Nursing Theory
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CHAPTER 10 Theory of Self-Effi cacy
Barbara Resnick
Self-effi cacy is defi ned as an individual’s judgment of his or her capabilities to organize and execute courses of action. The core of Self-Effi cacy Theory means that people can exercise infl uence over what they do. Through refl ec- tive thought, generative use of knowledge and skills to perform a specifi c behavior, and other tools of self-infl uence, a person will decide how to behave (Bandura, 1997). To determine self-effi cacy, an individual must have the opportunity for self-evaluation or the ability to compare individual output to some sort of evaluative criterion. This comparative evaluation process enables an individual to judge performance capability and establish self-effi cacy expectation.
■ PURPOSE OF THE THEORY AND HOW IT WAS DEVELOPED
The Theory of Self-Effi cacy is based on the Social Cognitive Theory and con- ceptualizes person–behavior–environment interaction as triadic reciprocal- ity, the foundation for reciprocal determinism (Bandura, 1977, 1986). Triadic reciprocality is the interrelationship among person, behavior, and environ- ment; reciprocal determinism is the belief that behavior, cognitive, and other personal factors as well as environmental infl uences operate interactively as determinants of each other. Reciprocality does not mean that the infl uence of behavioral and personal factors as well as environment is equal. Depending on the situation, the infl uence of one factor may be stronger than the other, and these infl uences may vary over time.
Cognitive thought—which is a critical dimension of the person–behavior– environment interaction—does not arise in a vacuum. Bandura (1977, 1986) suggested that individuals’ thoughts about themselves are developed and verifi ed through four different processes: (a) direct experience of the effects produced by their actions, (b) vicarious experience, (c) judgments voiced by others, and (d) derivation of further knowledge of what they already know by using rules of inference. Human functioning is viewed as a dynamic interplay of personal, behavioral, and environmental infl uences.
Copyright Springer Publishing Company. All Rights Reserved. From: Middle Range Theory for Nursing, Fourth Edition DOI: 10.1891/9780826159922.0010
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Initial Theory Development and Research
In 1963, Bandura and Walters wrote Social Learning and Personality Development, which expanded on the Social Learning Theory to incorporate observational learning and vicarious reinforcement. In the 1970s, Bandura incorporated what he considered to be the missing component to that theory, self-effi cacy beliefs, and published Self-Effi cacy: Toward a Unifying Theory of Behavior Change (Bandura, 1977). The work supporting self-effi cacy belief was based on research testing the assumption that exposure to treatment conditions could result in behavioral change by altering an individual’s level and strength of self-effi - cacy. In the initial study (Bandura, Adams, & Beyer, 1977; Bandura, Reese, & Adams, 1982), 33 subjects with snake phobias were randomly assigned to three different treatment conditions: (a) enactive attainment, which included actu- ally touching the snakes; (b) role modeling or seeing others touch the snakes; and (c) the control group. The results suggested that self-effi cacy was predic- tive of subsequent behavior, and enactive attainment resulted in stronger and more generalized (to other snakes) self-effi cacy expectations.
Expansion of the early research included three additional studies (Bandura et al., 1982): (a) 10 subjects with snake phobias, (b) 14 subjects with spider pho- bias, and (c) 12 subjects with spider phobias. Similar to the initial self-effi cacy study, enactive attainment and role modeling were effective interventions for strengthening self-effi cacy expectations and impacting behavior. The study of 12 subjects with spider phobias also considered the physiological arousal com- ponent of self-effi cacy. Pulse and blood pressure were measured as indicators of fear arousal when interacting with spiders. After interventions to strengthen self-effi cacy expectations (enactive attainment and role modeling), heart rate decreased and blood pressure stabilized.
This early self-effi cacy research used an ideal controlled setting in that the individuals with snake phobias were unlikely to seek opportunities to interact with snakes when away from the laboratory setting. Therefore, there was con- trolled input of effi cacy information. Although this ideal situation is not pos- sible in the clinical setting, the Theory of Self-Effi cacy has been used to study and predict health behavior change and management in a variety of settings.
The literature explores factors that infl uenced the willingness of older adults to participate in functional activities and exercises. There was a recurring theme that suggested self-effi cacy and outcome expectations mattered to an individual’s willingness. Therefore, the theory helps to understand behavior and guide the development of interventions to change behavior.
