SELF-EFFICACY
Correlation between self-efficacy
and self-esteem in patients with
an intestinal stoma
Fariba Nasiriziba, Maryam Saati and Hamid Haghani
ABSTRACT
Background: Patients with an intestinal stoma experience psychological
difficulties, including disturbances in self-efficacy and self-esteem. There is
evidence that they are interdependent. Aim: This study aimed to determine
the correlation between self-efficacy and self-esteem in patients with an
intestinal stoma. Methods: A descriptive-correlational study was conducted
with 155 patients with an intestinal stoma. Participants were selected using
convenience sampling. Data were collected using demographic questions, the
stoma self-efficacy scale and the Rosenberg self-esteem scale, and analysed
using descriptive and analytical statistics. Findings: Seventy-nine men and
76 women took part; the 50–70 years age group had the highest proportion
of participants. Regarding diagnosis, 52.26% had cancer and 45.81% had
inflammatory bowel disease or related conditions. Pearson’s correlation
coefficient indicated a positive, significant correlation between total self-
efficacy and its dimensions with self-esteem (P<0.001; r=0.54). Conclusion:
Self-efficacy is positively correlated with self-esteem in patients with an
intestinal stoma. It is recommended that educational interventions are planned
and implemented to boost self-esteem and self-efficacy in these patients.
Key words: Self-efficacy n Self-esteem, n Intestinal stoma n Ostomy
n Colorectal cancer n Colostomy n Ileostomy
A
stoma is an opening in the abdomen for the
purpose of excretion; it is created for a variety
of reasons including cancer and trauma as well
as inflammatory and obstructive conditions
(Gozuyesil et al, 2017). Colorectal cancer is
considered to be one of the main reasons for stoma formation.
Among men, the three most prevalent cancers are pulmonary,
Fariba Nasiriziba, Lecturer, Enterostomal Therapist/Wound,
Ostomy and Continence Nurse, Medical Surgical Department,
Nursing and Midwifery School, Iran University of Medical
Sciences, Tehran, Iran
Maryam Saati, Medical Surgical Nursing Student, Nursing and
Midwifery School, Iran University of Medical Sciences, Tehran,
Iran, msaati349@gmail.com
Hamid Haghani, Assistant Professor, Biostatistics Department,
School of Health, Iran University of Medical Sciences, Tehran, Iran
Accepted for publication: July 2020
S22
prostate and colorectal; among women, breast and colorectal
cancer are the commonest (Jemal et al, 2011). Intestinal stomas
are created mostly in older people due to cancer; younger people
may need a stoma because of inflammation in the small intestine
(Bazalinski et al, 2014).
In Iran, there were 9864 new cases of colorectal cancer (9%
of all cancers) in 2018 (World Health Organization (WHO),
2019a). Worldwide colorectal cancer accounts for 10.2% of all
cancers (WHO, 2019b).
This disease is a problem in Iran because of the rise in the
number of colorectal cancer cases and low survival rates due to
the fact that diagnosis is often made at advanced stages (Adel
Mehraban et al, 2008). It is assumed that 40 000 new stomas will be
created annually in the US because of colorectal cancer (Ercolano
et al, 2016); about 13 000 people in England and 100 000 people
in the US will have colostomy surgery (Simmons et al, 2007;
Sheetz et al, 2014).
Although stoma surgery seems a common operation, more
than 70% of patients experience postoperative complications,
which incur a high cost for healthcare systems because of the
need for long-term hospitalisation (Sheetz et al, 2014). Difficulties
experienced after colostomy formation include stress, long
recovery times and concerns over remission after surgery (Follick
et al, 1984).
Changes in the ability to excrete cause psychological and
emotional problems in patients, and mostly affect self-esteem and
sexual activity (Salome and de Almeida, 2014). Mental health
difficulties affect various aspects of patients’ lives and include
poor body image, lower self-esteem and a greater risk of suicide
(Knowles et al, 2013). Illness and negative changes in body image
are important issues that can lower self-esteem (Gozuyesil et
al, 2017). Poor self-esteem is associated with behavioural and
communication problems, psychological disorders such as anxiety
and depression, and physical illness (Johansson et al, 2018).
