Enhancing Self-Esteem in Nursing Education

Chapter One Introduction

The need for specialists in all careers is a topic that is broadly mentioned. In nurse training, for one to gain capabilities, they ought to work as a registered nurse within the hospital; teaching as well as learning ought to take place in circumstantial applicable faculties that enable the improvement of skills that are required and in boosting the learner self-esteem. According to Zamanzadeh et al (2016), a factor that affects the development of students' self-esteem is the role that is played by the academic tutor. In recent years, researchers have explored the concept of shallowness which humans remember to be an exceptionally abstract concept that has distinct perceptions. That form of self-esteem is known as global self-esteem. That form of shallowness is known as international shallowness. Other times self-esteem is described as how humans evaluate their extraordinary attributes and abilities. Nursing is a unique career which has a selected body of knowledge that is derived from behavioral, social and physical sciences.

1.1. Background of the Study

The concept of self-esteem is a mid-point concept in the study and practice of education and psychology. Understanding how the study of the idea of self-esteem translates into the self-concept and the professional life and also the effect it has on the performance of an individual nurse (Hoeve, Jansen and Roodbol, 2014). Questions that are asked frequently are; what is professional self-esteem, how is it measured, how to teach and pass it on and even how it influences career practices like nursing (Tseng, Wang, and Weng, 2013). These questions, therefore, suggest the importance of the concept of self-esteem and its existence as a discipline in the nursing career. Self-esteem is used in psychology to refer to a person's self-assessment of their overall worth. People who have high self-confidence feel valuable despite the errors and flows (Mane, 2016). Self-esteem is a significant factor in different mental illnesses. It very powerful in such a way it predicts whether a person is happy or sad in life. Nurses are required to have very high self-esteem to play their roles and perform their duties in hospitals. Works of (Mane, 2016), reveals that the ideal nursing role requires high levels of mental health to influence the development of nursing students and the quality of their practice as professionals positively, and also their decision to remain in the nursing career in future. Therefore it is essential to outline the factors that affect the mental wellbeing. It is therefore relevant for them to have high self-esteem to shape the interpersonal relationship between nurses and the quality of care that they provide. Nurses who have high self-esteem give better care in terms of their career Nurses who manifest a high level of self-esteem have more confidence in their skills and therefore can work effectively under stressful and challenging situations. Nursing is one of the stressful professions in China; thus nurses who have high self-confidence can use their high self-value to do their work more effectively (Valizadehet al, 2016). Inevitably, nursing students should have the self-esteem to attend to patients effectively especially those that have unclear prognoses. It is significant that they are confident and reassuring. However, these skills are acquired as one builds knowledge and proficiency through training. It is in this concern that proposes to research to investigate the perception of self-esteem and nursing role ideal among nursing Students. The extent of the dissertation is such that the first chapter provides the background of the study. This incorporates the background information relating to the perception of self-esteem and nursing role ideal among the nursing students. Besides, this section will also comprise of the statement of the problem, the significance of the study and the aims as well as the research questions, which are to guide the research. The second chapter will focus on reviewing the current literature concerning the subject matter. The methodology and study design will be presented in section three while chapter four will show the analysis of the data. The recommendation and conclusions will be displayed in chapter five.

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1.2 Statement of the Problem

What impacts the advancement of a positive picture in male nursing understudies? Despite the fact that Florence Nightingale thought of nursing as a free vacation that isn't humble yet equivalent to everybody in the restorative calling. (Songbird 1969), In quite a while, nursing was said and seen as indistinguishable from the therapeutic vocation. In the therapeutic vocation, the restorative male-ruled calling solidly affected the job advancement, the position, and picture of medical attendants (Hallam 2000, Gordon 2005, Fletcher 2006). In different examinations on a similar point, it demonstrates that the attendants have known about the lowliness to the restorative vocation are as yet not happy with their profession decision. Twaddle and Hessler (1987) saw where the mastery of nursing by others originated from. They understood that in the west; generally during the 1900s, which is the point at which the order of male medical practitioners began. Those are the years that prescription likewise turned into a prevailing variable and specialists and medical attendants began dealing with the debilitated in foundations called emergency clinics. The investigation of Walby et al. (1994) advises us that in Western Europe, therapeutic callings and nursing have a tangled relationship which is controlled by subjection and chain of command. The investigations of Adamson et al. (1995) and Aiken and Sloane (1997) indicated how the impact of medicinal predominance on occupation fulfillment and independence prompted understanding results being diminished. Ever, medical attendants would not elude anybody to doctors due to irregularity between the two sexual orientations (Summers &Summers 2009). The image and role of nurses are seen as an oppressed group expression. The dominance of the male nurse might bring up low self-esteem onto the oppressed which in turn may lead to a negative presentation of oneself (Fletcher, 2007). (Arthur 1995, Arthur & Randle 2007), States that self‐concept related closely to the professional-concept which is a necessity for academic and vocational development of the professional identity Subordination is not the only factor that influences the self-esteem and professional status of nurses, but also there are other determinants which include; work values, education, and culture and work environment. Self-esteem and professional identity change because of interactions with colleagues, patients, and other healthcare professionals. (Arthur 1992, Pask 2003) , stated that the level of education and knowledge that one has determined the effect on the nurses' job satisfaction and self-esteem Fealy (2004) and Thupayagale‐Tshweneagae&Dithole (2007) stipulated that, there are differences between social and traditional cultural values which need to be taken into consideration when measuring nurses' self-esteem and professional identity

1.3 Significance of the Study

In China, nursing self-esteem is different in meaning and emphasis because of the associated history of high education in nursing and the influences of culture and economics. China developed the first nursing higher education program in 1920 but was suspended in 1951 while retaining the secondary diploma programs. To illustrate this, the initial baccalaureate nursing program was launch at Peking Union Medical College. However, due to cultural and economic aspects, it was shut down, leaving only the secondary diploma colleges. As elaborated by Hao et al, (2014) higher learning was later introduced in 1984. Current nursing education programs include secondary diploma, associate degrees, baccalaureate, and master's degree, and doctoral education programs. Valizadeh et al. (2016) observe that; while the number of enrolled and graduating registered nurses has been increasing, it has been noted that nursing students are having issues facing their self-esteem and professional identity which could have negative future implications on nurse turnover. (Hoeve et al., 2014), points out that in the past decade, more than a third of all baccalaureate graduates leave their positions or migrate to developed countries in search of the ideal nursing role. This has led to a severe shortage of nursing professionals in China. According to Lei Lyuet al. (2016), the issue of nurse shortage has remained a critical problem in China. As noted, 13 percent of the newly registered nurse leave their employment opportunities after working for one year, with over 37 percent leaving their professions. The shortage is reported to hit 1.05 million individuals in the year 2022. As presented by the Ministry of Health in China, the nursing workforce comprised of 2.2 million individuals with a ratio of 1.86 clinical nurses per 1000 individuals. The Statutory Hospital Authority was developed in the year 1990 by the government in Hong Kong ‘with the aim of presenting a new era of healthcare management. The body developed key policies towards implementing management frameworks within public hospitals and integrating the healthcare profession. However, the early conceptualization of high self-esteem could help improve the professional identity of students by contributing to students' success and their future perception of the ideal nursing role. Therefore, studying the interaction between perceptions of self-esteem and nursing role ideal in nursing student is significant for nursing educators, the governments, and the national healthcare systems.

1.4 Purpose

This segment provided the background to the study that concerns the feature of self-esteem. Self-esteem represents a delicate element in the field of psychology and education. Significantly, ideal nursing roles, identity, gender differences as well as professional improvement has affected the development of self-portrayal and positive reputation amidst the male nursing students.

1.4.1 Research Aims

a) To investigate the perception of self-esteem and nursing role ideal in nursing students.

b) To determine the factors influencing self-esteem and nursing role ideal in nursing students.

c) To evaluate the impact of self-esteem on nursing in nursing students.

1.4.2 Research Question

The research question guiding this research paper will be;

1. What are the perceptions and impact of self-esteem in the nursing role ideal in nursing students?

CHAPTER TWO 2.0 LITERATURE REVIEW

2.0 Introduction

Current research builds on previous research. According to Hougthon et al (2012), research is conducted for the purpose of filling existing research gaps, building up on already existing research findings, and developing new directions for future research. As such, it is important to evaluate exiting research on a particular area of study to identify existing research findings and more importantly, attempt to identify any existing research gaps that the current study may fill. This chapter does exactly that, by identifying existing research findings on the current research topic, in an attempt to establish hat is already known about the study and what is yet to be known. However, being a critical literarture review study, this section (chapter 2) should not be confused with subsequent chapters (especially chapter 4) because as opposed to those chapters, this chapter takes a wider view of literature and is not focused on any specific number.

2.1 Theoretical Review

Newly graduated nurses, globally, are faced with numerous challenges when transitioning from the role of a student to that of a professional nurse. Some of the challenges are an increased number of clients under their care and more complex medical conditions, inadequate positive mentorship, workplace diversity, among others (Hofler, 2016). Therefore, many graduates feel that academic clinical experience is insufficient in preparing them for professional nursing roles (Flott and Linden, 2016). Inadequate experience among nursing students affects their profession as well. Nursing students who are poorly prepared are disillusioned about their profession and are more likely to leave their nursing careers at an early stage in nursing school (Cowen, Hubbard, and Hancock, 2016). The health-care system is very dynamic and is constantly changing as better ways of medical service delivery are being implemented; thus nursing students must be able to think critically within a short period and provide solutions for the delivery of quality nursing services to a population of patients with complex healthcare needs. Literature notes that the self-esteem of students can affect the decisions they make in their different nursing roles, which is critical in the delivery of quality services to patients (Chesser-Smyth and Long, 2013). Kim et al. (2014) assert that self-esteem directly impacts a student's competency level. Consequently, it is important that nurse educators take into account the promotion of self-esteem in nursing students. To develop a significant level of self-esteem, student nurses should trust their abilities to give adequate medical care to clients (Porter, Morphet, Missen, and Raymond, 2013). Student empowerment is paramount in developing their self-esteem and defining a successful professional path. Examination of the factors that impact the self-esteem of a nursing student is very important and impetus for this research study.

2.2 Self-Esteem in Nursing

Professional proficiency is demanded across all professions resulting in the need for institutions of higher education to plan, educate and train each profession according to their diverse needs. More specifically, in the nursing profession, learners are exposed to the clinical environment throughout their training to develop the required skill, and positive self-esteem towards their role are registered, nurses. A critical factor in influencing the self-esteem of a nursing student is the role played by the academic facilitator (Zamanzadeh et al., 2016). Therefore, it is important to understand the concept of self-esteem. Self-esteem is an abstract concept, and its perspective differs among individuals. Sometimes it refers to the personality variable representing the emotional perspective of a person about themselves, but sometimes it describes the attributes and abilities of an individual (Zamanzadeh et al., 2016). Therefore, a person who is doubtful of their abilities in schools can be described as having low academic self-esteem. However, some theoretical perspectives depend on the researcher’s field of study. For instance, according to socio-culturists, self-esteem defines the attitude of a person about themselves while behaviorists define self-esteem as an acquired quality. Additionally, a humanistic perspective refers to self-esteem as skills that an individual needs to live, accept and respect herself or himself. Meanwhile, the nursing profession draws its body of knowledge from the physical, social, and behavioral sciences. Most literature acknowledges that many nursing students have low self-esteem. Understanding the nature of self-esteem is important in planning and implementing the practical steps that would help to improve the self-esteem of nursing students. It is therefore important that the exploration of the concept of self-esteem identifies the factors for developing the self-esteem of nursing students.

