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DOI: 10.1111/nuf.

12404

CONCEPT ANALYSIS

Emotional wellbeing in youth: A concept analysis

Suzanne E. Courtwright MSN, RN, PNP1 |


Mary Beth Flynn Makic PhD, RN, CCNS, CCRN‐K, FAAN, FANP, CNS2 |
Jacqueline Jones PhD, RN, FAAN3

1
University of Colorado College of Nursing,
Aurora, Colorado Abstract
2
Adult Gerontology Clinical Nurse Specialist Aim: The aim of this concept analysis is to report a synthesis of the extant literature
Program, University of Colorado College of
and define emotional wellbeing in youth as a concept of emerging importance.
Nursing, Aurora, Colorado
3
University of Colorado College of Nursing, Background: Emotional wellbeing is a national research priority in the United States.
Aurora, Colorado It is not well defined nor understood in the context of its ontology, mechanisms,
Correspondence biomarkers, or promotion. As a result, interventional research cannot be adequately
Suzanne E. Courtwright, MSN, RN, PNP, informed.
University of Colorado College of Nursing,
Ed2 North, 13120 E. 19th Avenue, Aurora, Design: A comprehensive review of the literature was conducted to inform the
CO 80045. sample.
Email: suzanne.courtwright@cuanschutz.edu
Data Source: The scientific databases PubMed, Cochrane Library, Ovid Medline,
PsycINFO, NCBI, Allied and Complementary Medicine, EMBASE, EBSCO, JAMAevi-
dence, CINAHL, Joanna Briggs Institute, and Reporter were queried.
Review Methods: The Walker and Avant method was utilized to analyze the resultant
sample for common themes of antecedents, attributes, and consequences of
emotional wellbeing.
Results: Seventeen scientific research studies were included in the final sample.
Conclusion: Attributes of emotional wellbeing in youth include overall positive
emotions, positive self‐esteem, and resilience. Antecedents are safe and stable
nurturing relationships; family and social connectedness, hope, and positive body‐
image. The consequences of emotional wellbeing in youth include self‐efficacy, self‐
actualization, the presence of positive health behaviors, and the absence of high‐risk
behaviors.

KEYWORDS
concept analysis, health promotion, pediatric, research, wellness programs

1 | INTRODUCTION youth in the US under age of 17 years face at least one adverse
childhood experience (ACE), such as abuse, maltreatment, violence,
In October 2018, five institutes and centers at the United States (US) and living with chronic disease.2-4 Empirical studies in adults
National Institutes of Health (NIH) named emotional wellbeing (EW) demonstrate a causal relationship between higher levels of emotional
a concept of national importance, a valid population health outcome wellbeing and overall better health, longevity and improved
and a high research priority.1 Anxiety and depressive disorders in morbidity and mortality; as well as decreased risk of disease, illness,
youth worldwide are at an unprecedented high and nearly half of all and injury.5-9 Nevertheless, the fundamental elements of emotional

106 | © 2019 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/nuf Nurs Forum. 2020;55:106–117.


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COURTWRIGHT ET AL. | 107

wellbeing, particularly in youth, and interventions promoting emo- in youth ages 3 to 24 years to better inform strategies that can
10
tional wellbeing across the lifespan, are not yet well understood. improve emotional wellbeing in this population.
Importantly, interventional research to improve emotional wellbeing
in this vulnerable population cannot be adequately informed without
a standardized conceptualization. 3 | METHODS
A conceptual definition accepted by the scientific community is
necessary to establish a body of science to address this emerging priority. The Walker and Avant19 method guided this systematic analysis of
A concept analysis on emotional wellbeing in youth has not been the extant literature. The following steps informed the process: (a) all
published as of the writing of this analysis. It is a concept of significance uses of the concept are described; (b) defining attributes are
to nurses who, by the very nature of our profession, provide healthcare determined; (c) examples of the model and contrary cases are
from a unique disciplinary perspective that encompasses the patient, offered; (d) antecedents and consequences are explained; and (e)
nurse, environment and health in a holistic approach toward disease empirical referents are defined. Most importantly, a standardized
prevention and health promotion.11 Nurse scientists have an opportunity conceptualization and operational definition of emotional wellbeing
to contribute to the body of knowledge of emotional wellbeing from this in youth is established as a product of the synthesized literature and
position and impact public health and health policy. will inform future research on this developing public health outcome.

