of the five judges, three (60.0%) had a Master's degree, two (40.0%) had a minimum clinical practice of 1 year in the area, 1 (20.0%) had a specialization in Stomal Therapy and five (100.0%) had graduated in the Northeast, resided in Rio Grande do Norte, had published research on diagnostics and/or ostomies and articles published on the same topic in indexed journals.
Situational low self-esteem nursing diagnosis in people with an ostomy: a diagnostic accuracy study Rev Esc Enferm USP · 2019;53:e03514 The frequency of the situational low self-esteem nursing diagnosis according to the judging by the diagnosticators was present in part of the sample (23.3%). Among the predominant defining characteristics were: self-deprecating verbalizations (33.3%), indecisive behavior (28.8%) and non-assertive behavior (26.1%), as evidenced in Table 1. Regarding the reasons for prevalence of the defining characteristics, the chances of people with an ostomy presenting the situational low self-esteem nursing diagnosis was approximately 11 times higher among people who expressed feeling worthless, 6 times higher among those who verbally reported the current situational challenge of their own value and 6 times higher among those who were assessed as incapable of dealing with situations or events, as shown in Table 2. All seven defining characteristics presented statistical association with the diagnosis under study. Regarding the accuracy of the diagnostic characteristics of situational low self-esteem, the characteristics with the highest sensitivity were indecisive behavior (71.0%) and expressions of feeling worthless (71.0%), which presented statistically significant likelihood and DOR values, as presented in Table 3.

Defining characteristics
Nursing diagnosis Among the seven defining characteristics, only one presented itself as not specific for the situational low self-esteem diagnosis: self-deprecating verbalizations (67%). Although the high specificity of the characteristic verbally reports situational challenge to their own value, it needs to be evaluated with caution, considering the indeterminacy in calculating the positive likelihood value and DOR.

