Relationship Between Social Anxiety and Self-esteem Among Undergraduate Nursing Students

Abstract

Social anxiety disorder is the third most common disorder in the general population. Social phobia has a significant impact on nursing colleagues’ self-esteem. The purpose of the current study was to assess social anxiety and its relation to self-esteem among nursing students. The study was a cross-sectional study. Data were collected from 231 nursing students through a convenience sampling method. The instruments of the study included “Social Phobia Inventory (SPIN)” and the “Rosenberg self-esteem scale.” The results indicated that the social anxiety mean was 15.1 ± 11.1 (ranging from 0 to 68) and the self-esteem was 19.9 ± 4.5 (ranging from 0 to 30). The current study indicates that female and social anxiety are predictors of self-esteem among nursing students. Also, the present study concludes that lower social anxiety is associated significantly with higher self-esteem among Palestinian undergraduate nursing students (r = −.35, P < .001). The study concludes that there are inverse correlation between social anxiety and self-esteem among Palestinian undergraduate nursing students. Even though most students showed modest levels of social anxiety and normal self-esteem.

• What do we already know about this topic?

• Addressing social anxiety and self-esteem among undergraduate nursing students is essential for promoting their academic success, professional development, and well-being

• How does your research contribute to the field?

• Research in this area contributes to the broader fields of nursing education, psychology, and healthcare by addressing the psychological well-being and professional development of undergraduate nursing students, ultimately benefiting both students and the patients they serve.

• What are your research’s implications toward theory, practice, or policy?

• Research on the relationship between social anxiety and self-esteem among undergraduate nursing students has implications for theory development, educational practices, clinical practice, mental health support policies, professional development, and advocacy efforts aimed at promoting student well-being and success.

Introduction

Social anxiety disorder is the third most common disorder in the general population. ¹ The prevalence of social phobia varies between different countries and cultures, with a reported rate of 7% to 13% in Western countries, 10% in India, and 11.7% in Saudi Arabia. ² More than one-third of students (34.60%) reported having an anxiety disorder. ³ According to the DSM-V, social anxiety is the ongoing fear of one or more social or performance circumstances where the individual may be confronted with unknowns or potential criticism from others. The person worries that they will behave in a way that will be embarrassing and humiliating or that they may exhibit anxiety symptoms. ⁴

Interpersonal communication and confidence are essential for nursing practice, yet social anxiety and low self-esteem are common issues among undergraduate nursing students. ⁵ This group is particularly prone to these issues, which can make it difficult for them to communicate with patients, coworkers, and healthcare teams. ⁶ Consequently, both the standard of patient care and their professional growth may be affected. ⁷ The lack of research on this topic among undergraduate nursing students in Palestine emphasizes the need for a thorough understanding of the variables that lead to social anxiety and low self-esteem among these students, as well as any potential ramifications for their education and future careers.

According to Maslow’s hierarchy of human needs, self-esteem is one of the most important psychological needs, playing a major role in motivation for self-actualization and success in interpersonal relationships and social interactions. ⁸ This is supported by Aristotle’s assertion that “Man is by nature a social animal; an individual who is unsocial naturally and not accidentally is either beneath our notice or more than human; society is something that precedes the individual.” ⁹

Studies have shown a strong link between social anxiety and low self-esteem. For instance, Murad’s ⁸ study indicates that people suffering from social anxiety are more prone to low self-esteem and negative thoughts about themselves. This is corroborated by Obadeji and Kumolalo, ¹⁰ who discussed the significant role that self-esteem plays in social anxiety disorders and how negative self-image maintains these disorders.

Nursing as a profession requires a specific level of social interaction, which affects nurses’ present and future professional practices and the quality of care they provide. ¹¹ A study conducted in Pakistan confirmed the strong interrelationships between self-esteem and the personality of healthcare workers, especially nurses. It found that people with high self-esteem cope with stress better than those with low self-esteem. ¹²

While several research has been done on social anxiety globally, there is little that directly relates social anxiety to self-esteem among university students. ¹³ The importance of studying self-esteem among university students lies in its effect on academic performance, well-being, and mental health. ¹⁴ A recent study among medical undergraduates in Bahrain found that 17.9% of individuals with low self-esteem also had social anxiety disorder. ¹⁵

