Nursing and Health Sciences (2002), 4, 9–14

Research Article

Self-esteem and student nurses:A cross-cultural study of

nursing students in Thailand and the UK
Siriphan Sasat, phd, rn,1 Philip Burnard, phd, rn,2 Deborah Edwards, mphil, bsc,2
Wassana Naiyapatana, phd, rn,1 Una Hebden, msc, rn,2 Wallapa Boonrod, msn, rn,1
Bussarin Arayathanitkul, bsn, msn1 and Waraporn Wongmak, bsn, msn1
1
Royal Thai Army Nursing College, Bangkok,Thailand and 2School of Nursing and Midwifery Studies,
University of Wales College of Medicine, Cardiff,Wales, UK

Abstract Self-esteem is a key feature in a person’s perception of their own worth. This report is of a study
of the reported self-esteem levels of two groups of student nurses: one in Thailand and one in the
UK. Purposive samples of 120 Thai students and 101 UK undergraduate nursing students were
given the Culture-Free Self-Esteem Inventory (CFSEI-2). The CFSEI-2 is a self-reported inven-
tory, which measures an individual’s perception of self. The findings of the study indicate that the
perceptions of own self-esteem in undergraduate student nurses in the UK and in Thailand were
comparable to the normal ranges of self-esteem as assessed by the instrument. An independent
sample t-test revealed that there were no significant differences in mean overall and subscale
self-esteem scores between UK and Thai nursing students. There were no indications of differ-
ences in levels of self-esteem for UK and Thai nursing students experiencing different parts of
their training.

Key words cross-cultural, self-esteem, student nurses, Thailand, UK.

