Self-Esteem And Assertiveness Levels Of Nursing Students

Abstract

This study was conducted as a descriptive study to determine the self-esteem and assertiveness levels of the nursing students and the influencing factors. The universe of the research was composed of 643 students studying at Health Sciences Faculty. 426 students were included in the study. The data were collected using the " Personal Information Form ", " Rathus Assertiveness Inventory (RAI)" and " Coopersmith Self-Esteem Inventory (CSEI )" after obtaining the necessary permits. The data were analyzed using percentage, variance, regression analyses and the significance test of the difference between two mean. The average CSEI scores of the students were 68,71 ± 17,25, 45,53% had low self-esteem and CSEI was affected by gender, the place of living, monthly income, choosing and being happy with the profession, self-identification, and their current place of residence (P <0.005). In addition, the average RAE score was 11,51±19,59 and 50.6 % were assertive at a low level. There was a moderate correlation between CSEI and RAE scores in the negative direction, but this relationship was not statistically significant (r = -0.064, p> 0.05). Considering the fact that nursing education is stressful and intensive, it is suggested to provide educational environments that will increase the levels of assertiveness and self-esteem of the students during the education process.

Keywords: Assertivenessnurseself-esteemstudentTurkey

Introduction

One of the main aims of nursing education is to educate the members of this profession as individuals who value themselves, who have high self-esteem, good human relations, and who are attentive in fulfilling their functions so that they become more successful, productive and sought- after individuals in the society they live in (Begley & Glacken, 2004). Nurses interact with their patients, colleagues and other health care workers due to their roles. The effectiveness of their role will increase when nurses have good communication skills. One of the main complements of effective communication is the ability to act assertively. Considered as the most effective form of communication, assertiveness consciously protects one’s honor, rights, views, feelings and thoughts without being passive or aggressive (Timmis & Mccabe, 2005). Assertive individuals are more likely to listen to others, find solutions by talking and tend to communicate and cooperate (Uzuntarla, et al, 2016). Assertiveness is based on the formation of mutual love, respect and trust among individuals by acting in the framework of equality and justice instead of doing what the others want them to do (Karataş & Tabak, 2009). It is stated that individuals with high levels of assertiveness are more successful in their social life and exhibit more effective communication skills (Voltan-Acar, et al, 2008).

It is very important that we can demonstrate the feelings and behaviors that are appropriate for us in establishing and developing healthy human relationships. This is because, as the individuals protect their rights, their relationships with others become easier, the consistence among their feelings, thoughts and behaviors improves and they take the responsibility of their behaviors more easily. It also enables individuals to be able to make a request from the others, to say no to things they do not want, to accept praise, to express their feelings more easily and their self-esteem and satisfaction increase (Terakye, 1998; Küçük, Buzlu, & Can, 2008). It is one of the main aims of nur ng education to educate the members of this profession as individuals with high self- siesteem and assertive behaviors in interpersonal relationships (Begley & Glacken, 2004; Timmis & Mccabe, 2005; Küçük et al., 2008). Providing health care at a desired level and being satisfied with this service can only be achieved by educating nurses with high self-esteem and self-confidence (Lin et al., 2004).

This research aimed to determine the assertiveness and self-esteem levels of the students studying in the nursing department, the variables influencing assertiveness and self-esteem, and the relationship between assertive behavior and self-esteem.

Problem Statement

Nursing is one of the occupational groups that prevent being assertive. Therefore, the issue of assertiveness in nursing has been investigated and the answer to the question "Does nursing need assertive behavior?" has been sought since 1970s (Kutlu, 2009). There are a lot of factors that influence the ability to be assertive. In particular, the most important reason why nurses do not show assertive behavior is the fact that nursing is a woman’s profession, and women have a traditional role in society. The role of the woman as a traditional sister and care giver sometimes causes her to be aggressive by being strict and authoritarian or to be passive. In addition, the reactions to stress, low self-esteem, lack of role model, lack of opportunities to learn to be assertive and hierarchical values can also cause nurses not to act assertively. For nursing students who will enter the nursing profession in the future, the problems caused by the school and hospital environment as well as the problems they experience as university students may prevent assertive behavior. Nursing education is a difficult process with all these aspects and it can be difficult for nursing students to act assertively (Dinçer & Öztunç, 2009; Kutlu, 2009; Koçak, Türkkan, & Tuna, 2014). In the studies conducted with the nurses, it was found that the assertiveness increased the cooperation and commitment of the nurses with the other team members, their job satisfaction, professionalism and quality of patient care while reducing their job stress (Timmis & Mccabe, 2005; Taghavilarijani, Sharifi Neyestanak, Ag-hagani, & Mehran, 2010). This situation was also reported to reduce the job dissatisfaction, burnout, job stress which can occur in nursing that is an intense and stressful profession while increasing the self-confidence of the individual (Koçak et al., 2014). It was determined that 70.7% of the nurses had a tendency to act assertively in a study carried out in our country that measured the assertiveness level of the nursing students (Dinçer & Öztunç, 2009).