2.3 Factors Influencing Self-Esteem

Two concept analyses were identified as explaining the factors influencing self-esteem, is precursors and consequences. Analyzing a concept offers a better comprehension of its meaning, characteristics, precursors, and consequences. The analysis of a concept synthesizes and differentiates the existing arguments of a concept (White, 2009). According to Perry (2011) defining a concept and identifying its attributes enables its effective use. The two concept analyses are the exploration of how self-esteem is developed within the clinical environment (Zamanzadeh et al., 2016; Perry, 2011), and analysis of how self-esteem impacts nursing role in nursing students (White, 2009; Valizadeh et al., 2016). According to Zamanzadeh et al. (2016), self-esteem has three primary attributes, namely: belief in one’s ability, including being optimistic and self-affirming; persistence including vision, resilience, and determination to achieve positive outcomes; and self-awareness which drives internal control of situations. Zamanzadeh et al. (2016) also identify the factors influencing self-esteem and the consequences thereof. Five factors are identified, namely: knowledge acquisition, support, experience, gearing-up, and success. First, gaining basic knowledge and skills before a task is essential in being self-confident. Second, support whether internal or external is imperative to being self-confident. Thirdly, gaining experience through practicing clinical skills and exposure to clinical situations increases self-esteem. Fourth, adequately gearing-up for a task is necessary for boosting self-confidence; however, self-confidence decreases with time as the expected task gets closer. Lastly, a successful outcome is the most critical factor because self-confidence will not be acquired if the outcome is not successful. Similar findings were reported by Perry (2011) who noted that belief in oneself is dependent on past experience and the nature of the surrounding. Both analyses identify knowledge, experience, and success as important factors influencing self-confidence. All these factor influence one another. This analysis provides an increased understanding of self-esteem. However, very little has been addressed in promoting and developing self-esteem and the associated impact on clinical outcomes.

2.4 Impact of Self-esteem in Nursing Students

After identification of the five factors, White (2009) outlined the impact of high self-confidence: intrinsic and extrinsic returns. Intrinsic return results in the establishment of autonomy leading to fuller self-confidence in nursing practice. On the other hand, extrinsic return relates to the positive outcome experienced by others such as the patient and their family because of the self-confidence of the health worker. Accordingly, low self-esteem will result in low self-confidence and in turn impact the development of trust in the role played by the nursing student. High self-esteem will result into high levels of trust between the nursing student and the role played which would, in turn, improve the relationship between the students and clients, instructor, and fellow nursing students leading to increased satisfaction. All of these aspects influence one another. On the other hand, Valizadeh et al. (2016) identified the challenges brought about by low self-esteem among nursing students. Valizadeh and his team found that low self-esteem is associated with a sense of despair, shame, embarrassment, a need to show off and be praised. Accordingly, low self-esteem results in two outcomes for nursing students: psychological challenges and professional challenges. The main psychological challenge is the risk of depression. It is therefore important for instructor and managers to find opportunities to address “the challenges of psychological consequences resulting from low self-esteem in students and how they can use available opportunities,” (p 10). At the same time, professionalism challenges occur as difficulty in engaging in interactive conversations with fellow students and the patients in a clinical setting as well as low levels of empathy and efficacy. Therefore, there is a need to carry out a qualitative study to determine whether students with high self-esteem are more interested in gaining the knowledge and skills required for different nursing roles.

2.5 Conceptual Framework

Different researchers have published both qualitative and quantitative data collected from nursing students through discussion and views they collect regarding self-esteem and nursing role ideal. Ideally, the themes of initial clinical anxiety, theory-practice gap, clinical supervision and finally the professional role emerge from further review of literature. Previous studies by Beauvais et al (2011) indicate that initial clinical anxiety is stressful for nursing students, and this made it hard for them to raise their self-esteem. The second-year students were more anxious in the clinical experience, making them have low self-confidence compared to their third and fourth-year counterparts. This is similar to the findings of research by Hisken (2011) who found the level of anxiety higher and lower self-esteem in second-year students. Edrakim et al (2012) outlined that there are three areas in which nursing students develop fear namely, fear of the patients, the feeling of not being or belonging to a nursing career or profession and lastly not being competent in registration. Similar areas of fear found by Al Jarrah (2013) to be what the students complained about in the focus groups. Besides, in the study by Cohen (2007) participants stated that students did not have sufficient clinical skills when they have completed their pre-registration program. The initial clinical experience has been revealed by existing literature to be the most anxiety-producing part of the clinical experience. In the study by Edrakim et al (2012), the fear of failing or making mistakes and being examined by the faculty members was outlined by the students as an anxiety-producing situation in the experience in the clinical area.

Building confidence is necessary for a nursing career. According to Beauvais et al (2011), developing confidence should be made easier by the process of nursing education. Moreover, Vilazadeh et al (2007) observe that conflict in nursing students is created by the differences between the actual and the expected behavior in the clinical career. The nursing students are given instructions that are entirely different from what they learn in class (Whyte et al, 2009). The students feel anxious, and the anxiety brings down their self-esteem, and in return, they impact their performance negatively. These insights corroborate with the observations made by Edrakim et al (2012) that the existence of a theory-practice gap in nursing students has been a problem for some time, and have proven to bring down self-confidence and delay the learning process. Hence, it is already known, based on available literature that nursing students experience the theory-practice gap problem which affects their level of self-esteem. Existing literature also indicates that the media's projection of pictures of nursing attendants in a way that disregards the official prerequisites of the calling additionally affects the perspective on people in general on nursing (Vilazadeh et al, 2007). This corroborates with the literature by Beauvais et al (2011) indicating that medical caretakers tend to be seen by the media as female and caring, not as self-sufficient social insurance suppliers. Also, literature by Vilazadeh et al (2007) indicates that through the media, nursing is viewed as a calling with restricted vocation opportunities. Nonetheless, other researchers also report increasingly positive discoveries. For instance, examinations by Edrakim et al (2012) likewise demonstrate that medical attendants are viewed as qualified, talented and decent experts. However, based on the literature by Whyte et al (2009), it is apparent that proficient nursing organizations and occupation locales are populating nursing on the web. However, inferences from these pieces of literature indicate that the picture of medical caretakers in the media does not (yet) meet the expert picture of nursing. In the study by Badiyepeyma (2014), clinical supervision was one of the themes that were profoundly discussed. for instance, it came out that the role of instructors is of great importance in the clinical experience. It was also remarked in this literature that instructors can either help to build the self-esteem of a nursing student or make the students lose their self-esteem. Furthermore, according to Badiyepeyma (2014), the instructor can either assist in enhancing education in the clinical area or not give the necessary skills needed. Badiyepeyma (2014) reached this conclusion by interviewing students who believed that the instructors were more concentrated on their evaluative than on their teaching role. However, Badiyepeyma (2014) conclude that the instructors play a massive role in building the confidence of the nursing students; they help in promoting the part socialization and also encourage the students to be independent which will help in having clinical competence. It is also important to note the remarks made by Edrakim et al (2012) that the role of the instructor is to support and have a socializing interaction with the nursing students. Indeed, these assertions are in agreement with those of Whyte et al (2009) that nurses should be encouraged by the clinical nurses specialist so as to enable the develop effective skills of responding to anxiety and thus having high self-esteem and well-being. Existing pieces of literature also highlight the issue of professional socialization and its impact on self-esteem. For instance, Beauvais et al (2011) identify the hierarchy of the occupation as one of the factors which the students expressed to be of major influence to their self-esteem. Besides, literature by Keog & O’Lynn (2007) highlight that Self-evaluation of professional values, knowledge, and skills are contributory factors to the student’s professional self-concept. Nevertheless, in the socialization process, as Whyte et al (2009) narrate, the acquisition of values, motives and career attitudes are essential. That said, Kalisch et al (2006) Suggested that professional self-concept among nursing students can be achieved through decision making, independence, and innovation. More importantly, though, literature by Lengacher (1994) has gone through the importance of faculty stuff preparing the students for the real clinical experience, in doing so, the author states that nursing students having or being nurtured to have high self-esteem are capable of developing effective capabilities of undergoing socialization process. Finally, on this note, research by Edrakim et al (2012) reveals how students discussed in the focus groups that they did not think of themselves as professional nurses. They are confused about their role since what they are taught in the classroom is different from what they are expected to do in reality.

2.6 Defining image, self-image, professional identity, and self-concept

From an existing literature point of view, the ideas picture, mental self-view, self-idea, and character are utilized incoherently, even by similar authors in similar research reports, therefore making it hard to develop a common meaning. For instance, in the study by Beauvais et al (2011) mental self-view and self-concept were utilized conversely; as were the proficient picture and expert character. However, for purposes of uniformity and consistency, Keog & O’Lynn (2007) limited their conceptualization to self-idea and expert character and uses the meaning of Tajfel and Turner (1986) on self-idea as: 'the manner in which we consider ourselves'. However, regarding the self-idea of medical attendants, in explicit, Keog & O’Lynn (2007) depends on the meaning of Takase et al’s definition: 'medical attendants' self-idea can be characterized as data and convictions that attendants have about their jobs, qualities, and practices' (Takase et al. 2002, p. 197). This definition can be located in the arguments of the Social Character Hypothesis of Tajfel and Turner (1986) which contends that the self-idea of an individual or a gathering (for example medical attendants) is gotten from the apparent picture of the gathering by society. When you expect that society has a favorable opinion of you, it will support your self-idea and the other way around. Self-concept (the manner in which we consider ourselves) can be utilized as an umbrella term, with mental self-view (the manner in which we see ourselves), confidence (the manner in which we feel about ourselves) and self-introduction (the manner in which we present ourselves to other people) as basic ideas (Tajfel and Turner 1986). We utilized the idea of self-idea all through this paper since it applies for the most part to the expert self (the calling), instead of to the mental self (the person). Therefore, it very well may be connected to proficient personality.

