Motivation in the First Year of Nursing Education: It’s Relationship with Professional Self-Concept, Self-Esteem

Methods: A total of 242 students participated in the descriptive and relational study. Data was collected using a student identification form, the Motivation Sources and Problems Scale (MSPS), the Professional Self Concept in Nursing Students Scale (PSCNSS), and the Stanley Coopersmith Self Esteem Scale (SCSES). In statistical evaluation, frequency, mean, the t test, the Pearson correlation analysis, the Stepwise Multiple Regression analysis, ANOVA, and the Kruskal Wallis test were used.


Introduction
Nursing is an occupation formed by professionals who have contemporary information, who research, question, plan, decide, and apply [1]. Nursing education is a planned education program that aims at students gaining proficiency in the use of values, attitudes, information and skills present within the nursing occupation [2,3]. Another aim of nursing education is to provide motivation for nurses to gain the necessary skills to provide appropriate and high quality health services to patients with multiple complex health problems [4]. Studies have shown that in the clinical environment and clinical training, the most important barrier was the lack of interest and motivation in students [3,5,6]. In order to help others in the future, nursing students need long term motivation. For this reason, in nursing education, which takes on the role of shaping human behavior and is realized in two sections as theoretical and clinical, the importance of paying attention to the concept of motivation is great [4].
Motivation is one of the most important power sources that determine the direction, intensity, and determination of the learning behavior of students, and is one of the processes that initiates the effectiveness of learning [3,6,7]. In the period when they have just began their education, there are many factors that can affect the many definitions of professional self-have been made, these can be summarized as becoming one with the occupation, perceiving oneself as a member of an occupation, being sure of occupational roles and responsibilities, feeling close to occupational information and skills, and internalizing the philosophical principles, values, beliefs, and attitudes of the occupation [10,11]. For nursing students to effectively perform their duties in the future as professional nurses in the clinical environment alongside other health care professionals, the formation of a positive professional self-concept is important. When professional self does not develop positively, problems such as not having a say in the occupational field, not being able to perform the nursing role successfully, problems in the transition from education to the occupation, and insufficient ties to the occupation arise [12]. This, in turn, affects care quality and patient satisfaction [4]. It is well known that the professional identity forms largely during the nursing education process, and that the concept of self is a basis for the shaping of professional identity [13]. Self-esteem is the state of satisfaction that a person reaches as a result of evaluating oneself and approving oneself [1,14,15]. Factors such as an individual feeling that he/she is valuable, being able to exhibit his/her knowledge and skills, being accepted within the community, being loved, and embracing his/ her physical characteristics have important roles in the development and formation of self-esteem. The contribution of self-esteem to the development of professional values and professional self is also high [16][17][18]. A positive self-perception is very important to the positive development of the professional self [19].
Nursing education aims at developing the self-esteem of students as well as providing theoretical information and skills [16]. Students with higher levels of self-esteem are more enterprising in their social relations and school efforts, more confident, and more open to learn new things [14,20]. Additionally, self-esteem helps one gain information, skills, and independence, supporting the development of professionalism and helping students with social, cultural, and emotional adaptation [15], and supports efficient coping skills [21]. Students with low self-esteem levels have a lack of motivation [16], are less confident, and feel that they may not succeed in performing what they are asked to do [20]. In a study by Jahromi, Kargar and Ramezanli, an important correlation between the self-concept and clinical performances of nursing students was found [22]. In another study, self-esteem, self-sufficiency, and nursing motivation were found to affect the professional self-concept of nursing students [23]. In this context, increasing the education and clinical application motivation of students would be important in the positive development of their self-esteem and professional self-concept [24]. In a number of studies, motivation was found to positively affect academic performance [25][26][27]. Additionally, it has been stressed that motivation increases occupational development and service recipient satisfaction [28,29]. Increasing quality in nursing education raising nurses that will perform their jobs happily and willingly, determining the motivation levels of student to increase care quality and patient satisfaction are all important. Examining the motivation levels of nursing students in the first year of their education and the relationships between motivation levels and professional self and selfesteem levels are important with regard to early contribution to the positive development of professional self, which starts forming with entrance to the education process and develops almost fully during education. Additionally, this study carries importance for guiding tutors in determining motivation and professional self-development strategies according to the characteristics of the students.

Aim and design
The descriptive and relational study was conducted in order to examine the motivation levels of nursing students in their first year and the relationships between motivation levels and professional selfconcept and self-esteem levels, as well as determining the personal and occupational characteristics that affect motivation.

