Mastectomy tattoos: An emerging alternative for reclaiming self

Abstract

Recent discourses within breast cancer and gendered studies literature suggest some women are challenging postmastectomy bodies as abject bodies. Tattooing is an emerging body project in contemporary society that can offer women who live disembodied from their postmastectomized body an alternative. We consider embodied health movements, a type of social movement, to explore how acquiring meaningful tattoo art over a mastectomized site can been seen as challenging hegemonic, gendered discourses of the female breast and patriarchal ideals of beauty, post mastectomy. As part of emancipatory practices, tattooed bodies have historically been used to challenge dominant discourses related to identity and is currently evolving into practices of self‐expression, healing, and transformation. As an emerging phenomenon among women, it is important for nurses to understand the prevalence and role of tattoos more broadly, and the possible means for women to embody healing and transformation post mastectomy.

1. INTRODUCTION

According to the Canadian Cancer Society, approximately 27 400 women will be diagnosed with breast cancer in 2020, representing 25% of new cases in Canadian women. ¹ Many women with breast cancer require surgical intervention to eradicate or control the spread of disease, with approximately 40% in Canada having a mastectomy. ² , ³ , ⁴ Less than one in five women will pursue breast reconstruction following a mastectomy, ⁵ leaving many to “live flat”; a term used to denote the absence of breasts in women who have had breast cancer. Women who live in the world without breasts are acutely aware of societies heteronormative body ideals, some considering themselves abject in contrast. ⁶

Interestingly, some women are choosing a tattoo as a form of adornment over a mastectomized area. ⁷ Offered here, is the possibility for postmastectomy tattooed bodies to enrich the discourse about what constitutes beauty, femininity, and sexuality, while offering these women agency to reclaim their body and refine concepts of self.

The aim of this paper is to explore a growing phenomenon of women acquiring tattoos in North America ⁸ and anecdotal evidence that mastectomy tattoos can be transformative. ⁹ We consider whether seeking mastectomy tattoos may become an embodied health movement of breast cancer.

We begin, by briefly locating our discussion of acquiring a mastectomy tattoo within a framework of social movements. Next, we explore the breast as a signifier for being female in western cultures and the mastectomized body as abject. We describe the evolving history and role of body tattoos in North America alongside the increasing prevalence and reasons why women tattoo. Finally, we examine the process of being tattooed, and speculate why mastectomy tattoos may become an alternative signifier for beauty, femininity, sexuality, and agency for some women post mastectomy. As a growing phenomenon, it is important for nurses to be aware of this move toward “nonnormative body projects such as tattooing” ¹⁰ and the implications for nursing practice.

2. SOCIAL MOVEMENTS AND BREAST CANCER

Social movements challenge dominant discourses and tackle issues of access, inequity and inequality based on race, ethnicity, class, gender, and sex/sexuality. ¹¹ Of importance here, are the gendered discourses of the female breast and how taken‐for‐granted western assumptions about normative female bodies, can leave women feeling disembodied or distanced from their body when unable to meet these heteronormative criteria. Familiar findings in breast cancer literature report women who have had a mastectomy often feel less feminine, sexual, and beautiful. ¹² , ¹³

Brown et al ¹¹ are sociologists who have studied health social movements including campaigns related to breast cancer. Social movements are broadly understood as, “informal networks based on shared beliefs and solidarity which mobilize around conflictual issues and deploy frequent and varying forms of protest.” ¹¹ The well‐known pink ribbon campaign and “run for the cure” are examples of organized advocacy around a health issue that challenged medical policy and practice. In their research, Brown et al ¹¹ provide a theoretical understanding of what they call “health social movements” and trace how such movements have successfully altered health policies and practices to enhance equity, education, and access to healthcare (eg, the routinizing of mammogram screening). Brown et al ¹¹ have also developed a social movement subset, which they call “embodied health movements,” that are of interest in our discussion of mastectomy tattoos as a promising approach for transforming concepts of beauty, femininity, sexuality, and identity in postmastectomized bodies.

Embodied health movements have three key characteristics: (a) they include the biological body and people's experience of living with illness; (b) introduce alternative knowledge and practices to medical and scientific approaches; and (c) they involve activists and advocates alongside professionals in developing public awareness and policy. ¹¹ While there is limited “hard” evidence, we believe these characteristics support our speculation that seeking mastectomy tattoos may become an embodied health movement of breast cancer. We are seeing anecdotally how women are challenging current gender and societal perspectives of postmastectomy bodies by considering the mastectomy tattoo as a form of adornment.