INTRODUCTION to individuals’ perceptions of the quality of their own

relationships with peers; and personal self-esteem
Self-esteem refers to the perception the individual
refers to individuals’ most intimate perceptions of
possesses of his or her self-worth. A person with high
self-worth.
self-esteem is an individual with self-respect, who
Individuals who feel good about themselves are
considers him/herself to be of worth, is proud of
confident, take pride in their work, and demonstrate
his/her achievements (Rosenberg, 1985) and who can
respect and concern for patients and colleagues. It
minimize the effects of stress (Turner & Roszell,
has been suggested that the roots for building high
1994). An individual experiencing low self-esteem
self-esteem may lie in the educational process. During
may lack confidence, is self-critical and considers
socialization in nursing education, the student ac-
him/herself to be less worthy and competent than
quires a concept of self as a nurse. Having a feeling of
others (Rosenberg, 1985).
self-confidence and self-worth is basic to developing
Self-esteem has also been described as comprising a
leadership skills for baccalaureate nursing graduates.
number of facets or components that include general,
A positive self-image, and hence professional identity,
social and personal self-esteem (Coopersmith, 1967;
is a prerequisite for a nurse to have a strong and
Battle, 1981, 1990). General self-esteem is the aspect
therapeutic relationship with a patient (Ohlen &
of self-esteem that refers to individuals’ overall per-
Segesten, 1998). Nurses develop a more positive self-
ceptions of their own worth; social self-esteem refers
image through career advancement and advanced
education (Porter & Porter, 1991).
The concepts of ‘self’ vary from culture to culture
Correspondence address: Philip Burnard, School of Nursing and (Mashaba, 1995; Kareem & Littlewood, 2000). The
Midwifery Studies, University of Wales College of Medicine, Heath
Park, Cardiff CF14 4XN, Wales, UK. Email: burnard@cf.ac.uk
aim of the present study was to explore the issue of
Received 2 April 2001; revised 31 October 2001; accepted 2 November self-esteem in two groups of student nurses, one from
2001. the UK and the other from Thailand.
10
Literature review
This literature review attempts to bring together the
wide range of research in the area of self-esteem and
self-concept. However, it is difficult to make direct
comparisons between studies because of the wide
range of different instruments used.
In a study of 280 nursing students in Thailand,
self-esteem was measured using a questionnaire
developed by the authors based on Coopersmith’s
conceptual framework of self-esteem (Coopersmith,
1967). Self-esteem was found to be significantly nega-
tively correlated with job satisfaction, with a trend
towards early retirement (Navapanit, 1994). Tunkoon
(1999), using the same framework, investigated self-
esteem in 148 fourth year nursing students from
Bangkok. Self-esteem was found to be significantly
positively correlated with the achievement of clinical
practise and was significantly negatively correlated
with stress (Tunkoon, 1999). Both of these studies
developed their own questionnaires and, although
both were piloted, the results should be treated with
caution.
Boey (1998), in a study of nurses working in a
public hospital in Singapore, used an adapted version
of the Rosenberg self-esteem scale to identify self-
esteem levels (Rosenberg, 1985). The nurses were cat-
egorized into two groups: (i) stress resistant (n = 205);
and (ii) distressed (n = 160). Stress-resistant nurses
had higher self-esteem and were described as enjoy-
ing good mental health status. In contrast, distressed
nurses reported four or more symptoms of ill-health
(as identified by the General Health Questionnaire-
12 [GHQ-12]), and were considered to have mild
mental-health problems. A limitation of this study is
that the authors adapted a well-validated scale, which
makes comparisons with other studies difficult.
Imai (2001), in a Japanese study, investigated occu-
pational factors contributing to low self-esteem in
registered nurses (552), licensed practical nurses (146)
and unemployed registered nurses (433). Regression
analysis revealed that employment status and qualifi-
cations were the most important factors in determin-
ing the self-esteem of these nurses. It is difficult to
compare these findings with other studies due to the
inclusion of unemployed registered nurses within the
sample (unemployed nurses have not been included
in other studies).
In a study of 700 Korean hospital registered nurses,
Arthur et al. (1998a) used the Rosenberg Self-Esteem
Inventory (Rosenberg, 1985) and his own validated
scale, the Professional Self-concept of Nurses Instru-
ment (PSCNI). A significant relationship between
professional self-concept and self-esteem was estab-
S. Sasat et al.
lished. The respondents came from a university
setting; therefore it is difficult to generalize these find-
ings to Korean nurses in general.
There have been few studies reported from the
UK over the past 10 years, and what is available is
of an anecdotal nature. However, there have been
a number of studies conducted in the USA and
Canada. Moyer (1996), using Perlow’s Self-Esteem
Scale with a sample of 247 female junior and senior
baccalaureate nursing students, concluded that self-
esteem could be linked positively to improved self-
perception of clinical competence. The findings also
revealed that there was no difference in self-esteem
between junior and senior nurses at both pre- and
post-semester time. A study undertaken using the
Rosenberg Self-Esteem Inventory with 253 home-
care nurses revealed that self-esteem was positively
correlated to social intimacy and job satisfaction and
negatively correlated to stress (Moore et al., 1997).
Other studies have explored the area of self-
concept as opposed to self-esteem. A positive self-
concept has been defined as positive self-evaluation,
self-respect, self-esteem and self-acceptance (Arthur
& Thorne, 1998b). Cremeans (1988) reported that,
in a group of 50 nursing students, a significant re-
lationship could be detected between academic
performance and clinical performance, although the