2.7 Work Environment and Work Values

In the study by Keog & O’Lynn (2007), workplace and work esteem were referenced as elements of impact on medical caretakers' expert character. Medical caretakers gain from their work encounters and expert connection with associates, in particular, were found to be exceedingly esteemed. In the investigation of Arthur et al. (1999), the expert self-idea, innovative impacts and minding characteristics of 1957 Enrolled Medical caretakers in 11 nations were analyzed. They found that the example, in general, esteemed proficient collaboration with associates and trusted in the abilities of medical caretakers. This view is shared by Gregg and Magilvy (2001), who likewise discovered that attendants gain from their work encounters. Through association with different attendants, they learn things about nursing and about themselves and filling in as a medical attendant may likewise add to their self-improvement and self-idea (Gregg and Magilvy 2001). The Swedish medical caretakers in the investigation of Ohlen and Segesten (1998) referenced that they build up their expert personality through collaboration with different attendants and by sharing their encounters in an account and intelligent way. Takase et al. (2001) found that the members in their investigation assessed their execution as attendants emphatically and that this positive self-idea is identified with the expert socialization process. Nurses build up an expert character through the skills, knowledge, and qualities natural in their calling. The investigation of Fagermoen (1997) demonstrated that functioning as medical caretakers keep up and upgrades their self-idea, both as attendants what's more, as people. Three interesting themes have emerged in the reviewed literature including incorporated professional self-image, identity, and self-esteem. Particularly, existing research identifies some of the signs placed on self-reputations as the critical aspects of the professional identity that is of interest to the current research. For instance, Zamanzadeh et al. (2016) suggested that even though the benefits of the retentions and the risk of the turnover minimally significant as a way of describing nurses’ motivation and professional self-confidence, self-esteem is essential in the professional identity. Similarly, studies by Beauvais et al (2011) indicated that self-esteem has a possible fixed connection with the nursing staff turnover. Yet, the excellent reputation of the self-image of the nurse students clearly outlines a good part of the retention and the risk turn over. Some of the following factors directly relate to individuality perception of personal identity. While others identify social evaluation and the self-image as well as termed social modeling procedure accounted for as 6.9% and 5.3% of the variance in the research conducted by Valizadehet al. (2016). In a combination of the above factors, they are categorized as a relational measurement. According to the hypothesis of (Mane, 2016), nurse students can readjust in the progress of their professional career by considering the social comparison behavior and self- image as well as social modeling. However, the fourth issue identified independent professional options and counted for the minimum percentages of the variance (5.5%). Some of the initials sources specify that PINS devices are accurate and dependable measure with the internal uniformity and the scale integrity. The PISNS validity was created in relations with information as well as constructs validity. However, the truth of the validity of the PISNS was confirmed to be true through evaluations by the experts. However, it was realized by the Cronbach's alpha while the split-half reliability is showing that seventeen items maintained constancy of the construction. These items highly support the internal consistency reliability.

Moreover (Yu-Fang et al., 2014), affirmed that the unchanging internal subscales were calculated by Cronbach's alpha varied from 46 to 83. This clearly shows that these items had strong correlations. In the imaginative statistics indicates that the average mean score of the five things is ranging within the neutral and agree. However, between them, the average score in the multiple of 2(3.3) and 4(3.4) was proximity to the rating of the neutral. Among them, less than half of the multiples could balance the benefits of the retentions and the risk turnover (43%) and as well selects profession self-reliant (48%). Similarly, quite proportions of these participants suggested that a large number were negative in factor 2 (22.0) and factor 4(27). (Yu-Fang et al., 2014), suggested that this demonstrates that the probability of the nurse students in China to be weak are high in terms of balancing the benefits of retentions and the quick turnover. They can be as well likely to range from 56.1% of them having a real career of self-image to 34.0% with lack of bright idea. Also, the proportion of 11.55% indicates students with a negative attitude toward the course. More importantly, it is necessary for 45% of the students who are pursuing nursing to strengthen their ability towards the path. However, 62.1% of the contestants could easily discover their professional development by producing their interest, character and believing in themselves. (Valizadehet al., 2016), stated that evaluations revealed that a significant percentage of half of the nursing students that's 66.4% love to communicate with predecessors of the nursing fields and have a high interest in knowing more. Lastly, some of the outcomes show how the influence of culture which is dominated by other people when making the comparison over the succeeding generation.

2.8 The Level of Students’ Self-esteem

Several researchers have also dwelled on issues regarding the levels of self-esteem, a majority of them citing medium or low self-esteem among nursing students. However, in the study by Whyte et al (2009), the minimum level of self-esteem amongst the nursing students is one of the major problems, which the nursing students were experiencing in their profession. This is more contrary because there are normal feelings towards the course in other fields of the studies reviewed. This is quite the opposite of the findings of other studies most of the studies that have been conducted before. For instance, studies by Flott, and Linden (2016) found that 56.2% of nursing students in Iraq had low self-esteem, and approximately 91.9% of the students had immense self-confidence in another field of the studies. Subsequently, some of the concerns were raised to identify factors that could make the margin of low self-esteem and high self-esteem in the most different institutions. Surprisingly, some of the mediate answers are the different teaching method as well as a training method, which greatly relied on the behavior of the students towards self- esteem. Findings of some researchers (e.g. Mane, 2016; Yu-Fang et al., 2014; Chan et al., 2014) on the dimensions on the self-esteem inventories revealed that the general assessment of the self-esteem is the best scale to measure. However, according to some of the researchers, general self-esteem is highly accompanied by useful concepts while some of the exact self-esteem incorporates both useful ideas and awareness. In general, the creations of exacts tools are needed for the measurement of the specific structure of the self-confidence that is in nursing students. High self-esteem has significant impacts in attaining academic success in line with the personal and social concern of the people. Self-esteem is a considerable factor that directs the individuals' emotional states to success and happiness. Contrarily, low self-worth depicts the sense of humiliation, disgrace, embroidered arrogance, as well as showing the need for a tribute to others. The literature on the psychosocial challenges of low self-esteem indicates that some of the evaluated studies directed on the students' self-esteem have engrossed on the connection between the risk of despair and low self-esteem (Whyte et al, 2009). Therefore, in dealing with problems, being opportunistic has been outlined as the core factor of the solutions. Through the suggestions of the bodies concerned, students are advised to readjust their mind to numerous challenges that come on the way that may make them have low self-esteem (Whyte et al, 2009). Our literature review also showed that nursing students with low self-esteem were less likely to participate in the intense talks with classmates and clients. Also, the level of effectiveness, as well as understanding, was also lower among them. Moreover, different studies show that self-esteem is a significant issue in the student's career. (Mane, 2016), said that ideal nursing roles consist of good traits that are associated with behavioral characteristics. Similar to the results, which were evaluated, most students show a sense of low self-esteem. It also revealed that some of the experts' behavior might also dictate the students' attitudes towards their career.

CHAPTER THREE METHODOLOGY AND METHODS

3.0 Introduction

This section will include the logic and research, clarification of the distinctive ways to deal with research and talk of the literature review as the research strategy of this investigation. Besides, this chapter will describe various approaches to conducting an effective literature review and the various advantages that a researcher stands to gen when they choose literature review as their preferred research methodology.

3.1 Research Philosophy

Nursing research work requires to be grounded on specific philosophy for it to be relevant in nursing practice (Polit et al, 2001). Nursing research may utilize two ideal models namely: the positivist worldview and naturalistic/interpretivist/constructivist worldview. Bowling (2009) explained that naturalistic worldview entails thoughts and suppositions of the topic under inquiry, and is generally a method for separating the unpredictability of the present reality. Hougthon et al (2012) referenced that the worldview makes an extension between the points of research and the techniques by which to accomplish those points. Moreover, the naturalistic worldview incorporates other philosophical contemplations namely the metaphysics and epistemology (Hougthon et al 2012). Metaphysics entails the convictions about the real world while Epistemology alludes to the connection between the analyst and what can be known. Naturalistic worldview speaks to a noteworthy elective framework on leading research in the nursing field (Polit et al 2001). Naturalism depends on the rule that all learning gets from human recognition and the research must consider realizing how human subjects comprehend the world (Allsop 2013). As expressed by Allsop (2013), it is also based on the grounds that the logical strategy is definitely not a reasonable course to comprehend human activity. The naturalistic analyst’s conviction is that there are distinctive impressions of reality in individuals' minds in a given circumstance. They have distinctive discernments on account of their history and the world is evolving. Thus, they interface with the earth and settle on translations and choices (Munhall 1989). Moreover, the translations of people who are being considered are essential for the naturalistic specialists to comprehend the marvel of intrigue (Polit et al 2001). Nonetheless, the present study took the positivist world view approach. The positivist worldview is a customary logical methodology in directing research (Polit et al 2001). Positivism uses logical approaches to anticipate designs in the physical world (Suppe and Jacox 1985). It intends to pursue the logical standards and strategies to create a proof for an information claim (Allsop 2013). Furthermore, it is based on the premise that the fact of the matter is out there and it can be examined and known i.e. nature is fundamentally requested and exists autonomous of human perception (Polit et al 2001). As per Weaver and Olson (2006), the positivist worldview has been utilized in nursing research based on a logic known as sensible positivism. In this regard, positivist scientists endeavored to maintain a strategic distance from inclinations so to as conceivable in their research exercises (Polit et al 2001). This justifies the use of positivism research philosophy in the current study.

3.2 Research methodology

3.2.1 The Critical Literature Review Methodology

Colling (2003) defines critical literature review as the process of critically examining existing data from secondary data sources with the aim of identifying specific information that is relevant to the current research topic. This study chose the critical literature review methodology with an aim of recognizing, examining, evaluating and deciphering a collection of learning identified with a specific theme through the choice of accessible records (both distributed and unpublished) that give data, thoughts, information and proof so as to accomplish the study objectives by evaluating certain perspectives and apply a powerful assessment of the data from the reviewed literature materials in connection to the proposed research questions (Hart 1998). As per Cowell (2012), a critical literature review is an essential way to evaluate the condition of science. Aveyard (2010) expressed that literature review is a far-reaching study and elucidation of research identified with a specific focus and intrigue. Furthermore, the literature review is a basic stage on characterizing a research question, in the wake of perusing the report from others in the equivalent or comparative subjects another research thought may create (Abbott 1993). Neale (2009) likewise concurred that critical literature review can expedite the current learning a specific point together to condense, assess, integrate and decipher the past research, contentions, and thoughts so as to explore the branch of knowledge. In this way, critical literature review grows new research advancements and thoughts while making more noteworthy comprehension about a point. Besides, critical literature review stresses the significance of evaluating the esteem and commitment of applicable literary works in the theme instead of to make an end from the discoveries of one article (Aveyard 2010). The fundamental aim of the critical literature review is to create a capable review of a collection of writing (Hart 1998). It is not only an outline of what singular work says but also centers around the assortment of work and perspectives in general (Aveyard 2010). Carnwell and Daly (2001) also point out that a decent critical literature review not only evaluates the content of literature but also recognizes the methodological issues and the research areas. In nursing, the nursing understudies and their teachers can rely upon the condensed information to settle on an evidence-based choice with respect to the job of confidence in the nursing job for the nursing understudies. As Whittemore and Knafl (2005) expressed that dependent on the joined consequences of various examinations about confidence in nursing, the quality of the outcomes can be assessed and the proof can likewise be outlined for the future reference. Colling (2003) likewise distinguished that the elements of critical literature reviews are to elucidate the issue recognized for study and to confirm that the issue is critical to advance confidence in nursing understudies.

