Self-esteem challenges of nursing students : an integrative review

Introduction Self-esteem can be defined as an individual’s perception of feeling worthy and satisfaction with themselves. In other words, it means how close the real self is to the ideal self.1 People’s self-views play an important role in how they think, behave and feel.2 Self-esteem is one of the most important factors affecting mental health.3 It is a developmental phenomenon because it is formed and will vary over time and a dynamic phenomenon because although it has stability but is open to change.4 Thus, Rosenberg5 considers self-esteem as a stable characteristic of adults, while contemporary researchers believe that it is a developmental process that is affected by new situations.5 The nature of nursing demands that nursing students face various stressful situations,6 and the relationship between self-esteem and the quality of nursing care is undeniable.3 In nursing, it is suggested that self-esteem is one of the most influential factors on occupational behaviors of nursing students.7 Accordingly, there is no doubt in the significance of self-esteem among nursing students.8 According to our review of the literature, it seems that the majority of studies on nursing students’ self-esteem have focused on determining the level of self-esteem9-13 or strategies to improve it.14-17 No review studies that comprehensively show the existing schema (knowledge or what is known and what is unknown about this topic) on stu-


Introduction
Self-esteem can be defined as an individual's perception of feeling worthy and satisfaction with themselves.In other words, it means how close the real self is to the ideal self. 1 People's self-views play an important role in how they think, behave and feel. 2 Self-esteem is one of the most important factors affecting mental health. 3It is a developmental phenomenon because it is formed and will vary over time and a dynamic phenomenon because although it has stability but is open to change. 4Thus, Rosenberg 5 considers self-esteem as a stable characteristic of adults, while contemporary researchers believe that it is a developmental process that is affected by new situations. 5e nature of nursing demands that nursing students face various stressful situations, 6 and the relationship between self-esteem and the quality of nursing care is undeniable. 3n nursing, it is suggested that self-esteem is one of the most influential factors on occupational behaviors of nursing students. 7Accordingly, there is no doubt in the significance of self-esteem among nursing students. 85][16][17] No review studies that comprehensively show the existing schema (knowledge or what is known and what is unknown about this topic) on stu-dents' self-esteem were found.Therefore, it is necessary to conduct studies to show the existing schema, determine challenges and to recommend what researchers, instructors and nursing managers should focus on to deal with possible challenges.An integrative review of research is one of the best methods to determine the current knowledge in a particular area. 18To this end, we used an integrative literature review as a research methodology.This study was designed based on this method, and aimed at illustrating the existing knowledge and discovering the self-esteem related challenges among nursing students.Results from this study can establish the context for researchers in determination of qualitative and quantitative research priorities in the field of self-esteem among nursing students.

Materials and Methods
This study aimed to identify and classify the existing challenges to self-esteem among nursing students according to relevant specialized studies.Integrative reviews are the broadest type of research review method, allowing for simultaneous inclusion of experimental and non-experimental research in order to more fully understand a phenomenon of concern. 19These reviews are conducted to identify, analyze and synthesize the results from independent studies to determine what is known and unknown in a particular area. 18An integrative review progresses through three stages: literature search, data evaluation and data analysis. 20

Literature search (search strategy for identification of studies)
The databases ProQuest, Medline on PubMed, Science Direct, Google Scholar and IranMedex were used to review and analyze the relevant studies.Search terms were combined in various ways according to database structure (using and, or, etc).

Search terms
The following search were used for databases: nursing, self-esteem, nursing student and challenge.

Hand searching
The reference list of included studies was searched.

Study Selection
Titles and abstracts were screened by the two reviewers to identify articles to retrieve in full.Full articles were reviewed by the two reviewers against the inclusion criteria.Reasons for exclusion were recorded.For example, in the Science Direct database, the search began using the advanced search section.In the "search for" section, the words "self-esteem" and "nursing" were used by selecting the icons "title" and "and." In the "refine your search" section, the icon "nursing and health profession" was selected.The years of study were also selected from 1960 to 2014.Accordingly, 12 articles were found in the search results.The articles were investigated in terms of the inclusion and exclusion criteria.The same process was also repeated for the aforementioned database using the "keywords" icon.