Setting and subjects
The universe of the study consisted of 254 freshmen studying at the department of Nursing. Without sample selection, the aim was to reach the whole of the universe. In this context, 242 students who agreed to participate in the study and filled out the data forms completely were included in the study.

Data collection tools
Data was collected using one form and three scales.

The Introductory Information Form:
The form, which was prepared by the researchers consists of 18 questions regarding the socio demographic, nursing occupation related and education related characteristics of the students (age, gender, status regarding willing choice for the nursing occupation, choice number in university selection and reasons etc.)

Motivation Sources and Problems Scale (MSPS):
The scale was developed and tested for validity and reliability by Acat and Kosgeroglu [30]. Firstly, to verify the validity of the scale prepared, the opinions of five expert educationists in the department of the science of education and four experts in the department of nurse education were sought. In the light of the suggestions made, the necessary alterations were made on the questionnaire. The first form of the scale consisted of 40 items of three sub-scales. This scale was applied to the same students with an intervention of three weeks through the test and retest method. After the items eliminated through the retest method were excluded, the scale was revised in order to verify the reliability of the remaining 30 items in the scale. To achieve this, this scale was applied to 400 students. These students who participated in the test/retest procedure were not included in the final analyses. The components of the factors of the scale were determined as a result of the analysis of the data obtained. The scale was comprised of 30 items prior to the preliminary application. Prior to rotation, items with loadings of the factors lower than 0.30 were excluded. The categorization of the remaining 24 items into three sub dimensions after the rotation was determined [30]. The internal motivation sub scale consists of 11 questions, the negative motivation sub scale consists of 8 questions, and the external motivation sub scale consists of 5 questions. The intrinsic motivation is the desire to be successful, the external motivation is the motivation that arises from the working environment of the individual, and the negative motivation is an amotivated when they perceive a lack of contingency between their behavior and outcomes. The scale is the 5 way likert type. 16 items in the scale are scored straight, while 8 are scored in reverse. Scores that can be received from the scale change between 24 and 100. The average score obtained from three sub dimensions of the scale show the occupational learning motivation level of the individual. Higher scores, mean higher motivation. The Cronbach Alpha coefficient of the scale was found to be 0.82 in the original study of the MSPS and 0.85 in this study.

Professional Self Concept in Nursing Students Scale (PSCNSS):
The scale was developed and tested for validity and reliability by Sabanciogullari and Dogan [11]. The 4 way likert type 81= I don't agree at all, 4= I completely agree) scale consists of 45 questions. The scale has 3 sub dimensions; occupational satisfaction, occupational proficiency, and occupational characteristics. Occupational satisfaction refers to nursing students' occupational satisfaction and is the person's perception of themselves as the member of the profession. Occupational proficiency includes questions of oneself in terms of occupational qualifications, such as problem solving skills, decisionmaking, occupational knowledge and skills, and occupational competency required to perform the nursing student profession. Occupational characteristic includes questions regarding feelings, thoughts and beliefs related to the fulfilment and the qualifications of the profession. 31 items in the scale are scored straight, while 14 are scored in reverse. Scores that can be received from the scale change between 45 and 180. High scores indicate that the professional selfconcept of the nursing students develops positively. The Cronbach Alpha coefficient of the scale was found to be 0.88 in the original study of the PSCNSS and similarly 0.88 in this study.

The Stanley Coopersmith Self-Esteem Scale (SCSES):
The swelf esteem levels of the students were determined using the Stanley Coopersmith Self-Esteem Scale (SCSES). The scale, which was developed by Stanley and Coopersmith (1986) and adapted to Turkish and tested for validity and reliability by Turan and Turfan [31] consists of 25 items. These items contain terms regarding the life views, family relations, social relations and resilience of the individual. The scores that can be taken vary between 0 and 100. Evaluations are made according to whether the scores received are higher or lower than the average. Scores lower than the average indicates low selfesteem while scores higher than average mean high self-esteem. The Cronbach Alpha coefficient of the scale was found to be 0.76 in the original study and 0.70 in this study.

Procedure
Data collection forms were applied to the students during a classroom hour. Before data gathering, students were informed on the purpose and importance of the study and their verbal consent was taken. The forms were filled out by the students themselves and handed back to the researchers.

Data analysis
Data analysis was performed using the Statistical Package for Social Sciences (SPSS) ver. 21.0 package program. In statistical analysis, frequency distributions, mean values, the t test, the Pearson correlation analysis, the Stepwise Multiple Regression analysis, ANOVA, and the Kruskal Wallis test were used.

