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TEACHERS’ TOPICS

Teaching Self-concept and Self-esteem in a Clinical Communications Course

Melissa S. Medina, EdD

The University of Oklahoma Health Sciences Center College of Pharmacy

Submitted February 1, 2006; accepted March 19, 2006; published October 15, 2006.

Effective interpersonal communication skills are needed for pharmacists to deliver patient-centered care. To achieve this outcome with pharmacists, communication skills are emphasized in pharmacy school in required coursework, such as a clinical communication course. One important concept to include in communication coursework is content on perceptions because perceptions influence com- munication interactions. Specific emphasis should include a focus on self-perceptions and self-concept, because related empirical literature demonstrates that accurate academic self-concepts predict aca- demic success. These results were extrapolated to a pharmacy clinical communications course where a lecture and laboratory series was designed to emphasize self-concept and facilitate communication skills improvement. The instructional design of this series promoted the advancement of students’ communication skills by using communication inventories, self-reflection activities, peer and class discussion, and lecture content. Class discussions, self-reflections, and baseline, and follow-up coun- seling activities throughout the semester provided evidence of improvements.

Keywords: communication, self-concept, self-esteem, curriculum

INTRODUCTION In order to provide patient-centered care and pro-

mote optimal patient outcomes, pharmacists need to have effective interpersonal communication skills. Effective communication skills are not innate; they must be devel- oped. For pharmacists, the development of these skills is often emphasized during pharmacy school in a clinical communication course where topics such as empathy, listening, nonverbal communication, assertiveness, and perception are covered.

1 Perception is a particularly im- portant topic in a communications course because our perceptions of others affect the way we communicate with them. Standard course content on perceptions emphasizes verbal and nonverbal messages communicated by others.

Coursework on perceptions should also include con- tent on self-perception/self-concept because the way we communicate with others (our interpersonal skills) is also shaped by how we view ourselves.

2 Having an accurate academic self-concept is a critical predictor of a student’s academic success.3 Likewise, a student’s awareness of his/her communication self-concept and ability to define himself/herself accurately relates to the ability to commu- nicate with others successfully. Therefore, course content

on perceptions should include emphasis on self-concept, because this focus should help students become more effective communicators. The self-concept content should focus on helping students reflect on their personal definitions of self, communication preferences, ability to articulate thoughts and needs, and overall communication strengths and weaknesses. Helping students realize that how they view themselves contributes to their communi- cation ability is a primary and crucial step in the advance- ment of their skills.

A lecture and laboratory series on the importance of self-concept in advancing communication skills was cre- ated for a clinical communications course given to third- professional year doctor of pharmacy students on 2 campuses.

One goal of the lecture/laboratory series is to help students appreciate the role an accurate self-concept plays in their ability to communicate successfully in any situa- tion. Thus, the context of the series is that of everyday life and their future roles as pharmacists.

A second goal is to help students understand how they define who they are (self-evaluation and evaluation by others) and the evolution and accuracy of their self-concept. Related to this goal, the series illustrates the relationship between self-concept and self-esteem, as well as how per- sonal reflection and social comparison influence how people feel about the skills, knowledge, and attitude they possess.

Corresponding Author: Melissa S. Medina, EdD. Address: OUHSC College of Pharmacy, 1110 N. Stonewall Ave., PO Box 26901, Oklahoma City, OK 73190. Tel: 405-271-6484. Fax: 405-271-3830. E-mail: [email protected]

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The third goal is to relate the series content to pre- vious lectures on perceptions and provide a foundation for future communication lectures designed to facilitate the advancement of clinical communication skills. This se- ries on self-concept allows students to assess their per- ceived and actual communication abilities at the beginning of the semester. The baseline information facil- itates students’ reliable and valid assessment of growth over the semester in the clinical communications course.

These goals translate into 12 total lecture and labora- tory objectives (see modified list below). The lecture objectives focus on exploring the definitions, features, and development of a person’s self-concept, as well as how self-esteem relates to self-concept, and the role self-esteem plays in effective communication. Once this foundation of knowledge is constructed, the laboratory objectives concentrate on students’ application, analysis, and evaluation of their self-concept through pre-assign- ment inventories and assessments and in-class active- learning exercises. The series content emphasizes the im- portance of self-evaluation and personal reflection, as well as how each student’s definitions of self compare to those of his/her peers. The peer comparisons and dis- cussions stress the role of social comparison and its re- lationship to self-esteem and self-concept.

