Nursing Theory

Bandura’s Theory of Self-Efficacy

While researching the topic of postpartum maladaptation syndromes, a recurrent risk factor emerged from the literature, self-efficacy. First-time parenting, breastfeeding challenges, infant illnesses, lack of support, traumatic deliveries causing prolonged recovery periods, all have the protentional to challenge a mother’s feelings of self-efficacy. Bandura (1982) argues that competence requires work and adaptation to ever changing circumstances, as in parenthood, and perceived self-efficacy is concerned with the judgement of how well an individual can deal with the prospective situations. Bandura (1982) also argues that an individual’s self-appraisal of their ability to deal with unexpected circumstances dictates behavior and emotional responses when circumstances arise. This statement has direct applicability to a new mother’s perceived ability to deal with the unexpected occurrences and the emotional responses in those events. Enactive attainments or the mastery of a task, vicarious experiences, verbal persuasion, and the physiological feedback of the body influence an individual’s feelings of self-efficacy (Bandura, 1982). Many mothers are aware of the vicarious experiences of surrounding friends and family members, and this certainly plays a role in the maternal views on self-efficacy. In the early days of motherhood, mastery of tasks can be successful, as in a successful breastfeeding relationship, creating positive self-efficacy or unsuccessful in the opposite and can precipitate feelings of negative self-efficacy. Verbal persuasion, as in the encouragement of spouses, mothers, and the care team is often present in the early days of a mother and child relationship and positive affirmation likely plays a role in feelings of self-efficacy. Physiological feedback in the body as in feelings of uneasiness or feelings of confidence can also play a role in the development of feelings of adequate or inadequate self-efficacy. According to Bandura (1982), self-referent misgivings create stress and impair performance, but in contrast individuals who are strong in self-efficacy enjoy the challenge of a situation and celebrate accomplishment of the task.

State of Science

An extensive review of current literature was conducted in pursuit of research regarding the impact of self-efficacy on mothers with postpartum anxiety. To obtain the most current research regarding this topic the University of Cincinnati library of resources was utilized. Using the key words postpartum, anxiety, mother, and self-efficacy, and narrowing the research to full-text online, peer-reviewed scholarly articles, in English, within the last 5 years provided for the most appropriate and applicable literature.

Farr, Dietz, O’Hara, Burley, and Ko, (2014) sought to identify the burden and infant outcomes associated with anxiety and comorbid depression in postpartum women. Postpartum women in a stratified sample of individuals who where involved in a Pregnancy Risk Assessment and Monitoring System (PRAMS) were contacted for involvement in the study. PRAMS is a standardized method of obtaining information from mandatory birth certificate information in 40 states in an approved process by the Centers for Disease Control (CDC). Using PRAMS the authors contacted the selected women and provided a standardized questionnaire with special focus on the questions “I have felt restless and fidgety” and “I have felt panicky” (p.121) to help identify women with postpartum anxiety symptoms (Farr et al., 2014). The authors also obtained information regarding demographic data, pregnancy factors, Medicaid coverage, drug and alcohol status, and stressful life events that had occurred during the pregnancy (Farr et al., 2014). A total of 4639 women were surveyed and placed in groups identified by the authors as having postpartum anxiety symptoms only, postpartum anxiety and depression symptoms, postpartum depression symptoms only, and neither postpartum depression or anxiety symptoms (Farr et al., 2014). In this study 18% of the postpartum women were identified as experiencing postpartum anxiety symptoms (Farr et al., 2014). In the women who experienced postpartum anxiety, positive correlations were noted with those who had a higher number of stressors during pregnancy, delivering a pre-term infant, pre-existing diabetes, and smoking in pregnancy (Farr et al., 2014). For women who had <1-2 vaginal deliveries the incidence of postpartum anxiety symptoms was 11.6% of the population and 9.9% of the population of mothers with <1-2 cesarean deliveries (Farr et al., 2014). The large sample size and the stratified method of sampling of the Farr et al. (2014) study promotes confidence in the research. The specific questions proposed by the authors to address presence of anxiety and depressive symptoms in the mothers have been shown to be 75% sensitive and 77% specific (Farr et al., 2014). According to the Facchiano & Snyder (2012) hierarchy of evidence scale, the Farr et al. (2014), article would constitute a level 4 rating due to the focus of the study being a case control study in which individuals with postpartum anxiety and/or depression are compared to those who do not have postpartum anxiety and/or depression.