relationship between self-concept and clinical perfor-
mance was not significant.
Thirty-two baccalaureate nursing students from
New York were studied to ascertain changes in self-
concept (Klug, 1989). The findings revealed that 44%
of the nursing students reported more characteristics
reflecting a negative self-concept at the completion of
their final year, compared with their responses at
the beginning of the nursing program. However, the
authors developed their own questionnaire and the
sample size was too small for any generalizations to
be made.
Ellis (1980) applied the Tennessee Self-Concept
Scale to 177 nursing students and found that, in com-
parison with the norms for the instrument, the
nursing student population means for the subscale of
self-criticism and physical self were lower and for
moral-ethical self were higher. The data revealed that
that self-confidence and self-esteem, which were
higher at the beginning of the nursing program, de-
creased with each subsequent year of the program.
In a study conducted by Shepherd & Brooks
(1991), 200 associate degree, diploma, and generic
baccalaureate nursing students were investigated to
compare levels of self-concept using the Tennessee
Self-Concept Scale. There were no significant differ-
ences in this measure of self-concept among the four
Self-esteem in Thai and UK student nurses
programs. This was an exploratory study and further
work needs to be conducted with larger sample sizes
in order to investigate the relationship between nurs-
ing program and self-concept.
Arthur & Thorne (1998b) investigated professional
self-concept in a group of 127 Canadian students. This
sample included 40 students studying a Masters of
Science nursing course, 28 in a post-basic Bachelor
of Science course, 27 in the fourth year of a generic
Bachelor of Science course and 32 in the second year
of a generic Bachelor of Science course. The instru-
ments used were the PSCNI and the Rosenberg Self-
Esteem Inventory. They reported that professional
self-concept and self-esteem improves with years of
experience, with life experience and with university
education.
Further work was undertaken using the PSCNI
with 1957 registered nurses from across 11 countries
(Australia, Canada, Hong Kong, China, Korea, New
Zealand, the Philippines, Scotland, Singapore, South
Africa and Sweden). Nurses from Korea were found
to have the lowest mean score, and the highest mean
score was found in the sample from New Zealand
(Arthur et al., 1999). However, comparisons between
the samples should be interpreted with caution as the
sample was not matched and nurses from the Asian
countries were younger and less experienced.
METHODS
Sample and setting
Two purposive samples were used for the present
study. Purposive sampling is a form of non-probability
sampling where the researcher selects respondents
on the basis of a personal judgement about which
ones will be most representative or productive (Polit
& Hungler, 1991). The total population, in each case,
comprised university students in Thailand and the UK
who were undertaking a degree course in nursing.
The instrument
Self-esteem was measured using the Culture-Free
Self-Esteem Inventory (CFSEI-2). The CFSEI-2 is
a self-reported inventory, which measures an individ-
ual’s perception of self. The CFSEI-2 has been shown
to be a valid and reliable tool in the measurement of
self-esteem amongst adults (Battle, 1981). The CFSEI-
2 for adults contains 40 items and four subtests: (i)
general self-esteem (16 items); (ii) social self-esteem
(eight items); (iii) personal self-esteem (eight items);
and (iv) lie subtest (items that indicate defensiveness,
eight items). The items in the instrument are divided
11
into two groups: those that indicate high self-esteem
and those that indicate low self-esteem. The responses
are of a forced choice variety; the individual checks
each item either ‘yes’ or ‘no’.
Battle (1990) argues for the culture-free aspect of
the scale by indicating that it has been translated into
several languages with no objections of cultural bias
from practitioners. The stimulus items in the CFSEI-2
were chosen in part for content that was least sensi-
tive to change from one culture to another (Battle,
1990). Therefore, the present study began with the
translation of the questionnaire into Thai by the Thai
authors who are senior academics. The translated
instrument was checked for face validity (Parahoo,
1997), by a small panel of four experts, who compared
and contrasted the original and the translated instru-
ments. This panel of experts was a group of people
who were able to confirm (or otherwise) the apparent
validity of, in this case, the translation of the instru-
ment (Davis, 1992). The panel was made up of four
senior educators fluent in Thai and English. Various
small adjustments were made to the instrument fol-
lowing the advice of the panel. This process helped
to provide face validity, and the accuracy of the trans-
lation was assured using reverse translation by a
Professor of English at a Thai university. Thus, the
translation and back-translation were independent of
each other, which ensure the validity of the transla-
tion. A small pilot study, involving 10 Thai students,
was then conducted to ensure further validity of the
instrument.
The CFSEI-2 was administered according to the
instructions supplied with the instrument, and the
questionnaires were scored manually. Scores from
both datasets were then entered into the spss soft-
ware program (Chicago, USA) and descriptive statis-
tics were computed.
Raw scores for total self-esteem, and subtests
and corresponding percentiles and T-scores were ob-
tained. A percentile rank indicates how a subject’s
raw score compares with that of others in the stand-
ardized group. A T-score is a standard score with a
mean of 50 and a standard deviation of 10. T-score
conversions permit normalization of a distribution of
scores.
The procedure
Questionnaires were sent to 140 Thai university
nursing students out of a total population of 280. One
hundred and twenty questionnaires were completed,
giving a response rate of 85%. Of these, there were 31
students from year one, 29 from year two, 30 from
year three and 30 from year four. Questionnaires
12 S. Sasat et al.