Moreover, a study conducted at the University of Baghdad showed that most nursing students have low self-esteem, with an index of self-esteem scale at 80%, and that social interaction anxiety affected 15%, followed by social phobia inventory at 5.8%. Social phobia significantly impacts nursing students’ self-esteem. ¹⁶

Nursing students with high social anxiety may struggle with classroom participation, group projects, and clinical placements, all of which are crucial components of their training. ¹⁷ Low self-esteem can further exacerbate these difficulties, potentially leading to poorer academic outcomes. ¹⁸ Additionally, nursing requires strong interpersonal skills and confidence in patient interactions. ¹⁹ Students with high social anxiety and low self-esteem may find it challenging to develop these skills, affecting their competence and confidence in clinical settings. ²⁰ Understanding the relationship between social anxiety and self-esteem can help identify students at risk for mental health issues, allowing for targeted interventions to support their well-being. ²¹

Palestinian students contend with unique obstacles due to the ongoing Israeli-Palestinian conflict, which results in frequent disruptions to their education through school closures and restrictions on movement. Economic hardships, such as high unemployment rates and poverty, further exacerbate these issues, often forcing students to drop out to support their families. Additionally, resource limitations in the educational sector significantly affect the experiences and self-esteem of nursing students in Palestine. These limitations include inadequate infrastructure, lack of access to modern educational resources, and insufficient funding. Such challenges can exacerbate social anxiety and negatively impact self-esteem among students. ²² The First Intifada began in December 1987, leading to widespread protests, strikes, and civil disobedience against the Israeli occupation. During this period, Palestinian educational institutions frequently faced closures, with Israeli authorities imposing curfews and restrictions on movement. Students and teachers experienced significant disruptions, contributing to a stressful educational environment. ²³ The Second Intifada began in September 2000, resulting in intensified violence, increased Israeli military operations, and stricter movement restrictions. The conflict led to widespread destruction of infrastructure, including schools, and frequent closures due to security concerns. The psychological toll on students was significant, with increased levels of trauma and anxiety reported. ²² Since 2006, the West Bank faces periodic closures and movement restrictions due to security measures. ²⁴ Therefore, the purpose of the current study is to assess social anxiety and its relationship to self-esteem among nursing students.

Methods

Study Design and Setting

This was a correlational, cross-sectional study. The study has followed the relevant EQUATOR guideline. Data were collected from Palestine Ahliya University. This university in Bethlehem city in the West Bank. The data was collected in the second academic semester between January and February 2024.

Research Question

What is the relationship between social anxiety and self-esteem among nursing students?

Population and Sampling

The Faculty of Nursing at Palestine Ahliya University boasts a substantial bachelor’s program, accommodating a total of 500 students. Having commenced 3 years ago, the program has steadily grown in stature and reputation. For the study in question, the focus is squarely on students in their second and third academic years, specifically during the second semester of the 2024 academic year. Notably, the initial academic year is dedicated to general university requirements, with the nursing curriculum kicking in during the subsequent year. As such, the sampled students for this study encompass those in their second and third years, reflecting the progression of the program. Given its duration, the highest academic level available within this program is the third year. “The sample size was computed using the Raosoft applications with a 95% confidence level, a margin of error of 5%, a population of 500 nursing students, and a response rate of 50%. This study required a total of 218 participants. To compensate for missing surveys and dropouts, an additional thirty nursing students were included. So, the ultimate sample size was 248 participants. The study was accomplished with a convenience sample of 231 nursing students.”

Inclusion Criteria

Nursing students who are registered in the second and third years of the nursing bachelor program at Palestine Ahliya University.

Exclusion Criteria

Nursing students who are registered in the first year of the nursing bachelor program because they take general university requirements.

Instrument

The first section of the instrument encompasses the demographic profile of the participants. Following this, the second section comprises the Social Phobia Inventory (SPIN) as outlined by Davidson. ²⁵ This inventory is valid and reliable scale with Cronbach’s alpha more than .78.^26,27 Also, previous studies support the temporal stability, internal consistency, and construct validity of the SPIN.^28,29 It consists of a 17-item scale, ranging from 0 to 68, where respondents rate their experiences from 0 (not at all) to 4 (extremely). Scores falling within the range of 20 or below generally do not suggest social anxiety. Scores within the 21 to 30 range indicate mild social anxiety, while scores within the 31 to 40 range suggest moderate social anxiety. Scores within the 41 to 50 range signify severe social anxiety, and scores of 51 and above indicate very severe social anxiety. ²⁵