This critical literature review provides an opportunity is the ability for nursing students to enhance their confidence in the nursing job based on logical learning, plan and distinguish the required regions of progress in a compelling and proficient route with proof (Abbott 1993). As per Aveyard (2010), critical literature reviews draw most significant research and other data altogether to give a total image of the specific field of concentrate so as to outfit solid proof to furnish flow best practice. Evidence-based practice has been perceived as methods for expanding the adequacy of medicinal services intercessions in a previous couple of decades (Jones 2013). Critical literature reviews tend to develop a pool of evidence to promote evidence-based practice. McFadden and Thiemann (2009) characterized that evidence-based practice looks for the most present and best proof related with a given subject, considers past clinical encounters and ability to make judgment about the best activities and coordinates the patients' esteem and convictions into the choices up for considerations, thus the need for a critical analysis of existing research evidence. Polit et al (2001) likewise expressed that evidence-based practice utilizes the research findings as a premise under which nursing practice incorporates basic leadership, activity, and connection with patients. Likewise, medical attendants have a wide scope of data that should be evaluated to confirm best practices in numerous clinical regions. It is also essential for them to assess top-notch data so as to structure and assess result on the adequacy, weightiness, achievability, and suitability of various wellbeing strategies and intercessions (Pearson et al 2005). There are two sorts of literature reviews namely narrative literature review and critical literature reviews. But, Aveyard (2010) expressed their basic point is to give an outline of what is thought about a specific research topic and what gaps of information exist. Be that as it may, the narrative literature review just accentuates on distinguishing the key ideas and the specific hypothetical methodologies embraced to comprehend a research problem while critical literature means to add to rehearse through an appraisal of the adequacy of a specific data and supports much analysis of evidence (Jones 2013). Therefore, as referenced by Aveyard (2010), literature review is a research strategy that the foreordained research question can be replied through seeking and breaking down the important written works by utilizing an orderly methodology. Neale (2009) additionally expressed that critical literature reviews are viewed as a 'high-quality level' as indicated by the chain of importance of what is seen as the best proof. As per this dissertation, the critical literature review has efficiently utilized an approach to explore evidence on the self-esteem of nursing students. The research identified with this theme was perused altogether and the most significant research papers will be chosen and investigated efficiently by utilizing the proper basic research apparatuses. Subjects and discoveries of these research papers were recognized and discussed.

3.3 The Process of Conducting Literature Review

3.3.1 Literature Search

Basically, the process of searching for literature is to assemble and recognize the most momentum and significant data accessible on the research theme (Parahoo 2006) and information that can give the most grounded proof to help the postulation of the research question (Machi and McEvoy 2012). Artisan (1993) recorded that the data on nursing subjects can be retrieved from various materials and sources such as diaries, books, reports, research records, gathering procedures, journal articles, and publications. In any case, the research and factual data might be obsolete by the occasions (Mason 1993, Parahoo 2006). Diaries are typically written in a couple of pages and nearly take a year from acknowledgment to distribution, and they are crisp and less tedious to peruse (Parahoo 2006). Artisan (1993) likewise expressed that research records are the most proper wellspring of writing for nursing research venture. Reports can be in the types of introduction that gave data to the executive’s basic leadership yet their quality differs (Mason 1993, Parahoo 2006). Gathering procedures are modified works or outlines of papers that submitted to the meetings; for the most part, they are just concise data or perhaps at draft organize (Mason 1993, Parahoo 2006). Taking everything into account, each kind of data source has its own an incentive as indicated by the sort and the nature of data it gives (Parahoo 2006). As per Medina and Pailaquilen (2010), materials for a literature review can be retrieved from through electronic database. Automated databases are gigantic subject lists of diary articles and other writing identified with the point that can be sought (Aveyard 2010). Subsequently, electronic databases are the fundamental spotlight for literature search. The most widely recognized and valuable electronic databases for nursing research are CINAHL (Cumulative Index to Nursing and Allied Health Literature and MEDLINE (Medical Literature On-Line) (Polit and Beck 2014). It is important to recognize keywords and equivalent words that identified with the study topic so as to conduct a successful literature search (Mason 1993). The use of 'Boolean administrators’ was employed to consolidate keywords/catchphrases in database seek (Jones 2013). The most well-known Boolean administrators are 'AND', 'OR' and 'NOT' which are utilized to expand or limit the pursuit that the pertinent written works can be recovered (Jones 2013). Besides, Aveyard (2010) asserts that; the required literature review is additionally prescribed in view of some key articles may be missed through electronic seeking because of the manner in which the paper is ordered (Aveyard 2010).

Also, incorporation and avoidance criteria will be created to enable the researcher to distinguish the pieces of literary materials that are relevant to the research question (Aveyard 2010). Aveyard (2010) likewise brought up that the primary basis for setting these criteria is to center defines the scope of the study. Hence these criteria ought to be unequivocal, extensive and have enough subtleties to figure out which articles ought to be included in the literature review (Aveyard 2010).

3.3.2 The Basic Appraisal/evaluation of the Literature

A basic evaluation is an organized procedure to examine literary materials so as to establish qualities and characteristics. As per Mhaskar et al (2009), basic evaluation is the way toward inspecting literary materials cautiously and methodically ascertain on their reliability, relevance, and robustness for a specific study area. After evaluating the quality, relevance, and reliability of the selected literary materials, the materials articles ought to be scrutinized based on a predetermined criterion in so as to establish their nature and suitability for the current study (Aveyard 2010). This procedure is based on the writings by Consumes and Grove (2001) who referenced that literature search process incorporates an orderly and rigorous procedure that considers all the necessary steps involved in establishing the significance of the selected literary materials to determine their benefits and limitations. Katrak et al (2004) played out an efficient review of on 121 basic evaluation apparatuses and presumed that there was fluctuation in aim, parts, development and psychometric properties of distributed basic research instruments for research reports. But, as far as this study is concerned, there is no particular basic research apparatus for a research structure, nor regularly customized for united wellbeing research prerequisites (Katrak et al 2004). Nonetheless, the basic evaluation apparatus ought to contain a proof of use of the experimental premise, and of the device development, legitimacy, elucidation, dependability, and rules for use (Katrak et al 2004). Subsequently, the basic evaluation apparatus can be utilized in a standard way. In this dissertation, a basic research evaluation device/apparatus: Critical Appraisal Skills Program (CASP) was used to evaluate the selected studies. CASP was chosen for this research because it is easily accessible, obviously characterized and effectively comprehended.

3.3.3 Thematic Analysis of Literature

After the basic evaluation of the distinguished writing, it is important to perform investigation and combination of the data in the related research papers (Aveyard 2010). As indicated by Hart (1998), one of the techniques for investigation is thematic analysis/subject mapping which is utilized to sort out and extract data from the selected literary sources. Through the thematic analysis, diverse thoughts can be mapped out and the association between these thoughts can likewise be inferred (Hart 1998).

3.3.4 Ethical Considerations

The use of in any research study moral thought is unequivocal (Polgar and Thomas 1991). Besides, as expressed by Polit and Beck (2014), analysts must think about moral issues in any research with individuals or creatures. Boulton (2009) additionally presumed that morals are basic to properly done research. A good research study must fulfill the high guideline of morals. Beauchamp and Childress (2001) explained the Belmont Report which outlined four basic moral aspirations of research ethics namely: helpfulness, non-wrathfulness, regard for people and equity. These standards were adopted by the current research to inform its ethical considerations. When undertaking a literature review, it is pointless to acquire ethic endorsement from any research ethics board, mainly because literature reviews are based on secondary data (Aveyard 2010). Be that as it may, there are some ethical considerations referenced by Hart (1998) for conducting literature review studies. For instance, researchers ought to comprehend, be open-minded and tolerant while dissecting and assessing the selected literary materials. Besides, because they are basing their research on other’s work, they must recognize the authors of such (Hart 1998). Furthermore, as per Machi and McEvoy (2012), researchers ought not to manipulate the information to suit their research objectives, but rather, interpret the information in a manner that addresses those objectives. Moreover, researchers need to maintain a strategic distance from false information. This is in addition to the consideration that plagiarism should be avoided by using and acknowledging other author’s thoughts while adding the current author’s thoughts. Taking everything into account, writing survey as the procedure will be utilized in this exposition to investigate the effect of confidence in the nursing job in nursing students. The techniques, methodologies and inquiry terms or catchphrases of how to look through the research articles will be talked about in part 4. The basic research and the topical investigation will likewise be assessed in the accompanying parts.

3.3.5 Search Strategy

As per Aveyard (2010), scanning for literature should adopt a precise strategy and an extensive inquiry system; ought to be performed so as to recognize the important literature on the research theme. The literature search strategy entails gathering, recording and reporting information that will enable the development of a valid conclusion of the study findings (Machi and McEvoy 2012). A research conducted in the very fast expressed that once the writing has been chosen from seeking, the point will be qualified and refined to be smaller and progressively concrete. Subsequently, the predefined look into inquiry will be replied through examining and orchestrating of the gathered information. with specific reference to the research question: ' what are the effects of nursing student's self-esteem levels on nursing role ideal?', the literature review will be set up through an orderly hunt technique with centered inquiry terms in various database altogether (Machi and McEvoy (2012). Moreover, incorporation and avoidance criteria will likewise be connected to recognize the applicable literature for the review.

3.3.6 Electronic Database Search

These days, electronic databases are the most helpful and compelling route in looking data. They can give and modern data for analysts. In this examination, the electronic library of Oxford Brookes University and the Hospital Authority EKG were searched to. The databases incorporate CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE (Medical Literature On-Line) and PUBMED were utilized to look through the data about telemonitoring and hypertensive patients. The CINAHL database is an imperative and successful database for medical attendants. It is on the grounds that CINAHL gives references to many nursing and united wellbeing diary articles. MEDLINE contains around 5000 restorative, nursing and wellbeing diaries that spread in excess of 21 million records. PUBMED is a free web crawler getting to basically the MEDLINE database. The above databases are helpful, compelling and easy to use that reasonable for nursing scientists to seek data.

3.3.7 Search Terms

This study is aimed at determining the effect of confidence on the nursing role ideal in nursing students. Notably, there are some key terms that are utilized for the purpose of evaluating the data at hand. This hunt can give an unmistakable spotlight on recognizing and characterizing the research question for the foundation section. The Boolean Search Table can upgrade a far-reaching literature search by joining the pursuit terms or watchwords. Hunt terms or catchphrases that were utilized in the underlying Boolean Search for foundation section are appeared table 1.

A far-reaching inquiry can be done to extend or limit the pursuit through the Boolean administrators with 'AND', 'OR', 'NOT' (Polit and Beck 2014). 'Furthermore, considers every one of the terms included has been sought, 'OR' signifies to catch it is possible that some term that can be picked and 'NOT' would dispose of that inverse. What's more, the truncation office '*' will expand all the conceivable endings of the key term chosen. After the underlying Boolean Search result for the foundation data, a research question has been characterized. It is important to look through the pertinent writing so as to respond to the research question by utilizing the Boolean Search Table once more. Some scan terms were utilized for the Boolean Search and appeared in Table 2.