Self-esteem concerns the positive and negative feelings people
have about themselves. In other words, it shows how valuable
people consider themselves to be (Coopersmith, 1990).Without
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doubt, it affects mental health, and good self-esteem is linked to
positive psychological health (Su et al, 2016).
Ostomy has a huge impact on social interaction. For example,
social activities are reduced and relationships with friends and
relatives are affected (Simmons et al, 2007). Social and psychosocial
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SELF-EFFICACY
functions are reduced because of changes in body image and a
lack of self-confidence in social relationships (Geng et al, 2017).
Patients often reported having problems exercising, sleeping, being
in a community, in their sexual relationships and with dressing
(Su et al, 2016). A study involving Japanese and British patients
with a colostomy found that they experienced social problems,
such as disruption in social interactions to various degrees for
up to 2 years after stoma surgery (Krouse et al, 2007). In Iran,
Mahjoubi et al (2010) showed that psychological problems (like
other complications) are very common among patients with an
intestinal stoma. Ostomy often causes changes and difficulties in
social interactions, with work and with daily activities.
Jain et al (2007), in their study on patients with an intestinal
stoma, found that 80% of participants experienced changes in
lifestyle, and more than 40% had sexual problems. Between 30%
and 59% of patients with an intestinal stoma limit one or more of
their daily routines and there are significant differences between
the social interaction of patients with and without an intestinal
stoma (Simmons, 2014). Patients with a stoma were more likely
to avoid meeting new people, and less likely to take part in
recreational activities or use public transport (Simmons, 2014).
According to the Iranian Ostomy Association, most patients
do not access high-quality bags because of their high costs and a
lack of standard ostomy equipment (Mahjoubi et al, 2009).The
low number of enterostomal therapists means that stoma care is
difficult (Mahjoubi et al, 2005; Naseh et al, 2012). Pouresmail et
al (2017) found that 96% of patients had not received regular,
planned education and 73.7% needed the help of someone
while in hospital. Patients with an intestinal stoma often require
continuing help with stoma care. Patients find this unpleasant
and having to have help reduces their self-efficacy.
Self-efficacy is a psychosocial concept derived from Albert
Bandura’s (1997) social learning theory (Pouresmail et al, 2017); it
concerns a person’s confidence about their ability in succeeding
with a task or achieving desired results. Self-efficacy involves
individuals judging their own ability, and their beliefs in their
abilities affect their perseverance and effort. In other words, self-
efficacy is the ‘belief of the individual’ in their ability to finish
tasks. In patients with an intestinal stoma, higher self-efficacy is
a predictor for fewer psychological problems in the early post-
operative years. Stoma self-efficacy is defined as self-efficacy in
the care of the ostomy and the expected social functioning of
an individual (Rafii et al, 2012). Individuals with strong self-
efficacy, while facing challenges, are more effective at regulating
their emotions and more active in solving problems. They
consider wider goals, make more effort and, in the face of such
circumstances, are more determined; in contrast, those with low
self-efficacy feel they are helpless and unable to control life events
and believe their efforts are futile so, when faced with obstacles,
if their initial efforts fail to deal with problems, they are quickly
disappointed (Campbell and Ntobedzi, 2007).
The number of people who lose the ability to excrete normally
is increasing, and the social and psychological consequences of
this cannot be ignored. Extensive physical and psychological
problems, such as self-efficacy and self-esteem disorders, arise
following the creation of stoma. Psychosocial conditions in these
patients have attracted the attention of researchers in fields such
S24
as nursing, mental health and social medicine (Simmons, 2014).
Disruption of self-efficacy and self-esteem is always a serious
issue in these patients because they encounter the most important
challenges shortly after ostomy surgery, which include how to
care for their stoma, taking part in the community, engaging in
everyday activities and pursuing their occupation.They also have
to adapt to changes in body image and appearance, maintaining a
positive attitude towards themselves and their sense of self-worth.
Practitioners, especially enterostomal nurses, who have the
closest relationship with patients in the early postoperative
period, need to pay attention to patients’ levels of self-efficacy
and self-esteem. This study’s aim was to determine the
correlation between self-efficacy and self-esteem in patients
with an intestinal stoma.
