INTRODUCTION
Rejection sensitivity can be defined as a cognitive-affective processing disposition to an anxious expectation of rejection, a heightened perception of rejection cues, and an exaggerated emotional response to perceived rejection [1]. Rejection occurs as a one-time incident or manifest as a repeated experiences [2]. Although all individuals encounter rejection, their responses differ [3]. Some individuals respond with mild tolerance to the disappointment of rejection, while others react excessively, experiencing strong negative emotions that can harm their social relationships and negatively impact their well-being [1,4,5]. This could lead to increased aggression [6] or depression [3]. The term “rejection sensitivity” refers to individuals who respond excessively to and anxiously anticipate rejection situations [1,7]. To understand why reactions to identical social situations differ, Feldman and Downey studied the origins of rejection sensitivity and found a connection between parent and child relationship an exaggerated response to rejection situations [7]. Children develop their self-perceptions and future relationships based on past experiences with parents [8]. If the caregiver consistently meets the child's needs, the child develops a secure attachment model, fostering the ability to feel loved and accepted in future relationships [8,9]. Conversely, if a caregiver adopts a rejecting manner when addressing the child's needs, the child's rejection sensitivity increases [1,10] making it a legacy of parental rejection [7]. Although the rejection in parental acceptance is significant, what matters most in this context is the perception of rejection [11]. Thus, perceived parental rejection depends on the child's beliefs, irrespective of the parents' specific actions. In Korean family culture, parents consider responsibility and a sacrificial attitude toward their children as essential aspects of their roles [12]. Parents express their affection for their children by silently meeting their children's needs rather than by verbally or behaviorally expressing them. Individuals in Korea who are sensitive to rejection exhibit higher levels of anxiety and possess heightened expectations of rejection [12]. In contrast to individuals with low rejection sensitivity, Koreans high rejection sensitivity exhibit heightened reactions to perceived social rejection. They often experience feelings of abandonment or rejection, even in situations where no rejection is intended [1].
They frequently experience feelings of abandonment or rejection, even in contexts where no rejection is intended [1]. In addition to hurt feelings and emotional distress, research has indicated the clinical implications of rejection sensitivity. Links connecting rejection sensitivity with social anxiety [13], depression [14,15], and borderline personality disorder [15] exist to the extent that the Diagnostic and Statistical Manual of Mental Disorders [16] incorporates sensitivity to rejection in all three disorders.
The method of Walker and Avant’s conceptual analysis [17] has the advantage of clarifying meaning and can be used to develop or refine new definitions [17]. This study aims to clarify concept of interest through a multidisciplinary comparison using their method [17]. This approach allows for the reinterpretation of nurses’ clinical decision-making within the current nursing practice from a fresh perspective.
Minimal research has been conducted of rejection sensitivity in nursing care. Additionally, there is a a lack of clarity regarding related concepts. This study provides essential foundational data to promote the development of nursing practices aimed at enhancing patient health, particularly in relation to the identified attributes of rejection sensitivity. Most importantly, it will contribute to the development of nurses' essential integrated competencies. Furthermore, a model and additional case studies are presented, and an effort is made to understand the antecedents and consequences of nurses' understanding of rejection sensitivity.
METHODS
1. Study Design
This study attempted a concept analysis of the rejection sensitivity by applying the method described by Walker and Avant [17].
2. Data Sources and Data Collection
Data were collected through a literature search for articles published between 1936 and 2023. For the analysis, the literature search was conducted from April 20 to May 20, 2023, using “rejection sensitivity” in all fields in the flowing databases: Pubmed, Web of Science, CINAHL and RISS. The inclusion criteria for the literature in this study were a consisted of that (1) were written in Korean or English, (2) provided full text, and (3) detailed the concept and characteristics of rejection sensitivity. The exclusion criteria were (1) did not explain the concept, and (2) were conference presentation materials.
Literature selection was performed by sequentially reviewing the search terms, titles, abstracts, and full texts. In total, 942 abstracts were identified during the initial search. The abstracts were reviewed to assess their inclusion and exclusion criteria, as well as the appropriateness of their content. Articles with unclear abstracts underwent a fulltext analysis to determine their eligibility for inclusion or exclusion. After removing duplicate articles, the final sample of publications consisted of 249 articles (Figure 1).
3. Data Analysis
The concrete analysis process using Walker and Avant's methods as follows [17]:
• Choose concept of rejection sensitivity and confirm its definition.
• Clarify the concept of rejection sensitivity for data collection.