diScuSSion
Regarding the prevalence of the investigated diagnosis, 23.3% of the people with an ostomy presented the situational low self-esteem nursing diagnosis. Such patients are more likely to present this diagnosis since the individual is faced with the presence of a collection bag due to the ostomy, which often has repercussions on their physical, psychological and emotional dimensions. Then there are stages of denial, self-rejection, loneliness, anxiety, depression and suicidal thoughts. In addition, they also encounter a mutilation sensation of their body image associated with the incapacity, loss, inferiority, shame and stigma (16)(17) .
However, the low prevalence of the diagnosis in this study can be explained by the insertion of people with an ostomy in a specialized care service, the CERHRN. Participation in a support network has been described as a relevant factor which promotes explanations about the illness process, facilitates coping with the new condition, provides a new identity for people with an ostomy, and improves their self-esteem (16,18) . Thus, the situation is viewed with confidence and optimism, as the individual better adapts to the difficulties by developing strategies to deal with the new way of living (18)(19)(20) .
The literature corroborates the earlier statement by mentioning that patients who frequently attended the association of people with an ostomy were exactly those who had the better fit and acceptance of the ostomy in their lives. On the other hand, those who did not attend www.ee.usp.br/reeusp Situational low self-esteem nursing diagnosis in people with an ostomy: a diagnostic accuracy study Rev Esc Enferm USP · 2019;53:e03514 or received no guidance had feelings of denial, negative lifestyle changes and lower self-esteem (2) .
Among the defining characteristics of this diagnosis, the following stand out: self-deprecating verbalizations, indecisive behavior and non-assertive behavior.
Self-deprecating verbalizations are common in people with an ostomy, as they feel unable to cope with the demands of the new condition. Living with an ostomy requires that the person break from their usual elimination pattern, since the stool will be expelled through the abdominal wall, causing psychological damage and difficulties to the individual, who often experiences disgusting feelings about themselves (17) , as well as feelings of revolt, rejection, dissatisfaction, hopelessness and worthlessness (17)(18) .
As shown in the results, the "indecisive behavior" characteristic, which involves the ability to act and to make decisions, presented the best values among the several studied indexes, obtaining high prevalence, good sensitivity and specificity measures, as well as statistical significance in the likelihood and DOR values.
Such a characteristic may be a reflection of the lack of adequate communication by the health team, and consequently of the person's lack of understanding in relation to their self-care, the achievement of their self-esteem and the development of their autonomy. When guided on the new condition, these subjects become able to make secure decisions, exercising control over their own life and their self-care, even though with limitations (21) .
In addition, it is emphasized that uncertainty in decision-making and insecurity regarding future events directly affects the functioning of daily dynamics, quality of life, the adaptation process and the degree of self-esteem (22)(23)(24) .
Another frequently defining characteristic in people with an ostomy was non-assertive behavior. There are feelings of impotence and failure in the life of a person with an ostomy, mainly related to the modifications of self-image in facing the new physical condition, to the difficulties in returning to living in the community and in performing their role in society, impacting on the adaptive process and the quality of life of the individual (17)(18) .
These feelings can be visualized at various moments in life and relate to the different limitations that the ostomy imposes on the daily activities of individuals. Returning to their work routine and leisure activities are some examples which cause distress due to the possibility of leakage and odor in public places, impairing socialization with their family (25) . Added to this is the difficulty of social reintegration, which isolates them from work and leisure activities (24) .
Corroborating these aspects, a study evaluating the self-esteem and the quality of life of people with an ostomy regarding the functional scales identified that in relation to physical, emotional, cognitive and social function, means varied between 62.69 and 77.28, and among these role performance (60.64) was the most affected, thus relating to the aforementioned characteristics (26) .
The defining characteristic verbally reports current situational challenge of their own value was the most specific found in this study, despite the indeterminacy of positive likelihood and DOR values. This characteristic is related to the moment in which the person with the ostomy starts to question their own value. Thus, the adaptive difficulty related to reduced individual values sometimes culminates in social isolation, given the limitations imposed by the ostomy and by feeling discriminated by themselves and others (27) .
It is observed that the defining characteristic of self-assessment as being incapable of dealing with situations or events increases the possibility of people with an ostomy presenting the situational low self-esteem nursing diagnosis by approximately six times. As the person encounters difficulties in facing situations, feelings of impotence and insecurity arise, making it difficult to accept their new reality, thus resulting in decreased self-esteem (2) .
Regarding the specificity, it is verified that six clinical indicators appeared as specific to the nursing diagnosis under study. The value that the individual attributes to themselves influences the perception of their self-esteem; thus, the significant modifications resulting from the presence of an ostomy lead to devaluing the self and consequently constitute a reduction in the patients' self-esteem (24) .
With respect to the support given to people with an ostomy, it is verified that it has great influence on the adaptation and aspects related to the subject. Authors point out that support for this clientele can and should be provided by everyone who surrounds them, so that the family, spouse, friends and the multiprofessional team play a fundamental role in the process of perceiving protection and acceptance by the ostomy patient (28)(29) .
Non-assertive behavior as a specific result of the diagnosis exposes the negative conception coming from the ostomy and the transformations instituted by it. Difficulties encountered by people with an ostomy cause misconceptions about their ability to develop satisfactory attitudes and achieve their goals (29) .
Given nurses' fundamental role in the recovery process of self-esteem and adaptation by people with an ostomy, the NP is perceived by nurses as a decisive step which is able to provide subsidies to implement comprehensive and individualized care according to the needs of each individual (30) .
Among the difficulties and limitations of this study, a lack of studies on the accuracy of the defining characteristics of the situational low self-esteem nursing diagnosis in the investigated population stands out, making it difficult to compare with other clienteles with the same diagnosis due to the particularities involved.
concluSion In view of the objectives proposed in this study, a low frequency of situational low self-esteem diagnosis was observed in people with an ostomy, and the most frequent characteristics were self-deprecating verbalizations, indecisive behavior

DESCRIPTORES
Estomía; Diagnóstico de Enfermería; Autoimagen; Atención de Enfermería. and non-assertive behavior. All seven defining characteristics were statistically associated with the aforementioned nursing diagnosis. Regarding the reasons for the prevalence of the defining characteristics, the chances of people with an ostomy developing the situational low self-esteem nursing diagnosis in the presence of the characteristics were greater in expressions of feeling worthless, verbally reporting current situational challenge of their own value and self-assessment as unable to cope with situations or events.
Regarding the diagnostic accuracy, the defining characteristics which presented the greatest sensitivity were indecisive behavior and non-assertive behavior. In relation to the more specific characteristics, the following stood out: verbally reports situational challenge of their own value, expressions of feeling worthless, self-assessment as incapable of dealing with situations and events, and expressions of helplessness.
The study confirms that the situational low self-esteem nursing diagnosis can be identified in people with an ostomy, and there are defining characteristics inserted in this diagnosis which better predict and increase the chance of its occurrence. In this sense, nursing care is important in the process of adapting and developing the self-esteem of this population, since they have the necessary support for the treatment such as the use of nursing diagnoses, which are broad technologies in the healthcare area and subsidize differentiated demands to provide care.