3.1 | Databases searched


2 | BACKGROUND
The scientific databases PubMed, Cochrane Library, Ovid Medline,
In 2014, the US Surgeon General declared emotional wellbeing a PsycINFO, NCBI, Allied and Complementary Medicine, EMBASE,
priority in the national prevention strategy essential to overall EBSCO, JAMAevidence, CINAHL, Joanna Briggs Institute, and
health.12 The NIH formed the Emotional Wellbeing High Priority Reporter were queried using the following search terms: emotional
Research Network in 2018 and charged researchers to increase wellbeing AND pediatrics; emotional wellbeing AND children; and
understanding of the fundamental constituents of emotional well- emotional wellbeing AND adolescents. Then, another search with
being across the lifespan and refine and test the concept.1 emotional wellbeing as MeSH topic, subtopic, and the term was
Emotional wellbeing has been described throughout history by utilized. For both searches, the resultant samples were reviewed for
ancient philosophers and modern‐day psychologists and sociologists the following inclusion criteria: English language; and the terms
with varying terminologies.1,13-17 Interestingly, the core essence of “emotional wellbeing,” “emotional wellness,” or “psychological well-
the concept has remained consistent. The ancient Greek philosopher being” in the title or abstract. The search was not limited by the
Aristotle described emotional wellbeing using the Greek word timeframe. Figure 1 demonstrates the search strategy used.
eudaimonia, meaning a state of having good indwelling spirit, or
happiness.14 The Greek words eu, meaning good, and daimon,
3.2 | Data sources
meaning spirit, entymologically form of the word eudaimonia that
Aristotle used to describe emotional wellbeing.13,14,17 Socrates and The initial sample consisted of 1324 studies. Duplicates were removed,
other ancient philosophers have been described to be in agreement titles and abstracts of full‐text articles were screened, and eligibility
with Aristotle that eudaimonia was the overall pursuit of man.16,17 criteria were applied to the initial sample. The abstracts in the resultant
Early 20th century psychologists have interpreted Aristotleʼs sample were then read and the following inclusion criteria were applied:
writings on eudaimonia and emotional wellbeing to mean human the subject of emotional wellbeing or psychological wellbeing, the
flourishing and prosperity.15-17 Bradburn17 described the evolution definition of either term, and/or discussion on attributes, antecedents,
of physicians and psychologists’ focus in western medicine from and consequences. Exclusion criteria were the following: participants
physical diseases and mental disorders to exploring the realm of under age 3 years, over 24 years, or only the parents studied. We chose
psychological wellbeing. As such, his research described eudaimonia this age group to account for the overlap in the definitions of youth
and psychological wellbeing as a concept of utmost importance to amongst differing agencies. For example, the United Nations defines
human flourishing, but as one that still remained undefined in the youth as ages 15 to 24 years whereas the United States includes
scientific literature as to its attributes.17 In fact, the modern‐day participants ages 0 to 17 in national studies.20,21 To conduct a thorough
study of emotional wellbeing in youth has been termed by pediatric search of the literature, the reference lists of the sample were reviewed
experts in a modified Delphi study as the emerging “science of for publications relevant to the inclusion criteria.
thriving,” and urge a required paradigm shift for science to build a
caring capacity in pediatric medicine and focus on wellbeing,18
(p. S39). The Academic Pediatric Association, largely comprised of 4 | RESULTS
pediatricians, set this agenda.18 The aim of this study is to report a
synthesis of the extant literature and establish a standardized A resultant sample of 27 sources of evidence consisted of high level
conceptualization and operational definition for emotional wellbeing meta‐analytic systematic reviews, quantitative and qualitative
17446198, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nuf.12404 by Victoria University Of Welling, Wiley Online Library on [03/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
108 | COURTWRIGHT ET AL.

Records identified through database


searching
(n = 1324)

Identification
PubMed n=285
EMBASE n=99
OVID MEDLINE R (1946-present),
PsycINFO, Medline, CINAHL,
Joanna Briggs, AMED n= 940

Duplicates removed
(n=255)
Screening

Titles or abstracts screened


(n=1069) Excluded by title or abstract
(n=667)
Adults > age 21 n=634
Only parents of child studied n=33
Full-text articles assessed
wellbeing
for eligibility
(n= 687)
Eligibility

Hand search of references


Additional records identified through hand
(n=20)
searching
(n=7)
Full-text articles assessed
for eligibility Gastroenterology Nursing n=4
(n= 27) Journal of Advanced Nursing n=1
Perspectives in Public Health n=1
International Journal of Qualitative
Duplicates removed
Studies on Health and
(n=0)
Included

Wellbeing n=1

Titles or abstracts screened


(n=27)

