Nursing Students' Understanding of the Concept of Self-Esteem: a Qualitative Study.

INTRODUCTION: The concept of self-esteem has several definitions in different paradigms. Nursing has a unique and combined paradigm; therefore it is necessary to explore nursing students' understanding of the concept of self-esteem. The present study aimed to discover the extent and characteristics of the concept of self-esteem from the perspective of Iranian nursing students through a qualitative approach.
METHODS: This study was conducted using the conventional content analysis method with the participation of 14 nursing students. Purposive sampling was used to recruit participants and data were collected through in-depth semi-structured interviews and analyzed simultaneously.
RESULTS: Study findings showed that the nursing students' self-esteem is related to the sense of worthy they perceived as being a nursing student. Nursing students' self-esteem was determined through sense of worthy related to their perceived professionalism level, socialization into the profession, and enthusing of them about being a nursing student.
CONCLUSION: If a nursing student was proud of her or his nursing role, then he or she would enjoy the nursing course and all that entailed; such as communication with colleagues, performing the tasks and, generally her or his career.

Introduction

The overriding need for professional proficiency across a wide range of careers has resulted in the need for university’s to plan and provide education and training which is tailored to the diverse needs of each profession.[1] Within nurse education specifically, in order to gain the skills required to work as a registered nurse in the hospital, teaching and learning needs to take place in contextually relevant faculties, which facilitate development of the required skills and the self esteem of the learner.[2] An important factor, influential to the development of the students’ self esteem, is the role of the academic teacher or facilitator.[1]

In recent years many studies have explored the concept of self-esteem,[3] which is considered to be an extremely abstract concept

with different perspectives.[4] Sometimes self-esteem is used to refer to a personality variable that represents the way in which people generally fell about themselves. This form of self-esteem is called global self-esteem. But sometimes it is used to the way people evaluate their various abilities and attributes.

For example, a person who doubts his ability in school may be said to have low academic self-esteem.[5] In the various theoretical perspectives on self-esteem, most researchers offer differing explanations. For instance, from the socio-cultural perspective, self-esteem is an attitude that the person has about her or himself, whilst from a behavioral perspective self-esteem means a construct or an acquired quality. Meanwhile, from a humanistic perspective, self-esteem refers to an individual’s skill to live, respect and accept his view of himself.[6]

Nursing is a profession with a particular body of knowledge which is drawn from the social, behavioral and physical sciences.[7]

Considering the importance of the concept of self-esteem in relation to academic study and specifically within the unique context of nursing education; and also the fact that different paradigms have somehow defined self-esteem, a question arises: what are the aspects and characteristics of the concept of self-esteem for nursing students?

Most studies within the literature acknowledged the existence of low levels of self-esteem within nursing students.[8-11] Having knowledge of nursing students’ levels of understanding about the nature of self-esteem would enable academics to plan and implement practical steps to help student nurses improve their self-esteem. For this, it is essential to explore the concept of self-esteem and identify factors which limit or enable development of this concept in nursing students, in order to plan enabling strategies which may facilitate increased self-esteem in this group.

The literature revealed no studies undertaken around the meaning of the concept of self-esteem in nursing students. In a previous study, the effect of social values and cultural variations on self-esteem revealed further dimensions of the construct. In this study self esteem focused on the context of individualistic (mostly western) and collectivistic (mostly eastern) cultures. At the other hand, the Western culture tends to give more importance to the independence, uniqueness and individuality of the person whereas, the Eastern culture focuses more on collectivism, dependence, and compliance.[12]

Therefore, it seems necessary to explore the concept of self-esteem in cultural contexts to emphasize its various manifestations in the specific cultural context of nursing education.[6]

We could not found any special study in this regard in Iran. With regard to the need to explore the concept of self-esteem in nursing students and the impact of culture on their understanding of this concept, the specific aim of this study was to investigate nursing students’ understanding of the concept of self-esteem.

Materials and methods

This qualitative study was based on a content analysis approach. In-depth one to one interviews utilized to gather data about nursing students’ experiences. In this study, a purposive sample of 14 participants (nursing students) was recruited from Tabriz and Maragheh faculty of nursing and midwifery, and Islamic Azad University (Tabriz and Bonab branch). Data were collected between September 2014 to January 2015. The semi-structured interviews were conducted either in the researcher’s offices within the faculty. However, participants were informed that they could change the interview's location and time if they wished. Each interview lasted between 45 to 60 minutes.