Problem Statement

This study will answer the following questions: What are the levels of assertiveness and self-esteem of nursing students? Are their levels of assertiveness and self-esteem sufficient for professionalism? Which socio-demographic variables affect students' assertiveness and self-esteem levels? Does self-esteem affect assertiveness?

Purpose of the Study

This research aimed to determine the assertiveness and self-esteem levels of the students studying in the nursing department, the variables influencing assertiveness and self-esteem, and the relationship between assertive behavior and self-esteem.

Research Methods

This is a descriptive study and its universe consisted of the nursing students at Karadeniz Technical University Health Sciences Faculty (n=643). The universe was taken as a sampling group and no sample selection was made.The data collection forms were administered face-to-face by the researchers between February 2014 and March 2014, on different days, with the students who were present at school on that day and volunteers for the research before their classes began. A total of 460 students were reached. The data were evaluated using 426 students’ forms as 34 students did not complete their forms.

The data were collected by using the "Personal Information Form", "Rathus Assertiveness Inventory (RAI)" and "Coopersmith Self-Esteem Inventory (CSEI)" after obtaining the required permissions.

Personal Information Form: Prepared by the researchers in the direction of the literature, this form consists of 15 questions to determine the socio-demographic characteristics of the students.

Rathus Assertiveness Inventory (RAI): It was developed by Rathus and its validity and reliability in Turkey was performed by Voltan. Voltan determined the alpha consistency coefficient of the inventory as 0.70 and the test-retest reliability as 0.92. In this thirty-item inventory, the participant evaluates him/herself with a 6-point scale from -3 to +3. The total score of the participants will be between -90 and +90; -90 refers to highest degree of unassertiveness and +90 refers to the highest level of assertiveness. According to the score obtained from the scale, it is evaluated as unassertive behavior between -90 and +9 points and assertive between +10 and + 90 points (Voltan-Acar, 1980).

Coopersmith Self-Esteem Inventory (CSEI): The self-esteem of students was assessed using CSEI developed by Stanley Coopersmith (1986) and its validity and reliability were performed by Turan and Tufan (1987) by adapting it to Turkish. Turan and Tufan found test-retest (one year later) reliability as 0.65 and 0.76, respectively. The scale consists of 25 items that can be marked as "like me" or "not like me." In these items, there are expressions about the individual’s point of view of life, family relations, social relations and endurance. The scores to be obtained from the scale range from 0 to 100. Self-esteem is assessed according to whether it is above or below the average. The scores above and below the average indicate high self-esteem and low self-esteem respectively (Turan & Tufan, 1987).

In the analysis of the data collected by the researcher, the effect of the independent variables on the self-esteem and assertiveness levels were evaluated using One-Way ANOVA in the groups of more than two and t test in the groups of two. The relationship between some of the independent variables and the scales was assessed using correlation, and the descriptive properties were shown as percentages. LSD (Least Significant Difference) analysis was performed as a post-hoc test when the variance analysis was significant at 0.05 level (p <0.05).

Findings

Of the 426 students, 81,2% were girls, 50,5% were Anatolian high school graduates and 44,6% were first grade students. 59,9% of their mothers, 39,4% of their fathers were primary school graduates, 92,32% of their mothers were housewives, 35,2% of their fathers were self-employed and 76,3% of them spent most of their lives in the city. It was determined that 40,8% had 4 siblings and over, 32,2% had family income of 1000-1499TL, and 83,3% were in the nuclear family structure. 67, 8% selected their profession willingly, 61,0% liked their profession, and 51,9% defined themselves as assertive.

The mean RAI score of the students was 11, 51 ± 19,59 and the mean CSEI score was 68,71 ± 17,25. It was determined that 50,6% of the students had a low level of assertiveness, 49,3% had an unassertive nature, and 54,5% had self-esteem above the average and 45,5% had lower self-esteem below the average (Table 1 ).

Table 1 -
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In Table 2 , some characteristics of the students and the distribution of the mean RAI and CSEI scores are presented. Compared to the male students (12.20±18.73), the mean RAI scores of female students (11.35±19.81) showed an increase, however, there was no statistically significant relationship between gender and the mean RAI scores (p <0.05). It was found that the mean CSEI scores was high in the female students (69.75 ± 17.25) and low in male students (63.65 ± 17.96) and this difference was statistically significant (p <0.05).