Documents included in
Full-text articles assessed
analysis
for eligibility
(n= 27)
(n= 27)

FIGURE 1 Search Strategy

studies, to lower‐level evidentiary review articles, books, and reports. feeling.”22 Various other definitions are proposed throughout the
Only scientific studies were included in the final sample of 17 studies. scientific literature, and the Centers for Disease Control and
The sample is representative of studies from five continents and Prevention (CDC) reports this lack of consensus as a barrier to
across multiple disciplines including psychology, medicine, sociology, conducting research on this concept so that interventional research
philosophy, and nursing. Half of the studies are qualitative, and all may be better informed.10 The CDC, NIH Emotional Wellness
qualitative studies explored emotional wellbeing in youth living with Toolkit, the NIH Emotional Wellbeing High Priority Research
chronic disease. One‐third of the studies are US based and, of those, Network, and the National Center for Complementary and Integra-
four are published in the last 5 years indicating the emerging topic of tive Health all offer varying definitions of emotional wellbeing (see
priority. Participants’ ages ranged from 3 to 24 years. Table 1 Table 2).
demonstrates the resultant sample. A definition of emotional wellbeing in youth has not yet been
defined as of the writing of this analysis. One is proposed as a result
of the synthesis of the scientific literature. Emotional wellbeing in
4.1 | Definition and uses of the concept youth can operationally be defined as an overall positive state of
The dictionary definition of emotional wellbeing was limited to a emotions, self‐esteem, and resilience that leads to self‐actualization,
definition of wellness without the qualifier of “emotional,” and is self‐efficacy, and health‐promoting behaviors. This definition cap-
defined as “the state of being happy, healthy, or prosperous.” 22 tures the core essence of the concept as described throughout
Emotional was defined with its root word “emotion” as “a state of history.1,10,13,17,18,24-26,30,31,37,38,40
T A B L E 1 Current literature on emotional wellbeing in youth

Age range,
Author(s)/date Country Title y Methods Antecedents Attributes Consequences Funding
COURTWRIGHT

Amato and Keith26 US Parental divorce and the Preschool‐ Meta‐analysis of 92 Family connectedness Resilience Self‐ University of Nebraska—
wellbeing of children: a college quantitative studies Self‐esteem actualization Lincoln Research Council
ET AL.

meta‐analysis Absence of high‐risk


behaviors
Berntsson et al.27 Sweden Adolescents’ experiences 12‐19 Qualitative Social connectedness The Swedish Mayflower
of well‐being when living interpretive Hope Charitable Foundation for
with a long‐term illness phenomenology Children
or disability
Bethell et al.18 US Prioritizing possibilities 0‐17 Modified Delphi Family connectedness Self‐ Robert Wood Johnson
for child and family approach and Social connectedness actualization Foundation, Child and
health: an agenda to grounded theory SSNRs Adolescent Health
address adverse Measurement Initiative
childhood experiences Vision and Leadership
and foster the social and Fund; The California
emotional roots of Endowment, the Children’s
wellbeing in pediatrics. Hospital Association, Lucile
Packard Foundation for
Children’s Health, Autism
Speaks, Prevent Child
Abuse America, and the
Maternal and Child Health
Bureau
Bluth et al.28 US Adolescent sex 13‐19 RCT Social connectedness Resilience Francisco J. Varela Award by
differences in response overall positive the Mind and Life
to a mindfulness emotions Foundation; National
intervention: a call for Center on Complementary
research. and Alternative Medicine;
National Institute of Mental
Health
Coverdale and UK Emotional wellbeing and 18‐24 Exploratory Social connectedness Resilience + self‐ Self‐
Long29 mental health: an qualitative Family esteem + emotions actualization
exploration of health descriptive connectedness + body‐ Self‐efficacy
promotion in young phenomological image
people and families study
Dudovitz et al.30 US What do you want to be 15‐17 Secondary cross‐ Hope + self‐esteem Self‐efficacy NIH National Institute on
when you grow up? sectional data Minority Health and Health
career aspirations as a analysis Disparities; NIH National
marker for adolescent Center for Advancing
well‐being. Translational Sciences;
UCLA Children’s Discovery
|

and Innovation Institute


109

(Continues)