Table 1. Mean self-esteem scores

95% CI
Score Country Mean SD t Lower Upper P

Overall UK 48.11 9.53 –0.539 –3.22 1.84 0.591

Thailand 48.80 9.47
General UK 48.74 9.55 –0.768 –3.33 1.46 0.443
Thailand 49.68 8.50
Social UK 49.17 10.82 1.278 –1.08 5.07 0.202
Thailand 47.18 12.12
Personal UK 47.33 9.17 –1.539 –4.37 0.54 0.125
Thailand 49.24 9.24

were sent to 110 UK university nursing students out Table 2. Categorization of scores
of a total population of 110. One hundred and one
questionnaires were completed, giving a response rate UK Thailand
of 92%. This sample from the UK included 29 stu- Level of self-esteem N % N %
dents from year one, 19 from year two, 31 from year
Very low 14 13.9 11 9.2
three and 25 from year four. The majority of students
Low 22 21.8 22 18.3
from both countries were female and within the age Intermediate 37 36.6 52 43.3
range 18–40 years (direct information on gender and High 22 21.8 20 16.7
age was not available due to a number of respondents Very high 6 5.9 15 12.5
failing to complete the relevant information). Total 101 100 120 100

RESULTS
These undergraduate student nurses from the UK
and Thailand had perceptions of their self-esteem that
were comparable to the normal ranges of self-esteem
as assessed by the instrument (norms: overall 23.1;
general 11.8; social 6.6; personal 4.7). An independent
sample t-test revealed that there were no significant
differences in mean overall and subscale self-esteem
scores between UK and Thai nursing students
(Table 1).
The relationship between self-esteem and year of
study was investigated for both samples using one-
way anova. There were no differences in overall or
subscale mean scores with year of study.
When the overall self-esteem scores were catego-
rized into various levels of self-esteem (very high,
high, intermediate, low and very low), more nursing
students in Thailand appeared to fall into the very
high category (12.5%) when compared to the UK
nursing students (5.9%). However, these results did
not reach statistical significance due to the small
numbers of students within each group (c2 = 2.744;
P = 0.098). These results are displayed in Table 2.
Table 3 shows the categorization of subscores for
the different levels for general, personal and social
self-esteem. When the subscales are examined, it can
be seen that 78.2% of UK students and 70.8% of Thai
students rated themselves as having a high/very high
level of social self-esteem.
The range of scores in the overall measure for the
UK students was 5–31, and for the Thai students was
3–32. The range of scores in the general subscale was
UK students 3–16, Thai students 1–16; the social sub-
scale, UK students 1–8, Thai students 1–8; the per-
sonal subscale, UK students 0–8, Thai students 0–8;
and the lie test, UK students 2–8, Thai students 1–8.
The mean ± SD lie test score was 6.34 ± 1.48 for the
UK students and 5.35 ± 1.33 for the Thai students.
Ninety-six percent of the sample (UK and Thailand
combined) scored 4 or better, indicating that the
majority displayed a lack of defensiveness when
responding to the lie items.
DISCUSSION
Arthur (1995), in reviewing the literature from the
1970s onwards, suggests that low self-esteem is a
problem for student nurses. However, the findings of
the present study indicate that undergraduate student
nurses’ perceptions of their own self-esteem is compa-
rable to the normal ranges as assessed by the instru-
ment. According to Rosenberg (1985), self-esteem
Self-esteem in Thai and UK student nurses 13