Method
This descriptive-correlational study was conducted with patients
with intestinal stoma who had been referred to the two hospitals
affiliated to Iran University of Medical Sciences and the Iranian
Ostomy Association in 2018. Sample size was defined using a
95% confidence interval and 80% power; the self-efficacy rate in
relation to self-esteem in patients was taken as being at least 5%.
The required sample size was determined to be 155.
Inclusion criteria
The inclusion criteria were literacy (reading and writing), being
aged 18 years and above, being at least 1 month post-surgery and
having an intestinal stoma such as an ileostomy or colostomy,
which could be permanent or temporary.
Instruments
Tests used included the stoma self-efficacy scale, the Rosenberg
self-esteem scale (RSES) (Ciarrochi and Bilich, 2006) and
demographic form data.
The stoma self-efficacy scale has 28 items in two dimensions.
There are: 14 items that measure the self-efficacy of the person
in caring for their stoma and social self-efficacy and14 items that
measure the efficacy of the person regarding social function.The
scoring for responses on the Likert scale ranged from ‘I am not at
all sure’ (1 point) to ‘I’m pretty sure’ (5 points).The lowest possible
score was 28 points and the maximum 140 (highest self-efficacy).
It also allows self-efficacy scores in each dimension (stoma care
self-efficacy dimension and social self-efficacy dimension), with
a minimum score of 14 (lowest self-efficacy) and a maximum of
70 (highest self-efficacy score). High scores are related to positive
self-efficacy (Bekkers et al, 1996).
The RSES has 10 items, which use a 4-point Likert scale
ranging from totally agree (3 points) to totally disagree (0 points).
The overall score range is 0–30; for items 2, 5, 6, 8 and 9,‘totally
agree’ scores 0 points and ‘totally disagree’ scores 3 points. For
items 1, 3, 4, 7 and 1, ‘totally agree’ scores 3 points and ‘totally
disagree’ scores 0 points. A higher score is indicative of higher
© 2020 MA Healthcare Ltd
self-esteem (Ciarrochi and Bilich, 2006S).
The demographic information collected included age, sex,
marital status, education level, contribution to ostomy care, change
of job after surgery, diagnosis (the reason for stoma formation)
and how long a patient had had the stoma.
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SELF-EFFICACY

questions were read out by the researcher or research assistant, and

Table 1. Demographic variables (n=155)
patients’ responses were entered into the questionnaire verbatim.
Variable Response Total Percentage Collection took place between August 2017 and January 2018
Post-surgery job Yes 37 24 and no data were missing.
change No 117 76
Data analysis
Duration of ostomy 1 month–1 year 108 69.7 Data analysis was done using the SPSSv16 statistical package.To
1–5 years 21 13.5 describe the sample’s characteristics, descriptive statistics including
>5 years 26 16.8 absolute frequency distribution and frequency (for qualitative
Level of education Academic (college and university) 25 16.1 variables), mean and standard deviation (for quantitative variables),
Non-academic (school) 130 83.9 frequency distribution tables, calculation of numerical indices,
and inferential statistics and t-test independent and variance
ANOVA were used. Pearson’s correlation coefficient was applied
Table 2. Self-efficacy to determine the correlation between the two variables of self-
Variable Range Mean SD Minimum Maximum efficacy and self-esteem.
Ostomy care 14–70 53.61 9.92 28 70
Results
Social self-efficacy 14–70 40.86 12.19 16 80 The mean age of the participants was 54.23 years (range 18–86
Total self-efficacy 28–140 94.47 19.06 48 139
years). Of the subjects, 51% were men and 49% women; 74.2%
were married and 25.8% were single.A majority (69%) needed at
least one person to take care of them, while the remaining 31%
Table 3. Self-esteem looked after themselves without assistance. Nearly 53% stoma
Variable Mean SD Minimum Maximum surgeries were carried out because of cancer and 47% were due
to other causes, such as inflammation of the intestine, Crohn’s
Self-esteem 19.10 4.26 7 30
disease, irritable bowel syndrome, bowel obstruction, trauma,
constipation or chronic diarrhoea, incontinence and diverticulitis).
Table 4. Correlation between self-esteem and self-efficacy Additional information is presented in Table 1.