Dennis et al. (2017) state that the negative outcomes of postpartum anxiety impact the mother in physical and mental aspects, and also has detrimental effects on the development of the infant due to impaired maternal-infant interactions. Due to the widespread nature and important effects of the postpartum anxiety disorder Dennis et al. (2017) found it to be important to study the risk factors present in mothers experiencing the disorder. Participants of the study were provided with informed consent and the study was authorized by the health regions and university research ethics board (Dennis et al., 2017). Dennis et al. (2017) recruited a convenience sample of a total of 857 women to complete questionnaires at 1,4, and 8 weeks postpartum. The questionnaire included items from 10 assessment tools, which were identified and tested in other reputable literature, to identify anxiety symptomology, vulnerable personality styles, significant life events, family violence and substance abuse, childcare stress, support, relationship-support, breastfeeding self-efficacy, self-esteem, and depression symptomology (Dennis et al., 2017). Using the Likert score for many answers the authors were able to quantitively and categorically group the women according to their responses. The number of women completing the week one survey dropped sharply from the individuals who were identified as being appropriate for the study. The week 1 sample size included 594 mothers, week 4 included 535 mothers, and week 8 included 498 mothers. Dennis et al. (2017) used the data to create a regression of risk factors for sustained postpartum anxiety. Many of the identified risk factors were found to have a statistically significant relationship with sustained postpartum anxiety. Most importantly to the focus of this paper was the variable of maternal adjustment including breastfeeding self-efficacy at 1 and 4 weeks and self-esteem at 4 weeks as having a statistically significant relationship with sustained postpartum anxiety. The sample size for this study was large and according to Dennis et al. (2017) encompassed women from a variety of healthcare locations in Canada. Although, the authors were aware that the sample may have failed to include women without access to healthcare, which is a vulnerable population to the development of postpartum anxiety. According to the Facchiano & Snyder (2012) rating scale, the research by Dennis et al. (2017) would qualify for a rating of a level 4 evidence due to the comparison and regression of the variables of postpartum mothers with sustained anxiety and those who do not have sustained postpartum anxiety.

Ashford, Ayers, and Olander (2017) discussed many recent research articles that emphasize the growing and possibly under-supported number of postpartum women who struggle with anxiety and depression. Ashford et al. (2017) reported that some of the detrimental effects of postpartum anxiety include increased maternal healthcare usage after discharge, decreased breastfeeding duration, colic in the newborn, and possible negative effects on the child’s development. In the United Kingdom (UK) postpartum women are in contact with a qualified home visitor to help support the new mother and infant in the early weeks after delivery. With the identification of the prevalence of postpartum anxiety Ashford et al. (2017) sought out to qualitatively determine the UK home visitors’ experiences and views about supporting women with postpartum anxiety. The authors utilized a convenience sampling of thirteen home visitors who were working in cooperation with the National Health Service and were willing to participate in in-person or over-the-phone interviews (Ashford et al., 2017). Many of the home visitors spoke to the commonality of postpartum anxiety, especially in first-time mothers, but were concerned about identifying when the anxiety becomes problematic (Ashford et al., 2017). Although anxiety was identified as a common issue in postpartum mothers, the home visitors stated that most screening tools available focus on postpartum depression and not anxiety (Ashford et al., 2017). Another finding of the study focused on the overuse of healthcare services due to maternal worrying over the well-being and development of the child, and the additional strain that is put on health care services to provide reassurance (Ashford et al., 2017). Ashford et al. (2017) argued that the views of the home visitors highlight the need for better assessment tools for postpartum anxiety, increased availability of mental health services for women, and continued awareness in this topic. Although the study by Ashford et al. (2017) is a small, qualitative study, the publication of this article in a peer-reviewed journal lends itself to trustworthiness of the information and qualifies for level 5 on Facchiano’s and Snyder’s hierarchy of evidence scale.

