DTIC ADA521985: Teaching Mental Skills for Self-Esteem Enhancement in a Military Healthcare Setting

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Teaching Mental Skills for Self-Esteem Enhancement
in a Military Healthcare Setting
Jon Hammermeister, Michael A. Pickering and LTC Carl J. Ohlson
The need exists for educational methods which can positively influence self-esteem,
especially in demanding military healthcare settings. Warrior Transition Units
(WTU's) are tasked with the challenging mission of caring for seriously injured
or ill U.S. Army Soldiers. This paper explored the hypothesis that an education
ally-based Mental Skills Training (MST) intervention can enhance self-esteem in
members of a Warrior Transition Unit in the U.S. Army. The sample was comprised
of 27 WTU cadre members who participated in an Army Center for Enhanced Per
formance (ACEP) MST educational workshop at a large Army installation on the
West Coast. Instruments included the Ottawa Mental Skllls Inventory (OMSAT-3;
Durand-Bush & Salmela, 2001) and the Self-Esteem Rating Scale (SERS; Wagnild,
1993). Results showed that SERS scores were significantly higher following the
intervention. Furthermore, the ACEP instructional components of self-confidence,
imagery, and mental practice were significant predictors of self-esteem. Results
suggest that MST might be a viable educational approach for enhancing self-esteem
in the WTU cadre.
Introduction in 2008 (Kennedy, 2008). This greater than
Although the U.S. military is respon three-fold rise in Soldiers assigned to WTU's
sible for fighting and winning the nations' substantially increases the workload and the
wars, caring for and rehabilitating Soldiers associated amount of job-related adversity
who become seriously injured or ill while experienced by the WTU cadre members
serving their country is also of prime im (Kennedy, 2008).
portance. To address this concern theAnny Positive self-esteem is an important at
has developed "Warrior Transition Units" tribute for workers wishing to cope effectively
(WTU's) to aid wounded warriors through with worksite adversity in any demanding
their recovery process and their transition situation (Folkman, 1998). This is especially
either back to Army units or to civilian life. true in health care settings as workers with
Not surprisingly, as engagement in the War high self-esteem are likely to affect patient
on Terror continues, the number of injuries care in positive directions (Abraham, 1999;
to Soldiers, and therefore the number of Sol Browning, et aI., 2006; Chen, Thomas and
diers being assigned to WTU's, is increasing. Casper 2004). Having high self-esteem
For example, approximately 6000 Soldiers means health care providers feel good about
were assigned to WTU's in 2007, but this themselves. As individuals become more
number is projected to grow to over 20,000 positive about themselves, they generally
become more positive about others ,resulting
in a more positive "bedside manner" which
Jon Hammermeister, Ph.D., Michael A. is essential for caregiver success (Anders
Pickering, Ph.D .,LTC Carl J. Ohlson,Ph.D.,Army
son 1993).
Center for Enhanced Perronnance, United States
While it is difficult to argue the need for
Military Academy, West Point, NY.
good self-esteem among healthcare workers,
Correspondence concerning this article
little is known about how to enhance this
should be addressed to Dr. Jon Hammenneister
at 23011 Kingsbury Road, S.W., Vashon, WA attribute within the military healthcare com
98070. munity, and more specifically, with members
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2009 2. REPORT TYPE 00-00-2009 to 00-00-2009
4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
Teaching Mental Skills for Self-Esteem Enhancement in a Military
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Healthcare Setting
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2/ Journal of Instructional Psychology, Vol. 36, NO.2
of Warrior Transition Units. portance of an individuals' mental "skill-set"
Mental Skills Training (MST), devel (e.g., self-confidence, ability to concentrate,
oped primarily for enhancing mental fitness goal-setting skill, ability to control emotions,
and perfonnance in sport settings, represents etc.) as being an important contributor to
a potentially innovative educational approach psychosocial health, and self-esteem in
for enhancing attitude-related cognitions such particular. Similarly, Dandura (1997) and
as self-esteem. However, to date, no studies Flammer (1990) found that individuals with
have investigated its potential for impacting high self-efficacy beliefs, a construct strongly
cognitions within military healthcare environ related to self-confidence (Feltz, 1988), also
ments. Therefore, the focus of this study was report strong feelings of well-being and high
to explore the possible utility of using this self-esteem in general.