3. FEMALE BREAST AS SIGNIFIER

Breasts signify and define womanliness and femininity in many cultures. ¹⁴ , ¹⁵ , ¹⁶ As symbols, breasts are associated with motherhood, politicized when used to make statements for moral goodness such as when promoting breast feeding, and often used commercially as a means to sell products. In the context of health care, breasts become medicalized, perceived as vulnerable to disease or requiring modification. ¹⁷ Social discourses tend to objectify female breasts with normative standards dictating ideals of shape and size including being full‐breasted, ¹⁵ ideally situated higher on the chest, preferably round, firm, and symmetrical ¹⁸ while implying there should be two. ¹⁶

In contemporary North American societies, breasts are often associated with appearance‐related concerns expressed by women with breast cancer and those who have had a mastectomy. ¹⁹ To explore the mastectomized body as abject (a term used by Kristeva ²⁰ to theorize reactions that occur in response to aspects or functions of the body deemed unacceptable to society), we turn to the intersections between embodiment of cancer and what Hopwood and Hopwood ²¹ term “embodied body image.”

4. MASTECTOMIZED BODIES AS ABJECT

We draw on social theories that view the mind and body as interconnected to consider how the embodiment of cancer and embodied body image can affect perceptions of the body post mastectomy. Of interest to our discussion, is the theoretical understanding of “embodied body image” to describe “all the ways that people conceptualize and experience their body,” ²¹ which include social and physical realities of the body. Three of Schatzki's ²² intrinsic dimensions of embodiment are used by Hopwood and Hopwood ²¹ to describe an embodied body image: being a body; having a body; and using a body. Within the context of having a mastectomy following breast cancer, we propose, when considered through these intrinsic dimensions, the mastectomized body could be perceived as abject. That is, the view that one's body is no longer in harmony with personal or societal expectations and implications of such perceptions. For clarity, the dimensions of embodiment are discussed in relation to experiences of breast cancer.

Being a body can be considered ontological (as an existential being) allowing for experiences where we sense and perceive. Expressed differently, our understanding of self includes a taken‐for‐granted sense of being a body. Following a diagnosis of breast cancer, women may perceive their body as an ongoing existential threat, ²³ as abnormal cells grow, multiply and possibly spread to adjacent or distant areas. These changes can betray the concept of self being a “healthy” body. Furthermore, being a body following a mastectomy can be met with feelings of dissonance if women perceive their “new” body as foreign or strange, ¹⁹ deformed, or less than ideal. ¹⁶

Having a body refers to being cognizant that our body has experiences, most notably, when something negative affects our body. ²¹ Experiences of having a body without hair (because of chemotherapy), with thermal injury, such as a burn (adverse effect from radiation), scarring (following removal of cancerous lumps or breast(s), and weight loss or gain (associated with chemotherapy and hormonal therapy, respectively) can be met with angst and considered “out of place” in society.

Using a body is purposeful, where the body is used to “accomplish desired actions.” ²¹ Some women described feeling “physically handicapped” ²⁴ with their unsymmetrical bodies out of sync with social narratives of how women should look and perform. Sexually, using one's body as a way to entice can be unsettling for some women who consider their mastectomized body as “wretched.” ²⁵ These feelings of being physically and sexually unattractive may cause women to conceal their chest or scars during intimacy ²⁶ believing they are incomplete physically, sexually, and emotionally. ²⁷

A lack of research prevents us from understanding exactly how or if a mastectomy tattoo influences women's experiences of the embodied dimensions of being, having and using a body. We look to how tattoos have been used in the past to resist cultural norms and to consider how the mastectomy tattoo could transform perceptions of the mastectomized body as abject.

5. RESISTING CULTURAL NORMS WITH TATTOOS

Feminist scholars have long acknowledged the body “as a source of knowledge [and] as a site of resistance.” ²⁸ Women are resisting cultural dictates of gender and the body by acquiring tattoos as a way to reclaim authority over their body, identities, ²⁹ and in unique ways, defining beauty. ⁸ Women are the largest group of people seeking tattoos in the Unites States ³⁰ , ³¹ and in Canada. ³² Among the reasons for seeking a tattoo are as acts of social protest, ²⁹ and a way to transform significant traumatic experiences. ³³ , ³⁴ The history of body engraving goes back hundreds of years, but the inclusion of women and the range of motivations for acquiring tattoos is quite recent.