Stoma self-efficacy Social self-efficacy Total self-efficacy The mean total self-efficacy score was 94.47 out of 140, with
scores in the range 48–139 (Table 2).The mean self-esteem score
Correlation r=0.39 r=0.53 r=0.54 was 19.10 out of 30, within a range of 0–30 (Table 3).
P<0.001 P<0.001 P<0.001 Pearson’s correlation coefficient showed that there was a
positive, significant correlation between self-esteem and self-
Although the tools were valid and reliable, they were revalidated efficacy (P<0.001); there was also a positive, significant correlation
by three Iran University of Medical Sciences faculty members. between self-esteem and dimensions of self-efficacy (P<0.001).
To ensure the reliability of the instruments, 15 patients with The highest correlation was found in social self-efficacy (r=0.53)
an intestinal stoma who did not take part in the main study and the least correlation in stoma self-efficacy (r=0.39) (Table 4).
also completed the questionnaires; reliability was confirmed by The results of ANOVA and the independent t-test showed
internal consistency with Cronbach’s alpha coefficient of 0.9 for there was no relationship between self-efficacy and demographic
the stoma self-efficacy scale and 0.86 for the RSES. characteristics except for marital status (Table 5). The results
of ANOVA and the independent t-test showed there was no
Ethical considerations and procedure relationship between self-esteem with demographic characteristics
The study received approval from the ethics committee (ethics (Table 6).
code IR.IUMS.REC. 1396.9511686003) of the Iran University
of Medical Sciences and was granted jointly by the Iranian Discussion
Ostomy Association and the hospitals. There was a positive, significant correlation between total self-
The study goals and design were clearly explained to patients efficacy and its dimensions with self-esteem in patients with an
by the researcher and his assistant. Because patients can be reluctant intestinal stoma.
to cooperate, it proved difficult to collect all the data from 155 Evaluating the mean scores of self-efficacy and its dimensions
patients. So, in addition to the researcher, data were collected showed that patients had weaker self-efficacy in the area of
by two nursing students. One of these assistants was a master’s ostomy-related social activities. This is similar to the results of
student who worked with ostomy patients, and the other was a Wu et al (2007) and Rafii et al (2013). In a study by Dehvan et
bachelor’s nursing student. al (2019), the average self-efficacy score was similar to that in
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After patients’ written consent had been obtained, the
questionnaires were distributed, completed and collected on
the same day.There are limitations to this method; some patients
did not want to fill out questionnaires by themselves because
of a psychological or physical condition. In such cases, the
the present study.
Su et al (2016) found that 85.6% of patients had low or
moderate self-efficacy in the dimension of stoma care, which
required a focus on mental and social health as well as social
support for patients.

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 SELF-EFFICACY

Social self-efficacy concerns personal performance regarding Table 5. Relationship between self-efficacy and demographic characteristics
social functions associated with having a stoma (Bekkers et al,
1996). High self-efficacy is associated with active coping strategies, Variable Number Mean SD Test result
seeking social support, problem-solving and optimism. On the Age (years) <30 7 84.85 15.94
other hand, low self-efficacy has been characterised by symptoms 30–39 20 98.65 17.75
of anxiety and depression, as well as psychosomatic symptoms 40–49 24 102.25 18.14 f=1.61
and poor wellbeing. 50–59 43 91.93 17.54 P=0.15
Social self-efficacy has a direct relationship with self-confidence,
60–69 41 92.58 20.15
life satisfaction and optimism (Quintana et al, 2006).Therefore, the
>70 20 93.70 21.56
level of social self-efficacy of patients with an intestinal stoma in
the present study needs to be further investigated and interventions Sex Male 79 95.48 2.21 t=0.66
are required in this regard. Ostomy often leads to changes and Female 76 93.43 2.12 df=153
difficulties in social interactions, occupational considerations P=0.50
and daily activities (Mahjoubi et al, 2010). Patients often report
Marital Single 15 96.53 18.77
problems with exercising, sleeping, being in a community, having status Married 115 83.80 21.01 f=3.60
