Pressure and protective factors influencing nursing students' self-esteem: A content analysis study Leila Valizadeh a , Vahid Zamanzadeh b , Rahim Badri Gargari c , Akram Ghahramanian b , Faranak Jabbarzadeh Tabrizi b, ⁎, Brian Keogh d a Department of Pediatric nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran b Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran c Department of Psychology, University of Tabriz, Tabriz, Iran d School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland summary article info Article history: Accepted 20 October 2015 Keywords: Nursing student Self-esteem Qualitative research Nursing Background: A review of the literature shows that the range of self-esteem in nursing students ranges from nor- mal to low. It is hypothesized that different contextual factors could affect levels of self-esteem. Objective: The main aim of this study was to explore these factors from the viewpoint of Iranian nursing students using a qualitative approach. Design: A qualitative content analysis study. Setting: Faculty of Nursing and Midwifery, 2014. Participants: Fourteen student nurses and two qualified nurses. Methods: This study has been applied to various depths of interpretation. Semi-structured interviews were used to collect the data. Fourteen student nurses and two qualified nurses were interviewed. Results: Two main themes of the “pressure factors” with subthemes: low self-efficacy, sense of triviality, ineffec- tive instructor–student interaction, low self-confidence and “protective factors” with subthemes: knowledge ac- quisition, mirror of valuability, professional autonomy, religious beliefs, and choosing the nursing field with interest was extracted in this study. Results showed that these themes have interaction with each other like a seesaw, as pressure factors decrease, the effect of protective factors on the self-esteem are increased. Conclusion: Nurse educators not only should try to improve the students' skills and knowledge, but should also try to enhance the protective factors and decrease pressure factors by enhancing the nursing students' feeling of being important, using participatory teaching methods, considering students' feedback, and attempting to im- prove facilities at the clinics are also recommended. © 2015 Published by Elsevier Ltd. Introduction As early as 1890, William James pointed out that people form an idea of their own individual characteristics (for example, their needs, abili- ties, etc.) and therefore they gain an impression of their own character. This impression is described as the person's self-concept and this self- concept is not limited to a description of the individual, but rather an evaluation which is described as self-esteem (Kanning and Hill, 2012). In general, low self-esteem has been linked with depression (King et al., 1993), anxiety (Rosenberg, 1986), and is associated with poor mental health, self-efficacy, body image, and sense of leadership (Ni et al., 2010). Nursing students have a great responsibility in the future in terms of the role they play as health care providers (Cha and Sok, 2014). It can be argued that the presence of negative feelings in nursing students will result in far more negative consequences than students of other disciplines (Megahed and Mohammad, 2014).Therefore, it can be hypothesized that nursing students need to have a high level of self-esteem (Megahed and Mohammad, 2014). Unfortunately, this does not appear to be the case as many studies identify that low self-esteem among nursing students is prevalent (Barkhordary et al., 2009; Dimitriadou–Panteka and Koukourikos, 2014; Megahed and Mohammad, 2014). There are some studies, however, which suggest a normal or medium range or rising trend of nursing students' self- esteem during their education (Suliman and Halabi, 2007; Furegato et al., 2008; Janati et al., 2012). It is hypothesized that different contex- tual factors could be affecting the diversity of levels of self-esteem. Based on this hypothesis, we decided to further explore self-esteem among nursing students using the research question: “What are the fac- tors that affect levels of self-esteem among nursing students?” A review of the literature demonstrated that most studies which fo- cused on the factors affecting students' self-esteem were done using Nurse Education Today 36 (2016) 468–472 ⁎ Corresponding author at: Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Phd Candidate of Nursing, Tabriz University of Medical Sciences, Tabriz, Iran. Tel./fax: +98 4134770648. E-mail address: jabbarzadehf@tbzmed.ac.ir (F.J. Tabrizi). http://dx.doi.org/10.1016/j.nedt.2015.10.019 0260-6917/© 2015 Published by Elsevier Ltd. Contents lists available at ScienceDirect Nurse Education Today journal homepage: www.elsevier.com/nedt