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110

TABLE 1 (Continued)
|

Age range,
Author(s)/date Country Title y Methods Antecedents Attributes Consequences Funding
31
Feller et al. US Emotional well‐being and 18‐24 Review + Self‐esteem Rapid Research Advances for
public health: proposal Progress in Disparities
for a model initiative. Mental Health Award from
the CA State Behavioral
Center of Excellence; UCLA
Clinical Translational
Science Institute
Giannakopoulos Greece Adolescents’ wellbeing 11‐18 Quantitative Social connectedness + Self‐ Self‐efficacy
et al.32 and functioning: exploratory Family connectedness esteem + emotions Self‐
relationships with descriptive and actualization
parents’ subjective multivariate
general physical and analysis
mental health.
Glozah33 UK Exploring Ghanaian Average Qualitative Social + Self‐esteem Self‐efficacy
adolescents’ meaning of age 16.8 Interpretive connectedness + body‐ Absence of high‐
health and wellbeing: a phenomenology image risk behaviors
psychosocial Family connectedness
perspective
Herrmann et al.34 Germany Factors associated with 3‐12 Quantitative Family connectedness
the emotional health of
children: high family
income as a protective
factor
Kirk35 UK How children and young 8‐19 Qualitative grounded Social Self‐ Department of Health/
people construct and theory connectedness + body‐ actualization Health Foundation Primary
negotiate living with image Care Post‐doctoral
medical technology. Fellowship
Lynch36 New A qualitative study of 16‐21 Qualitative Hope
Zealand youth living with Crohn interpretive
disease phenomenology
McCaffrey37 Australia Major stressors and their 5‐15 Qualitative Social + Self‐esteem
effects on the well‐being interpretive connectedness + body‐
of children with cancer. phenomenology image
Mutumba et al Uganda Psychosocial challenges 12‐19 Qualitative Social connectedness University of Michigan
(2015) and strategies for coping interpretive
with HIV among phenomenology
adolescents in Uganda: a
qualitative study.
(Continues)
COURTWRIGHT
ET AL.

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17446198, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nuf.12404 by Victoria University Of Welling, Wiley Online Library on [03/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
COURTWRIGHT ET AL. | 111

4.2 | Defining attributes

University of Malaysia Post‐


at the University of British
Early Learning Partnership
Hawn Foundation; Human

graduate Research Fund


Three defining attributes of emotional wellbeing in youth were
revealed in this concept analysis, and include overall positive
emotions, positive self‐esteem, and resilience.

Columbia
Funding

4.3 | Positive emotions


Consensus among philosophers, scientists, and theorists in both the
Consequences

Self‐efficacy adult literature and the pediatric and adolescent literature describe
positive emotions as a central attribute to emotional wellbeing.
Positive emotions refer to the expression of feelings of happiness,
optimism, and general satisfaction with oneʼs life, the majority of
the time as opposed to the expression of negative emotions the
majority of the time, such as worry, fear, anger, and overall
dissatisfaction.1,5,7,10,13,14,17,38,41
+ Emotions
Attributes

4.4 | Positive self‐esteem


connectedness + body‐

Positive self‐esteem is defined as satisfaction with oneself.22


Social connectedness

Research demonstrates positive self‐esteem is exhibited by youth


with emotional wellbeing; and is a recurring theme in the literature
Antecedents

describing this concept in this population. This finding was evident


across a wide range of participants, ages 5 to 24
image
Social
Hope

Hope

years.1,10,26,29-32,37,38,40 For example, youth ages 18 to 24 in a


descriptive phenomenological study described the centrality of
positive self‐esteem to emotional wellbeing with phrases such as
phenomenology

Abbreviations: RCT, randomized controlled trial; SSNR, safe and stable nurturing relationship.

“feeling good with yourself,” “being comfortable in your own skin,”


Quantitative

Quantitative

Quantitative
descriptive

descriptive

and “being happy with who you are.”29 Another study demonstrated
Methods

a direct relationship between positive self‐esteem and emotional


wellbeing in adolescents.30 Schonert‐Reichl38 found a stronger
association between positive self‐esteem and emotional wellbeing
Age range,

among preadolescents than early adolescents. The literature demon-


9.4‐13.4

13‐17

strates that feeling good about oneself is important for youth to be


8‐17

emotionally well.
y

and social and emotional

among adolescents with


childhood epilepsy care:
Exploring the needs and
adolescents’ well‐being
education program on

challenges of parents
and their children in

and without chronic


Emotional well‐being
a qualitative study.
mindfulness‐based

4.5 | Resilience
The effects of a

pre‐ and early

competence.

conditions.