Ethical considerations
Written permission from the ethical board of a university was taken for the study to be performed (Decision No: 2014-04/08) were taken. Each student to be included in the study was verbally informed and gave written consent.

Results
The average age of the participants was 19.19±1.04 where 62% were female and 38% were male. 52.5% of the students had graduated form a normal high school, 46.7% had medium economic status, and 32.6% lived their lives mostly in towns.
The MSPS and PSCNSS general and sub dimension scores as well as the SRS general score averages of the students were given in Table  1. The MSPS general score average of the students was 91.66±12.06, their external motivation score average was 21.34±3.21, their internal motivation score average was 44.77±6.54, and their negative motivation score average was 25.52±6.22. The general score average for the PSCNSS was determined as 141.10±13.97. The occupational satisfaction sub dimension average of the PSCNSS was 23.71±3.74, the occupational proficiency score average was 21.35±3.14, and the occupational attitude and skill score average was 96.04±9.70. The SRS score average was 70.82±15.62.
The relationship levels between The MSPS and PSCNSS general and sub dimension scores as well as the SRS general score averages of the students were given in Table 2. A positive, medium and higher level significant relationship between the MSPS general and sub dimension scores and PSCNSS general and sub dimension scores was found (r=.44-.63; p<0.001). A significant relationship close to the medium level was found between MSPS general and sub dimension scores and SRS score averages was found (r=.17-.36; p<0.001).
The Stepwise Multiple Linear Regression Analysis regarding the examination of motivation according to age, occupation choice number, self-esteem, and professional self-concept general score and Table 1: Distribution of nursing students' mean motivation resources and problems, professional self-concept, and self-esteem scores (n=242)  sub dimensions was given in Table 3. When the results of the t test regarding the significance of the regression coefficients was examined, the self-esteem, professional self-concept, and occupational satisfaction sub dimension variables were found to be significant predictors for motivation (R=0.64, R2=0.41, F=56.44, p= 0.000). The self-esteem, professional self-concept, and occupational satisfaction sub dimension variables together explained 41% of the total variance in motivation. In the Stepwise Multiple Linear Regression Analysis age, occupation choice number, and the proficiency and occupational characteristics sub dimensions of the professional self-concept were the excluded variables.

Professional Self Concept in Nursing Students Scale
The comparison between the personal characteristics of the nursing students and their MSPS general score averages were given in Table 4. No significant differences were found in motivation scale score averages according to the gender, income status and residence of the nursing students (p>0.05). Alongside this, the MSPS general score average of the students who had graduated from health vocational schools were significantly higher compared to graduates of other types of high schools (F=4.968/ p=0.002).
The comparison between the occupational characteristics of the nursing students and their MSPS general score averages were given in Table 5. 82.6% of the students stated that they chose nursing willingly. 67.8% stated that they were glad to receive nursing education, 89.3% stated that they evaluated the future of the occupation to be positive, 89.3% stated that they saw the occupation as an important part of society, 34.3% stated that they had graduate education plans, and 71.5% stated that they wanted to work as nurses after graduation. The MSPS general score averages of students who selected nursing voluntarily (t=3.95/p=0.000), who were glad to receive nursing education (KW=19.899/p=0.000), didn't want to receive any other training than nursing (F=6.485/p=0.002), and thought positively regarding the future of their occupation (t=2.780/p=0.006) were found to be significantly higher compared to other students.