• Identify the data that can be conceptualized its attributes, antecedents, and consequences.
• Determine the specific attributes of rejection sensitivity.
• Construct the model case focusing the attributes.
• Construct the borderline, related, and contrary cases focusing the attributes.
• Identify antecedents and consequences of rejection sensitivity.
• Identify criteria for the concept of rejection sensitivity and conclude the conclusions for the analyzed content.
RESULTS
1. Dictionary Definition of the Concept
Rejection sensitivity is a trait that makes a person expect, perceive, and react intensely to real or perceived rejection [18]. Rejection sensitivity is defined as cognitive-affective processing disposition characterized by an anxious expectation of, heightened perception of, and exaggerated reaction to rejection [1].
2. Conceptual Use of "Rejection Sensitivity" in Other Disciplines
“Rejection sensitivity” has been applied and studied in various disciplines beyond nursing. Here are some examples of how rejection sensitivity is conceptualized and utilized in different fields, along with the relevant literature.
1) Transplant medicine
Rejection sensitivity may be relevant in the field of transplant medicine, where patients undergoing organ transplantation face organ rejection risks. Rejection sensitivity can influence patients’ emotional responses, adherence to medication, and engagement in self-care behaviors necessary for successful transplant outcomes [19].
2) Psychology and mental health
Rejection sensitivity has been extensively studied in psychology, particularly in terms of interpersonal relationships, self-esteem, and mental health outcomes [20,21]. Researchers have examined the role of rejection sensitivity in various psychological disorders, such as anxiety disorders, depression, and borderline personality disorder [14,20]. This concept is used to understand the cognitive, emotional, and behavioral responses to perceived rejection and its impact on psychological well-being.
3) Social psychology
In social psychology, rejection sensitivity is often studied in the context of social interactions, group dynamics, and social exclusion [22]. Researchers have investigated how rejection sensitivity influences individuals’ responses to rejection and their subsequent behavior in social settings. This study explores topics such as ostracism, social inclusion or exclusion, and interpersonal functioning.
4) Education and school psychology:
Rejection sensitivity has implications for educational settings, particularly in understanding students’ social and emotional experiences. Research has examined the influence of rejection sensitivity on academic achievement, peer relationships, and school adjustment [23,24]. Understanding students’ rejection sensitivity can help educators create supportive environments and implement interventions that promote social-emotional well-being.
3. Conceptual Use of "Rejection Sensitivity" in Nursing
The concept of “rejection sensitivity” has significant implications in the field of nursing, particularly in understanding and addressing the emotional and psychological needs of patients. While there is no substantial body of literature specifically addressing rejection sensitivity in nursing, the concept can be applied within the context of patient-centered care, therapeutic relationships, and mental health nursing.
1) Patient-centered care
Rejection sensitivity can influence how patients perceive and respond to healthcare interactions. Understanding a patient’s rejection sensitivity levels can help nurses tailor their approaches and communication to create a safe and supportive environment. By being aware of potential triggers and adopting strategies to minimize perceived rejection, nurses can cultivate a sense of trust, empathy, and collaboration, which are essential elements in patient-centered care [25].
2) Therapeutic relationships
Rejection sensitivity can affect the development and maintenance of therapeutic relationships between nurses and patients. Nurses need to be sensitive to signs of rejection sensitivity in patients and adapt their communication and behavior accordingly. Building rapport and actively listening to and validating patients’ feelings and concerns can help alleviate the fear of rejection and enhance the therapeutic alliance [26]. Recognizing and addressing rejection sensitivity can contribute to a positive nurse-patient relationship and improve patient outcomes.
3) Mental health nursing
Rejection sensitivity is related to mental health and relevant to mental health nursing. Patients with borderline personality disorders, depression, or anxiety disorders often exhibit heightened rejection sensitivity. Understanding and assessing rejection sensitivity can assist nurses in tailoring interventions and providing appropriate support to these individuals [20,21]. Incorporating strategies, such as validation, empathy, and cognitive-behavioral techniques, can help patients manage their fear of rejection and promote emotional well-being.
4. Defining Attributes
Defining the attributes of a concept can establish a clear definition, which is essential for its characteristics [17]. Moreover, defining attributes is fundamental to concept analysis because it provides the insight for a concept [27]. The identified attributes of rejection sensitivity were rejection expectation, perception of rejection, and reaction to perceived rejection (Figure 2).