Leahy-Warren, McCarthy, and Corcoran (2011) echoed the importance of perceived social support for postpartum mothers in positive adaptive behaviors. Although this article examines the relationship of social support and self-efficacy in development of postpartum depression, the authors were able to specifically apply Bandura’s theory of self-efficacy to this important population of postpartum mothers. Leahy-Warren et al. (2011) sought out to determine if the “more a mother feels able to successfully handle the demands of new motherhood, the less is her experience of stress and depression” (p. 389), which is a hypothesis created based on Bandura’s theory of self-efficacy. Leahy-Warren et al. (2011) utilized Blau’s social exchange theory to develop a questionnaire with a Cronbach’s alpha score of .80 to test social support, maternal self-efficacy was tested using a Likert-scale style tool with a Cronbach’s alpha score of .89, and to test postnatal depression symptoms the widely used Edinburgh Postnatal Depression Scale with a Cronbach’s alpha coefficient of .88. The quantitative study by Leahy-Warren et al. (2011) was approved the Teaching Hospitals Ethics Committee, and all 589 mothers were provided with informed consent and confidentiality agreements. The sample of mothers was a convenience sample of a large maternity hospital in Ireland. Several inverse statistically significant relationships existed between domains of support and the incidence of postnatal depression (Leahy-Warren et al. 2011). Most importantly to the topic of this paper, a statistically significant correlation was found between informal family and friend structural social support and maternal self-efficacy (Leahy-Warren et al. 2011). The outcomes of this study supported two “principles of Bandura’s theory of self-efficacy: that social persuasion in the guise of informal support positively influences parenting self-efficacy and that psychosocial variables such as depression have inverse relationships to self-efficacy” (Leahy-Warren at al., 2011, p. 394). Due to the retrospective nature of this study and the reliance of the researchers on the participants to provide accurate feedback, this study would qualify for a level 4 on the Facchiano’s and Snyder’s (2012) hierarchy of evidence scale.

All 4 research studies consulted for the purposes of this paper point to a high incidence of anxiety in postpartum women. Ashford et al. (2017) discussed that postpartum anxiety may be more common than postpartum depression but is less routinely screened. Many of the authors reported a need for a more extensive and validated screening tool to assess for sustained postpartum anxiety. Dennis et al. (2017) and Farr et al. (2014) identified that women who experienced stressors related to housing, finances, feelings about the pregnancy, adverse life events and many more were at increased risk for postpartum anxiety. The Edinburgh Depression Screening was mentioned in the literature as a highly validated and utilized tool for postpartum depression, but only two of the questions focus on postpartum anxiety symptoms. Only one study, the study involving the home visitors in the UK focused on the limited availability of mental health resources to postpartum women. All research identified the importance of addressing this topic to improve outcomes for mothers and infants.

The reviewed literature discussed the impact of low feelings of self-esteem and self-efficacy in maladaptation syndromes in the postpartum period. Ashford et al. (2017) identified that women who report worry about normal infant development or have increased usage of health care services in the first weeks of infant life may have an increased need for reassurance. Farr et al. (2014, on the other hand, made the profound statement that “mothers with postpartum anxiety have higher stress, lower sense of competence, and less social support than healthy controls” (p.120). Leahy-Warren et al. (2011) postulated that the more a mother feels able to successfully manage the demands of new motherhood, the less is her experience of stress and depression. Meanwhile, Dennis et al. (2017) discussed that other populations of individuals with “high self-esteem do not experience negative emotions as often as those with low self-esteem and develop better coping strategies” (p.135) and this concept applies to new mothers.

The current state of science is clear; new mothers are at high risk for developing postpartum maladaptation syndromes including anxiety and depression. The evidence is also clear that healthcare providers need to push for further knowledge on this topic to encourage development of a valid assessment tool and interventions. The stakes are high for children and the women where postpartum anxiety is present and this is certainly a topic that deserves the attention of providers, researchers, and support systems.