Interviews began with general questions such as “May I ask you to speak about your experiences of nursing students’ self-esteem” or “How do you feel about yourself as a nursing student”. As the interview progressed more detailed questions were asked such as: “can you give an example? How was your experience?" (Table 1).

Table 1

Most important interview questions

Variable

Examples of general questions

May I ask you to speak about your experiences of nursing students’ self-esteem?

How do you feel about yourself as a nursing student?

What comes to your mind when you hear this phrase: “Nursing Student’s self-esteem”?

What are the signs for you to understand who has high self-esteem and who has low self-esteem when you go to the ward for internship with your friends?

Examples of detailed questions

Can you give an example?

How was your experience?

The process of data analysis was based on conventional content analysis as proposed by Wildemuth in 2009. In this method the first step is to prepare the data to make sure all the data is transformed into written text before analysis. Then in the second step, the unit of analysis needs to be classified during content analysis. Usually, coding schemes can be developed both inductively and deductively, after the code is developed, the coding scheme is applied on a sample of text to check whether there are any clarity and consistency problems of the coding scheme. If there is no problem, then all the text can be coded by this method.

Before conclusions are drawn from the coded data, the coding consistency needs to be assessed again. The last step is to report the methods and findings.[13] According to this method, each interview was listened and was transcribed verbatim. Following review, meaningful texts, words, sentences, and paragraphs were considered as semantic units and according to their connotation, reached the level of abstraction and conceptualization.

Data were coded, and all codes were compared in terms of similarities and differences and then classified into more abstract categories with specific labels. The coding and classification of data into categories and subcategories was discussed among the researchers continuously until they reached consensus on classification. Data collection continued so until data saturation occurred in categories in relation to the process of data coding. At the end of the last three interviews, the researchers were confident that new ideas, concepts and categories of data would not be obtained.

To enhance the rigor of our findings, several strategies were employed, including participants being asked to verify the themes that emerged following each step of data analysis. Member checking and external control were both utilized to verify the accuracy and credibility of the data analysis process. Data credibility was established by two experts in qualitative nursing research and peer reviewers. The researchers developed an audit trail, which is a systematic collection of materials and documentation reviewed by an independent auditor to confirm and approve the process.

Ethical approval was achieved from the ethical committee of Tabriz University of Medical Science (Ethics code: 5/4/7617). The ethical considerations of the study were as followings: informed consent; right to withdrawal from the study; confidentiality and anonymity and permission to audio recording of the interview. Therefore, prior to the study, participants were informed about the aim of the study; it was mentioned that they could withdraw from the study at any time; then informed consent was obtained. To protect the privacy, confidentiality, and the identity of the participants, interviews were conducted only with the participation of the interviewer and the interviewee.

Results

Demographic variables of nursing students who participated in this study are shown in table 2.

Table 2

Demographic variables of nursing students participated in the study

Variable	N (%)
Age
19-21	2 (14.29)
22-24	11 (78.57)
>24	1 (7.14)
Sex
Male	8 (57.15)
Female	6 (42.85)
Semester
1-2	1 (7.14)
3-6	7 (50)
7-8	6 (42.86)
Times of interview
1	11 (78.57)
2	3 (21.43)
University
Tabriz University of Medical Sciences (Tabriz and Maragheh branch)	10 (71.43)
Islamic Azad University (Tabriz and Bonab branch)	4 (28.57)

The results revealed that from the nursing students’ perspective (n=14), self-esteem referred to the value they gave to being a nursing student. From the findings, three main themes emerged and related to “enthusiasm about being a nursing student”, “socialization into the profession”, and “sense of worthy related to perceived professionalism level” (Table 2).

Theme 1. Sense of worthy related to perceived professionalism level

The findings revealed that if a student views nursing as a profession rather than simply a job and believed that they were in possession of the requisite traits to undertake that profession (traits such accountability and the use of critical thinking; ethics; prestige; professional knowledge and skills and professional independence), they would subsequently feel more worthy as education in nursing field. The following quotes from participants illustrate how they wanted to develop deeper understanding in order to better serve the profession as a whole:

“We would become more proud of being a nurse as we attended more specialized units…” (P1)

“I want to know the reason for each procedures I’m performing… I don’t want to care for patients thoughtlessly…” (P2)

Sense of being worthy is determined through the feeling of power, usefulness, and a sense of spirituality and holiness. A student said:

“Nursing student's self-esteem means the feeling of power.” (P6)

Another participant said:

“The spiritual value of nurses is very high ...” (P11)

The feeling of being important is somehow associated with the sense of superiority over other professions. If a student feels that her or his profession is not inferior to other professions, she or he will try to express her or himself. According to one of the participants:

“Self-esteem means that a nursing student shall respect her or himself, should not underestimate her or himself, should not withdraw her or himself and should show her or his presence”.

