burn injury is a major global problem with special importance in the east mediterranean region , including iran . in iran ,
burn injuries have high incidence and mortality rate , in that at least eight people die from burn every day .
it is ranked as the third cause of mortality after traffic accidents and trauma . despite the survival of many of such patients , due to
the recent advances in medical treatment , psychological problems and deformities are still among the main consequences of burn injuries . in that ,
devastating and traumatic effects of burn injuries on all physical , emotional , psychological , social , and economic dimensions have challenged the iranian health care system in treating , rehabilitating , and providing palliative care to such patients .
heavy burdens of burn injuries such as loss of function , altered appearance , and psychological distress are a threat to the patient 's successful return to the life he / she had before burn and to society .
patients may experience severe feelings of anger , guilt , and disappointment affecting their mental health and readiness for involvement in their treatment programs .
in addition , the pain caused by a devastating experience , functional and aesthetic impairment , and altered body image and social roles negatively impact the patient 's essence , particularly his / her self - concept .
hopelessness , loss of meaning , and existential distress among such survivors can be differentiated from depression and is recognizable in palliative care settings .
it is associated with chronic medical illness , disability , body disfigurement , fear of loss of dignity , social isolation , and a subjective sense of incompetence  feeling of greater dependency on others or the perception of being a burden . because of the sense of impotence or helplessness , some of the survivors can predictably progress to a desire to die or to commit suicide .
these patients need complex mental efforts to redefine their identity in struggling against difficult condition after burn injury .
consequently , investigating how to deal with changes in self - concept in burn patients , who are experiencing complex treatment interventions , has been considered to be very important . in a limited number of relevant studies ,
there are reports of different positive / negative experiences of identity , roles , lifestyle , relationships , and physical function as the factors affecting self - concept in burn patients . in this respect ,
a number of psychological theories have shown that patients with deformities have lower self - esteem level ; however , other experimental research has not supported this claim .
some researchers have suggested that the observed changes in self - concept , measured by the questionnaire , lack adequate reliability . on the other hand , despite a number of cross - sectional and qualitative studies on the potential impact of changes in the appearance and functions on self - esteem , a few of them have addressed compatibility with these disorders .
therefore , researchers have suggested more in - depth investigations on the achievement and preservation of self - concept in this group of people . in this
regard , conducting qualitative studies seems to be useful , due to their ability in describing slow recovery experience and giving more in - depth understanding of how to achieve a new self - concept , which makes post - burn life bearable . with respect to the effect of social , cultural , and religious dimensions of this experience , the limited number of qualitative studies , and also different cultural and religious contexts in iran , investigating burn patients experiences of how the new self - concept is formed in life after burn injury seems to be essential . since focusing attention on self - concept in palliative care
is vital , this study was conducted to investigate the burn patients experiences of preserving self - concept in life after burn injury in iran . due to lack of a comprehensive plan for palliative care for burn survivors in our country
, this study can be used as a conceptual framework for palliative care program in iran .
the present work is a qualitative study , which seeks to determine , using qualitative content analysis , the true meaning and message of the deep interview conducted with the patients having survived burns .
a purposeful sampling was used to achieve the purpose of the research . to ensure primary access to the participants ,
the burn patients above 20 , from whose burn tragedy a minimum of six months had elapsed and who had been discharged from burn wards of sina hospital , tabriz , iran were included in the present study conducted in 2010 - 2013 . in a qualitative research , sampling is often started purposefully aiming to select people who have experienced the phenomenon in question , and are able to offer their experiences ; i.e. those rich in information to participate actively and help the researcher to understand their lives and their social interactions in a better way .
this process continues by theoretical sampling , in which the selection of each new participant depends on previous samples or participants and the data obtained from them .
selection of the next subjects depends on who were selectedfirst and what information has been obtained from them . in the course of the study , purposive sampling
is gradually replaced with theoretical sampling . at the start of the sampling , the researcher was looking for people who , as the key knower , were rich sources of information about burn experience ; thus , could help to have a better understanding about the phenomenon of preserving self - concept .
sampling was performed atfirst through an objective - based method and after formation of initial concepts and their characteristics and spectrum , the next objectives were selected via theoretical sampling to further complete the concepts and the obtained classes , and further discover the relation between classes .
individuals selected for the study included people who had been contacted over the phone , and having expressed their willingness to participate in the study ; they were assured their information would be kept confidential .
subsequently , considering the factors affecting the burn patients experience , 17 people were selected for the study trying to ensure maximum variety of the subjects in terms of gender , age , profession , education , the burn type , percent and severity , and of course their willingness to participate in the study .
sample size was determined by data saturation when the researchers found that no new information is emerging .
general characteristics of the participants ( p 17 ) the main method used for data collection was in - depth unstructured interviewing with open - ended questions .
this type of interview is appropriate for qualitative research because of its flexibility and depth .
interview with open - ended questions allowed the participants to fully explain their experiences about the phenomenon under study .
all interviews were conducted by the third researcher and started off with a general question : 
the following questions were asked based on the information provided by the participant and were focused on clarifying the main question that was the process of preserving self - concept .
the length of personal interviews varied between 45 and 120 minutes and was 82.5 minutes , on average .