3.4 Search Results

1216 references were gotten from the original search. After title screening, 287 digests were incorporated for further appraisal. 58 articles were inferred by surveying the modified works by the primary writer and their importance on the job of the examination. Afterward, all writers checked on the 58 articles and just 18 articles were considered in this talk paper. Instances of important examinations are; ponders talking about the job of the open picture of the nursing calling, considers that inspected how nurture builds up their self-idea and expert personality. Every one of the examinations utilized was heterogeneous as far as configuration, test, and setting. Tests utilized are from 1963 RNs and six correspondence experts. The figure indicates a determination process flowchart.

3.5 Inclusion and Exclusion Criteria

After the research subject and inquiry terms are concluded, the consideration and avoidance criteria ought to be incorporated to concentrate on the important writing that reasonable and suitable for the research question. As per Parahoo (2006), in spite of the fact that the auxiliary source has been merged and condensed with the essential information, the data is emotional and the first work might be mutilated or misjudged and the unwavering quality will be influenced. Along these lines, just essential research will be utilized for the literature review. Moreover, the time set for distributions following quite a while of 2000 expects to assemble more state-of-the-art data to keep away from obsolete information. The research papers ought to be in full content and written in English.

3.5.1 Inclusion Criteria:

1. Primary research identified with confidence in nursing role ideal in nursing understudies

2. Primary research from 2000 to introduce

3. Primary research must be written in English

4. Primary research that could be a similar report between confidence in nursing understudies and enrolled medical attendants.

3.5.2 Exclusion Criteria:

1. Primary research before 2000

2. Primary research not written in English

3. Primary research on job of confidence in the nursing job yet not focusing on understudies.

3.6 Study Methods

After the literature search, ten research articles were chosen. These chose articles will be fundamentally evaluated by reasonable and suitable basic research devices. In this examination, the Critical Appraisal Skills Program (CASP) for Randomized Controlled Trial (RCT) will be utilized as a basic evaluation apparatus to scrutinize and broke down randomized controlled preliminary research. Basic Appraisal Skills Program (CASP) is suggested for new analysts since it is broadly assessable, plainly characterized and effectively comprehended and connected so as to respond to normal inquiries with respect to a logical report. Then again, the basic research structure by Coughlan et al (2007) will be utilized to study non-randomized controlled preliminary quantitative research. This system empowers analyst to study the writing altogether by thorough and well basic inquiries. These two basic research devices give reasonable rules and inquiries to study and investigation the chosen research papers in order to guarantee their dependability, legitimacy, transferability, believability, and reliability. After a completely basic evaluation of the chose articles, the qualities and shortcomings are being recognized and the research proof will be sorted out and integrated into real topics. Subject mapping and topical research will be utilized as the investigation strategies to break down the principal topics and ideas of all the chosen articles. Topical investigation can find examples and regularities, just as irregularities by looking at all caught article (Polit and Beck, 2014). Topic mapping can assist specialists with organizing and distinguish the primary substantive topic, remove various topic with various thoughts and close associations between these thoughts (Hart 1998).

CHAPTER FOUR RESULTS

4.0 Introduction

As illustrated in the methodology section of this paper, the researcher selected five (5) most relevant journal articles for review. Among the five studies, one of them was qualitative study; three were quantitative while one was a randomized clinical study. In this chapter, the results of these five journal articles are presented – with specific focus to their aims, objectives, methods, design, strengths, weaknesses, findings and conclusions. This chapter will also illustrate a summary of the critique of these five studies, with a full critique attached to the appendix.

4.1 List of Selected Journal Articles

The listed-below papers were selected with strict adherence to the inclusion criteria. Ultimately, both qualitative and quantitative studies were included in the study for review – in order to achieve the main aim of the study, which is to explore the self-esteem and nursing role ideal among nursing students. Ideally, the researcher included the qualitative study to help gain an insight into the perceptions of self-esteem, which in turn helped in understanding the impact of self-esteem on the nursing role among nursing students. On the other hand, because an objective of the current study was to explore the factors influencing self-esteem among nursing students in different countries across the globe, it was important to evaluate studies that highlighted self-esteem as an important aspect in nursing education and the factors that influence it. Nonetheless, quantitative studies comprised of a major (3 out of 5) portion of the included studies. However, it is important to note that among the quantitative studies, there are some that employed certain elements of qualitative methodologies, and this exposed them to the potentiality of a biased view. Besides, the quantitative studies included in this dissertation, to some extent, address the challenges posed by the qualitative study; especially in regards to quantifiable variables such as educational attainment and knowledge. Through statistical methods used in the quantitative studies, the researchers could easily identify the relationships and patterns and illustrate them in an unbiased manner thereby developing more reliable findings. This justifies the inclusion of quantitative studies in the current dissertation. On the flipside, because part of the objective of the study was to explore the perceptions and impacts of self-esteem, quantitative studies could not help identify perceptions (i.e. perceptions can only be expressed contextually), thus justifying the inclusion of qualitative studies.

4.2 Methods and Design of Included Studies

Paper 1 (Poorgholami et al 2016) was a cross-sectional analytical study, paper 2 (Fouda et al 2016) a cross-sectional descriptive design, paper 3 (Alavijeh et al 2018) a cross-sectional study design, Paper 4 (Chan et al 2014) was a cross-sectional qualitative study design while paper 5 (Memura et al, 2018) was a cross-cultural analytic paper. According to Chenail (2012a), quantitative research design varies but is majorly aimed at identifying how various people think, feel or act in a specific way. The focus on quantitative aspects of the responses which are then analyzed quantitatively using statistical methods. Chenail (2012b) also say that in quantitative studies, results are gathered using structural techniques and instruments, with data in the form of numbers to enable a wider generalization of concepts, thereby assisting in the investigation of relationships between variables. Generally, the selected journal articles aimed to explore self-esteem as a prominent phenomenon among nursing students, factors influencing it, and its impacts on nursing students during practice. Chan et al (2014) explored the self-image of male nursing students based on the thesis that there is a close relationship between the nursing self-image of male nurses and their development in the female-dominated nursing profession. Besides, the objectives of Chan et al 2014 were informed by the argument that the male, a minority gender in the industry, tend to develop a negative self-image. Poorgholami et al 2016 was determined to identify the relationship between nursing student’s self-concept and their clinical performance, Fouda et al 2016 aimed to identify the relationship between self-esteem and the nursing profession among nursing students in a nursing secondary school, while Alavijeh et al (2017) were determined to investigate the relationship between self-esteem and academic achievement among nursing students in a medical sciences university. Lastly, Mimura et al (2008) investigated the relationship between nursing self-esteem, childhood acceptance and stress levels among nursing and pharmacy students in the UK. The five studies used varied methodologies and techniques to collect data. For instance, Chan et al used audio and written autobiographies to collect the experience’s, views and attitudes, as well as interviews and focus groups. According to Dyson & Norrie (2010), interviews are effective methods of data collection because they enable the researcher to investigate the issues at hand from an in-depth perspective, apart from enabling the researcher to have a clear discovery of how the respondents think about the topic under investigation, and why they hold certain opinions towards the topic of discussion. In regards to focus groups, Guenette & Marshall (2009) observe that they enable the researcher to evaluate how a group of participants feel and think about the topic, as well as why they think that way. On the other hand, Poorgholami et al used questionnaires (consisting of a 6-dimension Scale of Nursing Performance) to collect data from university students. Questionnaires enable the researcher to reach a large number of respondents in a relatively easy and economical manner while providing quantifiable answers to the research question (Hesse-Biber & Leavy, 2011). Fouda et al 2016 et al used Self-Esteem Inventory and Image of Nursing as a Profession Questionnaire; while Alavijeh et al used a self-reporting questionnaire to collect data from the participants. Lastly, Mimura et al used Self-esteem questionnaire distributed to students in the class – all who achieve the same advantages achieved by Poorgholami et al for using questionnaires as a method of data collection. Aiming to explore the feelings and experiences of male nursing students, Chan et al used a narrative approach of qualitative data collection to allow for an easier collection of hidden stories from male nursing students that have little opportunity to express their experiences. According to Eriksson & Koyalainen (2015), the narrative approach is often effective for use among marginalized persons in the society to provide them with an opportunity to uncover and review their practicum experiences and learning especially regarding sensitive topics. In doing so, the researchers did not only rely on structured questions but also on probing, so that the researcher has the flexibility and freedom to collect as much data as possible. Nonetheless, Chan et al recruited participants using the Snowballing sampling method. According to Flick (2015), the snowball sampling method has the advantage of enabling the researcher to easily and conveniently access participants especially when the population is a subgroup of a rare population. Snowball sampling method works like a chain referral whereby the researcher asks a participant to refer or identify people with similar interest or traits to participate in the study.

Achieving their objectives through a cross-sectional analytical methodology, Poorgholami et al used a census method, where every individual in the population studies (i.e. when the target population is small). According to Hart (2018), the census method allows the researcher to collect complete data – considering that the whole population participates. The inclusion criteria employed by Poorgholami et al is worth noting: the researchers excluded first and second-year students because they had not undergone certain training in the hospital and hence were not preview to certain experiences that were of interest to the study. Nonetheless, the included participants were those who were willing to participate, those who consented to participate, those with no chronic physical problems and those who had been junior and senior students. More importantly, although Hussein (2015) used questionnaires as their main data collection technique, data analysis majorly took a quantitative approach whereby data distribution was analyzed using SPPSS Version 16.0 – based on descriptive statistics (i.e. standard deviation and mean). Fouda et al used a descriptive cross-sectional research methodology to achieve their objective. Considering their research aim, the researchers were able to collect data on the perceptions of nursing secondary school students on self-esteem and how it affected their professionalism. Besides, the study setting (Secondary schools) was appropriate for the research objective because if they targeted young nursing students, secondary schools offering nursing courses presented the best setting and opportunity to access the target sample population. The Self-Esteem Inventory used by the researchers to collect data was an appropriate tool for data collection because according to Javadi & Koroush (2011), it evaluates a person’s opinions and perceptions about themselves including the negative and positive attitudes they hold about their self-image; as well as their evaluations about their self-concepts. The students’ inclusion criteria comprised of students who were open about their parent’s education levels, the type of jobs their parents were doing, and their own academic years. Alavijeh et al used different means to achieve their objective. First, they used a random stratified sampling method, whereby each faculty was used as a stratum, then selected a proportion of the population from each faculty to be represented in the study. The researchers then gave each volunteer a self-reporting questionnaire and each included participant was selected based on whether they were son study session during the 2016-2017 academic years, whether they were willing to cooperate with the researchers during the study and whether they were able to complete the questionnaires. Any participant who did not fit these criteria was excluded. The questionnaire used by Alavijeh et al was strategically designed into three sections with a total of 18 questions. Generally, the questions addressed different areas including the participant's demographic characteristics, their academic achievement, and various items lifted from the Rosenberg self-esteem scale. On the other hand, the researchers evaluated the participant’s self-esteem using the Rosenberg self-esteem scale – with each item measured based on a4-point Likert Scale type of measurement. Alavijeh et al then subjected their data to SPSS version 20 analysis, analyzing their data based on Pearson Correlation Statistical test, one –way ANOVA and t-test. Lastly, Mimura recruited a group of students on undergraduate nursing and pharmacy programs in two universities: one in Japan and the other in the UK. The researchers chose Universities within the capital cities of each country and only students who were native speakers of Japanese and English were included from each University respectively. The researchers used the Perceived Stress Scale to measure stress levels, while self-esteem was measured using the Rosenberg Self-Esteem Scale. Other instruments used by the researchers included the Parental Nurturing scale and demographic questions of age and gender. According to Noble & Smith (2015), the Perceived Stress Scale is an effective tool used to establish the levels of positive or negative attitude towards self, which uses a 10-item Likert scale to grade attitude levels. The scores are between 10 to 40 points and a high score means high self-esteem. On the other hand, the Perceived Stress Scale is a global measure of an individual’s perceived levels of stress by appraising a person’s situation levels as stressful within a range of 0 (no stress) to 56 (high stress). The penultimate tool used by Mumira et al is the Rosenberg Self-Esteem Scale, which according to Robson & McCartan (2016) measures an individual’s negative or positive attitude towards themselves within a Likert Scale of 10 to 40. Lastly, the researchers used the Parental Nurturing Scale to evaluate each participant’s parental nurturing they received by answering questions on a 5-point Likert Format.