Theme 2. Socialization into the profession

Findings showed that nursing students felt socialized into the profession when they were able to see beyond the role-related limbo and accepted nursing as their future professional role. In other words, they perceived nursing as a part of their future identity, as the following quote exemplifies:

“I once asked someone who loved nursing why she loved it, and he told me because it had become a part of his identity”. (P2)

Another student said:

”I thought to myself, now that I’m admitted in nursing and I don’t like it much, I don’t need to tell my friends or other people that I don’t like being a nurse … Because it will become a part of my identity. (P3)

Behaviors representative of role tolerance and the permanent state of confusion and fear of the future can be seen in those who remain in a state of role-related limbo. A student who is in role-related limbo constantly envies the students from other disciplines and, in fact, merely tolerates their current role as a nursing student. Regarding the role tolerance, a participant said:

“... My friend who had low self-esteem was always saying “I wish to get this course over with to be able to get on with my business” ...”. (P4)

Regarding the state of confusion, a participant said:

"Sometimes I would think of studying medicine, but sometimes it would think to myself that no, it would be better to study nursing… “or “… I’ll go start my own business once I graduated.”

According to the results, coping with roles is a characteristic of the students who have higher levels of self-esteem. To cope with roles means that there is acceptance the restrictions of the respective profession, but also hope of progress within it. Regarding the acceptance of the profession’s restrictions, a student said:

“I chose the nursing profession disregarding the positive or negative views of society.”(P11)

Regarding the hope of professional progression within the profession, a participant said:

”I believe that one can be successful in the nursing profession too.”(P1)

Theme 3. Enthusiasm about being a nursing student

Having pride in being a nurse was one of the major indicators of high esteem among the students. However, in relation to appreciation of one’s self as a nursing student, opinions ranged from dislike of the profession to being proud of it. As one student put it:

"I am a nurse, and I am proud of it”. (P3) Another feature was the joying associated with being a nurse. A student who enjoys being a nurse is always happy and cheerful. They enjoy and take pride in being introduced in public as a nurse. For them, the duties or tasks of the profession are not viewed a burden – they will undertake eagerly. However, not all students felt this way, as this quote illustrated:

“Changing the bed sheets was so unfavorable for me that I wished to finish the training hours soon...” (P5)

In contrast, another student stated:

“Self-esteem of students means that they perform the tasks assigned to them fully from deep in the heart.”(P9)

Regarding the characteristic of interest, a student said:

“… well, … self-esteem means…

A good feeling which a nursing student can have towards his or her major… yes… I have this feeling.”(P11)

Concerning the joy of learning, another student said:

“The types of nursing lessons are in a way that I have a pleasant feeling while studying them…” (P3)

About the joy of being recognized as a student nurse, other student said:

“I don’t still like to wear the label now…” (P7)

On the contrary, another student said:

“… I want to say that I am a nurse, and I am not anything else [other professions related to medical sciences] …” (P11)

Discussion

This study focused on the exploration of nursing students’ understanding of self-esteem as it applied to them, through expressing their experiences. The findings suggested that nursing students' self-esteem consisted of three main themes: “Sense of worthy related to perceived professionalism level”; “Socialization into the profession” and “Enthusiasm about being a nursing student”.

It seems that, the concept of organizational self-esteem, similar to the nursing students’ understanding of self-esteem, emphasized a certain aspect of self-esteem. This concept of organizational self-esteem is based on Cooper Smith’s definition of self-esteem.[14]Cooper Smith defines self-esteem as the extent to which the person believes in her or his capability, successfulness and worthiness.[15] Organization based self-esteem is regarded as the level to which an employee considers him or herself as a competent, valuable and significant member of that organization.[16]

Professional self-esteem is a multifaceted notion that determines the personal qualities of a profession and its effectiveness in specific working environments. In fact, professionalism not only involves the mental, emotional and psychological features of an individual but also their efficacy and practicability in her or his professional life.[17] Based on the researchers of this study, the meaning or the sense of professional self-esteem is no different from determining the characteristics and specific aspects of the concept of self-esteem in a range of similar vocational professions (such as nursing, teaching, medicine, etc.). Thus, Socialization in the nursing profession is one of the aspects of the concept of self-esteem among nursing students or their professional self-esteem.