■ CONCEPTS OF THE THEORY
Bandura, a social scientist, differentiated two components of Self-Effi cacy Theory: self-effi cacy expectations and outcome expectations. These two
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components are the major ideas of the theory. Self-effi cacy expectations are judgments about personal ability to accomplish a given task, whereas outcome expectations are judgments about what will happen if a given task is success- fully accomplished. Both were differentiated because individuals can believe that a certain behavior will result in a specifi c outcome; however, they may not believe that they are capable of performing the behavior required for the outcome to occur. For example, Mrs. White may believe that rehabilitation will enable her to go home independently; however, she may not believe that she is capable of ambulating across the room. Therefore, Mrs. White may not partici- pate in the rehabilitation program or be willing to practice ambulation.
Bandura (1977, 1986, 1995, 1997) suggests that outcome expectations are based largely on the individual’s self-effi cacy expectations. People anticipate that the types of outcomes generally depend on their judgments of how well they will be able to perform the behavior. Those individuals who consider themselves highly effi cacious in accomplishing a given behavior will expect favorable outcomes for that behavior. Expected outcomes are dependent on self-effi cacy judgments. Therefore, Bandura postulated that expected outcomes may not add much on the prediction of behavior.
Bandura (1986) postulates that there are instances when outcome expec- tations can be dissociated from self-effi cacy expectations. This occurs either when no action will result in a specifi c outcome or when the outcome is loosely linked to the level or quality of the performance. For example, if Mrs. White knows that even if she regains functional independence by participating in reha- bilitation, she will still be discharged to a skilled nursing facility rather than back home, her behavior is likely to be infl uenced by her outcome expectations (discharge to the skilled nursing facility). In this situation, no matter what Mrs. White’s performance, the outcome is the same; thus, outcome expectancy may infl uence her behavior independent of her self-effi cacy beliefs.
Expected outcomes are also partially separable from self-effi cacy judgments when extrinsic outcomes are fi xed. For example, when a nurse provides care to six patients during an 8-hour shift or to 10 patients in the same shift, she receives the same salary. This could negatively impact the performance. It is also possible for an individual to believe that he or she is capable of perform- ing a specifi c behavior rather than the outcome of performing that behavior is worthwhile. For example, older adults in rehabilitation may believe that they are capable of performing the exercises and activities involved in the reha- bilitation process, but they may not believe that performing the exercises will result in improved functional ability. Some older adults believe that resting rather than exercising will lead to recovery. In this situation, outcome expecta- tions may have a direct impact on performance.
Both self-effi cacy and outcome expectations infl uence the performance of functional activities (Galik, Pretzer-Aboff, & Resnick, 2011; Pretzer-Aboff, Galik, & Resnick, 2011; Quicke, Foster, Ogollah, Croft, & Holden, 2016; Resnick,
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2011; Resnick & D’Adamo, 2011; Scarapicchia et al., 2015), adoption and main- tenance of exercise behavior (Chase, 2011; Grim, Hortz, & Petosa, 2011; Hays, Pressler, Damush, Rawl, & Clark, 2010; Nahm et al., 2010; Qi, Resnick, Smeltzer, & Bausell, 2011), dietary intake (Resnick, Hammersla, et al., 2014), smoking cessation (Kamish & Öz, 2011), sex education for children (Akers, Holland, & Bost, 2011), and hip fracture prevention behaviors (Nahm et al., 2010). Outcome expectations are particularly relevant to older adults. These individuals may have high self-effi cacy expectations for exercise, but if they do not believe in the outcomes associated with exercise (e.g., improved health, strength, or function), then it is unlikely that there will be adherence to a regular exercise program (Chase, 2011).
Generally, it is anticipated that self-effi cacy will have a positive impact on behavior. However, it must be recognized that there are times when self-effi - cacy will have no or a negative effect on performance. Some research found that there is a negative effect of self-reported personal goals on performance such that higher personal goals can cause low performance (Vancouver & Kendell, 2006; Vancouver, Thompson, & Williams, 2001). Consistent with a multiple goal process conceptualization, self-effi cacy was also found to relate positively to directing resources toward a goal but negatively to the magnitude of resources allocated for accepted goals (Vancouver, More, & Yoder, 2008). High self-effi cacy expectations can actually be counterproductive. High self- effi cacy may lead people to have a false sense of confi dence and not put in as much effort as needed to perform optimally (Jones, Harris, Waller, & Coggins, 2005). This may be particularly true of behaviors such as exercise in which adequate resources to perform are needed (i.e., adequate physical strength), and the individual may have limited experience on which to draw and appro- priately evaluate his or her self-effi cacy expectations.