4.3 Limitations

Each of the 5 studies displayed different levels of limitations and strengths. This affected the generalizability of the study findings. for instance, in the study by Chan et al, the researchers only selected 1 nursing training institution to conduct their study. This translated to a smaller sample size, which according to Chenail (2012a), affects the transferability of the study findings. Besides, Chan et al only focused on male students, while staff nurses were excluded. Ideally, this affects the accuracy with which the difference in self-esteem, if any, between male student nurses and female student nurses, is measured. This is of particular concern because if a deeper comparison of male and female self-esteem could be conducted, more influence of self-image on male nurses could be revealed. Another study that displayed some significant limitations is Alajiveh et al. First, the researchers based their data collection on self-reporting, yet according to Chenail (2012b), this technique is often highly prone to recall bias. Besides, the researchers relied on a smaller sample of the population thereby limiting the generalizability of the study findings. Nonetheless, the study by Mimura et al also had several limitations that may be of interest to note. Firstly, the researchers only drew their population from one institution in each country, resulting in a smaller population thereby affecting the generalizability of the study (Dyson & Norrie, 2010). Besides, the data collection was one-off, and not longitudinal, this data could have been affected by prevailing situations and circumstances (Guenette & Marshall, 2009). Next, the researchers used convenient non-randomised sampling and according to Hesse-Biber & Leavy (2011), this could affect the interpretation of various parameter estimates such as childhood acceptance, self-esteem, and stress. The penultimate limitation of this study is that the respondents were all undergraduates, and therefore the researchers could have noticed a higher level of stress among this population than other populations simply because they were students. This affects the generalizability of the study findings. On a more important note, the study only conducted a comparison between nursing and pharmacy students. Hence, the extent to which the issues evaluated by the students are particular to nurses or pharmacists is not known. Lastly, as with issues of self-esteem and stress, some candidates in the study might have declined to participate on questions regarding childhood acceptance, self-esteem and stress due to fear that their personalities could be judged as poor. Consequently, it is highly likely that students who never wanted to be judged based on their interpersonal strengths and weaknesses did not participate in the study, and this may have led to a biased positive outcome of the study findings.

4.4. Ethical Considerations

Two of the five studies obtained ethical approval from the ethics committee or review boards of their respective institutions. Alavijeh et al, Fouda et al and Mimura et al did not indicate whether they obtained ethical approval or not. However, all the five studies obtained either written or verbal consent from the participants before collecting data, thus taking into consideration each participant’s rights. Another important aspect of ethical consideration is informed consent, which is crucial to the participants’ welfare. Erikson & Kovalainen (2015) defines informed consent as the process where participants get all the relevant information (e.g. study aims, objectives, and rationale) about the study before actually agreeing to participate in the study. Ideally, the process of obtaining informed consent is based on legal and moral premises that the participants should be accorded their autonomy during the entire process of the study. Against this backdrop, it is commendable that all the included studies obtained informed consent from participants.

4.5 Implication of Findings

There are several implications of findings identified from each of the five studies. After wanting to investigate negative and positive self-images of male nursing students in Hong Kong with a specific focus on their professional development, gender differences, and identity of nurses, they found that some male nurses had self-identity issues while others found an advantage on the fact that they were male and practicing in a female-dominated profession. These findings `implied that there is a need for the development of strategies meant to assist male nursing students including the development of curriculum strategies that enhance the ability of male nursing students to develop more positive image of themselves, and to develop a feeling for how they can make a difference in the life of a patient. These insights corroborate with the assertions of Brodie et al (2004) that it is only after realizing their value in contributing to the lives of patients that nursing students may appreciate their professional responsibilities and nursing ideal. Nonetheless, another possible implication of the findings by Chan et al is that there is a need for male nursing students to get a comprehensive experience of caring for patients as opposed to being restricted to certain wards (assumed to be professional areas for female nurses). Lastly, we infer from the findings by Chan et al that when developing nursing curriculums, consideration should be made on how such curriculums can promote the self-image of male nursing students and how the self-image is related to patient outcome in clinical contexts. As agreed by Chauke (2014), by considering the impact of self-image on patient outcome, curriculums can create an opportunity for male nursing students to appreciate their role in enhancing the ideal nursing practice. Determined to evaluate the relationship between clinical performance and professional self-concept of student nurses, Poorgholami et al surely found a relationship between the two variables. A possible implication of this finding is that when nursing students’ professional self-concept is enhanced during education, their clinical performance during practice is also likely to be enhanced. Thus, nursing college authorities, teachers and nursing managers have a responsibility of identifying the various factors that influence nursing student’s self-image and make efforts to address these factors with an aim of improving the professional self-concept of their students. These insights are in agreement with Abdel El-Halem et al (2011) that one effective way of developing the professional self-concept of nursing students is to set aside time for private consultation and conversations with the students to listen to their worries as well as their attitudes towards themselves while introducing them to realities of the nursing profession. Fouda et al aimed to identify the nursing image as a profession and how it related to self-esteem and nursing idea. They found several factors that positively influence nursing image and self-esteem, among them being the opinion of their parents toward their profession, their relationship with clinical staff within the training set as well as their relationship with teaching staff in the school setting. On the flipside, Fouda et al found that the public portrayal of the nursing profession in the media as one of the greatest factors that had a negative impact on their professional self-concept. A possible implication of these findings is that parents have a role in enhancing the self-esteem and professional self-image of nursing students, thereby enhancing their ability to serve with confidence while enhancing the nursing ideal. Besides, nursing managers and healthcare authorities have a role to play in checking on how the media displays the nursing profession on the media, or better still, they have a role to play in promoting a positive image of nursing as a profession.

Aiming to establish the relationship between self-esteem and the academic performance of nursing students, Alavijeh et al found a significant relationship between the two variables, a finding that corroborates with the findings of several other scholars such as (Hosseini 2016 and Tamannaifair et al 2010). For instance, Hosseini (2016) found that self-esteem had a strong correlation with students’ academic performance, despite Tamannaifair et al (2010) finding no correlation between students’ self-esteem and academic performance in a study that involved 400 college students. These findings are of important implications because they indicate the important role that self-esteem play on the academic performance of nursing students, and consequently the professional capabilities of such students later in practice. From these findings, it is possible to extrapolate that self-esteem among nursing students has a significant impact on nursing ideal because it directly impacts on the students’ academic performance, which relates to the professional skills they acquire during training. In simple terms, we imply from the findings of Alavijeh et al that students with high self-esteem are capable of achieving better academic success than those with low self-esteem during nursing training. These insights find their place in the studies by Hosseini et al (2007) indicating that whereas some studies have questioned the direct relationship between high self-esteem and academic achievement of students, there is a consensus among several studies that low self-esteem has a direct negative impact on students’ academic performance. The findings by Mimura et al also have significant implications for the current study. Firstly, they intended to identify the relationship between self-esteem, stress and childhood acceptance among nursing and pharmacy students. In the process, they identify several factors influencing self-esteem among nursing and pharmacy students who participated in their study. Nonetheless, their findings indicated that compared to the general population, Nursing and pharmacy students have are more susceptible to stress, which partly derives from self-development and self-esteem issues they encounter during the periods prior to their admission into nursing school. A possible implication of these findings is that to solve stress problem, there is a need to address self-esteem and developmental issues by focusing on the psychological factors of stress management rather than simply addressing the demand characteristics of the occupation.

4.6 Summary Grid of the Selected Studies

CHAPTER FIVE DISCUSSION

5.0 Introduction

This chapter gives a details discussion of the research findings from the five selected studies. It takes a thematic approach in discussion the key findings and attempting to relate them to the research findings. Ultimately, this chapter highlights all the themes related to each study objective so as to provide detailed answers to the corresponding research questions.