Specific lecture and laboratory objectives require students to:

(1) Define and evaluate your self-concept (general and communication);

(2) Reflect on development and evolution of your own self-concept;

(3) Analyze the accuracy of your self-concept; (4) Compare self-concept activity results through

the lens of self-evaluation and evaluation by others;

(5) Discuss and compare communication styles among your peers;

(6) Contrast self-concept and self-esteem; (7) Evaluate fluctuations and influences on your

own self-esteem; and (8) Utilize your self-concept to improve your abil-

ity to communicate effectively.

INSTRUCTIONAL METHODS AND CONTENT Pre-assignment

This lecture/laboratory series within the required clinical communications course is offered during the first 3 weeks of the fall semester in the third-professional year. On the first day of class (week 1) students are given a pre- assignment (specific handout materials are available from author) that is due the following week (1 week prior to the

lecture). The pre-assignment utilizes 4 activities that in- clude taking (#1) an online communication inventory, the Keirsey Temperament Sorter II;

4 (#2-3) 2 paper-and- pencil inventories, the Interpersonal Communications Assessment (ICA),5 and the UZoo Communication and Leadership Inventory.6 Students also (#4) describe and illustrate their communication strengths and weaknesses and indicate their top strength and top weakness.7 After students complete these 4 required assignments, they compile their results on a score sheet and submit the materials. Once all pre-assignment materials are col- lected, student results for all of the inventories are tallied and class averages and minimum and maximum scores are calculated.

The self-concept and self-esteem content is delivered during week 2 of the course and is designed to capture students’ baseline communication strengths and weak- nesses (handout materials and activities are available from the author). The 90-minute lecture emphasizes higher and lower levels of Bloom’s taxonomy of educa- tional objectives. At the lower level, the lecture’s objec- tives and content focus on knowledge accumulation with review of self-concept and self-esteem definitions, prin- ciples, origins, influences, and lifespan development. At the higher level, analysis and evaluation objectives are emphasized using class discussion and activities. Stu- dents self-reflect, analyze life experiences, describe their self-concept, determine the general level of their own self-esteem, and review personal and professional factors that contribute to their self-esteem. These activities are executed using personal introspection, peer discussion, and class discussion of personal thoughts and examples. These reflections are stimulated through class activities that ask students to develop a top 10 list of words that describe who they are and answer questions about how they and others see them (ie, I am skilled at, other people think that I am skilled at).

2,8

The 2-hour laboratory session occurs during week 3. The class of approximately 140 students is divided into 4 sections of approximately 30 students each and the labo- ratory session is repeated for each section. The 2-hour period is divided into 4 segments: general, communica- tion, personality, and leadership self-concept and self-es- teem. Each segment requires approximately 30 minutes to complete (activity handout material is available from the author). The first segment, general self-concept review, uses activities that require students to reflect on how they define themselves overall, then to compare their reflec- tions with a classmate, and then with the entire laboratory section. Students discuss and categorize their broad self- concept themes in 7 areas: skills, knowledge, personality and physical characteristics, social and professional roles,

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and belief systems.8 To conclude this section, the students are asked to decipher self-concept trends for the class based on the categorization of their self-concept lists.

The second segment, communications self-concept, follows a similar format as the general self-concept seg- ment, but the focus shifts to how students see themselves as communicators. The unique portion of this segment is the review of the Interpersonal Communications Assess- ment (ICA)

5 that the students completed in the pre-assign- ment. This laboratory activity interprets the following 3 sections of the inventory: listening/empathy, anger/asser- tiveness, and total score. Students also receive feedback about how their results compare to average scores on the inventory and to class results (emphasizing social com- parison and self-esteem). This allows students to more accurately self-reflect about their communication strengths and weaknesses, ie, self-concept building (see part A of laboratory handout in Appendix 1).

The personality segment (third segment) comple- ments segment 2 and emphasizes the Keirsey Tempera- ment Sorter II

4 results achieved during the pre-assignment. This pre-assignment is available free online and relates to the Myers-Briggs Type Indicator (MBTI).9 Since the cost and training required to offer the MBTI to this class is prohibitive, the Keirsey Temperament Sorter II is consid- ered an acceptable alternative, although the validity and reliability of the online instrument are not well established. The goal of this portion of the course is to give students insight into their temperament and ability to ‘‘read’’ others. During this third segment, the class discusses the catego- ries of the Keirsey Temperament Sorter II

4,10 and the MBTI9 (artisan, guardian, idealist, and rational types). The students then reflect on their personal results and whether they feel the inventory accurately captures who they are. To emphasize the ability to read others, the class predicts each student’s temperament type, followed by feedback provided by each student on the class’s accuracy. This segment also uses data related to current and histor- ical class percentages, as well as empirical results of the general population found in the literature

4,10 to emphasize social comparison (see part B of Appendix 1).