1) Rejection expectation
Rejection expectations refer to the anticipation or belief that rejection is likely to occur during social interactions or relationships. Individuals with high rejection sensitivity often have negative expectations regarding how others perceive and respond to them, leading them to be hypervigilant toward rejection signs. This attribute reflects the cognitive component of rejection sensitivity. Studies have shown that individuals with high rejection sensitivity tend to have pessimistic views on social interactions and expect more rejection from others [14,28].
2) Perception of rejection
The perception of rejection involves the subjective interpretation and sensitivity to cues that are perceived as rejection signs, even if they may not be intended as such. Individuals with rejection sensitivity may interpret ambiguous social cues as indicators of rejection, leading to heightened emotional reactions. This attribute encompasses the affective and perceptual aspects of rejection sensitivity. Research has demonstrated that individuals with high rejection sensitivity are more likely to interpret neutral or positive interactions as rejection, indicating a bias toward perceiving rejection [14,22].
3) Reaction to perceived rejection
Reactions to perceived rejection encompass the emotional, behavioral, and physiological responses that individuals experience when they believe they are rejected. This attribute reflects the behavioral and physiological manifestations of rejection sensitivity. Individuals with high rejection sensitivity may exhibit strong emotional reactions, such as sadness, anger, or anxiety, when they perceive rejection. Additionally, they may engage in self-protective behaviors, such as withdrawing or avoiding social situations, to prevent further rejection [29].
5. Antecedents and Consequences of Rejection Sensitivity
Antecedents are events that occur prior to the concept [17]. They were classified into early life experiences, attachment style, cultural factors based on the question, “What events occur before rejection sensitivity?” (Figure 2).
1) Early life experiences
Several studies have shown that adverse childhood experiences, such as emotional neglect, maltreatment, and rejection, contribute to the development of rejection sensitivity [21,29,30]. These experiences shape individuals' expectations and beliefs about rejection, leading to heightened sensitivity and hypervigilance towards potential rejection in their adult relationships.
2) Attachment style
Research has identified a link between insecure attachment styles and rejection sensitivity. Individuals with anxious or ambivalent attachment styles, characterized by fear of abandonment and a strong need for validation, are more likely to exhibit higher rejection sensitivity [22]. These attachment styles develop because of inconsistent or unpredictable caregiving during early childhood.
3) Cultural factors
Cultural influences play a significant role in the development of rejection sensitivity. For instance, individuals from collectivist cultures that prioritize social harmony and conformity tend to have higher levels of rejection sensitivity. The fear of social exclusion and emphasis on social acceptance within these cultures contribute to increased rejection sensitivity [12].
Consequences refer to phenomena that occur after a concept occurs [17]. We identified the consequences by posing the question, “What is the consequence of e-health literacy in older adults?” We determined the consequences of emotional distress, impaired interpersonal relationships, self-esteem and self-image, academic and occupational impacts, and mental health concerns (Figure 2).
4) Mental health concerns
Rejection sensitivity is linked to the development and maintenance of various mental health conditions. It is associated with an increased risk of depression, anxiety, borderline personality disorders, and interpersonal difficulties [20,21]. Rejection sensitivity can intensify the symptoms of these disorders and impede the use of effective coping strategies for managing mental health challenges.
(1) Emotional distress:
Rejection sensitivity is strongly associated with increased emotional distress. Individuals with high rejection sensitivity experience higher levels of anxiety, depression, and emotional reactivity when faced with perceived rejection [14,21]. These emotional reactions can be intense and long-lasting, affecting overall psychological well-being.
(2) Lower self-esteem and negative self-image:
Rejection sensitivity is associated with lower self-esteem and negative self-perception. Individuals who are highly sensitive to rejection often have negative self-beliefs and doubt their worthiness and likability [6,20]. This negative self-image can have cascading effects on various aspects of their lives, including confidence, decision-making, and overall self-concept.
5) Academic and occupational impacts:
Rejection sensitivity can impact academic and occupational functioning. Individuals with high rejection sensitivity may be more reluctant to engage in challenging academic tasks or pursue career opportunities with possibilities of rejection [2,5]. This fear of rejection can limit personal and professional growth, leading to missed opportunities and reduced achievements.
(1) Impaired interpersonal relationships:
Rejection sensitivity negatively affects the quality of interpersonal relationships. Individuals with high rejection sensitivity tend to have difficulties in forming and maintaining close relationships due to their hypersensitivity to rejection cues [2]. They may engage in self-protective behaviors, such as avoiding intimacy or seeking excessive reassurance, which can strain relationships and hinder their ability to develop genuine connections.