The third section assesses self-esteem using the Rosenberg Self-Esteem Scale (RSES) developed by Rosenberg. ³⁰ The scale has good predictive validity, as well as internal consistency and test–retest reliability.^{31 -33} This scale comprises 10 items designed to gage participants’ overall sentiments about themselves. Notably, items 2, 5, 6, 8, and 9 are reverse-scored. Participants rate items using a 4-point Likert-type scale ranging from 0 (strongly agree) to 3 (strongly disagree), yielding composite scores between 0 and 30. Higher scores on the scale suggest a higher level of self-esteem. ³⁰

Data Collection Procedure

Nursing students were enlisted to take part in the study following approval from the Palestine Ahliya University. To facilitate recruitment, the researchers sought the assistance of the vice dean of the nursing faculty. The vice dean’s role was to serve as an intermediary in approaching nursing program students. Specifically, the vice dean’s responsibilities included briefing students on the study’s objectives and methodology and inviting them to participate. Subsequently, the researcher was invited by the vice dean to provide interested students with detailed information regarding the study.

The participants were briefed by the researchers about the purpose of the study. It was made clear to the students that they might withdraw from the study at any point. A document requesting informed consent had to be signed by students who agreed to take part in the study. The questionnaires were administered by the researcher face-to-face, and the students completed the paper-based questionnaire in English.

Ethical Consideration

Ethical approval was obtained from the Palestine Ahliya University. Written informed consent was obtained from the participants. Confidentiality was assured during the study, with no personal information related to their identity. The participants were notified that they could withdraw at any time from the study without any harm and return incomplete questionnaires.

Statistical Analysis

Statistical analysis was completed using SPSS version 23. Descriptive statistics such as frequency, percentage, mean, and standard deviation were used. To ensure that the variables in this study are suitable for parametric tests such as the Pearson correlation, a normality check was performed using the Kolmogorov-Smirnov test. The results indicated that the data for the variables are normally distributed (P > .05), confirming the appropriateness of proceeding with parametric analyses.

Results

Partcipants’ Characteristics

A total of 231 nursing students consented to participate in the study and completed the surveys, yielding a response rate of 93.1%. Among these participants, 159 (68.8%) were female students. The average age of the participants was 20.7 years (SD = 2.5), with the majority, 129 (55.8%), belonging to the third year of their program. Approximately 159 (68.8%) of the students reported an academic GPA falling between 2 and 3. The majority of participants, constituting 69.3%, perceived themselves to have a moderate socioeconomic status. Moreover, a significant portion of the study cohort hailed from rural areas, with 111 (48.1%) reflecting this background. Notably, a vast majority, 212 (91.8%), reported no existing health problems. Furthermore, 204 (88.3%) stated that they did not currently take any medication, while 194 (84.0%) reported non-smoking habits (Table 1).

Table 1.

Demographic Characteristics of the Participants (N = 231).

Characteristics		M (SD)	n (%)
Age		20.7 (2.5)
Gender	Male		72 (31.2)
	Female		159 (68.8)
Academic year	Second year		102 (44.2)
	Third year		129 (55.8)
Academic GPA	Less than 2		29 (12.6)
	2-3		159 (68.8)
	Above 3		43 (18.6)
Residence	Rural		111 (48.1)
	Urban		94 (40.7)
	Camp		26 (11.3)
Socioeconomic status	Low		58 (25.1)
	Moderate		160 (69.3)
	High		13 (5.6)
Health problem	Yes		19 (8.2)
	No		212 (91.8)
Medication use	Yes		27 (11.7)
	No		204 (88.3)
Smoking	Yes		37 (16.0)
	No		194 (84.0)

The analysis indicated that the social anxiety mean was 15.1 ± 11.1 (ranging from 0 to 68). Also, the analysis revealed that the self-esteem of nursing students was 19.9 ± 4.5 (ranging from 0 to 30), as seen in Table 2.

Table 2.

Distribution of Participants Based on Level of Social Anxiety and Self-Esteem.