5.1. History of tattoos and their acquisition

The word tattoo comes from the Tahitian word tatu, meaning “marking something.” ³⁵ Throughout antiquity, the body has been used for both adornment and in identity formation as a member of a group or subculture. ³⁰ , ³¹ The Maori people's facial tattoo (moko design) signify tribal identity, ³⁶ and Japanese body tattoos called “irezumi,” a signifier of gang membership. ³⁰ Tattoos in Europe and North America have had a rich and complex history. Captain James Cook first introduced them, during the late 18th century and following their travels through the Polynesian island's members of his crew, returned to Europe with, “native tattoos” carved into their skin. ³⁰ , ³⁷ When Cook returned to Europe, he revealed his body inscriptions to Europe's “upper‐class” and by the end of the 19th century it was common to see members of elite society being engraved. ³⁷

Tattoos among the privileged, however, changed over time as tattoos became popular with marginalized groups including circus or stage performers, sailors, military, ³⁰ prisoners, gang members, ³⁸ , ³⁹ and so‐called “deviants.” ⁴⁰ As such, tattoos became associated with marginalized subcultures and “lower classes.” Nevertheless, we are experiencing a “tattoo renaissance.” This trend is attributed to the large number of fine arts graduates who entered the profession and revolutionized tattoo engraving by replacing stencils with custom designed works of art. ³⁰ , ⁴¹ The nomenclature of “being inked” has entered popular culture and tattoos are moving from the margin toward the center circles of society. Despite ongoing stigma in some circles, ⁴² tattoos are becoming almost commonplace among young and middle‐aged professionals including nurses, doctors, lawyers, and councilors. ⁴³ , ⁴⁴ It is no longer the sole purview of men; getting a tattoo is a shared social practice that crosses class, professions, and ethnicities. ³⁴

5.2. Prevalence

In Canada, according to an Ipsos Reid poll, 2 in 10 people reported having a tattoo in 2012, with women being 24% more likely than men (20%) to have a tattoo. Statistics drawn from Canadians indicate that 36% of Millennials (aged 18‐34 years of age), 24% aged 35‐54, and 8% over the age of 55 currently have a tattoo. ³² More recent statistics from a 2019 Ipsos Reid poll conducted in the United States indicate that these numbers are increasing. ⁴⁵ Speculation suggests this trend is related to cultural influencers including actors, musicians, athletes, and supermodels who have a tattoo, ⁴⁰ and the growing appreciation of tattoos as embodied art. ⁴⁶ , ⁴⁷ In a qualitative study of 36 women, Thompson quotes one young woman:

I have huge arguments with my grandmother. She's a painter. So, I try to explain to her it's art. And I've always wanted tattoos. Not just little ones, I've wanted full coverage. For me, it's for my own satisfaction, and they all mean something. And they're all an experience. I just love the way it looks. Some people get plastic surgery, some people get lots of piercing or change their hair. I get tattoos. ³⁴

5.3. Role and function of tattoos

People acquire tattoos for a variety of reasons. They serve to memorialize an important life‐changing event ⁹ , ³⁹ ; to commemorate a loved one; for group membership ⁴⁸ and for taking control of one's life and body following a traumatic experience. ⁴⁹ , ⁵⁰ , ⁵¹ Academics and professionals are also embracing their tattoos as a form of artistic self‐expression ³¹ , ⁵² , ⁵³ or for purely esthetic purposes. ⁹ , ³⁶ Furthermore, getting tattooed is associated with identity formation and self‐esteem. Thompson reported, “The tattoo has the potential for the collector to see them self in a new way” and “their tattoos… become part of their personal identity—[as] a tattooed person.” ³⁴

5.4. Why are women acquiring tattoos?

In focusing on women's motivations, we foreground three areas where, (a) tattoos are a form of self‐expression and empowerment; (b) as embodied art (esthetics); and (c) an emerging aim of therapeutic healing. We will explore each motivation category with our main interests, the aim of therapeutic healing, and a means to reclaim the body.