A third attribute with a high degree of consensus in the literature is


resilience.10,18,25,26,38 Youth who exhibit resilience generally meet
Title

challenges, recover and exhibit positive emotions within a relatively


quicker timeframe than their counterparts who struggle with
Malaysia
Country
Canada

resiliency. This attribute is described in the National Survey of


Childrenʼs Health2 as the expression of calm and a sense of being in
US
(Continued)

control when faced with a challenge for children and adolescents


38

aged 6 to 17 years. Resilience research demonstrates that childrenʼs


Wolman et al.40
Schonert‐Reichl
Author(s)/date

brains have neuroplastic properties that allow recovery when certain


Wo et al.39

antecedents are present. Resiliency is the attribute of emotional


TABLE 1

wellbeing that many youths have been shown to exhibit in spite of


their suffering traumatic ACEs.18,28
17446198, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nuf.12404 by Victoria University Of Welling, Wiley Online Library on [03/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
112 | COURTWRIGHT ET AL.

T A B L E 2 Definitions of emotional wellbeing in the current scientific literature; all refer to the general population; none exist for youth
Definition Source
“There is no universally accepted “definition” of mental wellbeing. Promotion of Mental Well‐being, World Health Organization23
Mental wellbeing includes cognitive, emotional and behavioral
responses”
“Overall positive state of oneʼs emotions, life satisfaction, sense of Emotional Wellbeing High Priority Research Network, Sabri, and
meaning and purpose, and ability to pursue self‐defined goals.” Clark,1 (p. 1); and The National Center for Complementary and
Integrative Health24
“The ability to successfully handle lifeʼs stresses and adapt to change and National Institutes of Health Educational Wellness Toolkit,25 (p. 1)
difficult times.”
“There is no consensus around a single definition of wellbeing, but there Centers for Disease Control and Prevention10
is general agreement that at minimum, wellbeing includes the presence
of positive emotions and moods (eg, contentment, happiness), the
absence of negative emotions (eg, depression, anxiety), satisfaction
with life, fulfillment and positive functioning.”

4.6 | Antecedents antecedent to resilience in youth, and ultimately emotional well-


being.36,38,44,51 Young people without hope cannot be resilient and
According to Walker and Avant,19 antecedents are those features
need intervention if they are to feel emotionally well again.
that must be in place before the occurrence of a concept. In order for
Adolescents with high hope for their future, exhibited by having
youth to exhibit emotional wellbeing, a high degree of consensus in
high career aspirations that require continued education, reported
the literature indicates three antecedents that must be present: high
higher levels of self‐actualization and ultimately, emotional well-
levels of social and family connectedness (recently described in the
being.30,36 For youth with chronic illness, hope for treatment and
scientific literature as safe and stable nurturing relationships
hope for competent care‐providers has been shown to be necessary
(SSNRs); positive body‐image; and hope.10,18,25-27,30,34,37,38,40,42,43
before feelings of emotional wellbeing can be demonstrated.40
Regardless of how hope is exhibited, the phenomenon itself is widely
described as an antecedent to resilience and emotional wellbeing in
4.7 | Safe stable nurturing relationships
youth.
High degrees of family and social connectedness are antecedents well
described in the literature as protective factors that enable children
and adolescents to achieve emotional wellbeing despite the presence of 4.9 | Positive body image
high‐risk factors. For example, youth facing ACEs, such as living with Body‐image is the other important antecedent to emotional well-
chronic disease, may still achieve emotional wellbeing when family and being in youth,27,30,35-37,40 In a study of over 1600 students in grades
social connectedness is high,10,18,26,27,32,34,37,40,44 Only in recent years 6 through 12, the variables of body‐image and family connectedness
has family and social connectedness been referred to as SSNRs, and were statistically significant antecedents to emotional wellbeing.40
42
described by the Centers for Disease Control and Prevention as a Other studies explored the direct relationship between body‐image
foundational building block to emotional development and wellbeing in and emotional wellbeing and demonstrated body‐image as a
youth. Bethell et al18 (p. S37) describe “an array of foundational particularly significant antecedent to emotional wellbeing in youth
initiatives” in recent years that have explored the centrality of SSNRs living with and without chronic disease.30,37,52,53
45-48
to emotional wellbeing in youth, implying correlation. Although
causality has not yet been determined as of the writing of this analysis,
a plethora of relational evidence exists that has “unleashed an 4.10 | Consequences
18
unprecedented focus on (causality between) SSNRs and resilience” Consequences are described as outcomes of a concept occurring.19 A
49
(p. S37). Earvolino‐Ramirez underscore the positive relationship synthesis of the literature has resulted in the identification of the
between “social support,” as an antecedent, and resilience in children in following consequences of emotional wellbeing in youth: self‐
their conclusion, “In studies with children, the presence of at least one efficacy, self‐actualization, the absence of high‐risk behaviors, and
healthy attachment to a significant adult is omnipresent when the presence of health promotion behaviors.10,18,25,26,30,37,38
resilience is identified” (p. 77).