Discussion
The motivation level of the student is very important in the successful completion of nursing education [27]. In literature, it has been stated that nursing students succeeding at school and later in professional life and being satisfied was tied to the motivation the student carried when he/she entered the occupation [3]. In the study, when the possible scores that could be taken from the scale (between 24 and 120) was considered, the occupational motivation levels of the students in the first year of their education can be said to be above average. This finding may indicate that the students started their education more willingly. In other studies performed with nursing candidates, similar results were found [6,32]. In a study performed in Sweden motivation was found to be higher in the first years of nursing education [26]. The motivation of students includes internal and external factors, and sometimes these factors may interact [7,32]. In internal motivation, the individual performs the behavior since he/ she sees it as necessary for himself/herself while in external motivation, the importance and necessity of external stimuli are believed in [7,8,[28][29][30]32]. Curiosity, the desire to know, the desire for sufficiency, and the desire for development can be shown as examples for internal motivation while a student being reinforced by a teacher for getting a high grade can be shown as an example for external motivation [33]. In our study, the internal and external motivation levels of the students were found to be high while their negative motivation levels were found to be medium. High internal motivation levels constitute an important finding since this affects professional selfconcept development positively. In the literature, internal motivation sources were stated to constitute stronger and continuous motivation [34]. In this regard, the findings of our study show that the students have high learning desire and that their internal motivation should be supported by the tutors throughout occupational education. In studies using similar scales in our country, the internal motivation levels of nurse candidates were found to be higher compared to other motivation types [3,6,29,35]. In a study by Ozlu et al. the negative motivation levels were found to be higher in nursing students [33].
In our study, the motivation levels of students who were health vocational school graduates, who selected nursing voluntarily, were glad to receive nursing education, didn't want to receive any other training than nursing, and thought positively regarding the future and efficiently [29]. In this context, the findings of the study show the importance of knowing the nursing occupation and choosing it willingly in being successful in nursing education. Thus, nursing tutors and nurses introducing the occupation to the public may be evaluated to be an important occupational responsibility.   Professional self is seen as an important part of the academic and professional development of the nursing profession [36]. In our study, it was determined that the professional self-levels of the students were above average. In studies by Najafi et al. [36] and Woo and Tak [37], the professional self-levels of the students were found to be high, while in a study by Iacobucci et al. the general levels of professional nursing values were found to be high [17]. The findings of our study show that the professional self-levels of the students participating in the study should be elevated when compared to students studying in other countries. This situation may arise from student not choosing nursing as a professional occupation but as a means of finding jobs easier.
Self-esteem is a personal characteristic that is an absolute requirement for health care professionals. It is a must have, and is considered a special requirement [38]. In our study, the self-esteem levels of the students were found to be higher than average. Similar results were attained in other studies [14,17]. In studies by Chaves et al. [15] and Shrestha [21], the self-esteem of 68% of nursing students was found to be high. In a study by Chris et al. nursing students were found to have low self-esteem [38]. In a longitudinal study performed with nursing students, self-esteem was found to decrease in the later years of nursing education compared to the initial years [13]. In another study, the self-esteem levels of nursing students were found to show no difference in the beginning and end of nursing education [39] In the literature, variables such as motivation and self-esteem, which are classified as personal characteristics, are stressed to have important effects on both psychological health and academic success [25]. In our study, a medium level, positive significant relationship between motivation levels and professional self and self-esteem levels was found. According to regression analysis, professional self-concept and self-esteem account for 41% of the total variance in motivation. When it is considered that there are many factors affecting the motivation of students, it can be said that professional self-concept and self-esteem are important factors in the motivation of nursing students. In other words, the motivation levels of students with positive professional self and self-esteem development can be said to be higher. Professional self-terms an individual perceiving oneself as a member of an occupation. Professional self can increase motivation by developing this sense of belonging. In previous studies, in concordance with the findings of this study, positive relationships between the motivation levels and professional selves and self-esteem levels of students were found [22][23][24]40]. In a study by Jahromi, Kargar and Ramezanli, an important correlation between the self-concepts of nursing students and their clinical performance was found [22]. In another study, self-esteem, self-sufficiency, and nursing motivation were found to affect the professional self-concept of nursing students [23]. In this context, increasing the education and clinical application motivation of students is important for the positive improvement of self-esteem and professional self-concept [24].

Conclusion
The motivation levels and professional self-concepts of nursing students are highly related to positive motivation, professional selfconcept levels and self-esteem levels, and are importantly affected by professional self-concept and self-esteem. In the context of the findings of this study and taking into account that the motivation, professional self-concept and self-esteem levels of students may show differences between years of education, it can be suggested that the motivation, professional self-concept and self-esteem levels of students should be continued to be evaluated according to years of study. The motivation levels of nursing students are highly affected by professional selfconcept and self-esteem. In this context, to ensure the continuation of the occupational motivations of the students, it can be suggested that the education system should be arranged to improve professional self-concept and self-esteem, and that counselor supported projects that would support the motivations, professional self-concepts and self-esteem levels of students and give direct responsibility to students should be formed. Since the motivation levels of students who selected nursing voluntarily, were glad to receive nursing education and thought positively regarding the future of their occupation form a load, it can be suggested that nursing tutors and working nurses should plan activities for the introduction of the occupation to the public and the conscious selection of the occupation. Lastly, it can be suggested that interventional studies on the improvement of the motivations, professional self-concepts and self-esteem levels of nursing students should be repeated with studies encompassing larger samples.