Variable	n (%)	M (SD)
Social anxiety		15.1 (11.1)
No social anxiety	166 (71.9)
Mild social anxiety	44 (19.0)
Moderate social anxiety	14 (6.1)
Severe social anxiety	5 (2.2)
Very severe social anxiety	2 (0.9)
Self-esteem		19.9 (4.5)
Low self esteem	17 (7.4)
Normal self esteem	186 (80.5)
High self esteem	28 (12.1)

A Pearson correlation test was applied to test the relationship between social anxiety and self-esteem. The analysis showed that there was a moderate negative relationship between social anxiety and self-esteem (P < .001), as seen in Table 3.

Table 3.

The Relationship Between Social Anxiety and Self-Esteem (N = 231).

Variable	r	P-value
Social anxiety	−.35	.001
Self-esteem

A multivariable regression analysis was utilized to identify the self-esteem predictors among nursing students. The independent variables (age, gender, academic year, academic GPA, residence, socioeconomic status, health Problem, medication use, smoking, and social anxiety) were entered into the model of predictors. The overall model was statistically significant (P < .001, R = .424, R² = .179, adjusted R² = .142). This stated that 17.9% of the variance in self- esteem was illuminated by the whole model.

The findings revealed that female was predictor of self-esteem (β = 2.068, P < .01) illustrating that a one-point increment in gender was associated with a 2.068 increase in self-esteem. Also, social anxiety was predictor of self-esteem (β = −.148, P < .01) illustrating that a one-point decrease in social anxiety was associated with a 14.8 increase in self-esteem, as seen in Table 4.

Table 4.

Predictors of Self-Esteem: Multiple Linear Regression.

Predictor					95% Confidence interval		Correlations
	B	Beta	t	P-value	Lower bound	Upper bound	Partial	Part
Age	0.076	.043	0.658	.511	–0.152	0.303	.044	.040
Gender (Female)	2.068	.215	3.106	.002**	0.756	3.380	.205	.190
Academic year	0.374	.042	0.634	.526	–0.788	1.537	.043	.039
Academic GPA	–.298	–.037	–.585	.559	–1.305	0.708	–.039	–.036
Residence	–.269	–.041	–.627	.531	–1.112	0.575	–.042	–.038
Socioeconomic status	0.116	.013	0.211	.833	–0.966	1.197	.014	.013
Health problem	–2.241	–.138	–1.730	.085	–4.794	0.312	–.116	–.106
Medication use	2.026	.146	1.802	.073	–0.190	4.242	.121	.110
Smoking	–.437	–.036	–.527	.598	–2.067	1.194	–.036	–.032
Social anxiety	–.148	–.368	–5.809	.000**	–0.199	–0.098	–.365	–.355

Note. CI = confidence interval; b = unstandardized beta; B = standardized beta.

^*Significant at P < .05. **Significant at P < .01.

Discussion

The current study exhibit low social anxiety among nursing students, indicating that they are generally well-adjusted and comfortable in social settings. This finding suggests that the educational environment, combined with their physical and psychological health, contributes positively to their social well-being. The low levels of social anxiety also reflect their ability to cope with the challenges of nursing education, particularly during the second and third years of study, when students have typically adapted to the demands of their program. This study finding was supported by the study conducted in Saudi Arabia which showed that the prevalence of social phobia was very severe in 2.2% of the total students, severe at 6.5%, moderate at 13.0%, mild at 18.1%, and no social phobia at 60.0%. ²⁸ Also, occurrence of social anxiety among the nursing students of selected nursing college was 71.2% of subjects with moderate social anxiety and 1.2% of the subjects with severe social anxiety. ³⁴ Furthermore, Dsouza et al ³⁵ found that two-thirds of their sample had no social phobia.

However, this is in disagreement with Obadeji and Kumolalo, Banappagoudar et al, Ahmad et al, Dsouza et al, and AbdElaziz et al, whose majority of their samples had anxiety levels between mild and severe.^{10,11,13,35,36} Also, a study conducted among medical students in Saudi Arabia revealed contrast results. Approximately, 29% and 24.3% had mild and moderate social phobia respectively, severe and very severe social phobia represented 19.1% and 19.8% respectively, and 7.9% didn’t suffer social phobia. ² The variations of results could be differences in sample characteristics, educational environments, and the stressors faced by nursing students.