4.11 | Self‐efficacy
4.8 | Hope
The directional relationship between self‐esteem and self‐efficacy is
50
Several researchers, including Seligmanʼs seminal work on positive described in the literature. In two examples, researchers describe
psychology, established hope as an essential protective factor and self‐efficacy as encompassing high self‐esteem and positive beliefs
17446198, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/nuf.12404 by Victoria University Of Welling, Wiley Online Library on [03/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
COURTWRIGHT ET AL. | 113

about the ability to change a situation and succeed29,54 (p. 28). expresses genuine happiness when her friends come to visit (SSNRs:
Researchers measure self‐efficacy as a marker of emotional well- social connectedness, positive emotions). Even though she shares her
being in youth.30 A consequence of emotional regression is parental extreme disappointment in missing the dance she worked so hard for,
dependence, suggesting the opposite of emotional wellbeing.37 she expresses to you that she has learned from previous asthma
attacks that melting down emotionally worsens her symptoms, and
she is focused on remaining calm to not exacerbate her symptoms
4.12 | Self‐actualization
(resilience). She expresses gratitude (positive emotions) for not being
Self‐actualization is described in the literature as visualizing and admitted to the intensive care unit, as in her last hospitalization. She
striving to achieve oneʼs potential.2,26,30,33 In his seminal work, attributes her lesser severity of the illness to valuing her own health,
55
Erikson concluded that adolescents, developmentally, are chal- believing that her actions can impact her asthma outcomes,
lenged with establishing an identity independent from parents and monitoring her symptoms, and taking her medications regularly
caregivers, and school‐aged children are challenged to establish a now (positive self‐esteem, self‐efficacy, presence of health promotion
sense of competence in what is commonly known as industry versus behaviors, and self‐actualization). Although Jasmine has arguments
inferiority. Teens who experience emotional wellbeing have been with her girlfriends at times and wishes she was 10 pounds lighter,
demonstrated to have hopes and dreams for career aspirations, and she indicates she is overall happy with her body and these concerns
demonstrate the beginnings of self‐actualization.30,33 Children in the do not keep her from sleeping or engaging in behaviors that are
National Survey of Childrenʼs Health described as flourishing harmful, such as purging (positive body‐image, absence of high‐risk
demonstrated the ability to make a plan and follow through with it, behaviors). She denies any drug use, unprotected sex, or suicidal
thereby exhibiting self‐actualization and emotional wellbeing.2 These ideation (absence of high‐risk behaviors). She offers that she
consequences have important implications for population health as considers her aunts, uncles, teachers, and coach to be close safe
this population grows into adults. and stable adults with who she can talk with about her concerns
(SSNRs: family connectedness). Jasmine is an honors student and
hopes to achieve a scholarship to college so she can move her mom
4.13 | Presence of health promotion behaviors and
and siblings to a safer home than one she grew up in (hope, self‐
absence of high‐risk behaviors
actualization).
Youth not having achieved self‐efficacy and emotional wellbeing have Jasmine meets the criteria for being a child at risk; however, she
been described as having higher levels of risky behaviors such as also describes many protective factors that serve as antecedents for
alcohol and substance use and risky sexual activity.30 Children with emotional wellbeings, such as family and social connectedness, hope,
chronic illness not having achieved self‐efficacy and emotional and positive body image. You assess that she exhibits the attributes
wellbeing may regress behaviorally, such as not being able to be of emotional wellbeings, such as resilience, positive self‐esteem, and
37
alone or sleep alone, thumb sucking and needing a security blanket. overall positive emotions; and the consequences of her emotional
Youth with high levels of self‐esteem, resilience, self‐efficacy, and wellbeing, such as self‐efficacy, self‐actualization, absence of high‐
emotional wellbeing demonstrate a determination to overcome risk behaviors, and presence of health promotion. This model case
challenges in the face of adversity and attain personal demonstrates an adolescent at risk who is exhibiting emotional
goals.29,30,33,37,39,40 wellbeing as a result of protective factors serving as antecedents, and
who is also reaping the benefits or consequences of emotional well‐
being.
4.14 | Diagram
A diagram of the antecedents, attributes, and consequences of the
4.16 | Contrary case
concept of emotional wellbeing in youth is provided in Figure 2.
The following scenario provides a contrary case of youth exhibiting
emotional wellbeing. Jasmine is a 16‐year‐old female with chronic
4.15 | Model case
persistent asthma (ACE) admitted to your unit and upon history, you
Jasmine is a 16‐year‐old adolescent who has witnessed interpersonal identify that she has witnessed interpersonal violence for many years
violence (ACE) at home for many years. She lost her brother to gang and her father is not in her life due to a restraining order (ACE). She
violence and her father is restrained from her home due to domestic has lost her brother to gang violence (ACE). Jasmineʼs family history
violence. She lives in a low socioeconomic neighborhood in a single‐ reveals that she moved to this city recently and has no family in the
family home with many cousins, aunts, and uncles close by, who she area (potential for lack of SSNR: family connectedness). She is having
describes as a very close‐knit family (SSNR: family connectedness). difficulty making friends in her school (potential for lack of SSNR:
Jasmine has chronic persistent asthma (ACE) and has been social connectedness). She admits that she feels overweight (altered
hospitalized several times. She is currently your patient on the body‐image) and does not feel worthy to join the popular girls on the
inpatient unit. During your history and physical, she expresses dance troop (altered self‐esteem). She expresses missing her old
sadness that she is missing her most recent dance recital but school terribly and tells you she feels hopeless in ever finding friends
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114 | COURTWRIGHT ET AL.