all interviews were recorded , and were immediately analyzed word - by - word using maxqd10 software . given that in a qualitative research the researcher has to be immersed in the information , he listened to the interviews and reviewed the typed texts several times .
in the first step , all the interviews were recorded and then immediately transcribed verbatim and used as the main data of research . in the second step , after listening carefully to the tape - recorded interviews several times and reading the transcribed material , the text was divided into meaningful units . in the third step , the meaningful units were abstracted and labeled with codes . according to the experiences of the participants , the visible and hidden meanings were identified as sentences or paragraphs , and then they were summarized and labeled with codes . in the fourth step , based on the similarities , differences and proportions , the codes implying the same theme were classified in the same category .
eventually , the main theme , which is considered aspects of experience structure was written down . using the group members comments and suggestions ,
the vague and obscure points requiring more attention were discovered and revised in the next interview .
concepts were specified based on the inner content of the text , which was reviewed and revised according to all data . during the study
long - term relationship with burn survivors increases trust and makes them more willing to share the truth , which in turn increases generation of real and authentic data .
member checking or respondent validation was used to verify data accuracy and to ensure data validity . sharing with participants some parts of the interview and his interpretations of their words ,
the researcher discussed his own interpretation and the meaning of participants words with them to achieve identical ideas and concepts .
member checking , reading the transcribed interviews , revision of initial codes , categories and concepts as well as receiving the participants feedback were all the techniques used for data validation .
data credibility was confirmed by peer review and the interview transcripts , codes , and categories were extracted .
additionally , the results were examined by three faculty members and there was compatibility between the extracted data .
the researcher shared the findings with some burn survivors who were not participating in the study and data compatibility was confirmed by them as well .
interviewing with different participants , using direct quoting , and providing examples and rich data representation made the data transferability and fittingness possible .
data dependability was provided by immediate transcription of interview and re - examination of all data using the external checking .
the accuracy of the data collection and analysis process according to the methodology principles was approved by professors and advisors , while it was reviewed as well in the meetings held every nine months , with experts and skilled people within the field of qualitative research ; the ambiguities or drawbacks were discussed and analyzed , and consensus was finally achieved .
this study is a part of a phd dissertation in nursing from tabriz university of medical sciences , which was approved by the ethics committee of that university .
a letter providing information about the study and the rights of participants was distributed to the participants .
participants were told that they were free to accept or reject to participation in the research .
the present work is a qualitative study , which seeks to determine , using qualitative content analysis , the true meaning and message of the deep interview conducted with the patients having survived burns .
a purposeful sampling was used to achieve the purpose of the research . to ensure primary access to the participants , the burn patients above 20 , from whose burn tragedy a minimum of six months had elapsed and who had been discharged from burn wards of sina hospital , tabriz , iran
were included in the present study conducted in 2010 - 2013 . in a qualitative research , sampling
is often started purposefully aiming to select people who have experienced the phenomenon in question , and are able to offer their experiences ; i.e. those rich in information to participate actively and help the researcher to understand their lives and their social interactions in a better way .
this process continues by theoretical sampling , in which the selection of each new participant depends on previous samples or participants and the data obtained from them .
selection of the next subjects depends on who were selectedfirst and what information has been obtained from them . in the course of the study , purposive sampling
is gradually replaced with theoretical sampling . at the start of the sampling , the researcher was looking for people who , as the key knower , were rich sources of information about burn experience ; thus , could help to have a better understanding about the phenomenon of preserving self - concept .
sampling was performed atfirst through an objective - based method and after formation of initial concepts and their characteristics and spectrum , the next objectives were selected via theoretical sampling to further complete the concepts and the obtained classes , and further discover the relation between classes .
individuals selected for the study included people who had been contacted over the phone , and having expressed their willingness to participate in the study ; they were assured their information would be kept confidential .
subsequently , considering the factors affecting the burn patients experience , 17 people were selected for the study trying to ensure maximum variety of the subjects in terms of gender , age , profession , education , the burn type , percent and severity , and of course their willingness to participate in the study .
sample size was determined by data saturation when the researchers found that no new information is emerging .
the main method used for data collection was in - depth unstructured interviewing with open - ended questions .
this type of interview is appropriate for qualitative research because of its flexibility and depth .
interview with open - ended questions allowed the participants to fully explain their experiences about the phenomenon under study .
all interviews were conducted by the third researcher and started off with a general question : 
the following questions were asked based on the information provided by the participant and were focused on clarifying the main question that was the process of preserving self - concept .
the length of personal interviews varied between 45 and 120 minutes and was 82.5 minutes , on average .
all interviews were recorded , and were immediately analyzed word - by - word using maxqd10 software . given that in a qualitative research the researcher has to be immersed in the information , he listened to the interviews and reviewed the typed texts several times .
in the first step , all the interviews were recorded and then immediately transcribed verbatim and used as the main data of research . in the second step , after listening carefully to the tape - recorded interviews several times and reading the transcribed material , the text was divided into meaningful units . in the third step , the meaningful units were abstracted and labeled with codes . according to the experiences of the participants , the visible and hidden meanings were identified as sentences or paragraphs , and then they were summarized and labeled with codes . in the fourth step , based on the similarities , differences and proportions , the codes implying the same theme were classified in the same category . then , the categories and sub - categories were formed .