sex and dressing (Su et al, 2016). Because self-efficacy is an aspect
of coping, it can make it easier to accept an ostomy and live with Widowed/ 25 85.44 17.17 P=0.03
divorced
it (Schwarzer et al, 2005); therefore, self-efficacy evaluation is
important in these patients. Level of Elementary 49 92.38 14.69
In this research, the mean score for self-esteem was 19.10 out education Middle school 41 90.41 19.00
certificate f=1.93
of 30 (Table 3); 31.3% of the patients took care of their ostomy
40 97.82 22.35 P=0.12
independently and 69.7% needed someone else’s assistance. Diploma
In a study by Kiliç et al (2007) women who had had a Academic 25 99.88 19.99
mastectomy for breast cancer had a normal level of self-efficacy and
a near to normal self-esteem level. In another study, patients with Job change Yes 37 94.43 19.49 t=0.08
an intestinal stoma had moderate self-esteem, but experienced No 117 94.73 18.91 df=152
problems relating to sexual difficulties (Gozuyesil et al, 2017). P=0.93
About 54.3% of patients could not take care of themselves and df: degrees of freedom; f=ANOVA f-test
50.8% thought that the procedure had damaged their social
lives. The study showed that 54.2% experienced fewer sexual Table 6, Relationship between self-esteem and demographic characteristics
relations and 44.1% had no sexual desire once they had a stoma
(Gozuyesil et al, 2017). Variable Number Mean SD Test result
Salomé and de Almeida (2014) showed that it was important Age (years) <30 7 16.85 2.26
for these patients to overcome psychological problems.This study 30–39 20 18.85 5.22
also indicated that patients with an intestinal stoma had low self- 40–49 24 20.08 4.33 f=0.81
esteem and a poor body image. Low self-esteem can be associated 50–59 43 19.51 4.25 P=0.54
with behavioural and communication problems, anxiety and
60–69 41 18.85 4.15
depression, as well physical and psychological problems (Johansson
>70 20 18.60 3.93
et al, 2018). Therefore, studying self-esteem levels in patients
with an intestinal stoma is important because of the links with Sex Male 79 18.77 4.28 t=0.98
mental health. Female 76 19.44 4.24 df=153
There was a significant correlation between self-efficacy P=0.32
and its dimensions with self-esteem in patients. The strongest
Marital Single 15 19.40 4.13
correlation was observed in social self-efficacy and the weakest in status Married 115 18.46 4.79 f=1.18
the dimension of stoma care. Connolly (1989) showed that there
was a positive correlation between social self-efficacy and self- Widow/ 25 18.08 4.50 P=0.30
divorced
esteem, social harmony and mental health. Najafi and Foladjang
(2007) found self-efficacy had a significant, positive relationship Level of Elementary 49 18.44 3.78
with good mental health. In a study by Pouresmail et al (2017), Education Middle school 41 18.63 4.78
f=1.46
the mean score for self-efficacy correlated significantly with the degree 40 19.60 4.13
P=0.22
total adjustment score. Research by Bazalinski et al (2014) found Diploma 25 20.36 4.31
a statistically significant positive correlation between self-efficacy Academic
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and satisfaction with life. Samadi et al’s (2013) results showed a Job change Yes 37 19.02 4.13 t=0.11
direct, positive relationship between self-esteem and quality of life.
No 117 19.11 4.33 df=152
Self-esteem is related to changes in self-efficacy (Lane et al,
P=0.90
2004). In addition, individual characteristics and self-esteem
provide a context for self-efficacy (Di Giunta et al, 2013). People’s df: degrees of freedom; f=ANOVA f-test

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SELF-EFFICACY
KEY POINTS
■ Colorectal cancer is a common reason for stoma formation; young people
may need stoma surgery because of inflammatory intestinal conditions
■ Self-efficacy and self-esteem are important factors in patients’ ability to
cope with living with an intestinal stoma
■ Patients who have a stoma experience psychological difficulties, including
disturbances in self-efficacy and self-esteem
■ Self-efficacy is positively correlated with self-esteem in such patients;
social self-efficacy was the most important aspect of this in relation to
self-esteem
■ The self-efficacy score of patients who were married was higher than in
those who were divorced or widowed
expectations regarding efficacy in performing a given task could
influence their self-esteem when success and failure are closely
linked to self-worth (Bandura, 1997; Lane et al, 2004).