Sources of Self-Effi cacy Judgment
Bandura (1986) suggested that judgment about one’s self-effi cacy is based on four informational sources: (a) enactive attainment, which is the actual per- formance of a behavior; (b) vicarious experience or visualizing other simi- lar people perform a behavior; (c) verbal persuasion or exhortation; and (d) physiological state or physiological feedback during a behavior, such as pain or fatigue. The cognitive appraisal of these factors results in a perception of a level of confi dence in the individual’s ability to perform certain behavior. The positive performance of this behavior reinforces self-effi cacy expectations (Bandura, 1995).
ENACTIVE ATTAINMENT
Enactive attainment, the actual performance of behavior, has been described as the most infl uential source of self-effi cacy information (Bandura, 1977,
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1986), and it is the most common intervention that is used to strengthen effi - cacy expectations in older adults. There has been repeated empirical verifi - cation that actually performing an activity strengthens self-effi cacy beliefs. Specifi cally, the impact of enactive attainment has been demonstrated with regard to snake phobias, smoking cessation, exercise behaviors, performance of functional activities, and weight loss. Enactive attainment generally results in greater strengthening of self-effi cacy expectations compared to informational sources. However, performance alone does not establish self-effi cacy beliefs. Other factors such as preconceptions of ability, the perceived diffi culty of the task, the amount of effort expended, the external aid received, the situational circumstance, and past successes and failures impact the individual’s cognitive appraisal of self-effi cacy (Bandura, 1995). An older adult who strongly believes that he or she is able to bathe and dress independently because he or she has been doing so for 90 years will not likely alter self-effi cacy expectations if he or she wakes up with severe arthritic changes one morning and is consequently unable to put on a shirt. However, repeated failures to perform the activity will impact self-effi cacy expectations. The relative stability of strong self-effi cacy expectations is important; otherwise an occasional failure or setback could severely impact both self-effi cacy expectations and behavior.
VICARIOUS EXPERIENCE
Self-effi cacy expectations are also infl uenced by vicarious experiences or see- ing other similar people successfully performing the same activity (Bandura, 1977; Chase, 2011; Martin et al., 2011). However, there are some conditions that impact the infl uence of vicarious experience. If the individual has not been exposed to the behavior of interest or has had little experience with it, vicari- ous experience is likely to have a greater impact. Additionally, when clear guidelines for performance are not explicated, self-effi cacy will be more likely to be impacted by the performance of others. Among older adults with cogni- tive impairment, vicarious experiences are particularly effective in increasing activity (Galik, Resnick, Lerner, Sabol, & Gruber-Baldini, 2015; Resnick, Galik, Nahm, Shaughnessy, & Michael, 2009).
VERBAL PERSUASION
Verbal persuasion involves telling an individual that he or she has the capabili- ties to master the given behavior. Empirical support for the infl uence of verbal persuasion has been documented since Bandura’s early research of phobias (Bandura et al., 1977). Verbal persuasion has proven effective in supporting recovery from chronic illness and in health promotion research. Persuasive health infl uences lead people with a high sense of self-effi cacy to intensify efforts at self-directed change of risky health behavior. Verbal encouragement from a trusted, credible source in the form of counseling and education has
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been used alone and with performance behavior to strengthen effi cacy expec- tations (Bennett et al., 2011; Chase, 2011; Clark et al., 2015; Gau, Chang, Tian, & Lin, 2011; Irvine et al., 2011; Kamish & Öz, 2011; Martin et al., 2011; Oberg, Bradley, Allen, & McCrory, 2011; Resnick, Wells, et al., 2016; Reifegerste & Rossmann, 2017; Rosal et al., 2011; Skinner et al., 2011; van Stralen, de Vress, Mudde, Bolman, & Lechner, 2011; Williams, 2011). For example, verbal encour- agement through telephone calls and email support was successful in increas- ing adherence to relevant self-care behaviors among adults with congestive heart failure (Clark et al., 2015) and encouragement through the computer was effective in strengthening self-effi cacy associated with behaviors to prevent unintended pregnancy and infections (Swartz et al., 2011) and in improving coping self-effi cacy associated with HIV (Brown, Vanable, Carey, & Elin, 2011).