eventually , the main theme , which is considered aspects of experience structure was written down . using the group members comments and suggestions ,
the vague and obscure points requiring more attention were discovered and revised in the next interview .
concepts were specified based on the inner content of the text , which was reviewed and revised according to all data . during the study ,
some methods were used to ensure data accuracy and stability . long - term relationship with burn survivors increases trust and makes them more willing to share the truth , which in turn increases generation of real and authentic data .
member checking or respondent validation was used to verify data accuracy and to ensure data validity . sharing with participants some parts of the interview and his interpretations of their words
, the researcher discussed his own interpretation and the meaning of participants words with them to achieve identical ideas and concepts .
member checking , reading the transcribed interviews , revision of initial codes , categories and concepts as well as receiving the participants feedback were all the techniques used for data validation .
data credibility was confirmed by peer review and the interview transcripts , codes , and categories were extracted .
additionally , the results were examined by three faculty members and there was compatibility between the extracted data .
the researcher shared the findings with some burn survivors who were not participating in the study and data compatibility was confirmed by them as well . interviewing with different participants , using direct quoting , and providing examples and rich data representation made the data transferability and fittingness possible .
data dependability was provided by immediate transcription of interview and re - examination of all data using the external checking .
the accuracy of the data collection and analysis process according to the methodology principles was approved by professors and advisors , while it was reviewed as well in the meetings held every nine months , with experts and skilled people within the field of qualitative research ; the ambiguities or drawbacks were discussed and analyzed , and consensus was finally achieved .
this study is a part of a phd dissertation in nursing from tabriz university of medical sciences , which was approved by the ethics committee of that university .
a letter providing information about the study and the rights of participants was distributed to the participants .
participants were told that they were free to accept or reject to participation in the research .
the text obtained from interviewing 17 participants with burn experience was considered as the analysis unit [ table 1 ] .
the concept of  self - locating  as the essence of participants experience in transition from different stages ( i.e. occurrence of accident , transferring to hospital and hospitalization , discharging from hospital and returning to home , and finally to society ) was extracted from following four categories : ( a ) self - exploration ( exploring the changes in one 's life ) , ( b ) others exploration ( exploring the changes in the life of family members and the relationship between self and others ) , ( c ) position evaluation ( self - position analysis ) , and ( d ) self - concept preservation .
findings showed that participants were involved with mental processes in transition from the accident phase to returning to society , and in an effort to preserve self - concept against the threat in different physical , emotional - psychological , spiritual , behavioral , and value dimensions .
this mental process included self - exploration , others exploration , and position evaluation , which helped the understanding of the current position and choosing facilitating activities for that transition .
at the first stages after an accident where burn injury posed only physical threat , self - exploration mainly included focusing on severe and unbearable feeling of pain , dealing with wounds , and wandering in oppressive atmosphere of the burn ward . a participant described the experience of pain as follows :  when they took us for dressing , when they poured water on the wounds , it was like knocking nails into the body , one by one .
the wounds were terrible and the ward had a very bad atmosphere ( p. 6 ) .
 self - exploration continued after discharge , returning to home , and gradual reduction of physical pain by exploring bodily changes . according to a participant , 
i could see unhealed skin grafts , wounds on my face , i needed my family 's help in doing even a small thing ( p. 1 ) . 
the inevitable continuation of life and the need for interacting with others were the common experience of the majority of participants from the third stage , i.e. return to society . at this stage ,
over this course , the goal of self - exploration was to investigate the results from such efforts as covering of scars and cosmetic surgeries to correct deformities and physical limitation .
a young female participant said :  it made me sad when i saw people looking at me strangely in the street .
i underwent a number of surgeries but my hands were not still in good shape and i had a burn scar on my face .
because of that , i always had gloves and tried to blur the burn site by wearing make - up ( p. 7 ) .  for the participants , the fourth stage was like a period that they had time to think about all dimensions and events . for some participants ,
burn memories continued to affect how they control and value their lives , even after 10 or 20 years . at this stage ,
helpful and hindering thoughts ran through the participants mind on a set of frightening and traumatic memories of the previous stages .
that is why self - exploration took place through self - struggling , engaging in inner dialog , fantasizing , and dreaming . according to a participant , 
i always feel pain and agony , they never leave my heart , when i think by myself .
i was dreaming the past , [ when ] i was not burnt and went out with my friend .
focusing on the burn consequences in family , exploring changes in interactions , and paying attention to social issues by the participants are among the characteristics of this category . in the initial stages , with participants wandering in the gloomy atmosphere of the burn ward and observation of other patients and families in agony , the others exploration mechanism gets activated in parallel with self - exploration .
another participant talked about her experience :  there were two rooms at the end of the corridor in the hospital for seriously injured patients .
from there , dead bodies were taken out one after another ( p. 3 ) .
 the same participant added about the effect of burn on his / her family :  you can imagine what happened to my mother when she heard about it .