F I G U R E 2 Conceptual model of
emotional wellbeing in youth

or happiness in this new city (absence of hope). She admits to feeling The KIDSCREEN 52, a health‐related quality of life questionnaire
depressed and having suicidal ideation. She wants to go back home for children and adolescents, measured the most elements with ten
and admits to not taking her asthma medications because she does dimensions as follows: physical wellbeing, psychological wellbeing,
not feel life is worth living. moods and emotions, self‐perception and autonomy, parent relation
This contrary case demonstrates an adolescent at high‐risk, and home life, financial resources, peer and social support, school
having experienced two ACEs without protective factors as environment, and bullying.56 Developed and tested in 13 European
antecedents to emotional wellbeings, such as a strong sense of countries, it was found to have acceptable levels of reliability and
family and social connectedness, a positive self‐image and hope for validity. Internal consistency of the dimensions screened was tested
her future. As such, Jasmine is not exhibiting the attributes of using Cronbachʼs α where coefficients above 0.7 were considered
emotional wellbeing, such as resilience, positive self‐esteem, or acceptable, and results ranged from 0.77 to 0.89. Because the toolʼs
positive emotions nor she is enjoying the consequences of emotional limitation is the population on which it was developed, convergent
wellbeings, such as self‐actualization, self‐efficacy, the absence of validity was determined using Pearson correlation coefficients to
high‐risk behaviors, and the presence of health‐promoting behaviors. compare the tool to other common assessments used to measure the
pediatric quality of life. Correlation coefficients were moderate
ranging between 0.3 and 0.5 when comparing the KIDSCREEN 52
4.17 | Empirical referents and the Pediatric Quality of Life Inventory, the Child Health and
Empirical referents can help facilitate the identification of a concept Illness Profile‐Adolescent Edition, and Youth Quality of Life Instru-
occurring, by measuring associated phenomena. 19
Across studies, ment Scales with statistical significance at P < .01.56 The latter scales
mostly qualitative methods informed the conceptualization of mentioned assess similar constructs; however, do not assess for
emotional wellbeing in youth. Less than half used quantitative positive emotions which is an attribute of emotional wellbeing.
methods, and of those, researchers used a wide variety of Although not aimed specifically to screen for emotional wellbeing,
instruments, such as the New General Self‐Efficacy Scale, the the KIDSCREEN‐52 assesses all the antecedents necessary for
Strengths and Difficulties Questionnaire, the Positive and Negative emotional wellbeing. Further study with this tool is indicated to
Affect Scale, the Minnesota Adolescent Health Survey, and the determine reliability and validity as related to emotional wellbeing.
KIDSCREEN 52 Instrument. 30,32,34,38,40
Not one instrument in the The authors of the study indicate that additional research is needed
sample comprehensively measures all the attributes of emotional to assess longitudinal validity.56
wellbeing in youth as defined by this analysis, highlighting the need Importantly, researchers recently proposed an item bank for
for conceptual standardization and further instrument development inclusion in the NIH patient‐reported outcomes measurement
for this important concept. information system (PROMIS) to measure childrenʼs eudaimonic
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COURTWRIGHT ET AL. | 115