5.1 The perception of self-esteem and nursing role ideal in nursing students

The theme of how nursing students perceived their self-esteem and how this impacted on the ideal nursing role was predominantly discussed in the study by Chan et al. Fundamentally Chan et al focuses on male nursing students, how they perceive themselves in a female-dominated occupation and how this perception affects their professional capabilities of ideal nursing roles. Nonetheless, in regards to the theme of self-esteem and its impact on the ideal nursing role, the study we have found a wide range of evidence highlighting the relationship between these two variables. For instance, we identified the existence of confusion among male students about their identities and roles. Particularly, participants in the study by Chan et al indicated that considering the nursing roles, anyone else, and not necessarily them, can perform these roles. Indeed, these findings are in agreement with the findings by Tan-Knick (2012) that both male and female nursing students tend to be concerned over their roles. However, it is commonly perceived that a nurse is someone who is female and this triggers male nursing students to develop a different perception of themselves from that of female students. Data from the participants in Chan et al’s study also reveal a belief by some patients and healthcare staff that nurses are always females and that there is a paucity of clear image for male nurses. However, this affects the male nurses’ professional development and ability to perform an ideal nursing role because if the male students are ignored by some patients and healthcare staff, they are unable to develop their identity as future nursing professionals. Another element of self-esteem that the current study found to have a detrimental impact on the nursing role ideal is self-depreciation, i.e. a feeling of self-inferiority among nursing students. In the study by Chan et al, the participants indicated that they felt less competent especially when handling female patients. This confirms assertions by Peyrovi et al (2012) that male nursing students and female nursing students tend to have a different self-image. Besides, from the findings by Chan et al indicate, we argue that the feeling of self-depreciation within the clinical setting also emerges from the fact that they still adequate experience – and this applies to both male and female students. The current study has also identified important insights regarding autonomy. First, we acknowledge that it is important for practitioners in the nursing profession to have the autonomy, and that autonomy contributes to the development of self0image among both nursing students and practicing nurses. In this regard, results from the current study indicate that student nurses tend to develop autonomy when they gain the hospital’s trust, especially in the clinical training setting. Nonetheless, another subtheme that has emerged is ‘instrumentalization’ construed as the use of people as tools for completing tasks while focusing on their performance rather than their feelings. In this regard, participants in the reviewed studies indicate perceived themselves as medical instruments used within the clinical setting. For instance, participants in the study by Chan et al indicated that in several instances, they have observed an idea held by mentors that men are more capable in doing manual labour within the clinical setting regardless of the lack of guidance forcing them to do so. Besides, it emerges from the reviewed studies that some male nursing students are given extra workload that prevents them from performing their personal activities, and this affects their self-image in the sense that they feel powerless and lack control of their own schedules just because of their male gender. Another sub-theme that has emerged under the theme of self-image and its impact on the nursing role ideal is ‘awareness of gender differences among nursing students and the impact of this awareness on self-image. Essentially, this theme emerged in the sense of how male and female nursing students pay attention to their gender differences, and how this attention affected their nursing role ideal. To understand this better, we can argue from two points of references namely: the impact of gender difference on patient caring, and the inherited gender characteristics. From the former perspective, reviewed studies suggested that whereas male and female nurses share the same roles, they execute their roles differently. For instance, a respondent in the study by Chan et al noted that female nurses have softer voices that are more comforting compared to their male counterparts who have deeper voices hence the perception that females have more psychologically comforting voices to patients than male nurses – while male nurses are better at solving problems. It can be argued therefore that nursing students hold certain opinions about their gender differences and how such differences influence their capabilities to perform nursing role ideal, and this affects their ability to practice.

Circumspection is one capability that enables the nurse to serve their patients better. The reviewed studies revealed much discussion on the sense of circumspection among either male or female nursing students. Particularly, one participant in the study by Chan et al noted that female nurses generally display a better sense of circumspection compared to male nurses, some even suggesting that they instinctively have a greater sense of circumspection than their male counterparts. It is possible to extrapolate from these findings that having a sense of circumspection and even being able to acknowledge that it exists has an influence on the nursing role ideal of nursing students because circumspection fundamentally means being more sensitive thus being able to serve patients better. Participants in the reviewed study also discussed their perception of the different capabilities in patient caring. For instance, participants in the study by Chan et al acknowledged that male patients would prefer to be served or cared for by nurses of the same gender and that sharing biological characteristics was one of the factors that enhanced a mutual understanding between male patients and male nurses. A possible implication of this discussion is that male nursing students perceive themselves and their gender as appropriate for serving a particular gender of patients (i.e. male patients), and this perception affects the patient they would prefer to serve, regardless of the requirements by NICE (2018) guidelines that nurses should never discriminate whom they prefer to serve. Indeed, this is reinforced by discussions indicating that male nurses perceive themselves to be better than female nurses in caring for older male patients because there is a better sense of mutual understanding between them and these kinds of patients especially when the patient only talks in gestures. One participant in the study by Cahn et al gave an example of the insertion of Foley catheter insertion where he noted that female patients may not perceive the patient’s feelings when asked to perform the insertion on a male patient – as opposed to their male counterparts who are likely to know the male patient’s feelings. The discussion on caring for patients also led to the discussion on performing nursing procedures on female patients without a chaperone. Particularly, male participants in the study by Chan et al perceived themselves as highly alert to the gender differences between their female patients and them and therefore noted that they would be concerned of sexual harassment accusations if they were left to care for the female patients alone. This indicates the extent to which self-perception among nursing students affect their nursing role ideals and how this may affect their level of professional development in the nursing practice setting. A discussion also arose on self-esteem and perceived career development especially among male nurses. First, it is important to note that the student male nurses on which this discussion ensued were at a stage of learning, and hence their perception is closely related to the experiences their encounter during their clinical education. Nonetheless, this discussion emerged in two subthemes namely clinical education and career development. First, from the discussion by Chan et al, some participants were still not aware of how their career path could develop i.e. the female nursing student participants perceived themselves to be capable of serving both male and female patients without feeling a sense of embarrassment while their male counterparts perceived themselves as still not accepted by the general public. Ideally, this perception is capable of causing male nursing students to develop a self-image that is different from their female counterparts, thus affecting their ability to perform their nursing role ideals. One of the reviewed studies (i.e. Poorgholami et al 2016) also showed that professional self-concept is correlated to the clinical performance of nursing students i.e. nurses with a strong professional self-concept will perform better in nursing healthcare practice, thus being able to adequately deliver the nursing role ideal. In-depth discussions indicate that professional self-concept acts as a motivational factor that has a greater influence on the nursing student’s clinical performance by initiating a feeling or responsibility, professional development, and greater insight. It has also indicated in one of the reviewed studies that self-concept has an impact on the educational performance of nursing students and that a positive self-image contributes to nursing educational success. These findings corroborate with the findings of an earlier study by Namdar et al (2013) which indicated that learner’s educational attainment is influenced by how they see themselves. Because nursing students, similar to students in other fields face several psychological issues, which affect their educational results, it is monumental to consider issues related to their mental health.

Results of this study also show that there is a relationship between emotional intelligence and clinical performance, a phenomenon that impacts on their ability to perform nursing role ideal, and a relationship between the educational satisfaction of nursing students and their academic success, findings that are confirmed by the findings of Beauvais et al (2011) and Edrakim et al (2012) respectively. However, these findings are in contrast with the findings of Tamannaifar et al (2010) which showed that there is no significant relationship between nursing student’s self-esteem or self-concept and their educational attainment, and therefore these variables cannot be used to determine their ability to perform nursing role ideal later in their careers. However, it is important to note that the discrepancies could be methodologically instigated because as opposed to Poorgholami et al (2016) who used professional self-concept questionnaire to evaluate nursing professional self-concept, Tamannaifar et al (2010) used Rodger’s self-concept questionnaire to evaluate personality traits. On the other hand, studies by Whyte et al (2009) did not find any relationship between nurses’ self-esteem and professional knowledge, and this indicated that whereas performance and knowledge are important elements of the nursing profession and contribute to the performance of nursing role ideals, other factors should also be considered while attempting to improve the clinical performance of student nurses. This implies that in a complex profession such as nursing, cognitive skills are important but not sufficient. All in all, discussions reveal that male and female student nurses have both negative and positive self-image about themselves as several participants in the reviewed study that focused on male students stated that that they lacked a clear image of themselves or did not find themselves to be of a reasonable status. However, some participants found a sense of self-worth among them and generally perceived themselves as capable of delivering quality care to patients and improving their quality of life.

5.2 Factors Influencing Self-Esteem and Nursing Role Ideal in Students

Discussions indicate that there are several factors influencing self-esteem and nursing role ideal among nursing students. For instance, findings indicate that the self-esteem of male nursing students is influenced by the confusion about their identity, lack of clarity about their roles, all which contribute to feelings of inferiority. It also emerges from the discussions that the lack of clinical experience may also contribute to poor self-image among nursing students. In the discussions about nursing student’s professional self-concept, it emerged that the self-concept as measured by the NSCQ was lower compared to the self-concept of similar students studying abroad. a similar study by Vilazadeh et al (2007), it was found that low professional self-concept was attributable to the society’s indifference to the nursing profession and how the society perceived it as worthless. Furthermore, the same line of discussions indicate that when nursing students realize that health facilities and hospitals are doctor-centered and that they are given tasks that are routine-based, the environment begins to appear directly or indirectly restrictive, and the students begin to feel as though their potential is not recognized. This contributes to poor professional self-concept. But discussions by the reviewed studies also show that it is easier to predict low professional self-esteem among nursing students. These findings corroborate with the results by (Edwards et al (2010) and Randle et al (2001) that nursing students tend to begin their professional courses with an average level of self-esteem and by the time they reach the end of their education, their self-esteem levels reach below average. That said, because the reviewed study considered both junior and senior nursing students, it is easier to extrapolate the predictability of their low professional self-concept levels. It is also evident that the level of study (i.e. the academic year) of nursing students is a significant influencer of their professional self-concept, and how they perceive their value professionally. This is especially true, considering the fact that no correlation has been found to exist between any demographic variable and the scores of both NSCQ and 6-DSNP. Indeed, this finding corroborates with the findings of Badiyepeyma (2014) which found no significant relationship between age and self-concept. Concerning cultural factors that affect the self-esteem and professional image of nursing students, the result indicates that the non-optimistic common image of the nursing profession in certain communities such as the Arab world is a great impediment to high self-esteem among nursing students in such societies. particularly, results show that in Arab societies, the public view nursing profession as a women’s job characterized by low salary income, low prestige a little respect, a phenomenon that not only presents women in the profession as subordinate but also affects the professional self-worth of male nurses. These findings are in agreement with the assertions of Tan-Kuick (2012) indicating that students in secondary schools intending to pursue nursing courses in college are affected by the negatively held social image of nursing as a profession.

The results also show that the social perspective of the nursing profession is a significant impediment to high self-esteem and personal image as future nursing professionals among nursing students. This social perspective is said to be influenced by the culture and traditions of the society that has a negative reflection on the nursing profession. In this regard, participants in the reviewed studies indicated that the society perceives the nursing profession as more of a women’s occupation that a men’s work and this largely affects the self-image and professional self-concept of male or trans-gender nursing students. A lack of positive self-image and poor professional self-concept may have a negative impact on their ability to undertake their nursing role ideal. Consequently, societies that have such a negative social perception about the nursing profession require more sensitization campaigns that are targeted at promoting a positive professional conception about nursing and encouraging males to join the profession. Nonetheless, the interpretation that the negative social perception held by Arab societies towards the nursing profession affects the self-esteem and professional self-image of male and female nursing students is echoed by Keog & O’Lynn (2007) and Kalisch et al (2006), and who noted that the Arab society tend to adopt a negative picture of the nursing profession and contributes to a fundamental questioning of the professional self-image nursing role ideal especially among the male nursing students. Besides, it is observable that in the Arab societies, the media paints a negative and unconstructive picture about the male nurse, and this affects how male nursing students perceive themselves against their career choice of becoming nurses. Indeed this, the finding is supported by the findings of Mee (2006) only 36% of their participants (mainly young men) perceived the nursing profession as a male and female job. Connected to the above findings, the current study has also found that the media portrayal a public image of nursing are some of the most prominent factors influencing the self-image and professional self-concept of nursing students. Particularly, this is due to the stereotypes and misconceptions that emerge from the distortion of nurses’ image on the media. This finding is echoed by Gordon and Nelson (2005) who found that the influence that media has on the image of nurses and the doctors’ subordinates, sexy associates and companions contributes to a low self-worth of nursing students who begin to see themselves as caring assistants and not as self-directed professionals who provide medical services to needy patients. Nonetheless, Ibrahim et al (2015) agree that being unable to be employed after finishing nursing training is one of the powerful determinants of the professional self-image of nursing students. Besides, it has been found that nursing is perceived as a profession with fewer job opportunities and this influences nursing students to perceive themselves as worthless members of society who are unable to contribute economically to the societal welfare by getting employed as members of the society. These findings corroborate with the assertions by Ben & Becker (2010) that even if they got employed, they would still suffer from these stereotypes, and this affects their morale and ability to perform their nursing role ideal. The findings also reveal that nursing students develop negative self-esteem and professional self-concept due to the perception that the nursing profession is subordinate to the medical profession. These findings corroborate with the findings of Savi & Pagon (2008) that there was prevalence if the belief that nurses are subordinate to doctors and therefore a feeling of inferiority emerged among them. When this belief is adopted by nursing students, they develop the inferiority perception and tend to have a lower professional self-concept especially when they compare themselves with their colleagues who undertake medical courses. The reliability of these findings is confirmed by Cohen (2007) who observed that Florence Nightingale portrayed nurses to be of a lower standard compared to doctors – a portrayal that generally hurts the self-esteem and professional self-image of nursing students. It is clear from the results that nursing student’s relationship with the medical staff during clinical training, the teaching staff in nursing school, and parent’s opinion are some of the factors that influence the self-esteem and professional self-image of nursing students. This finding is in agreement with the findings of Al Jarrah (2013) indicating that the self-esteem and professional self-image of nursing students is significantly influenced with the opinion of their family members and with the medical staff. The findings also corroborate with the assertions of Tan-Kuick (2012) indicating that the nursing student’s decision to complete their nursing studies and become professional nurses is influenced by the perception their parents and peers have about their profession as nurses.