6. Cases of the Identified Attributes of Rejection Sensitivity
Walker and Avant [17] stated that the model represents an ideal case that encompasses the attributes of the concept, whereas the related case pertains to the concept, but it carries a different meaning as it lacks the essential attributes associated with the concept. In addition, they mention that the boundary case includes only some attributes of the concept, whereas the contrary case excludes all attributes of that concept. This study identified the attributes of nurses’ clinical decision-making as clinical reasoning, the selection and application of challenging alternatives, and adjustment.
1) Model case
A model case includes all the attributes of rejection sensitivity and must include the critical attributes of the concept so that the concept of rejection sensitivity can be used correctly [17]. An example of a model case constructed based on the attributes of rejection sensitivity identified in this study is as follows:
John attended a networking event for industry professionals. As he entered the room, he immediately experienced a surge of anxiety and self-doubt. Despite his extensive experience and expertise, he feared being overlooked or rejected by others during the event. This expectation of rejection stems from his deep-seated belief that he is inherently inadequate. While mingling with the other attendees, John overhears a conversation in which a colleague offers constructive feedback to another. Although the feedback is unrelated to him, John instantly perceives it as a veiled criticism of his own abilities, believing that his colleague has subtly suggested that he is incompetent. Overwhelmed by his perception of rejection, John’s mood plummets, and he begins to doubt his professional worth and social standing. In response to his perceived rejection, John distances himself from the networking event. He retreats to the corner and avoids engaging in further conversations and interactions. He begins to question his decision to attend the event, convinced that his presence is unwelcome and not valued by his professional peers. His negative emotions intensify, leading him to ruminate about past instances of rejection, reinforcing his rejection expectations.
The model case includes the critical attributes of rejection expectations, perception of rejection, and reaction to perceived rejection. Thus, it becomes a model case.
2) Related case
A related case refers to a case that does not contain important attributes related to the concept being analyzed [17]. An example of a related case constructed based on the attributes of rejection sensitivity identified in this study are as follows:
Emily attends a social gathering with friends. Upon her arrival, she feels anxious. During the gathering, Emily notices that her friends are engaged in a conversation without her. Although they may simply be discussing a topic of mutual interest, Emily’s perception of rejection immediately kicks in. She interprets her exclusion as a deliberate act and assumes that they find her uninteresting or unworthy of attention. Overwhelmed by these feelings of rejection, she withdraws emotionally and begins to question her value as a friend. In response to her perceived rejection, Emily becomes defensive and distant. She begins to doubt her place within the friend group and contemplates withdrawing completely. Her fear of abandonment intensifies, leading her to doubt the authenticity of her friendships.
A related case includes the attribute reaction to perceived rejection. Therefore, it becomes a related case.
3) Boundary case
A boundary case contains most but not all of the attributes presented in the model case [17]. An example of a boundary case constructed based on the attributes of the rejection sensitivity identified in this study is as follows:
Alex has recently begun a new romantic relationship. Despite their strong feelings toward their partner, they constantly expect rejection and anticipate that the relationship will inevitably end. This expectation of rejection creates significant anxiety and insecurity within Alex, leading them to be overly cautious and hesitant to invest emotionally. During a conversation with their partner, Alex misinterprets a comment as a subtle form of rejection. Although the comment was innocent, Alex perceives it as a sign of their partner’s dissatisfaction or disinterest. This perception of rejection triggers a strong emotional reaction that causes them to withdraw and become distant. They struggle to communicate their feelings or concerns, and fear that expressing themselves will lead to further rejection or abandonment.
The boundary case includes the attribute, rejection expectations, and perceptions of rejection. Therefore, it becomes a boundary case.
4) Contrary case
The contrary case is contrary to the identified attributes and does not contain concept attributes [17]. An example of the contrary case constructed based on the attributes of the rejection sensitivity identified in this study is as follows:
Emma had recently applied for a job she was highly interested. Despite the competitive nature of the application process, she maintained a positive mindset and did not expect to be rejected. Emma understood that rejection is a common occurrence in job applications and did not take it personally if she were to encounter it. When she received the news that she did not get the job, Emma acknowledged her disappointment but did not allow it to deter her. She recognized that the decision was not a reflection of her abilities or worth as a professional. Instead, she reflected on the experience, identified areas of improvement, and continued to search for other opportunities without dwelling on the rejection. In her personal relationships, Emma approaches interactions with trust and confidence. She does not anticipate rejection from friends or romantic partners. If she faces rejection or disagreement, Emma remains calm and rational. She communicates her feelings assertively, respecting her own boundaries, while also understanding and considering others’ perspectives.