The fourth segment focuses on leadership and com- munication styles and addresses how students function on teams. This segment starts with a case activity that asks students to decide how to handle a dysfunctional team situation. Their approaches are compared to the UZoo Leadership and Communication Inventory6 pre-assign- ment results, which categorizes students as 1 of 4 animal types: lion, porpoise, koala, or eagle. The validity and reliability of the UZoo inventory has not been established, but the tool is used to stimulate student reflection, social comparison, and overall class discussion. To conclude

this segment, the 4 categories of the inventory are reviewed and the class counts for each category (includ- ing mixed results where students scored the same high score in 2 categories indicating that they possess traits from both animal types) are revealed (see part C of Appendix 1). The laboratory ends with a summary of the 4 animal types and stresses the importance of accu- rately defining one’s self-concept and practicing reading other students’ types in order to communicate effectively.

OUTCOMES The self-concept session of the communications

course has been offered for the past 5 years. Only 2 of the 5 years included the laboratory session due to sched- uling conflicts. In the other 3 years, the pre-assignment was still utilized, the laboratory content was included in the class lecture, and handouts with social comparison data were provided to students for self-study purposes. This alteration to the series was not ideal because the small- group setting of the laboratory sections stimulated partic- ipation in group discussion, which facilitated student’s personal reflection and peer comparison. In the labora- tory’s current design, the 2-hour time allotment is mini- mally sufficient to achieve the laboratory’s objectives. In order to finish in 2 hours, pre-laboratory preparation and focus are needed. Effective management of students dur- ing the session with significant attention to time on task is also needed. Expanding the laboratory to 3 hours (15 ad- ditional minutes to review each of the 4 sections) may be more beneficial for addressing all 4 areas. If the laboratory time could not be expanded or there was only enough time to complete 2 segments of the laboratory, the UZoo inventory

6 and the Interpersonal Communication Inven- tory5 appear to have the most impact on students. There- fore, students may benefit from altering the objectives to focus on these 2 of the 4 laboratory components.

There were 5 outcomes evaluated in the self-concept lecture and laboratory series. The first explored student completion rates of the inventories. All of the students in the course completed the pre-assignments for the lecture/ laboratory series. This allowed for complete reporting of inventory results that were used for social comparison. A second outcome assessment that measured the series’ impact was measured using baseline and follow-up pa- tient counseling videos completed at the beginning and end of the semester. Over the past 5 years, students demonstrated improvement on this assignment and this suggests the series offers a positive contribution to the advancement of students’ communication skills. How- ever, these data are confounded by the other topics that are offered during the semester, since all course content probably has a positive impact. Isolating the exact content

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that enhanced students’ skills is difficult under the current design. Future offerings of the series need to include a de- liberate measure of the impact of the self-concept content.

A third outcome of the series was that students par- ticipated well in the class and laboratory. This outcome was evidenced by their honest reflections in the writing exercises for their pre-assignment. The students were forthright during the explanations and illustrations of their communication strengths and weaknesses, with many comments focusing on significant relationship challenges they faced as a result of their communication weaknesses. The requirement to provide at least one specific personal example of a communication strength and weakness may have facilitated this honesty. This outcome was also evi- denced verbally, where this honesty transferred into the laboratory series of the class where students avoided ‘‘so- cially acceptable’’ answers. Instead students reiterated pre-assignment sentiments, and as a result, some epiph- any-like statements were made during the discussions that took place. The smaller and safer atmosphere of the lab- oratory sections may have encouraged this honesty. Over- all, the students’ ability to honestly reflect and discuss their strengths and weaknesses is an important component in making improvements in the course.

Similarly, the fourth outcome of the series was that anecdotally, students reported enjoying the series. They informally report liking the discussions of the UZoo personality/leadership/communication styles inventory, which may relate to the use of teams throughout courses in the curriculum and the re-emphasis of UZoo concepts by faculty members in other courses. College faculty members have recognized the impact that the UZoo part of the series has on students during team-based exercises, but these are faculty members who also use the UZoo results in their classroom to reemphasize the importance of teaming, knowing yourself, and reading others well. Students have not made specific comments about the lec- ture and laboratory series in end-of-semester course eval- uations; however, specific questions will be added to the course evaluations in future offerings of the course. This feedback will provide insight into the components that the students found most and least helpful so that appropriate emphasis and modifications can occur.