Individuals who have higher self-efficacy are more likely to
succeed in overcoming problems and leading a contented life
than those with a low self-efficacy (Bandura, 2017). They are
also likely to persevere more and perform better in challenging
situations (Sepahmansour et al, 2013).
It can be concluded that self-efficacy and self-esteem have a
positive correlation, because how successful a person is achieving
their personal goals largely depends on these two variables (Mone
et al, 1995). Wu et al (2007), who examined self-efficacy and
quality of life in patients with a stoma, found a positive relationship
between self-efficacy and with level of education and gender,
with higher self-efficacy among men.They also found a positive
correlation between social self-efficacy and both psychological
wellbeing and social wellbeing.
Su et al (2016), who studied self-efficacy and associated factors
in patients with temporary ostomies, found that self-efficacy
was associated with education level and type of ostomy. They
found that patients with higher levels of education had higher
self-efficacy.
Therefore, the relationship between demographic characteristics
and self-efficacy needs to be considered in further research.
In the present study, no specific relationship was observed
between self-esteem and demographic characteristics. Noghani
et al (2006), who investigated levels of self-esteem in men and
women with cancer, found no specific relationship between
gender and self-esteem. Gozuyesil et al (2017) also found no
difference between levels of self-esteem in female and male
patients. Moreover, other components related to self-esteem were
affected by stoma surgery: 50.8% of these patients did not want
to be out in the community and preferred to stay at home; and
54.2% reported having less sexual activity and 44.1% reported
that they had no sexual desire, with no differences found between
men and women (Gozuyesil et al, 2017).
Limitations
Respondents were recruited by convenience sampling from three
centres.This research looked at correlation, so conclusions cannot
be drawn regarding causation. To investigate this, longitudinal
studies are needed.
S28
In addition, differences in individual patient characteristics
when answering questions could have affected the results of
this study. 
Conclusion
Self-efficacy and self-esteem are important factors in patients with
an intestinal stoma. Self-efficacy was positively correlated with
self-esteem in these patients; social self-efficacy had the greatest
influence on self-esteem.Therefore, educational and supportive
interventions should be designed to improve patients’ self-esteem
and social interaction.
Most of the patients in this study had had their stoma for
less than 1 year. Therefore, it is recommended that healthcare
teams should plan to provide educational interventions as early
as possible. These interventions should include: replacing the
stoma bag correctly at appropriate intervals; leakage prevention;
obstruction; skin problems and damage; correct use of stoma
auxiliary equipment (such as paste, elastic tape and baseplates);
following the advice of enterostomal therapists and doctors; and
taking care of stoma during illness. In addition, an educational
programme on social self-efficacy should be designed to prepare
patients not only to communicate with others but also to talk
about their stoma with other people.
The goals of social self-efficacy training should include:
continuing activities at home and outdoors; wearing favourite
clothes; travelling by public transport; attending parties and
entertainment; going out to public places; having sexual
relationships with sexual satisfaction to the same extent as before
surgery; and being the person in charge of managing the stoma.
In setting educational goals and choosing the teaching method,
the psychological dimension must be considered in addition to
the practical aspects because self-efficacy, especially social self-
efficacy, and self-esteem have psychosocial dimensions.
Additional research is needed to investigate the efficiency of
interventions to improve self-efficacy and self-esteem in patients
with an ostomy. BJN
Declaration of interest: none
Acknowledgement: the researchers would like to thank the Iranian
Ostomy Society and the Rasool Akram and Firoozgar hospitals for
their cooperation with this research, as well as the patients who helped
with this study
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CPD reflective questions
■ How can nurses take a holistic approach when caring for patients with an intestinal stoma? How could this help meet patients’
psychological needs, including altered self-esteem and self-efficacy after surgery?
■ What strategies could nurses use to assess patients’ self-esteem?
© 2020 MA Healthcare Ltd
■ What help is available from mental health professionals to assess patients’ self-esteem where you work, and can patients be referred to
them for support?
■ How is research on improving the care of these patients and closer working disseminated to nurses and the wider team? How would you
know if this was sufficient and effective?
British Journal of Nursing, 2020, Vol 29, No 16 (Stoma Care Supplement)S29
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