No attribute exists in the contrary case. Thus, it becomes a contrary case.
DISCUSSION
In conclusion, rejection sensitivity is a psychological construct encompassing several attributes, including rejection expectation, perception of rejection, and reaction to perceived rejection. This trait is influenced by various antecedents, including early life experiences, attachment style, and cultural factors [22,30]. The consequences or events associated with rejection sensitivity span multiple domains and can significantly affect an individual’s life [1]. The literature suggests that high rejection sensitivity person often have heightened expectations of rejection and interpret ambiguous social cues as signs of rejection [14,28]. They are more likely to perceive rejection in interpersonal interactions, even it is neither intended nor present [14,22]. This perception can lead to intense emotional reactions, including anxiety, sadness, anger, and shame, all of which contribute to emotional distress [29].
Rejection sensitivity can profoundly affect interpersonal relationships and impair the ability to trust, establish closeness, and maintain healthy connections with others [5]. This can lead to difficulties forming and sustaining relationships, increased conflict, and social withdrawal [7]. Moreover, individuals with high rejection sensitivity may experience negative effects on their self-esteem and self-image as they internalize rejection and develop negative self-perceptions [6,20]. Furthermore, rejection sensitivity is closely associated with various mental health outcomes. It has been linked to increased vulnerability to anxiety, depression, and social anxiety disorder [29]. Constant anticipation and hypersensitivity to rejection can contribute to chronic stress and a diminished sense of well-being.
In the Korean family culture, parents consider responsibility and a sacrificial attitude toward their children as their role [12]. Parents express their affection by fulfilling their children’s needs rather than expressing them directly through words or actions. The practice of refraining from excessive praise and avoiding public displays of affection toward their children is considered parental virtues [12]. In contrast, Western parents are accustomed to actively expressing their love for their children directly through words and actions [7,8]. Parents in Asian countries are often unaccustomed to these displays of affection. Indirect affection refers to the ways in which parents show love and care for their children through actions rather than through open expressions of affection. Although there is no direct expression of affection toward the child, it includes the feeling that one’s parents love and care for them [30]. Korean family culture often has familistic characteristics that place value on the family [12], in contrast to the individualistic culture of Western society. According to interpersonal psychology, specifically attachment theory, problematic behavior in adolescents often stems from unmet emotional needs of parental affection and serves as a response to feelings of rejection [21]. Rejection sensitivity is particularly important in the Korean culture because of these cultural factors.
This analysis offers a conceptual definition of rejection sensitivity within the field of nursing and distinguishes it from other concepts that are often used interchangeably in the literature. A clear conceptualization of rejection sensitivity, including the identification of its antecedents and consequences, is essential to understanding its prevalence in nursing practice. This study included various academic disciplines in the concept analysis. Therefore, it cannot be definitively stated that efforts were made to completely exclude the researcher’s subjective judgment. One limitation of this study is that it was solely a concept analysis based on a literature review, underscoring the need for future research that includes in-depth interviews with patients. Nevertheless, given the current active research on rejection sensitivity across multiple academic fields, there is growing recognition of its significance and the need to clarify its concepts.
CONCLUSION
This study conducted a concept analysis of rejection sensitivity using the Walker and Avant method. The attributes of rejection sensitivity include rejection expectation, perception of rejection, and reaction to perceived rejection. By identifying these attributes of rejection sensitivity, it is possible to communicate the understanding of the concept of rejection sensitivity. As a psychiatric nurse, we encounter situations during the initial interviews in which clients sometimes refuse counseling. Understanding the concept of rejection sensitivity can be helpful in counseling. This can lead to therapeutic communication by understanding why the client refuses counseling more deeply. In addition, by exploring the concept of rejection sensitivity, we can gain a deeper understanding of clients’ interpersonal relationships, which can facilitate the recovery of clients’ social relationship planning. It will be possible to understand the characteristics of clients’ interpersonal relationships. Additionally, rejection sensitivity helps nurses make decisions in the nursing field. By comprehending the attributes of a client’s rejection sensitivity during the psychiatric nursing process through interviews, it becomes feasible to create patient-centered nursing plans. Furthermore, this study provides foundational data for the development and validation of assessment tools designed to measure rejection sensitivity.
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