The final outcome was that the series affected future content in the communication course seen with assign- ments that documented students’ improvement in skills over the semester. The series also influenced other courses in the curriculum because results from the pre-assignment inventories were used to assist with selecting teams for class activities and to review team-building skills.

Overall, the course could benefit from fine-tuning the outcomes that were assessed during the series in order to

capture the specific contribution that self-concept training has on communication skills improvement. It is possible that this could be achieved with precourse and postcourse skill testing and finding ways to reemphasize the series’ themes and measure their impact throughout the curricu- lum. In addition, since the course is currently given during the third-professional year, opportunities to reemphasize content, hold students accountable for learning, and mea- sure retention of course content are limited. The course itself may benefit from movement to the first year of the program so these concepts can be introduced earlier, be- come more embedded in the curriculum, and to allow students more time to practice these skills.

SUMMARY The teaching of self-concept is important in a clinical

communications course because perceptions of others and self have an important role in interpersonal commu- nication. Asking students to reflect on and articulate who they are as individuals and future professionals provides a foundation for making improvements in their ability to effectively communicate with others. Improving commu- nication ability is vital in pharmacy students preparing to enter professional practice, which increasingly requires refined interpersonal communication skills. Introspection is one of the first steps in this journey.

REFERENCES 1. Tindall WN, Beardsley RS, Kimberlin CL. Communication Skills in Pharmacy Practice. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003;1-35. 2. Verderber KS, Verderber RF. Inter-act: Interpersonal Communication Concepts, Skills, and Context. 9th ed. Canada: Wadsworth; 2001;42-69. 3. Bouchey HA, Harter S. Reflected appraisals, academic self- perceptions, and math/science performance during early adolescence. J Educ Psychol. 2005;97:673-86. 4. The Keirsey Temperament Sorter II. Available at: http:// www.keirsey.com/cgi-bin/keirsey/newkts.cgi. Accessed August 15, 2005. 5. Bienvenu MJ. An interpersonal communication inventory. J Commun. 1971;21:381-8. 6. Eckstein K. The UZoo Leadership and Communication Inventory [unpublished assessment tool]. University of Oklahoma Student Services, 2002. 7. Zinner-Dolphin C, Adler RB, Rosenfeld LB, Towne N. Proctor RF III. Instructor’s manual/test bank: Interplay: The Process of Interpersonal Communication. Forth Worth, TX: Harcourt Brace; 1998:27. 8. Adler RB, Rosenfeld LB, Towne N, Proctor RF III. Interplay: The Process of Interpersonal Communication. 7th edition. Forth Worth, TX: Harcourt Brace; 1998;72-131. 9. Myers K, Kirby L. Introduction to Type, Dynamics and Development. Palo Alto, Calif: Consulting Psychologists Press, 1998. 10. Berens LV. Understanding Yourself and Others: An Introduction to Temperament. Huntington Beach, Calif: Telos Publications; 1998;1-36.

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Appendix 1. Laboratory Handout of Inventory Results Used for Social Comparison Part A. Results of Interpersonal Communication Assessment5 for Current Class-Compared to the Inventory Scale

Part B. Results of Keirsey Temperament Sorter4,10 for the Current Class, Compared to Previous Pharmacy Student Classes, the General Population, and General Pharmacy Students

Part C. UZoo6 Type Results for Current Class

Total Score Listening/Empathy Anger/Assertiveness

Class Average (Inventory Scale Midpoint 5 17 for each section)

49 26 22

Highest Score in Class (Inventory Scale Highest Score 5 66)

66 33 33

Lowest Score in Class (Inventory Scale Lowest Score 5 0)

16 6 8

Temperament OU P3 Students

Fall 2002 OU P3 Students

Fall 2003 OU P3 Students

Fall 2004 General

Population4

SJ, %* Guardian, No.y

71% 46

70% 61

60% 68

40-45%

SP, %* Artisan, No.y

8% 5

15% 13

20% 22

35-40%

N, %* Idealist, No.y

16% 11

10% 9

15% 17

8-10%

NT, % Rational, No.y

3% 2

2% 2

5% 6

5-7%

*percentage of students in class or population who possessed this temperament type. yactual count of students for each class year (2002, 2003, 2004) who possessed this temperament type.

Letter and Type Class Count Mixed Results

A5Lion 10 L/P – 1y B5Porpoise 21

C5Koala 44 K/E – 2y D5Eagle 35

*actual count students in the current class year that possessed this animal style. yindication of the total number of students who scored the same high score in two categories indicating that they possess traits from both animal types.

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