The current study findings also reveal that the studying environment or setting also has a significant influence on nursing student’s self-esteem. Particularly, it has been found that students residing in rural areas had lower self-esteem (P≤ 0.04) that their counterparts from urban areas. These findings concur with the findings of Peyrovi et al (2012) who found a statistically significant correlation between self-esteem and the residential setting of nurses. Furthermore, these findings are comparable to the findings by Ghezelbash et al (2015) revealing how 33% of the nursing students participant agreed that the taking a job as a nurse is like being a housemaid who is disrespected because the job is portrayed by the media as one with inadequate necessities and with minimum employment opportunities. Results of the current study also indicate child acceptance as a significant factor influencing the self-esteem of nursing students. While the observed correlation between self-esteem and childhood acceptance observed in the current study are lower than those indicated in previous studies (e.g. Buri et al 1992), there is a general consensus among the current findings and findings of previous studies that there is a significant correlation between childhood acceptance and self-esteem in nursing students. Interestingly though, the strength of this correlation was found to be similar between nursing and pharmacy students, suggesting that as it is common with other groups of people, perceived child acceptance is associated with low self-esteem. Hence, perceived childhood acceptance is a key issue to be considered when addressing self-esteem issues among nursing students. Findings of the current study also indicate stress as a key influence of self-esteem among nursing students. Particularly, reviewed studies have indicated that the relationship between childhood acceptance and stress among nursing students is mediated by self-esteem levels. Yet, findings of the current study also show that nursing students generally have higher stress levels than the general student population. A possible implication of these findings is that there is a complex causative relationship between childhood acceptance, stress levels, and self-esteem among nursing students and therefore addressing self-esteem would require remedies that consider the two other variables.

5.3 Impact of Self-Esteem on the Nursing Role Ideal

Nursing role ideal is influenced by many factors, among them, being the academic achievement of nursing student, particularly because anywhere in the world, nurses are conventionally allowed to practice after gaining several certifications, most of which are pegged on their academic performance. First, the current study findings indicate that there is a significant relationship between the self-esteem levels of nursing students and their academic achievements. This finding corroborates with the findings of Janati that 91% of the students had high self-esteem, thereby showing the important contribution of self-esteem to academic achievement. The findings that academic self-esteem has an impact on the academic performance of nursing students are also supported with the findings of this study that indicated a significant relationship between self-esteem and the self-reported Grade total Grade Point Average of the participants in one of the reviewed studies. This finding implies that as important as the academic achievement of nursing student is to their ability to perform nursing role ideals, they may not be able to achieve the desired academic performance if they lack adequate self-esteem. However, there are other studies that have indicated contradictory results regarding the relationship between self-esteem and nurses’ academic performance. for instance, in a study by Tamannaifar et al (2010) that involved 400 male and female participants, there was no reported relationship between self–esteem and academic performance among the nursing students, and thus I was concluded that nursing students could still achieve good academic performance and execute their nursing role ideals regardless of their self-esteem levels. From the reviewed studies, results indicate that low self-esteem can affect the performance of nursing role ideals of nursing students in two major ways namely: poor communication and defensive behavior. In regards to the latter, it is fist acknowledgeable that at some point during the nursing course, the students are supervised by ward staffs or clinical instructors, and when these two levels of practitioners are not available, the ward staffs take over the supervision role. But, as results indicate, the ward staffs sometimes take over the jobs in the middle of the procedure because they feel the students are not doing it correctly. Such actions make them feel unconformable and hinder their ability to learn effectively. Similar remarks are made by Mabuda et al (2008) that in a clinical teaching setting, student nurses should be given opportunity to learn by finishing procedure – i.e. the provision of a proper environment for learning by supervisors, actors, mentors, and assessors. Results also indicate that nursing students are sometimes asked to perform certain tasks (e.g. administering medications) that they are not capable of doing, and this triggers their defensive behavior especially when they ask colleagues to perform such tasks on their behalf. In this regard, it is possible to argue that lack of self-confidence can negatively impact the nursing student’s ability to learn new information and techniques of addressing challenging tasks, and students with low confidence tend to display defeat before they make any attempt on the task. the above situation indicates that low self-confidence and self-esteem affects the student’s ability to perform certain tasks due to the feeling that they cannot, yet they might be able to perform them adequately if they tried. this is especially worrying considering that the after learning the theory in class, the students need the self-confidence to practice what they have learned in a practical environment so that they are capable to practically execute their nursing role ideals.

Sometimes, as results indicate, the student nurses are not appreciated or recognized by their clinical instructors when they think they have performed well or done a remarkable job. The feeling that they deserve a compliment when they perform well in the clinical setting, and the fact that they do not get such compliments, affects their self-confidence in performing such tasks next time, making them be more defensive when they are given same tasks next time. Mabuda et al (2008) commented that such scenarios can cause a conflict between the student’s attitude and behaviors, thereby affecting their ability to execute their ideal nursing roles. A possible implication of these findings is that supervisors, instructors or assessors should give the students constant guidance to prevent from developing despair or reactions that may affect their ability to perform their nursing role ideals. Besides, it is possible to extrapolate that while dealing with the students, there is a need for supervisors to develop a combination of clinical expertise and passion for teaching to enable an effective interaction between them and their students, and to be able to impart in them the skills that strengthen their abilities to perform nursing role ideals. Besides, the results indicate the important need for nursing student supervisors to perceive clinical supervision and teaching as part of their strategies to enhance quality care and nursing role ideal. This corroborates with the assertions by Namdar et al (2013) that hospital managers should ensure there are adequate clinical personnel and facilities to enable effective teaching of nursing students. The availability of good environment not only enables the nursing students to achieve professional development but also to improve service delivery. As earlier reported, a defensive behavior among student nurses emanates from low-self-esteem and self-confidence and affects the ability of nursing students to perform their ideal nursing roles. This corroborates with the assertions by Hisken (2011) that when nursing students are struggling with issues of self-esteem, it becomes difficult to interact with patients in a manner that promotes the delivery of quality person-centered care. When the students have low self-esteem, they critique themselves unconstructively and see themselves as incapable of delivering quality care. Even when things go wrong in the clinical setting, they fail to recognize their positive qualities and instead think they are not good enough. These observations elucidate the need for adequate encouragement from nurse educators, especially in regards to how they can participate in activities that improve their self-worth among their peers. Edrakim et al (2012) suggest that this can be done through team building activities, motivational talk or religious activities. Besides, the results indicate the need for adequate focus on creating self-awareness among nursing students about their job responsibilities as nursing students in terms of what they are supposed to and why they are doing such procedures.

Low self-esteem also affects nursing role ideal by affecting the nursing student’s communication abilities. Results indicate that nursing students with low self-esteem are shy and scared to communicate either with their peers, the nursing staff, teaching staff or supervisors. Yet, communication emerges as one of the most important elements of the nursing profession especially because nurses are in a service industry and deal with humans throughout their careers. As reiterated by other researchers such as Cassey & Wallis (2011), communication is a central element of human interaction and it is a way in which nurses understand their patients’ needs. However, results indicate that nursing students with low self-esteem find it difficult to develop a rapport with the clinical staff when they are in the clinical setting, as well as their lecturers, and this affects their learning ability especially in regards to performing the nursing role ideal. These findings corroborate with the findings of Tamannaifar et al (2009) that inability to effectively communicate with as a result of low self-esteem leads into lack of confidence to respond to patients or their family members while in the clinical setting. More worryingly, results indicate that inability to properly communicate as a result of low self-esteem creates fear among the nursing students even in regards toward rounds because they are afraid of being unable to answer questions from physicians or doctors.

CHAPTER SIX CONCLUSIONS AND RECCOMENDATIONS

6.1 Conclusion

The primary objective of this research involved conducting a literature review with the aim of establishing the perception of self-esteem and nursing role ideal ideal in nursing students. The research involved a critical review of the literature to identify specific themes of discussions that could answer the research questions. The information was examined, decoded and various these identified for the purpose of analysis. The research comprises of various limitations. Accordingly, the data obtained from the various sources utilized small sample size thus, making their outcomes less generalizable. As such, the findings of the researchers may have not sufficiently reflected in the entire nursing students. However, there was the transferability of the results in a broader context. The study utilized the literature review methodology that yielded the description of the information from both qualitative and quantitative research designs. The focus on the research emphasized the roles and identities of the nursing students, and how these roles are impacted by their self-esteem levels - this was linked to their professional development. As identified in the discussion, some of the students in the reviewed studies had positive self-identities while others had negative self-identities. Nonetheless, various barriers may limit nursing students from obtaining professional development within the nursing niches. The results of this study pave the way for the future establishment of positive role and self-esteem of the student nurses within their future careers.

6.2 Recommendations

Due to the present's weakness of the career choice, some of the recommendations were realized, which aims at promoting the behavior of the students towards their fields of profession. It was found that self-esteem and students' perceptions have significantly shaped the reputations of nursing students. Secondly, some of the professional development courses could help the students to publicize their professional identity. Also, good foundations at an early age also envisage the students to build a good future in them or may make them succeed in the future. However, the school should equip the learners with some of the facilities, which aim at benefiting their experience and enhancing the level of their graduation. This could include combing the theory and professional Ideal; lastly, the structure of the nursing courses delivered to nursing students should be reformed and designated in the manner that helps the students build their self-esteem and professional self-concept while pursuing effective leadership skills.

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