her eyes filled with tears ) ( p. 1 ) .  after being placed in a new position at home , exploration of the others continued by investigating the effect of burn on personal life and relationships .
a number of participants called the cost of treatment - induced economic burden on the family and/or the time spent for caring them as  imposing strict conditions on family life . 
 since i was burnt , my sister devoted her life to look after me .
i know how much he suffers from the heavy burden of all these costs and agonies ( p. 11 ) .
 by joining them , participants began to investigate the changes in the way others interact with them , through the same mechanism .
a young man said :  some of my friends were ashamed of walking with me on the street . because everybody looked at me with curiosity or pity ( p. 8) .
 another participant said ,  when you go to a public place , it seems that something is going on , all look carefully .
findings from the participants experiences showed that they arrive at a new position based on : ( a ) analyzing and comparing their conditions after burn with before that , and ( b ) evaluating and judging their individual and social positions , and their distance away from their dreams , goals , and desires in life .
for some participants , this new position was interpreted as an unusual and unnatural position . in this regard
, the participants expressed such experiences as  changing to someone else , duality .  for example : 
after a while when i recognized that i was not the same person , that i had changed , i felt very desperate .
at home i was a person , outside someone else ( p. 6 ) .  while some participants imagined themselves in a position caused by 
bodily and capability changes ,  where they could be the same person again with the same spirits , beauty , and close family ties by healing of their wounds ; they , considered burn as something that had only affected their appearance and capabilities :  eventually , one comes to terms with it , but you are no longer the same person , i used to work hard !
i am the same person with the same characteristics though , i only have problem with my leg ( p. 4 ) . 
burn patients employed such strategies as putting efforts and struggling , substituting the roles , dealing with deformities , paying attention to health , coping with pain , getting themselves busy , escape , violence , getting along , secrecy , and absorbing energy resource in transition from the accident to society .
the result of their efforts was self - concept preservation , ranging from maintaining the previous body image , being aware of the new body image , accepting the new body image , and rewriting the self - concept . during the first stage , which was mainly filled with the feeling of pain and agony
, participants sought to preserve their previous image by denying the severity of injuries and hiding their pain and agony from their families , as well as misrepresenting the conditions .
these efforts contributed to intensified pain caused by strict treatments and cares , as well as the agony of being dependent on others .
in addition , participants felt that they could prevent imposing more pain and agony to their families by means of such behaviors .
after that immense pain , when my parents came , i sat comfortably and upright to prevent them from becoming sadder ( p. 1 )  by arriving at home , participants mainly tried to preserve themselves from the understood changes , to improve their awareness , and to obtain new information .
for example , a participant said :  when i was discharged from the hospital , i still had problem in my leg , but no one instructed me .
when i found my leg severely infected , i visited the specialized hospital on my own ( p. 4 )  .
the other part of this awareness was acquired through interactions , examining others reactions to the wounds , and seeking information from them .
a participant said :  when the family came and saw my conditions , they said these wounds would gradually crumple , you should do something .
then , they suggested that i visit a good doctor in tehran1 ( p. 7 )  . at this stage , the participants attention
was focused on health and efforts to obtain information about and awareness of their new body image . with participants entering into society and due to the consequent need for more interaction with others
, they have to accept their new body image to preserve themselves in these interactions .
indeed , getting used to the new conditions and shifting from disturbing experiences to new ones such as the feeling of gratitude , calmness , feeling of pleasure , and raising spirit on the one hand , and performing such activities as self - care , role substitution , engaging in something , and improving personal relationships on the other hand , contributed to this acceptance . accepting the new body image paves the way for normalizing the new life by acquiring new skills and behaving and interacting with others more easily . in this way and by getting involved with the normal flow of life , the participants not only followed their normal roles , but also to some of them the injury was like an opportunity for spiritual growth .
the participants said :  after the burn accident , my attitudes towards plenty of things changed , i grew up , now i know what to do when someone gets sick .
how a burn patient suffers , how to behave toward him / her ( p. 7 ) . 
 i was jealous and thankless , but now i prostrate a thousand times a day ( p. 9 ) .
 although self - preservation moved toward the acceptance of the new body image with acquiring awareness of it , this study could not distinguish a clear time border between the two stages .
findings showed that living with burn injuries was a live experience of an internal journey for the participants ; a mental journey from awareness to acceptance , where one moves from home to society , and life activities move from falling into the habit to getting normal .
however , they were not sure about the duration of this experienced journey , most of them mentioned a period between four and eight years , during which they got used to living with burn injuries . regardless of returning to a normal life , memories of the burn accident still remained in the mind of participants who had passed a long time since the accident .
preserving self at this stage , which was occurring in parallel to other life stages , was in a mental context of the past memories , successes and current losses , and dream of future achievements .
 when i look at my pictures , i do nt want to see that my condition has changed , my story has completely altered .
now , i am obsessive , depressed , i can not stand anything , i am so exhausted ( p. 6 ) . 
the participants activities for preserving self - concept at this stage were in the form of a reciprocal effort to obtain or maintain independence , change life priorities , focus on life 's achievements and successes , and/or display such behaviors as threatening others , escaping , and getting along passively .