Mruk, provided a phenomenological theory of self-esteem including the interaction between two basic components of self-esteem, competence and worthiness. According to Mruk, competence as a functional aspect of self-esteem is related to the skillfulness of an individual and worthiness refers to an individual's effective evaluation about his abilities. He further discussed that competence is the behavioral component of self-esteem that is related to aspirations and successes which are easily observable.[6] It seems that the becoming professional is consistent with the competence aspect of self-esteem as proposed by Mruk. Meanwhile, the sense of being worthy, such as the sense of importance and the sense of power, is consistent with the worthiness aspect of this theory. Understanding the feeling of worthiness has long been one of the characteristics of self-esteem.

Another aspect of students' self-esteem is related to the level of their socialization into the profession. Professional socialization refers to a process in which novices enter the arena and develop into competent professional staff.[18]With respect to the results of another study, learning, interaction, development and adaptation are four critical attributes of professional socialization.[19] Following professional socialization, a sense of belonging and unique professional identity is gradually developed among individuals.[20] In fact, the professional identity of nursing is formed when its members (nurses) believe and see themselves as a nurse.[20]In the work context acting out a role creates a specific sense of professional identity with that role. The process that leads to the perception of unity with the job (role) is referred to as identification. According to Jansen et al., role membership and performance have consequences for self-esteem in identity theory.[21]Some studies have also stressed that professional socialization is effective in the improvement of professional self-esteem of nurses.[22]It seems that, the more a nursing student is able to accept the role of the nurse as a part of his or her identity, the more enthusiasm they exhibit for being a nurse; and this is indicative of a vertical relationship between the two mentioned aspects. Regarding the theme of “enthusiasm for being a nursing student” and the inner sense of being proud of nursing and enjoying this profession, it must be stated that the characteristics of this aspect of self-esteem often have an emotional aspect and are not clearly manifest. About loving herself or himself as a nurse, it should be stated that, if we did not already like ourselves we would not care whether or not we felt good about ourselves. Studies have indicated that individuals with high self-esteem show greater levels happiness and have less incidence of depression compared to those with low self-esteem[23] and individuals with a good sense about themselves take pride in their work and derive satisfaction from their endeavors.[24] According to the findings of this study, if the nursing student is proud of being a nurse, they will enjoy studying the courses, communicating with colleagues, and performing the tasks; and in general will enjoy her or his career. As a consequence, this will be evident in his or her feelings and behaviors.

Conclusion

The results of this study revealed that the nursing students’ self-esteem is influenced greatly by their professionalization and socialization. Because of the length of time students are under the guidance and supervision of academic institutes and academic staff, this issue should receive more attention. Cognizance needs to be given to factors that will facilitate the development of higher levels of self-esteem amongst nursing students during curriculum development.

Furthermore, the concept of self-esteem is affected by different cultural influences and contexts. This study was conducted in northwest of Iran, therefore findings will be context specific. It is recommended that similar studies be conducted in other countries.

Acknowledgments

This article was‏ part of a‏ PhD‏ dissertation approved by the research deputy of Tabriz University of Medical Sciences with the ethics code: 5/4/7617. Our sincere appreciation goes to Tabriz University of Medical Sciences for their financial support and to all the students who participated in this research.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study‏.

Table 3

The dimensions and attributes of nursing students’ self-esteem based on their perception

Themes and dimension/ attributes

The concept of self-esteem in nursing students

1. Sense of worthy related to perceived professionalism level

Becoming professional

Use of critical thinking

Ethics

Being prestigious

Efforts to have professional autonomy

Importance of clinical skills

Importance of knowledge

Efforts to expert the profession

Sense of worthy

Feeling of power

Feeling of usefulness

Feeling of importance

Spirituality and holiness

Self-expression

2. Socialization into the profession

Acceptance of nursing as the future professions

Acceptance of being a nurse

Role-related limbo

Role tolerance

Confusion

Regret

Anxiety

Coping with the role

Accepting the professional constraints

Hope for professional development

3. Enthusiasm about being a nursing student

Loving oneself as a student nurse

Interest

Pride

Joy of nursing

Mental vitality

Joy of performing tasks

Joy of communicating with counterparts

Joy of learning

Joy of being recognized as a student nurse