type of instructional approach to enhance Self-esteemandhealthcareworksiteout
self-esteem among the WTU cadre. comes. Self-esteem is positively associated
with work-related outcomes in healthcare
Warrior Transition Units settings. Chen, Thomas and Casper (2004)
In October of2007 theArmy established identified self-esteem as an attribute that
35 WTU's at major installations across the predicted increased job satisfaction, organi
force to streamline care for wounded, injured, zational commitment, and job involvement
and seriously ill Soldiers. The WTU mission in a sample of 159 healthcare employees.
is to facilitate the healing andrehabilitation of Improvement in self-esteem has also differ
Soldiers, return them to duty when possible, entiated employees who exhibit long-tennjob
or to prepare them for a successful life as a burnout from those who do not (Browning, et
veteran in their community. A typical WTU a!., 2006). Evidence also suggests that self
company will have aCommander,Executive esteem may mediate the antecedents of job
Officer, First Sergeant, six Platoon Sergeants complaining behavior(Heck,Bedeian & Day,
and 18 Squad Leaders. A key element of the 2005) as well as the relationship between ac
WTU framework is the "Triad of Support" tual job inequity ,job satisfaction and intended
which consists of a Primary Care Manager, job turnover (Abraham, 1999). Finally, in a
who is a physician; a Nurse Case Manager, qualitative study of nurse hospice workers,
who is a registered nurse; and a Squad Leader, Olthuis and colleagues (2007) identified
usually at the rank of Staff Sergeant, who will self-esteem as an important contributor to a
oversee 12 patients. nurses ability to positively view themselves
The Army Medical Command currently and their world. Olthuis argues that a nurses'
staffs WTU's with a cadre of approximately view of themselves is intertwined with how
2500 personnel. This includes approximately they view and interact with their patients and
750 active-component Soldiers, 380 National will ultimately influence the quality of their
Guard Soldiers, 380 Army Reserve Soldiers, job performance.
and 915 Army Civilians (Sheftick & Holzer,
2007). Mental Skills Training
Although the notion that self-esteem
Self-Esteem can positively influence healthcare worksite
Rosenberg (1965) provided a broad and perfonnance seems apparent, little inquiry
frequently cited description of self-esteem as has examined the most effective methods of
a favorable or unfavorable attitude toward the enhancing this attribute in military settings.
self(p.15). The mechanisms which facilitate One possible approach may liein the applica
the development of self-esteem are complex, tion of Mental Skills Training (MST). MST
however,Petlichkoff (2004) identified theim- refers to the systematic and consistent prac-
E .. /3
tice of techniques and strategies designed to self-esteem.
enhance mental skills that facilitate optimum
perfonnance(Vealy & Campbell, 1988). MST Method
is typically taught in an education context, Participants
as opposed to a clinical one. MSTprograms Participants in this study were 27
have been used ~xlensively in sport settings individuals from Warrior Transition Units
to develop psychological dexterity (e.g., (WTU's) located at a large military base on
self-confidence, attention control, appropri the west coast. The sample was comprised
ate management of energy) that enhance of 14 males, 12 females, and one individual
individuals' ability to use his or her mind who did not identify his or her gender. There
effectively in a variety of performance situ were 16 military enlisted personnel ranging
ations (Gould & Damarjian, 1998). in grade from E-5 to E-7, 5 civilian nurses,
The Army Center for Enhanced Per 4 civilian social workers, and 2 civilian oc
formance (ACEP) is a new Army program cupational therapists. Ages ranged from 24
tasked with improving Soldier functioning ~ 57 with a mean of38.3 years.
through the delivery of MST-based educa
tional curricula. ACEP provides instruction Instruments
to Soldiers in six primary areas related to Demographic andPh ysical Health Ques
performance enhancement: 1) mental skills tionnaire. The demographic questionnaire
foundations, 2) self-confidence, 3) goal-set was designed specifically for this study and
ting, 4) energy/emotion control, 5) attention assessed basic demographics such as age,
control, and 6) imagery. rank, gender, and occupation.