Table 2 -
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In our study, the mean RAI scores (13.39±21.08) of the students who spent most of their lives in the city and the mean CSEI scores (69.76 ± 16.90) those who spent most of their lives in the town were found high. It was determined that the relationship between the place where the students spent most of their lives and the mean CSEI scores was statistically significant (p <0.05). The study showed that, the mean CSEI scores (73.95 ± 15.44) was found to be the highest among the students who expressed monthly income of 2000 TL and over. It was determined that the relationship between the monthly income of the students and their CSEI scores was statistically significant (p <0.05). As a result of the advanced analysis, this difference was found to be due to the fact that the mean CSEI scores of the students who had monthly income of 2000 TL and above were higher than those of other income groups. No relationship was found between the monthly income and the mean RAI scores of the students (p> 0.05). The mean CSEI (71,04 ± 16,35) scores of the students who selected their profession were significantly higher (70.39 ± 15.87) than those of the students who selected the profession unwillingly (CSEI: 63,79 ± 18,13) and this difference was statistically significant (p <0.05). It was found that the mean CSEI scores (71, 40 ±16,36) of the students who loved their profession was found to be higher than the mean CSEI scores (69.20±17.25) of those who did not (60,46 ±15,72) and those who were indecisive (66,42±18,49) (p <0.05). According to the results of the advanced analysis methods, the difference appeared in the students who loved their profession. There was no statistical relationship between the mean RAI scores and their status of loving the profession (p> 0.05). The mean CSEI (74.8±16.02 ) scores of the students who defined themselves as assertive in our study were higher than the CSEI scores (62, 59±16.45) of those who defined themselves as unassertive and this difference was statistically significant (p <0.05). It was found that there was no statistical relationship between students' self-definition and the mean RAI scores (p> 0.05). In our study, a moderate relation in the negative direction was determined between the CSEI and RAI scores, but this relationship was not statistically significant (r = -0.064, p> 0.05). There was no statistically significant relationship between the high school the students graduated from, the grade they were studying in, their parents' educational level, their parents' occupations, family structure and the mean RAI and CSEI scores (p> 0.05).

Conclusion

This study investigated the relationship between the levels of assertiveness and self-esteem of nursing students, influencing variables, and their interrelationships. In our study, the level of assertiveness and self-esteem of nursing students, the factors influencing them, and the relationship between assertiveness and self-esteem differed. Considering that the tools used to collect the data in our study range from 0-100 for CSEI and 90 to +90 for RAI, we can generally say that nursing students' self-esteem is moderate and they are unassertive.

The mean RAI scores of the nursing students included in the study was 11.51 ± 19.59. As the score of the inventory increases, the individual's nature to act assertively increases. Approximately half (50.7%) of the students have a low level of assertiveness and the other half have an unassertive nature (49.3%). In other words, they cannot act assertively. It is known that individuals with unassertive behaviors cannot express themselves sufficiently and have an introvert nature, which in turn is predisposed to depression (Özcan, 2006). The mean RAI scores were reported as 21.50 ± 21.27 in the study by Dinçer and Öztunç (2009), 20.90 ± 25.00 in the study by Yılmaz (2000) and 36.29 ± 25.33 in the study by Karagözoğlu et al. (2008) (Yılmaz& Ekinci, 2001; Karagözoğlu, Kahve, Koç, & Adamişoğlu, 2008; Dinçer & Öztunç, 2009). When we compared our findings with the results of the studies above, it was seen that the average RAI scores of the students were low. On the other hand, the determination of nursing students to show unassertive behaviors in the study conducted by Rezayat and Deghan Nayeri (2014) (55.6% unassertive), Koçak et al. (2014), (9.49 ± 18.33) is compatible with the findings of this study (Rezayat & Deghan Nayeri, 2014; Koçak et al., 2014). We think that the fact that majority of nurses are females and nursing education is stressful may have increased the unassertiveness.

The mean CSEI scores of the students was 68.71 ± 17.25 and it was determined that 54.5% had high self-esteem. In the studies conducted in Turkey on this issue, it has been reported that the self-esteem levels of nursing students were 71.94 ± 15.86 in Dinçer and Öztunç‘s (2009) study and 74.78 ± 16 in Özkan and Özen’s (2008) study. The studies in the literature show that nursing students have moderate self-esteem which is consistent with the results of our study (Burnard, Hebden, & Edwards, 2001; Begley & Glacken, 2004; Edwards, Burnard, Bennett, & Hebden, 2010). Self-esteem is the focus of therapeutic patient nurse communication, and communication with patients is an indispensable part of effective treatment (Carson, Harman, Webb, Kimonis, & Kuipers, 2001). Nurses with low self-esteem are unlikely to be able to meet the demands of many policy and health services that affect health care, and thus patient care is adversely affected (Randle, 2003).