Data extraction
The articles were retrieved in three steps, including searching by search terms, reviewing the proceedings based on inclusion criteria and final retrieval and assessment of the available full texts.During the article data extraction process, journal name, author's name and publication date were deleted to reduce search engine bias.To this end, a number was assigned to each article.We explored 165 published papers on nursing students' self-esteem, fulfilling eligible criteria by searching in databases.Our research was restricted to English language studies published after 1960 and Persian language studies published between 1990 and 2014.The underlying reason for selecting the year 1960 as the reference for the review study was that the majority of self-esteem theories were advanced after this time.

Data evaluation
The literature review and selection of relevant articles was carried out in three steps (Figure 1).In the first step, 165 articles were collected using the keywords.In the second step, all articles, one by one, were screened through surveying the abstract and through inclusion and exclusion criteria as well.Then, 38 articles were chosen to be surveyed.Researchers chose only the articles which included the desired conditions and had full texts accessible from the website of Tabriz University of Medical Science were.Finally, 25 articles were reviewed (Table 1).

Inclusion criteria
Papers were included and eligible if they were associated with problems related to nursing students' self-esteem, if they were original or review articles and we had access to the full text of the articles (English or Persian).

Exclusion criteria
Those studies that focused only on the self-esteem of registered nurses or patients were excluded from this review.

Data analysis (data synthesis)
The primary goals of data analysis are to achieve a comprehensive interpretation of primary sources followed by an innovative synthesis of the findings. 19This is accomplished through the ordering, categorization and summarization of all eligible articles retrieved. 21Selected articles were completely studied and investigated and required information (purpose, methodology of the studies and also the specific instrument) was extracted and summarized using the designed extraction table (Table 1).

Focus of the studies
The focus of the studies can be classified into 4 categories.13]22 Among these, some of studies not only measured the level of self-esteem, they also compared the levels of self-esteem in different academic years.[17][33][34][35] Finally, a review study investigated the consequences of decreased self-esteem among students (Table 1). 8

Extracted challenges
The challenges extracted from previous studies are as follows: 1-Challenges associated with inconsistency in determining the level of students' self-esteem: Findings of the evaluated studies, showed that the self-esteem of the majority of nursing students was at medium or low levels 10,15,24,25,28 or their level of self-esteem showed a declining trend from entrance until graduation. 16But it seems that these results are different and sometimes contradictive.A number of studies reported that nursing students' self-esteem was within the normal range 22,31 or it was ascending. 12,132-Self-esteem associated challenges in professionalism of students: In findings of a review study, it was discovered that nursing students with low self-esteem were less able to engage in interactive communication with their classmates and clients.Furthermore, their efficacy and empathy were low in comparison with students with high self-esteem. 8In addition, self-esteem was identified as an important factor in student professionalism. 26In another study, the role of self-esteem was emphasized in the development of critical thinking of students. 24-The psychosocial challenges pertaining to the consequences of low self-esteem:In the studies which were reviewed, depression was identified as an important consequence of decreased self-esteem among students. 25It was also clarified that decreased self-esteem was directly relat- ed to the dropout rate of nursing students. 10,27

Discussion
Challenge means something that needs determination to deal with or achieve. 36In the present study, 3 major challenges associated with the self-esteem of nursing students were identified.