Application of Bandura’s Theory of Self-Efficacy

Repeatedly the research indicates that postpartum women who have strong informal support systems are likely to have higher feelings of self-efficacy, which leads to a decreased likelihood of anxiety. The 4 concepts by Bandura (1982), enactive attainments, vicarious experiences, verbal persuasion, and the physiological feedback of the body are directly applicable to encouraging self-efficacy in post-partum mothers. Bandura (1982) described enactive attainments as the positive feedback created by the mastery of a skill. In the population of new mothers, this could be applied in goal setting for the breast-feeding relationship, or in encouraging more hands-on care by the mother in the early days of life rather than healthcare personal providing diaper changes, first baths, and clothing of the infant. In many current healthcare facilities, the health care team provides many of the activities of daily living for the baby due to the view that it is part of the health care team’s responsibilities. But, perhaps if an educational piece could be provided that discussed the importance of allowing mothers to heavily participate in the care of the infant, then attitudes and actions among healthcare staff may change. To measure the outcome of this new process, would be to ask mothers upon discharge from a facility about the level of confidence with diaper changing, dressing, and bathing their infant. Vicarious experience involves role-modeling to encourage a positive outlook by the individual (Bandura, 1982). An intervention relative to vicarious experience is to encourage new mothers to seek out additional resources including support groups and childbirth and infant care classes in which the mothers could meet others who are facing similar successes and challenges. Bandura (1982) describes verbal persuasion as a widely used tactic to increase feelings of self-efficacy. Verbal persuasion very well may be the most important tactic in encouraging self-efficacy in new mothers. The support team for the mother, the husband, nurse, doctor, extended family, must be cognitively aware of the stressors a new mother is undergoing and the importance of positive affirmations. To specifically apply this idea, perhaps a study could be undertaken to ask new mothers to report the most helpful education or support received during the inpatient period, and to report any feedback that was especially detrimental. This information in combination with the research on risk factors for development of anxiety by Dennis et al. (2017) could be used to educate providers about the risk factors and helpful interventions for encouraging self-efficacy in new mothers. Lastly, Bandura (1982) discussed that individuals sometimes rely on the physiological feedback from their bodies to determine self-efficacy in a situation. This concept is especially important in new mothers who are already under physiological stress post-delivery. An intervention relative to Bandura’s concept of physiological feedback would be encouraging mothers to reflect, restore, and rest during this important postpartum period.

Conclusions and Applicability

In caring for mothers, it is evident that many mothers struggle with anxiety relative to feelings of negative self-efficacy. The research study by Dennis et al. (2017) helped to identify the prevalence and the risk factors of mothers with sustained postpartum anxiety. The qualitative study by Ashford et al. (2017) helped to recognize the need for a validated postpartum anxiety risk assessment and for increased availability of mental health services. The studies by Leah-Warren et al. (2012) and Dennis et al. (2017) validated that one of the single most important things in encouraging self-efficacy in new mothers is a strong support system. Bandura’s concepts statements regarding self-efficacy were perfectly applicable to the topic of postpartum anxiety and allowed for greater understanding of factors that would increase feelings of self-efficacy to decrease negative emotional responses. The research and completion of this paper has encouraged me to be more passionate about encouraging self-efficacy in the new mothers under my care. I have also been encouraged to petition my facility to begin research into a postpartum anxiety assessment tool and also to develop education about evaluating risk factors for sustained postpartum anxiety. The effort to increase awareness about postpartum anxiety and encouraging self-efficacy, will be well rewarded in healthier babies and more confident mothers.

References

Ashford, M. T., Ayers, S., & Olander, E. K. (2017). Supporting women with postpartum anxiety: Exploring views and experiences of specialist community public health nurses in the UK. Health & Social Care in the Community, 25(3), 1257-1264. doi:10.1111/hsc.12428

Bandura, A. (1982). Self-efficacy mechanism in human agency. American Psychologist, 37(2), 122-147. doi:10.1037/0003-066X.37.2.122

Dennis, C., Brown, H. K., Falah-Hassani, K., Marini, F. C., & Vigod, S. N. (2017). Identifying women at risk for sustained postpartum anxiety. Journal of Affective Disorders, 213, 131-137. doi:10.1016/j.jad.2017.02.013

Facchiano, L., & Snyder, C. (2012). Evidence-based practice for the busy nurse practitioner: Part one: Relevance to clinical practice and clinical inquiry process. Journal of the American Academy of Nurse Practitioners, 24(10), 579-586. doi:10.1111/j.1745-7599.2012.00748.x 

Farr, S. L., Dietz, P. M., O'Hara, M. W., Burley, K., & Ko, J. Y. (2014). Postpartum anxiety and comorbid depression in a population-based sample of women. Journal of Women's Health, 23(2), 120-128. doi:10.1089/jwh.2013.4438

Leahy‐Warren, P., McCarthy, G., & Corcoran, P. (2012). First‐time mothers: Social support, maternal parental self‐efficacy and postnatal depression. Journal of Clinical Nursing, 21(3‐4), 388-397. doi:10.1111/j.1365-2702.2011.03701.x