Petlichkoff (2004) has suggested that Ottawa Mental Skills AssessmentTool-3.
mental skills training can influence compo Durand-Bush and Salmela (200 I) developed
nents of psychological well-being, including The Ottawa Mental Skills Assessment Tool-
self-esteem. However, no studies have ap 3 (OMSAT-3) to measure a broad range of
peared that suggest how MST might enhance mental skills thought to be relevant for sport
well-being of individuals working in military performance. It includes 48 items, and as
healthcare settings, nor does any data exist sesses 12 mental skill scales that are grouped
showing which MST skills may be the most under three broader conceptual components:
appropriate to target. Thus, the purposes of (a) foundation skills (goal-setting, self-confi
this study were (I) to describe changes in dence, commitment), (b )psychosomatic skills
self-esteem scores reported by WTU cadre (stress reactions, fear control, relaxation,
members before and after an ACEP MST activation), and (c) cognitive skills (imagery,
educational intervention, and (2) to identify mental practice, focusing, refocusing, and
mental skills that most effectively predict
Table I
Summary of Stepwise Selection in Multiple Regression Analysis of
OMSAT-3Variables Predicting Self-Esteem
Variables Step Partial Model
Entered Entered R' R' Beta F p
Self-Confidence I .41 Ai .41 15.30 .0004
Imagery 2 .08 049 .60 3.40 .08
Mental Practice 3 .06 .55 -.33 2.50 .13
41 Journal of Instructional Psychology, Vol. 36, No.2
competition planning). The OMSAT-3 was following the delivery of the 12-hour ACEP
selected for use in this study because it as curriculum.
sesses a set of mental skills that are similar The ACEP educational intervention
to those targeted by the ACEP educational for the WTV consisted of eight 1.5 hour
program. educational modules designed to enhance
Each item on the OMSAT-3 is answered the cadre's skills and use of performance
on a "strongly disagree" to "strongly agree" psychology principles. The eight modules
7-point Likert scale (e.g., "I am determined included: I) mental skills foundations, 2)
to never give up"). Durand-Bush & Salmela self-confidence, 3) goal-setting, 4) attention
(2001) have reported acceptable internal control,5) energy management, 6) imagery
consistency and temporal stability of the for healing, 7) life-coaching theory, and 8)
OMSAT-3. team building.
In our study, internal consistency esti
mates of the OMSAT-3 subscales varied from Results
.66 to .92, with a mean value of .80. Pre-Post Differences in Self-Esteem
Seif-Esteem Rating Scale. The Self Results revealed a significant effect from
Esteem Rating Scale (SERS; Nugent & pre-(M = 78.85,SD = 31.74) to post-test (M
Thomas, 1993) is a 40-item instrument = 89.82, SD = 26.73) scores on the SERS (t
designed to provide a clinical measure of (23) = -3.26, p = .003).
self-esteem. Factor analysis of the SERS
(Nugent & Thomas, 1993) has confinned the Predicting Self-Esteem
uni-dimensional nature of the SERS, with all Stepwise mUltiple regression was used of
40-items loading positively on a single factor. SMR was used to identify which subscales of
SERS items are answered on a "never" to the OMSAT-3 made significant contributions
"always" 7-point Likert format (e.g., "I feel to the prediction of self esteem scores. A three
that I am an attractive person"). Twenty of variable solution was found, accounting for
the items are scored positively and twenty are 55% of the variance in self~esteem scores,
scored negatively yielding a possible range and included self-confidence, imagery, and
of scores from -120 to 120. The SERS has mental practice as predictor variables (see
demonstrated strong internal consistency Table 1. Because of the exploratory nature
as well as evidence of content and factorial of this study, alpha levels were set at .15 for
validity, and construct validity (Nugent & inclusion in the model.
Thomas, 1993).