finally , depending on the factors , affecting individual and social life , the action / interaction process makes them rewrite themselves appropriately or inappropriately . according to a participant :  you can never forget those memories , but when time passes and you see yourself ahead of others in several things , these are actually helpful .
it is no longer important , looks no longer matter , you have other priorities , you just do your own business , i think financial independence is the most important factor , meaning you are not dependent on others , and then entertainment and other enjoyments ( p. 1 ) . 
findings showed that participants were involved with mental processes in transition from the accident phase to returning to society , and in an effort to preserve self - concept against the threat in different physical , emotional - psychological , spiritual , behavioral , and value dimensions .
this mental process included self - exploration , others exploration , and position evaluation , which helped the understanding of the current position and choosing facilitating activities for that transition .
at the first stages after an accident where burn injury posed only physical threat , self - exploration mainly included focusing on severe and unbearable feeling of pain , dealing with wounds , and wandering in oppressive atmosphere of the burn ward .
a participant described the experience of pain as follows :  when they took us for dressing , when they poured water on the wounds , it was like knocking nails into the body , one by one .
the wounds were terrible and the ward had a very bad atmosphere ( p. 6 ) .
 self - exploration continued after discharge , returning to home , and gradual reduction of physical pain by exploring bodily changes . according to a participant , 
i could see unhealed skin grafts , wounds on my face , i needed my family 's help in doing even a small thing ( p. 1 ) .
 the inevitable continuation of life and the need for interacting with others were the common experience of the majority of participants from the third stage , i.e. return to society . at this stage ,
over this course , the goal of self - exploration was to investigate the results from such efforts as covering of scars and cosmetic surgeries to correct deformities and physical limitation .
a young female participant said :  it made me sad when i saw people looking at me strangely in the street .
i underwent a number of surgeries but my hands were not still in good shape and i had a burn scar on my face . because of that , i always had gloves and tried to blur the burn site by wearing make - up ( p. 7 ) .  for the participants , the fourth stage was like a period that they had time to think about all dimensions and events . for some participants ,
burn memories continued to affect how they control and value their lives , even after 10 or 20 years . at this stage ,
helpful and hindering thoughts ran through the participants mind on a set of frightening and traumatic memories of the previous stages .
that is why self - exploration took place through self - struggling , engaging in inner dialog , fantasizing , and dreaming .
i always feel pain and agony , they never leave my heart , when i think by myself .
i was dreaming the past , [ when ] i was not burnt and went out with my friend .
focusing on the burn consequences in family , exploring changes in interactions , and paying attention to social issues by the participants are among the characteristics of this category . in the initial stages , with participants wandering in the gloomy atmosphere of the burn ward and observation of other patients and families in agony , the others exploration mechanism gets activated in parallel with self - exploration .
another participant talked about her experience :  there were two rooms at the end of the corridor in the hospital for seriously injured patients .
from there , dead bodies were taken out one after another ( p. 3 ) .
 the same participant added about the effect of burn on his / her family :  you can imagine what happened to my mother when she heard about it .
 after being placed in a new position at home , exploration of the others continued by investigating the effect of burn on personal life and relationships .
a number of participants called the cost of treatment - induced economic burden on the family and/or the time spent for caring them as  imposing strict conditions on family life . 
 since i was burnt , my sister devoted her life to look after me .
i know how much he suffers from the heavy burden of all these costs and agonies ( p. 11 ) .
 by joining them , participants began to investigate the changes in the way others interact with them , through the same mechanism .
a young man said :  some of my friends were ashamed of walking with me on the street . because everybody looked at me with curiosity or pity ( p. 8) .
 another participant said ,  when you go to a public place , it seems that something is going on , all look carefully .
findings from the participants experiences showed that they arrive at a new position based on : ( a ) analyzing and comparing their conditions after burn with before that , and ( b ) evaluating and judging their individual and social positions , and their distance away from their dreams , goals , and desires in life .
for some participants , this new position was interpreted as an unusual and unnatural position . in this regard , the participants expressed such experiences as  changing to someone else , duality .  for example :  after a while when i recognized that i was not the same person , that i had changed , i felt very desperate . at home
i was a person , outside someone else ( p. 6 ) .  while some participants imagined themselves in a position caused by 
bodily and capability changes ,  where they could be the same person again with the same spirits , beauty , and close family ties by healing of their wounds ; they , considered burn as something that had only affected their appearance and capabilities :  eventually , one comes to terms with it , but you are no longer the same person , i used to work hard !
i am the same person with the same characteristics though , i only have problem with my leg ( p. 4 ) . 
at the first stages after an accident where burn injury posed only physical threat , self - exploration mainly included focusing on severe and unbearable feeling of pain , dealing with wounds , and wandering in oppressive atmosphere of the burn ward .
a participant described the experience of pain as follows :  when they took us for dressing , when they poured water on the wounds , it was like knocking nails into the body , one by one .
the wounds were terrible and the ward had a very bad atmosphere ( p. 6 ) .
 self - exploration continued after discharge , returning to home , and gradual reduction of physical pain by exploring bodily changes . according to a participant , 
i could see unhealed skin grafts , wounds on my face , i needed my family 's help in doing even a small thing ( p. 1 ) .