5.4.1. Tattoos as self‐expression and empowerment

A tattoo becomes part of the individual and can signify unique personal meanings. Taliaferro and Odden ³⁵ suggest that “there is, in a sense, an inherently existential, individual nature to getting a tattoo: the decision to be tattooed is one that will mark you as an individual indefinitely.”

Similarly, a study by Mun et al ⁵⁴ explored the meaning women attributed to their tattoo and how it influenced their sense of self. Findings suggest that participants positively changed in how they viewed themselves after obtaining a tattoo. A growing body of knowledge suggests positive effects of tattooing on women's identity development and sense of empowerment. ¹⁰ , ²⁹ , ⁵¹

In addition to strengthening self‐image, Baltzer‐Jaray and Rodriguez ⁵⁵ found that obtaining a tattoo helped some women by redefining beauty, “on her own terms, according to her individual taste.” Furthermore, Dadlez ⁹ in her essay on reasons why tattoos are philosophically interesting argues that “mastectomy tattoos make the best case for the tattoo as personally transformative.”

5.4.2. Tattoos as embodied art

Many who ink see their body as a canvas for art, adorned like a piece of beautiful jewelry. ⁵⁶ This can be “art for art's sake,” however, many have a strong personal connection with their tattoo. Some authors have written about a synergy that exists between the subject (individual's body) and object (tattoo ink). ⁵⁷ Pritchard, ⁵⁸ explores the “in‐betweenness of tattoos' that are not fully inside or outside the body…suggesting that the tattoo is not fully one's own, nor another's …” and that tattoos tell a story in artistic form.

The power of tattoos to narrate and produce esthetically appealing effects, may explain why a tattoo can be considered a work of art where the body is the canvas. While views on what constitutes “art” vary, according to Michaud, ⁵⁹ something becomes a piece of art if it can evoke expression or emotion. Emotions are highly regarded in expressionist art suggesting that if a narrative either accompanies the creative piece, or comes alive through a creative piece, it is art. Using the body as a canvas means the recipient is intrinsically part of the narrative and part of the esthetic experience. ⁵⁹ Extant tattoo literature reveals that people's stories are often part of creating a tattoo or the reason for acquiring particular body art. ⁵⁰

5.4.3. Tattoos as therapeutic healing

Of greatest interest here, is the healing potential of tattoos however, research into the therapeutic role and function of tattoos for women has not kept pace with the growing numbers of women seeking tattoos. Nevertheless, a small but growing body of work suggests women are using tattoos as part of their recovery in making sense of significant experiences and traumas. ³³ , ⁴⁹ , ⁵⁰ , ⁶⁰

We can look to online commentary about the transformative nature of tattoos. Anecdotal narratives are found in blogs and websites about covering self‐harm scars with tattoos, (eg, Irish tattoo artist's Sean Kelly's “Scars behind beauty project”) or modifying tattoos acquired by women trapped in human trafficking. ⁸ The therapeutic quality of tattoos is reported across a range of populations. In a recent study, Maxwell et al ⁵¹ shared findings from women who self‐identified as survivors of sexual violence and sought tattoos as a form of healing. The tattoos were seen as “cathartic ink” and a means of regaining control of their bodies while resisting patriarchal norms.

Additionally, a recent study conducted by Eschler et al ⁴⁹ explored the significance of “cancer survivor tattoos” in people who experienced trauma following the diagnosis and treatment of cancer. Their findings focused on posttraumatic growth (the good that can come from traumatic experience) and describe how tattoos can be therapeutically healing and a way to empower and reclaim control of the body following cancer as reflected by one woman:

I look up [after the tattoo is finished] and I'm half naked, it seems that I'm beaming, and I'm so excited, and I for once in four or five years have finally looked in the mirror and not been punched in the face… I felt like I was on top of the world [after the tattoo]… ⁴⁹

A growing body of evidence suggests that modifying the body through inscription can allow women to therapeutically heal, regain control, and reclaim their body after traumatic experiences while simultaneously redefining femininity. ⁶¹

5.5. Tattoos post mastectomy

With a focus on breast cancer, women's reasons for getting tattooed also include social and political motivations. There are anecdotal narratives of women who obtained tattoos over their mastectomy site as a means to challenge postmastectomy bodies as abject bodies and for some, as an alternative to breast reconstruction. ⁶² , ⁶³ Published biographies began in the 1990s with social activists who used artwork and images to raise awareness of breast cancer and women's suffering, by making it visible through art. ⁶⁴ In 1993, the New York Times journal featured a cover story that challenged dominant narratives of breasts, beauty, and the impact of breast cancer. The cover image was a self‐portrait of a one‐breasted activist, artist and photographer Joanne Matuschka. The image depicted Matuschka draped in a white cloth with her mastectomy scar exposed under the title, “Beauty Out of Damage.” Subsequent photographs of Matuschka, reveal a flower tattoo covering her mastectomy scar.