Challenges associated with inconsistency in determining the level of students' self-esteem
Regarding challenges related to levels of self-esteem, most of the studies reported medium or low self-esteem. 10,15,24,25,28Low levels of self-esteem among nursing students is still considered one of the most important challenges to the nursing profession 8 However, the level of self-esteem of students was reportedly normal in some of the other studies reviewed. 22,31In domestic studies, these results were different and sometimes contradictive.For example, in a study conducted in Iran, 56.1% of nursing students had low self-esteem. 25However, almost 91% of students had high self-esteem in another study conducted in 2000. 31In yet another study in 2009, the majority of students (73%) had medium self-esteem. 24In one study, students' self-esteem had an increasing trend as academic years increased, 12 while in another study there was a decreasing trend. 11Now the issue of concern is which factors influence the reported changes in self-esteem among nursing students?In some of the evaluated studies, students' low self-esteem was thought to be associated with educational systems. 8ome of them employ either different teaching methods or training methods based on behavior change models to improve self-esteem. 6,35Now the question is, what are other factors involved in students' low self-esteem?For example, how can students' personality traits such as their self-confidence influence their self-esteem?Which factors play a greater role in changing students' self-esteem?In other words, "Which conditions reduce the self-esteem of students or stabilize it at normal ranges?"In the review of the literature, no study of this nature was located.Studies with a mixed method or purely qualitative methodology are recommended.
In the majority of studies, the Rosenberg self-esteem scale was used to evaluate the self-esteem of students. 15,24,25,28t is one of the most widely-used inventories to measure general self-esteem. 37Regarding the measurement specificity of self-esteem inventories, some researchers believe that measurement scales addressing a general evaluation of self-esteem are the best scales to measure the structure of self-esteem.However, some other researchers such as Marsh and Smith believe that the more specific the inventories are, the more superior they are to other ones. 37According to some researchers, general self-esteem is more involved with affective aspects, whereas specific self-esteem encompasses both affective aspects and cognition. 38s a result, the development of specific tools is required for the measurement of specific domains of self-esteem, such as self-esteem in nursing students.High self-esteem has an important role in achieving academic success along with the individual and social responsibility of people. 39,40In other words, self-esteem is a very important factor that leads to individuals feeling a sense of success and happiness.Conversely, low self-esteem or feeling inferior to others is displayed as a sense of embarrassment, shame, exaggerated arrogance, a need for showing off and an intense desire to be praised by others. 41

The psychosocial challenges pertaining to the consequences of low self-esteem
Results of the present study demonstrated that some of the evaluated studies conducted on students' self-esteem have focused on the relationship between risk of depression and low self-esteem.On the other hand, according to most studies, the level of students' self-esteem was medium or low.Therefore, this question has been raised: what interventions could be conducted to prevent psychological consequences of low self-esteem such as depression?
In dealing with challenges, using opportunities has been stated as one of the best possible solutions.Therefore, it is suggested to focus on what opportunities are available to nursing instructors and managers to cope with the challenges of psychological consequences resulting from low self-esteem in students and how they can use available opportunities.It is suggested to conduct specific studies in this field.

Self-esteem associated challenges in professionalism of students
Findings of a review study indicated that nursing students with low self-esteem were less able to engage in interactive communications with classmates and clients.In addition, the levels of efficacy and empathy were also lower among them 8 and in another study, self-esteem was identified as an important factor in student professionalism.Professionalism includes special attributes, one dimension of which is associated with behavioral traits. 42According to the results of evaluated studies, since the majority of students indicated mediocre or low levels of self-esteem, it appears that other attributes of professionalism such as becoming an expert or developing skills and knowledge may be influenced by student's levels of self-esteem.Given what was mentioned, the following questions can be discussed.First, what attributes does the definition of self-esteem include in relation to the nursing students?On the other hand, how are such attributes related to professionalism among students?Are the students with high self-esteem more inclined to acquire the knowledge and skill required for the nursing profession?It is recommended that exclusive qualitative studies be conducted on this area.

Conclusion
Accordingly, the need for performing specific research, especially of the qualitative type, into increasing and decreasing factors of self-esteem among nursing students, defining professional self-esteem specific to nursing students and developing instruments specific to students' self-esteem seems essential.In addition, conducting studies, especially of the qualitative type, for controlling and improving self-esteem outcomes in nursing students is recommended.The design and psychometrics of specific inventories are recommended for the evaluation of self-esteem among students.
Regarding the role of self-esteem in professionalization of nursing students and its relationship with psychological consequences, it seems that nursing educators should pay more attention to issues of self-esteem in nursing students.
In the current study, the papers that were freely accessible through Tabriz University of Medical Sciences were used.Further studies should be conducted on this field.

Figure 1 .
Figure 1.Search and selection strategy.

Table 1 .
List of considered articles related to challenges of nursing student self-esteem from 1960 to 2015 in second retrieval phase