 the inevitable continuation of life and the need for interacting with others were the common experience of the majority of participants from the third stage , i.e. return to society . at this stage ,
over this course , the goal of self - exploration was to investigate the results from such efforts as covering of scars and cosmetic surgeries to correct deformities and physical limitation .
a young female participant said :  it made me sad when i saw people looking at me strangely in the street .
i underwent a number of surgeries but my hands were not still in good shape and i had a burn scar on my face . because of that , i always had gloves and tried to blur the burn site by wearing make - up ( p. 7 ) .
 for the participants , the fourth stage was like a period that they had time to think about all dimensions and events .
for some participants , burn memories continued to affect how they control and value their lives , even after 10 or 20 years . at this stage ,
helpful and hindering thoughts ran through the participants mind on a set of frightening and traumatic memories of the previous stages .
that is why self - exploration took place through self - struggling , engaging in inner dialog , fantasizing , and dreaming .
i always feel pain and agony , they never leave my heart , when i think by myself .
i was dreaming the past , [ when ] i was not burnt and went out with my friend .
focusing on the burn consequences in family , exploring changes in interactions , and paying attention to social issues by the participants are among the characteristics of this category . in the initial stages , with participants wandering in the gloomy atmosphere of the burn ward and observation of other patients and families in agony , the others exploration mechanism gets activated in parallel with self - exploration .
another participant talked about her experience :  there were two rooms at the end of the corridor in the hospital for seriously injured patients .
from there , dead bodies were taken out one after another ( p. 3 ) .
 the same participant added about the effect of burn on his / her family :  you can imagine what happened to my mother when she heard about it .
 after being placed in a new position at home , exploration of the others continued by investigating the effect of burn on personal life and relationships .
a number of participants called the cost of treatment - induced economic burden on the family and/or the time spent for caring them as  imposing strict conditions on family life . 
 since i was burnt , my sister devoted her life to look after me .
i know how much he suffers from the heavy burden of all these costs and agonies ( p. 11 ) .  by joining them , participants began to investigate the changes in the way others interact with them , through the same mechanism .
a young man said :  some of my friends were ashamed of walking with me on the street . because everybody looked at me with curiosity or pity ( p. 8) . 
another participant said ,  when you go to a public place , it seems that something is going on , all look carefully .
findings from the participants experiences showed that they arrive at a new position based on : ( a ) analyzing and comparing their conditions after burn with before that , and ( b ) evaluating and judging their individual and social positions , and their distance away from their dreams , goals , and desires in life .
for some participants , this new position was interpreted as an unusual and unnatural position . in this regard ,
the participants expressed such experiences as  changing to someone else , duality .  for example : 
after a while when i recognized that i was not the same person , that i had changed , i felt very desperate .
at home i was a person , outside someone else ( p. 6 ) .  while some participants imagined themselves in a position caused by 
bodily and capability changes ,  where they could be the same person again with the same spirits , beauty , and close family ties by healing of their wounds ; they , considered burn as something that had only affected their appearance and capabilities :  eventually , one comes to terms with it , but you are no longer the same person , i used to work hard !
i am the same person with the same characteristics though , i only have problem with my leg ( p. 4 ) . 
burn patients employed such strategies as putting efforts and struggling , substituting the roles , dealing with deformities , paying attention to health , coping with pain , getting themselves busy , escape , violence , getting along , secrecy , and absorbing energy resource in transition from the accident to society .
the result of their efforts was self - concept preservation , ranging from maintaining the previous body image , being aware of the new body image , accepting the new body image , and rewriting the self - concept . during the first stage , which was mainly filled with the feeling of pain and agony
, participants sought to preserve their previous image by denying the severity of injuries and hiding their pain and agony from their families , as well as misrepresenting the conditions .
these efforts contributed to intensified pain caused by strict treatments and cares , as well as the agony of being dependent on others .
in addition , participants felt that they could prevent imposing more pain and agony to their families by means of such behaviors .
after that immense pain , when my parents came , i sat comfortably and upright to prevent them from becoming sadder ( p. 1 )  by arriving at home , participants mainly tried to preserve themselves from the understood changes , to improve their awareness , and to obtain new information .
for example , a participant said :  when i was discharged from the hospital , i still had problem in my leg , but no one instructed me .
when i found my leg severely infected , i visited the specialized hospital on my own ( p. 4 )  .
the other part of this awareness was acquired through interactions , examining others reactions to the wounds , and seeking information from them .
a participant said :  when the family came and saw my conditions , they said these wounds would gradually crumple , you should do something .
then , they suggested that i visit a good doctor in tehran1 ( p. 7 )  . at this stage ,
the participants attention was focused on health and efforts to obtain information about and awareness of their new body image . with participants entering into society and due to the consequent need for more interaction with others
, they have to accept their new body image to preserve themselves in these interactions . indeed , getting used to the new conditions and shifting from disturbing experiences to new ones such as the feeling of gratitude , calmness , feeling of pleasure , and raising spirit on the one hand , and performing such activities as self - care , role substitution , engaging in something , and improving personal relationships on the other hand , contributed to this acceptance . accepting the new body image paves the way for normalizing the new life by acquiring new skills and behaving and interacting with others more easily . in this way and by getting involved with the normal flow of life , the participants not only followed their normal roles , but also to some of them the injury was like an opportunity for spiritual growth .