In our study, the SERS demonstrated Discussion
strong internal consistency displaying an MST Training and Self-Esteem
alpha coefficient of .97. Mean SERS scores were significantly
higher following completion of the 12-hour
Procedure ACEPintervention. Further, multiple regres
Following United States Military Acad sian results revealed that self-confidence, im
emy (USMA) Institutional Review Board agery, and mental practice uniquely predicted
approval, WTV cadre members were asked cadre members' self-esteem scores.
to participate in the study prior to their Se if-confidence. Self-confidence training
engagement in a regularly scheduled Anny was a major part of the ACEP educational
Center for Enhanced Perfonnance (ACEP) intervention and focused on teaching cadre
educational workshop. Participation in the members how to a) exercise selective percep
study involved completion of the survey tion (Gauron, 1984), b) control their self-talk
instruments described above prior to and (Zinsser et aI., 2001), c) employ meaningful
E .. /5
affinnations (Rushall, 1979; Syer & Connolly, variety of ways (Rushall, 1988). One com
1984), and d) to effectively interpret and attri monly used function of systematic imagery
bute successes and failures (Seligman,1991; for improving performance and well-being
Weiner, 1985). Of the potential OMSAT-3 includes motivational components for en
predictors, self-confidence accounted for the hancing self-confidence (Callow, Hardy, &
most variation in SERS scores. This finding Hall, 1998).
clearly suggests that educationally-based WTU cadre members in this study were
self-confidence curriculums may also be a instructed to image successful execution
viable technique for enhancing self-esteem. of their jobs. They were also instructed to
As this study was correlational in nature, develop imagery scripts and were guided
the mechanisms driving this finding still re through the process of implementing these
main unknown. However, the well-known scripts as a tool for more systematic imagery
link between self-confidence and self-efficacy practice. Thus, cadre members were able to
may provide some clues. Self-efficacy (Ban refine their imagery use during the interven
dura, 1977) is a specific self-perception, and tion by more consistently creating images
has been referred to as a situational specific that were positive, self-reinforcing, and well
fonn of self-confidence (Feltz, 1988). Confi controlled. In turn, these types of positive
dence (defined as the finnness or strength of images may have contributed to how the cadre
one's belief; Bandura, 1997) has been used members' "viewed" themselves, and thus
as an overarching concept that encompasses providing a potential the link to improved
self-efficacy as well as the notion of compe self-esteem.
tence. Given that relationship, our finding Mental practice. Finally. the regression
seems consistent with Bandura's contention results highlight the importance of mental
(1997) that self-efficacy is strongly related practice (e.g., the frequency with which
to self-esteem. Bandura (1997) argued that systematic mental training occurs) as an ad
efficacy expectations to perform a given task ditional behavior that might further enhance
could influence perceptions of self-esteem self-esteem. Since the results of this study
when the success/failure is heavily tied in with suggest that self-confidence and quality
self-worth. In our study. it is possible that imagery ability appear to be related to self
WTU cadre members placed a high degree of esteem, it's important to note that the pres
importance to their job-related activities, thus, ence of these skills may not be enough. As
self-esteem is likely to be derived from the self-confidence and imagery need consistent
cadre's efficacy expectations about their job reinforcement to be optimally integrated into
ratherthan the reverse. The MST intervention, one's mental skill-set (Yealey & Campbell,
we believe, provided educational material 1988; Callow, Hardy, & HaU, 1998), the
which enhanced the WTU cadres' efficacy systematic and consistent practice of these
expectations about their ability to perform skills may be an integral part of the process
their job, thus influ~ncing their self-esteem. of maintaining self-esteem.
Unfortunately, the cross-sectional design of
this study does not allow for confirmation of Limitations
the directionality of these relationships. The findings of this exploratory investi
Imagery. Imagery's role as a significant gation were based on a small (n = 27) sample
predictor of self-esteem is also noteworthy. of the WTU cadre, and without a comparison
Numerous studies have revealed that imagery group, we cannot rule out alternative explana
has been used effectively by outstanding tions for the improvements reported in self
performers in various settings (see Martin, esteem. Likewise, the cross-sectional nature
Moritz, & Hall, 1999 for a review) and in a of the design does not facilitate causal con-
6/ Journal of Instructional Psychology, Vol. 36, No.2
clusions regarding the relationship between Durand-Bush, N., & Salmela, 1.H. (2001). The
mental skills and self esteem, nor did this Ottawa Mental Skills Assessment Tool (OM
study address potential moderators of the SAT-3). The Sport Psychologist, 15, 1-19.
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