The current study demonstrated average levels of self-esteem, aligning with findings from a study conducted at a public university in Saudi Arabia, where 76.6% of nursing students had moderate self-esteem levels. This study identified significant correlations between self-esteem and factors such as year of study, physical health, psychological health, and father’s education. ⁵ Additionally, this result is consistent with Banappagoudar et al’s ¹¹ study on B.Sc. nursing students, which revealed that 73.3% of students had normal levels of self-esteem. These consistent findings across different contexts underscore the importance of considering these factors in understanding and addressing the self-esteem and social anxiety of nursing students.

In contrast, Bibi et al ¹² found that 61% of undergraduate nursing students had low self-esteem. This discrepancy may be related to the distribution of students’ years in the program, with 30% in Year 1 and 60% in Year 2. These early years are characterized by the beginning stages of adaptation to a new environment, which can be challenging and impact self-esteem levels. ¹² The differences in the stage of study and the associated adjustment period likely contribute to the variation in self-esteem findings between these studies.

The current study indicates that female and social anxiety are predictors of self-esteem among nursing students. This finding highlights the importance of considering gender when addressing self-esteem issues within this group. Specifically, it suggests that female nursing students may experience different factors influencing their self-esteem compared to their male counterparts. In Palestinian society, cultural norms, traditional gender roles, and the political situation significantly influence the self-esteem of women. They are typically seen as the backbone of family support, managing household duties while also pursuing professional and educational goals. This dual role can create immense pressure, affecting their self-esteem both positively and negatively. ³⁷ The ongoing Israeli-Palestinian conflict profoundly affects the daily lives of Palestinians, including their mental health and self-esteem. Palestinian women, in particular, may feel a strong sense of duty to resist occupation and contribute to their community’s resilience. This resistance often requires high self-esteem and personal strength. ³⁸ This finding is consistent with Makkawi’s ³⁹ study suggests that attending female schools and having positive relationships with female peers can enhance academic achievement and subsequently increase self-esteem among Palestinian females. Further in-depth interviews and focus groups with female nursing students can provide rich qualitative data on their personal experiences. This method can uncover nuanced insights into how cultural expectations and the political situation affect their self-esteem and mental health.

Arshad et al ⁴⁰ who studied self-esteem and academic performance among university students in Pakistan, they found that male students had higher self-esteem than female students. However, in a study conducted in Maternity Curriculum at Assiut University revealed that there no differences in self-esteem levels between males and females nursing student. ⁴¹

According to the current study, social anxiety is a significant predictor of self-esteem among nursing students. This result is consistent with findings by Murad in Jordan, Khan et al in Pakistan, Cao and Liu in China, Jose et al in India, and Seema and Kumar, all of whom reported a significant relationship between social anxiety and self-esteem.^{8,42 -45} However, this result contrasts with the findings of Kumar whose research among nursing students indicated no significant correlation between social anxiety and self-esteem. ⁴⁶

Strengths and Limitations of the Study

The main strengths of this study are its large sample size, use of an accurate and validated all-inclusive evaluation instrument, and uniqueness as one of the few studies carried out in Palestine. On the other hand, its cross-sectional design, dependence on convenience sample techniques, and vulnerability to possible self-report biases are major limitations.

Recommendations

Based on our findings, we recommend implementing targeted support programs to address social anxiety and boost self-esteem among nursing students. Establishing counseling services and peer support networks can provide essential mental health resources. Training academic and clinical staff to recognize and address these issues will ensure students receive the necessary support. Creating a welcoming learning environment with open communication channels is crucial for reducing anxiety and fostering self-confidence. Offering skill-building workshops and clinical training opportunities will further equip students to manage stress and enhance their competence. Promoting health and wellness programs and providing socioeconomic support can alleviate external stressors affecting students. Regular mental health assessments and tailored interventions will help identify and support at-risk individuals. Encouraging active student participation in extracurricular activities and leadership roles will also contribute to higher self-esteem and lower anxiety levels. Furthermore, considering innovative insights such as cultural sensitivity and resilience training is suggested.

Conclusion

The present study concludes that lower social anxiety is associated significantly with higher self-esteem among Palestinian undergraduate nursing students. The current study indicates that gender and social anxiety are predictors of self-esteem among nursing students. Also, the study indicated low social anxiety and average self-esteem compared to those of students in other regions. One possible explanation is the supportive environment within nursing programs, which may foster strong peer connections and a sense of community, thus mitigating social anxiety. Furthermore, the structured nature of nursing education, with its emphasis on teamwork and communication skills, might help students build confidence and reduce anxiety.