PHYSIOLOGICAL FEEDBACK
Individuals rely in part on information from their physiological state to judge their abilities. Physiological indicators are especially important in relation to coping with stressors, physical accomplishments, and health functioning. Individuals evaluate their physiological state or arousal, and if aversive, they may avoid performing the behavior. For example, if the older adult has a fear of falling or getting hurt when walking, a high arousal state associated with the fear can limit the performance and decrease the individual’s confi dence in ability to perform the activity. Similarly, if the rehabilitation activities result in fatigue, pain, or shortness of breath, these symptoms may be interpreted as physical inef- fi cacy and the older adult may not feel capable of performing the activity.
Interventions can be used to alter the interpretation of physiological feedback and help individuals to cope with physical sensations, enhancing self-effi cacy and resulting in improved performance. Interventions include (a) visual- ized mastery, which eliminates the emotional reactions to a given situation (Bandura et al., 1977); (b) enhancement of physical status (Bandura, 1995); and (c) altering the interpretation of bodily states (Resnick, Galik, Gruber-Baldini, & Zimmerman, 2011; Resnick, Gruber-Baldini, Galik, et al., 2009; Resnick, Gruber-Baldini, Zimmerman, et al., 2009; Resnick, Wells, et al., 2016; Schnoll et al., 2011; Van der Maas et al., 2015). Interventions that decrease the pain associated with the use of pain medication or ice treatments and interventions focused on decreasing fear of falling have been shown to increase participation in rehabilitation and exercise among older adults (Resnick et al., 2011; Resnick, Gruber-Baldini, Galik, et al., 2009; Resnick, Gruber-Baldini, Zimmerman, et al., 2009; Schnoll et al., 2011; Van der Maas et al., 2015).
■ RELATIONSHIPS AMONG THE CONCEPTS: THE MODEL
The Theory of Self-Effi cacy was derived from the Social Cognitive Theory and must be considered within the context of reciprocal determinism. The four
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sources of experience (direct experience, vicarious experience, judgments by others, and derivation of knowledge by inference) that can potentially infl u- ence self-effi cacy and outcome expectations interact with characteristics of the individual and the environment. Ideally, self-effi cacy and outcome expectations are strengthened by these experiences and subsequently moderate behavior. Since self-effi cacy and outcome expectations are infl uenced by performance of a behavior, it is likely that there is a reciprocal relationship between perfor- mance and effi cacy expectations (see Figure 10.1).
Measurement of Self-Effi cacy and Outcome Expectations
Operationalization of self-effi cacy constructs is based on Bandura’s (1977) early work with snake phobias. Self-effi cacy measures were developed as paper and pencil measures that list activities—from least to most diffi cult—in a specifi c behavioral domain. In Bandura’s (1977, 1986) early work, participants were asked to indicate whether they could perform the activity (magnitude of self- effi cacy expectations) and then evaluated the level of confi dence they had in performing the given activity (strength of self-effi cacy).
Traditionally in the development of self-effi cacy measures, items are derived based on the combined quantitative and qualitative research exploring factors that infl uenced adherence to a specifi c behavior, such as exercise (Bandura, 1986; Resnick & Jenkins, 2000). For example, the self-effi cacy for exercise scale includes nine items, with each item refl ecting a commonly recognized chal- lenge associated with exercise for older individuals (Resnick & Jenkins, 2000). Participants then responded by indicating that they have no confi dence (0) or are very confi dent (10).
Development of outcome expectation measures has been less well-defi ned, although the process of establishing appropriate items is the same as it is for self- effi cacy expectations. However, there is increasing evidence of measurement of
Informational sources
• Performance
• Verbal persuasion
• Role modeling
• Physiological feedback
Person
Environment
Self-efficacy expectations
Outcome expectations
Behavior
FIGURE 10.1 Self-Effi cacy.
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outcome expectations across a few behaviors, such as physical activity, specifi - cally exercise (M. Choi, Ahn, Jung, 2015; Hall, Wójcicki, Phillips, & McAuley, 2012; Millen & Bray, 2009; Resnick, 2005; Sriramatr, Berry, & Rodgers, 2013; Wilcox, Castro, & King, 2006), function (Harnirattisai & Johnson, 2002), medica- tion adherence (Qi et al., 2011), and breast cancer treatment (Rogers et al., 2005).