wellbeing as part of a trio measuring pediatric subjective wellbeing esteem, as well as the strong correlation between SSNRs and
57
(SWB) (p. 212). While determining items for inclusion, the authors resilience—a critical element to emotional wellbeing in
acknowledge adapting concepts from the adult literature “starting youth.18,26-29,32,33,35,37,39,40
with a systematic review of candidate item concepts and extant Importantly, the results of this synthesis of the scientific
instruments for measuring SWB,”57 (p. 216). Ultimately, the concepts literature and concept analysis, particularly the small resultant
chosen for the pediatric SWB item banks are exactly the same used sample size and dates of publication, reflect the call for more
to measure adult psychological wellbeing, ie, (a) life satisfaction, (b) research on this emerging topic for youth across the globe. An
positive affect and (c) meaning/purpose.58 The authors acknowledge: operational definition is proposed and future theoretical and
empirical research may be better informed. Notably, this definition
“There has been very little attention given to the distinguishes the concept of EW in youth from the many definitions
developmental origins of SWB, whether these concepts that currently exist for the general population as a whole.
are relevant to children’s life experiences, health and The Academic Pediatric Association and many pediatric providers
coping with the disease and how to best measure SWB in are calling for a paradigm shift from a medical model of healthcare
pediatric populations”57 (p. 208). delivery to one embracing emotional wellbeing for youth.31 The
results of this study reflect the critical nature of the need to further
The 10 international content experts consulted in the study develop this area of science.

“lacked consensus on whether preadolescent children


would have the cognitive capabilities to provide evaluative 6 | I M P L IC A T I O N S F O R NU R SI N G
judgments of life satisfaction or meaning and purpose … PRACTIC E AN D R ESEARCH
[and] despite this uncertainty, it was suggested we explore
the inclusion. … These item banks could be statically Nurses, from a disciplinary perspective, are concerned with the
linked with adult measures of the same concepts forming a interaction of person, environment, disease/condition, and relation-
life course measurement system for SWB”57 (p. 212). ship with the nurse; and as such, are well‐positioned to lead
interdisciplinary research, generate new knowledge, and translate
The authors acknowledge that additional “theoretical studies are findings into clinical practice to improve emotional wellbeing.11 Now
needed to enrich our knowledge of the development of SWB that a definition of emotional wellbeing in youth is proposed based
concepts”57 (p. 216). This concept analysis, grounded in scientific on a scientific synthesis of the evidence, nurse scientists can
methods, serves to inform the development of a sound theoretical generate a middle‐range theory on emotional wellbeing in youth,
framework to guide the innovation and testing of developmentally investigate the interrelationships between concepts, and innovate
appropriate instruments to measure emotional wellbeing in youth. novel interventions aimed at improving the antecedents of emotional
wellbeing.
Implications for practice and policy development emerge from
5 | D IS C U S S IO N this analysis. For example, scientists should consider further
development of instruments to include additional concepts; and
Of critical importance is to clarify concepts of EW that are important practitioners should consider conducting routine screening for the
to youth so that interventional research can be adequately informed presence of SSNRs, hope, and body‐image in the youth under their
in this population.10 The pediatric and adolescent literature reflects care. The KIDSCREEN 52 is an HrQOL instrument that encompasses
consensus on the constituent elements of EW in youth. Notably, they all the antecedents of emotional wellbeing in youth; yet, the
differ slightly from those proposed by some current measurement development of a tool that specifically assesses these constituent
tools for pediatric emotional wellbeing.56,57 For example, some of the elements of emotional wellbeing in youth may be more impactful.
concepts, such as positive emotions and hope are congruent; yet, Interventions for at‐risk youth need to be investigated to develop the
many are unique to the developmental stages of adolescence such as antecedents at the community level in schools and homes. Nurses are
body image, social connectedness, safe stable nurturing relationships, well‐poised to conduct this research.
and self‐esteem. Concepts, such as family and social connectedness,
safe, stable and nurturing relationships, hope, and positive body‐
image are well described in the literature as the antecedents 7 | L IM I T AT IO N S
necessary for emotional wellbeing in youth. The attributes of
resilience, positive self‐esteem, and positive emotions are also well Limitations of this concept analysis are important to mention. One
described, as are the associated consequences of self‐actualization, limitation is the notion that the Walker and Avant19 method is
self‐efficacy, the absence of high‐risk behaviors, and the presence of rudimentary and does not allow the author to ground the concept
10,27,35,36,39
health promotion behaviors. The literature also reflects in theory. Walker and Avant19 confute this claim as long as the
the clear and direct relationship between body image and self‐ analysis reveals clear implications for future research and
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116 | COURTWRIGHT ET AL.

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