When self-esteem and assertiveness levels were examined in terms of gender variable in the literature, it was seen that self-esteem and assertiveness were related to some male-specific characteristics, and girls' self-esteem and assertiveness were lower than men (Uzuntarla, et al., 2016). There was no statistically significant relationship between male students' attitudes compared to female students in our study and there was no statistically significant difference among male students' mean RAI scores (p> 0.05). However, in some studies, it was found that female students were more assertive (Adana, Betül, Sevda, & Hicran, 2009; Ekici et al., 2013). Compared to male students, female students had higher self-esteem and a statistically significant relationship between the mean RAI scores of female and male students was found (p <0.05). The results of this study are similar to those of Karagözoğlu et al. (2008). It is believed that male students' lower self-esteem is largely due to the fact they selected a profession in which the majority are women.

Starting an undergraduate education gives an individual greater confidence and responsibility. The student takes more responsibility to control his/her own life and to be influential on the future, develops his/her independent thinking skills and gains confidence that s/he can solve his/her problems. Thus, at the end of undergraduate education, the level of self-esteem and assertiveness is expected to increase. When the studies in the literature are reviewed, it is seen that the self-esteem and assertiveness of the students who are about to finish the undergraduate program increase (Begley & Glacken, 2004; Karadağ, Güner, Çuhadar, & Uçan, 2008; Dinçer & Öztunç, 2009; Ekinci, Altun, & Can, 2013). The controversial studies showing that the levels of assertiveness and self-esteem are higher at the onset of the nursing program and decline in the following years are also notable in the literature (Randle, 2003; Edwards et al., 2010). In our study, although there was no significant difference in assertiveness and self-esteem scores according to the grades of the students, as the class level increased, the scores of assertiveness and self-esteem decreased. As nursing education is a repressive and stressful experience, it is thought that it affects the self-esteem and assertiveness levels of the students negatively, and as the class level increases, the self-esteem and assertiveness scores decrease.

In our study, there was a difference between the level of family income and self-esteem (p <0.05) and it was determined that the students with income over 2000 TL had higher self-esteem than the other income groups. In some similar studies, while there were no statistically significant outcomes between the students' income and the mean self-esteem scores (Kutlu, 2009), it was reported to find a significant relation by Çam, Khorshid, & Özsoy (2000), Dinçer & Öztunç (2009), Uzuntarla et al. (2016). It was determined that the self-esteem of the students who willingly selected and loved their profession was significantly higher than the others and this difference was statistically significant (p <0.05). Küçük et al. (2008) reported that the assertiveness scores were higher in those who preferred the profession in the first place (Küçük et al., 2008), which is similar to the findings of this study.

Our study demonstrated that the students who defined themselves as assertive had higher self-esteem than those who defined themselves as unassertive. This difference was statistically significant (p <0.05). It may be thought that this result can arise from their efforts to prove their value, to demonstrate their skills, to improve their interpersonal relationships and academic success. There is also a significant positive relationship between assertive behavior and self-esteem in the related studies (Karagöz, et al., 2008; Dinçer & Öztunç, 2009). In our study, there was no statistically significant relationship between the CSEI and RAI scores of the students in the negative direction (r = 0.588, p <0.01).

In our study, the nursing students' low RAI scores indicated that they were unassertive and their self-esteem decreased as their unassertiveness increased. It was determined that half of the nursing students showed unassertive behavior and their self-esteem was moderately high. An insignificant negative relationship was found between the nursing students’ assertiveness and self-esteem levels. Self-esteem was found to be influenced by gender, the place in which one spends most of his/her life, the average monthly income, self-identification, occupational choice and the love of profession. Considering the findings of the research; it may be advisable to carry out training and supportive activities for student nurses to increase the level of assertiveness in this profession in which the majority are females and to carry out studies to determine more detailed and effective factors on the level of self-esteem and assertiveness.

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09 April 2019

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Multicultural education, education, personal health, public health, social discrimination,social inequality

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Bulut, H. K., Çalık, K. Y., Erdöl, H., & Yılmaz, G. (2019). Self-Esteem And Assertiveness Levels Of Nursing Students. In E. Soriano, C. Sleeter, M. Antonia Casanova, R. M. Zapata, & V. C. Cala (Eds.), The Value of Education and Health for a Global, Transcultural World, vol 60. European Proceedings of Social and Behavioural Sciences (pp. 819-827). Future Academy. https://doi.org/10.15405/epsbs.2019.04.02.101