Equally avant‐garde was poet Deena Metzger's self‐named tattoo “The Warrior,” photographed by Hella Hammid, in 1978, that depicted a tree branch concealing her mastectomy scar. ⁶⁵ The photograph later became part of a black and white poster designed by Sheila Levrant de Brettville, with the following poem written by Metzger:

I am no longer afraid of the mirrors where I see the sign of the amazon, the one who shoots arrows. There is a fine line across my chest where a knife entered, but now a branch winds about the scar and travels from arm to heart. Green leaves cover the branch, grapes hang there, and a bird appears. What grows in me now is vital and does not cause me harm. I think the bird is singing. When he finished his work, the tattooist drank a glass of wine with me. I have relinquished some of the scar. I am no longer ashamed to make love. Love is a battle I can win. I have a body of a warrior who does not kill or wound. On the book of my body, I have permanently inscribed a tree. ⁶⁶

More recently, Inga Duncan Thornell's chest tattoo of a lush garden with animals, insects and butterflies is depicted in Margot Mifflin's ⁶³ “Bodies of Subversion” employed as a destabilizer for heteronormative body ideals for women post mastectomy. While there are websites available for women considering tattoos post mastectomy (eg, p.ink.org provides information about mastectomy tattoos and artists to “cancer survivors”), little research was found for why some women are choosing to be inked over their mastectomy scar. Furthermore, considerations for tattooing over scar and radiated skin or women's experiences of being tattooed post mastectomy is absent in the literature.

Despite being anecdotal, we can look to the article written by Chicago‐based tattoo artist, David Allen, published in the Journal of the American Medical Association, to learn about the transformative nature of tattoos post mastectomy, where he observes that tattoos transform feelings of “disfigurement and loss of control into feelings of beauty and agency.” ⁶⁷ This leads us to speculate, embodying tattoo art may be a way for some women post mastectomy to reclaim their body, challenge postmastectomized bodies as being abject, and reconceptualize concepts of femininity, beauty, sexuality, and identity following breast cancer.

5.6. Process of tattooing

Regardless of the reasons why women are seeking tattoos post mastectomy, understanding the process of being tattooed with indelible ink is important for nurses working with women interested in this option. What follows is a brief introduction to illuminate an often multistep‐engaged process that women undergo when acquiring extensive tattoos. The process begins with exploring the design. Tattoo artists today often have baccalaureate and even master's degrees in fine arts, and bring knowledge of art theory, esthetics, history, and technique to their practice. ⁴¹ , ⁶⁸ Contemporary tattoo artists develop sophisticated, innovative, and esthetically pleasing designs; they have some “familiarity with the visual art world” ⁴¹ and the ability to draw with great aptitude and proficiency in a range of tattoo styles.

Collaborating with an artist to codevelop the type of design, colors, and placement is an important part of the process, ³³ especially with current interests in adorning original and unique tattoos. ⁴¹ , ⁵⁴ Some innovative styles associated with the contemporary tattoo artists include New Skool, black and gray art, and biomechanical art. ⁴⁰ , ⁴¹ The technique of flash tattoos, selected from a standard collection and mass‐produced by artisans, are becoming part of the distant past. Contemporary tattoo art and artists are progressive, esthetically focused, and professional. ⁴¹

According to Faille and Edminston, ⁶⁹ the most common instrument used “to ink” is a coiled tattoo machine. This machine uses an electromagnetic circuit to move needles (located inside) to imprint the design into the skin. Needles containing ink are repeatedly inserted into the dermal layer of the skin (2000‐2500 insertions per minute). ⁷⁰ When a fine technique is required, fewer needles are used, compared to when a large area is being colored or shaded in, more needles are needed to dispense the ink. The length of the procedure can vary depending on the intricacy of the tattoo and how much body surface is being covered. Typically, a small tattoo takes about an hour and a half to complete and large tattoos may take weeks, months, and even years. ³⁴