after the burn accident , my attitudes towards plenty of things changed , i grew up , now i know what to do when someone gets sick .
how a burn patient suffers , how to behave toward him / her ( p. 7 ) . 
 i was jealous and thankless , but now i prostrate a thousand times a day ( p. 9 ) . 
although self - preservation moved toward the acceptance of the new body image with acquiring awareness of it , this study could not distinguish a clear time border between the two stages .
findings showed that living with burn injuries was a live experience of an internal journey for the participants ; a mental journey from awareness to acceptance , where one moves from home to society , and life activities move from falling into the habit to getting normal .
however , they were not sure about the duration of this experienced journey , most of them mentioned a period between four and eight years , during which they got used to living with burn injuries .
regardless of returning to a normal life , memories of the burn accident still remained in the mind of participants who had passed a long time since the accident .
preserving self at this stage , which was occurring in parallel to other life stages , was in a mental context of the past memories , successes and current losses , and dream of future achievements .
 when i look at my pictures , i do nt want to see that my condition has changed , my story has completely altered .
now , i am obsessive , depressed , i can not stand anything , i am so exhausted ( p. 6 ) . 
the participants activities for preserving self - concept at this stage were in the form of a reciprocal effort to obtain or maintain independence , change life priorities , focus on life 's achievements and successes , and/or display such behaviors as threatening others , escaping , and getting along passively .
finally , depending on the factors , affecting individual and social life , the action / interaction process makes them rewrite themselves appropriately or inappropriately . according to a participant :  you can never forget those memories , but when time passes and you see yourself ahead of others in several things , these are actually helpful .
it is no longer important , looks no longer matter , you have other priorities , you just do your own business , i think financial independence is the most important factor , meaning you are not dependent on others , and then entertainment and other enjoyments ( p. 1 ) . 
findings showed that the participants achieve the  self - locating  issue through such mechanisms as self - exploration , others exploration , and position evaluation .
this concept refers to a new understanding of one 's position in the process of surviving and returning to society .
morse ( 1995 ) illustrated this process in the form of vigilance , enduring , and suffering .
concept , which is subjective in nature , manifests as preserving the previous body image , awareness of the new body image , acceptance of the new body image , and finally rewriting the self - concept , at each stage of transition toward returning to society .
concept prepares the subjective context for choosing the strategies that fit one 's current position at each transition stage
. however , based on the effective external , internal , and interpersonal factors , entering into and transition from this path differ from person to person . based on a qualitative meta - analysis of the studies , investigating human responses to threats from diseases , morse ( 1997 ) combined two theories of illness constellation model and preserving self , a five - stage model , in which self - comforting strategies were embedded for preserving the self .
however , the described stages in this theory have been properly given as a comprehensive model based on other theories ; the presented concepts as well as the border of each stage is not clearly developed .
in addition , in terms of the new concept , a clear description of people 's mental processes has not been provided .
this study provides further description of the burn patients mental process by explaining such concepts as self - exploration , others exploration , and position evaluation .
in addition , it presents a number of assumptions about self - concept over the post - burn course . during the course from occurrence of the accident to physical stability , self - exploration
is usually done by focusing on severe and intolerable feeling of pain , facing with the wounds of the selves and of the other patients , and wandering in the oppressive atmosphere of the burn ward .
in addition , observing the suffering endured by the family members is the result of the exploration of the others within this period . by means of position evaluation ,
one searches for the conditions , where he / she is capable of tolerating the current pain and suffering .
consequently , he / she looks for the strategies to be employed for preserving his / her previous integrity by downplaying the damages and preserving his / her previous image . rejecting the severity of damage at the time of the accident and during the first days of hospitalization , denying the pain , and pretending to be looked calm and elegant when visiting the family are all proofs of repression of emotions by the participants of this study
moreover , other experiences such as refusing to see the wounds in some studies are examples of trying to deny the severity of the damage and preserving the previous body image . at this stage ,
when the pain is severe , its onset puts major stress on the patient , in a way that it attracts all of his / her energy and attention to self - preservation .
the patient feels that he / she is threatened and humiliated . at this stage , maintaining emotional control to endure all types of fear or phobia of physical threat is essential .
morse ( 1997 ) showed that suppressed emotions , during the enduring to survive , places the person in a state of  shut down . 
the present study showed that at this stage ,  self - locating  helps the patient in enduring the suffering from severe pain , aggression toward bodily realm , and dependence on family in doing daily activities .
however , other studies show that when there is a severe pain , people employ pain preventing strategies like distraction , shutting it out , focusing on something like staring at the ceiling , and/or disembodying . in a grounded theory - based study , which has investigated the processes from the rehabilitation aspect , suspecting , reading the body , observing , overwhelming , maintaining emotional control , and accepting help are introduced as the first human responses to the threat against his entirety at the vigilance stage . after rescue and survival ,
the results from this study indicate that at this stage , the main mental activity of the participants is having awareness of their new selves .