Table 3. Categorization of subscales

Social General Personal

Level of UK Thailand UK Thailand UK Thailand
self-esteem n % n % n % n % n % n %

Very low 2 2.0 2 1.7 3 3.0 6 5.0 18 3.0 13 10.8

Low 3 3.0 10 8.3 10 9.9 3 2.5 20 9.9 28 23.3
Intermediate 17 16.8 23 19.2 38 37.6 53 44.2 34 37.6 40 33.3
High 47 46.5 49 40.8 26 25.7 41 34.2 25 25.7 27 22.5
Very high 32 31.7 36 30.0 24 23.8 17 14.2 4 3.8 12 10.0
Total 101 100 120 100 101 100 120 100 101 100 120 100

involves an attitude of approval of oneself, and those
with high self-esteem are likely to have self-respect
while those with low self-esteem are likely to lack
confidence, be self-critical and consider themselves
less worthy and competent than others. If Rosenberg
is right, the findings from the current study are
encouraging.
There are indications from the literature that some
nursing educational processes may have deleterious
effects on aspects of self-concept, with previous
research suggesting that self-confidence and self-
esteem decreases as nursing courses progress and that
new graduates lack self-esteem (Olsen, 1994). Ellis
(1980) revealed that self-confidence and self-esteem
was higher at the beginning of the nursing program
and decreased with each subsequent year. Klug
(1989) observed a decrease in self-concept over a
two-year period among baccalaureate nursing stu-
dents. However, findings from the current study do
not indicate a difference in levels of self-esteem for
UK and Thai nursing students at different stages of
their training. This is in accord with findings from
the USA in which there were no differences in self-
esteem between junior and senior nursing students,
or at the beginning or end of the semesters (Moyer,
1996).
Findings from a much larger Canadian study
suggest that a student may develop a stronger sense
of professional self-concept as the transition from
student to nurse progresses. Fourth year students
express a higher professional self-concept than their
second year counterparts (Arthur & Thorne, 1998b).
Shepherd & Brooks (1991) found no differences
between self-concept amongst senior students in four
types of nursing education programs in the USA.
Findings from the two groups in the present study
suggest that there were few differences between the
two groups in terms of self-esteem. Previous research
investigating professional self-concept in nurses from
11 different countries found that Korean nurses had
the lowest score, and nurses from China (Hong
Kong), Singapore and China (Beijing) have lower
scores than nurses from New Zealand, the Philip-
pines, Canada, South Africa, Sweden, Scotland and
Australia (Arthur et al., 1999). Many of these dif-
ferences may be explained by differences in the quali-
fication level across the samples, while in the current
study the nurses were all studying at the degree
level.
Limitations of the study
The current study has some limitations. First, a conve-
nience sample was used from both sites. Arguably, a
random sample would be a ‘safer’ sample from which
to generalize findings. Second, despite the precautions
taken to produce a good translation of the instru-
ment, differences of meaning are bound to occur in
reading and interpretation. In view of these limita-
tions, the findings should be treated with caution.
However, the present study offers an interesting start-
ing point from which to debate cross-cultural issues in
self-esteem and nursing.
Future research should, perhaps, concentrate on
following a cohort of nursing throughout the entire
period of their course, in order to determine if any
differences in levels of self-esteem exist. This proce-
dure would also enable the evaluation of any differ-
ences between first and final year students as the
research evidence in this area is contradictory.
ACKNOWLEDGEMENTS
Thanks to Major General Prai Kleowplodtook,
Director of the Royal Thai Army Nursing College,
Colonel Paranee Lerkyen, Chair of the Royal Thai
Army Research Committee, and the nursing students
who participated in this study.
14
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