Inga Duncan Thornell, writes on her website, that she spent one Sunday per month over two and a half years, to complete her chest tattoo, due to the intricacy of the design and the expanse of body surface being tattooed. The cost of a tattoo is variable depending on the size, style, and reputation of the artist. Some tattoo artists have wait‐lists of several years and people have reported traveling to various locations across the world, to have a piece of art created by a well‐known artist. ³⁴ Notably, however, is the activism of some renown tattoo artists from North America donating time and artistry to create free mastectomy tattoos through not‐for‐profit organizations. ⁷

Formal studies regarding the unique techniques employed when tattooing over scar tissue and radiated skin are lacking. Again, we look to David Allen, an expert in tattooing over such skin variation, for knowledge. Allen states:

Traditional tattooing is relatively heavy‐handed, typically relying on 5 to 9 needles for drawing hard outlines, then 11 or more needles to fill in the lines with solid color. Given what the women's skin has been through, I need to be more thoughtful and gentler. My technique is essentially pointillism, as opposed to the standard slathering of color, and is oriented toward efficiency and minimal trauma. I use a quiet, lightweight rotary machine and a small grouping of 3 needles directed toward one point. The needles and skin meet while I hold the machine and tube as perpendicular as possible, moving and adjusting dimensionally over the lay of the skin. My other hand stretches the skin taut during the application. It also works as a depth gauge based on variations in the vibratory response of the epidermis and papillary dermis, given its postsurgical density and elasticity. ⁶⁷

We appreciate through Allen's ⁶⁷ description of tattooing over scar tissue, some of the intricacies involved in this type of body work. Future research is needed to uncover other complexities involved in contemporary alternatives (such as tattooing), so women can make informed decisions. Greater knowledge about postmastectomy options and the accompanying best practices is also important for nurses who play a supportive role in the lives of women diagnosed with breast cancer. Next, we explore the implications for nursing practice and recommendations for future research.

6. NURSING IMPLICATIONS AND FUTURE RESEARCH

Nurses, who work with women diagnosed with breast cancer, play an important role in supporting women to make informed decisions about all aspects of their care. Nursing knowledge is the foundation needed to have well‐informed, meaningful conversations with women about their cancer experiences and treatment decisions.

Specific recommendations for nursing practice include: creating a space for authentic conversations with women about their body image and identity following cancer; inquiring where appropriate if postmastectomy options are being considered; providing information about postmastectomy options, and including alternative options that exist outside of mainstream breast cancer discourses (such as tattooing). Finally, sharing evidence informed information about taking the time needed to process cancer experiences and the changes associated with treatment.

Nurses who work with women considering a mastectomy tattoo should also advocate for future research to inform best practices for tattooing over scar tissue and radiated skin and in providing aftercare. Importance should be placed on learning more about the process of tattooing, advocating for experienced artists to create the tattoo over a mastectomized area and providing evidence informed health teaching about care for the tattoo after it has been created. Further studies are also needed, to learn more about tattoo artists' techniques, discover potential long‐term effects of acquiring extensive tattoos, and to communicate findings to a wider audience. The knowledge gained through additional inquiry should be shared with tattoo artists, to create awareness and greater understanding about the intricacies involved when tattooing over scars or radiated skin, so women receive safe competent work with high‐quality outcomes.

7. CONCLUSION

In contemporary society, women are being tattooed more frequently than men. As part of an embodied health and social movement, tattooing as an emerging body project can offer women who live disembodied from their postmastectomized body, an alternative. Reasons why women are tattooing suggest the tattooed body is a work of art capable of transforming a woman's identity, empowering her to redefine beauty and heal following traumatic experiences. Research is needed to learn more about best methods for tattooing over specialized skin/scar tissue, as are studies involving women who have a tattoo over their mastectomy scar. Findings from such studies, could be utilized by nurses who work with women who have breast cancer and are exploring options following a mastectomy, setting the stage for an alternative discourse. In sum, generating a discourse of the mastectomized body that is centered on the possibility for embodied agency, transformation, and empowerment.

Reid‐de Jong V, Bruce A. Mastectomy tattoos: An emerging alternative for reclaiming self. Nursing Forum. 2020;55:695–702. 10.1111/nuf.12486