this awareness is acquired through focusing on the altered appearance or others reaction to self .
based on the present study , this awareness in a group of patients is limited to bodily changes and in the other group is represented in the form of a global change .
it sometimes is understood based on the expressed experiences , i.e.  changing to someone else .
 at this stage , self - locating will help self - image awareness , i.e. understanding one 's present position .
when people admit their fears along this path , they will begin controlling and investigating their body .
acknowledging the seriousness of the situation indicates people 's awareness of selves , environment , and anything making them involved internally or externally . in a phenomenological study ,
moi et al . ( 2008 ) extracted the concept of  a new bodily awareness  as the essence of burn patients experience of life . a new and difficult awareness of the limitations , acquired by seeing a strange and vulnerable body , sadness , disability , and insecurity .
in this regard , a number of researchers have mentioned the experience of  inner dialogue  ,
i.e. communications that patients have in their heads , which help and guide them toward patience .
awareness of the altered appearance and the new self - image , as a part of burn injured patients experience , is one of the most important psychological variables affecting their life quality it plays an important role in short - term and long - term adaptability .
nonetheless , despite acquiring extensive knowledge from psychometric evaluations , further information is still required to understand the differences observed in personal experiences of such patients .
the importance of the present findings , compared to the majority of quantitative studies that have investigated the short - term effects of burn injuries , is their focus on long - term experiences of burn patients .
in addition , the social reception level , adaptability and emotions , and such characteristics as introspection are all affecting adaptability with new situations . in this respect
, findings from the present study showed that after 1 - 8 years and acquisition of awareness of the new position , the patient gradually enters another stage by observing wound healing and normalization of others behaviors , listening to the experiences of the preceding burn patients , and specially finding out that the appearance of burn scars is downplayed by close friends and relatives . at this stage
, self - locating encourages people to endeavor to seek ways of acquiring further capabilities .
then , by going through this path , acceptance of the new self - image is cultivated .
despite what was said , the risk of dissatisfaction with the new body image always affects adaptability and life quality of such people . by accepting the new body image and returning to normal life ,
exploration of the self and the others focuses on the values , beliefs , and life expectations achievement level .
burn patients value and judge the quality of life by evaluating the achievements , as well as comparing their life before burn with their post - burn life , and/or with the life of others .
deformities can lead to lack of social skills , with increased level of shyness , social anxiety , rejection , and behaviors associated with fear and shame .
they can also impair one 's satisfaction with life and his / her functions by entering the patient into a faulty social cycle . in this
studies show that psychosocial problems , as important causal factors , precede burn injuries in causing post - injury adaptive immune reactions ; in that , in some moderate burn - injured patients , returning to a normal life has been challenging even after full recovery .
in addition , those who receive further social support from friends and relatives , during the position evaluation stage , enjoy a more positive body image and self - esteem than others .
the present study identified the concept of  self - locating  as the essence of patients experiences at different stages after burn .
this phenomenon , described in form of self - exploration , others exploration , position evaluation , and self - concept preservation subcategories , will help clearing and understanding relevant comprehensive theories .
however , further investigations are recommended to understand the consequence of this phenomenon in the palliative care process of burn survivors .
burn survivors are engaged with a complex mental process at all stages from post - accident , transfer , and hospitalization to returning to home and society . in this way , they achieve self - locating through exploration of the self and the others and position evaluation .
self - locating refers to understanding the present position and choosing such activities that preserve them from changes .
the obtained results can be used as a conceptual framework for understanding the burn survivors response to self - concept changes in life after burn .
in addition , the concepts presented in this study can be employed to design rehabilitation and palliative care models in compliance with the existing cultural context in iran .
 background : burn injury is a devastating experience affecting all aspects of a person 's essence , including his / her identity and perception . 
 these patients require complex cognitive efforts to redefine their identity to deal with difficult condition after burn injury and preserve self - concept . 
 the experience of life after burn injury is generally a solitary one , closely related to the patients cultural and religious context . 
 therefore , this study was conducted aiming at investigating burn patients experiences regarding how to preserve self - concept in life after burn injury in iran.materials and methods : this qualitative study was carried out using qualitative content analysis and in - depth unstructured interviews with 17 surviving burn subjects.results:during the qualitative content analysis process , the concept of  locating  as the essence of the participants experience was extracted as follows : ( a ) self - exploration ( exploring the changes in one 's life ) , ( b ) others exploration ( exploring the changes in the life of family members and the relationship between self and others ) , ( c ) position evaluation ( self - position analysis ) , and ( d ) self - concept preservation.conclusion:the present study has developed new understandings of mental experiences of burn patients self - concept by describing the concept of  self - locating  . 
 it helps us in classifying and understanding the concepts described in comprehensive theories developed in this area . 
 they do this by focusing on what burn patients experience for choosing self - preservation strategies and having a meaningful life . 
 the finding can be used as a conceptual framework for palliative care program in iran . 
INTRODUCTION
MATERIALS AND METHODS
Design
Sampling procedure
Data collection
Ethical considerations
RESULTS
Self-locating
Self-exploration
Others exploration
Position evaluation
Self-concept preservation
DISCUSSION
CONCLUSION