■ USE OF THE THEORY IN NURSING RESEARCH
The Theory of Self-Effi cacy has been used in nursing research focusing on clini- cal aspects of care, education, nursing competency, and professionalism. The number of studies exploring the relationship between self-effi cacy and exer- cise or testing the impact of exercise interventions on exercise behavior over the past 5 years was approximately 5,774. Of these, 4,637 were published in nursing journals. Increasingly these studies incorporate outcome expectations as well as self-effi cacy expectations and address both nursing behavior and patient behavior across the entire life span.
Self-effi cacy expectations are used in cross-sectional work to describe the sample and consider the relationship between demographic factors and self- effi cacy, psychosocial factors, performance of behaviors, and/or outcome expectations. Alternatively, self-effi cacy expectations are used to predict behav- ior in longitudinal research and to guide interventions and change behavior in intervention studies. These studies cover behaviors associated with exercise, physical activity, function, parenting, nursing skills, health promotion behav- iors, and management of chronic illness, among others. The majority of these studies have been done within the United States, although there is an increas- ing literature supporting the use of this theory among Asians as well as other cultural groups. The most important with regard to the use of the Theory of Self-Effi cacy in nursing research is that the researcher maintains the behav- ioral specifi city by developing a specifi c fi t between the behavior that is being considered and effi cacy and outcome expectations. If the behavior of interest is walking for 20 minutes every day, the self-effi cacy measure should focus on the challenges related to this specifi c behavior (time, fatigue, pain, or fear of falling).
Self-Effi cacy Studies Related to Managing Chronic Illness
Self-effi cacy is commonly used to explain and improve the management of chronic illnesses (Horowitz, Eckhardt, Talavera, Goytia, & Lorig, 2011; Quicke et al., 2016). Gortner and colleagues were some of the fi rst nurses to initiate self- effi cacy intervention research in chronic illness management with the focus of the work being on cardiovascular disease (Gortner & Jenkins, 1990; Gortner, Rankin, & Wolfe, 1988). Jenkins’s work built off that of Gortner et al., and she tested a self-effi cacy intervention on recovery of 156 patients following cardiac
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surgery (Gortner & Jenkins, 1990). The use of Self-Effi cacy Theory to help indi- viduals manage chronic illness continues to be prevalent in patients with con- gestive heart failure (Granger, Moser, Germino, Harrell, & Ekman, 2006; Han, Lee, Park, Park, & Cheol, 2005; Johansson, Dahlström, & Bromström, 2006), after an acute coronary event (Blanchard, Arthur, & Gunn, 2015; Flora, Anderson, & Brawley, 2015), with hypertension (Grant, 2014; Martin et al., 2011); those with diabetes (Lorig et al., 2010; Muzaffar, Castelli, Scherer, & Chapman-Novakofski, 2014; Oberg et al., 2011; Rosal et al., 2011), rheumatoid arthritis (Niedermann et al., 2011), stroke (Shaughnessy & Resnick, 2009), cancer (McCorkle et al., 2011), renal disease (Patterson, Meyer, Beaujean, & Bowden, 2014), multiple sclerosis (Suh, Joshi, Olsen, & Motl, 2014), osteoporosis (Qi et al., 2011), and mental ill- ness (Druss et al., 2010; Kramer, Helmes, Sellig, Fuchs, & Bengel, 2014), among others. In addition, the self-effi cacy work in chronic illness has focused on self- management of the symptoms associated with chronic problems such as pain (Bennett et al., 2011; Gustavsson, Denison, & von Koch, 2011; Quicke et al., 2016).
Consistently, self-effi cacy expectations have been associated with outcome behavior (e.g., management of pain, medication use; Davis et al., 2017; Johnson et al., 2016; Qi et al., 2011) and more recent work focuses on interventions geared to strengthening self-effi cacy and associated outcome behavior relevant for the chronic medical problem. Innovative approaches such as using text mes- sages to remind adolescents with asthma to use their inhalers have been tested and shown to lead to improvements in self-effi cacy related to medication and increase adherence to inhaler usage (Johnson et al., 2016). Text messaging was also used to improve adherence to oral cancer medications among a group of adults (Spoelstra et al., 2015). Combined pharmacological and behavioral interventions used to strengthen self-effi cacy and symptom management with regard to pain and depression have been shown to be effective (Damusch et al., 2016; Tahmassian & Jalali Moghadam, 2011). For example, a 12-month study with primary care patients exposed to therapy sessions to manage these two symptoms led to improvements in self-effi cacy and improvements in both pain and depression (Damusch et al., 2016).
Self-Effi cacy for Health-Promoting Activities Such as Exercise and Weight Loss
Self-effi cacy approaches are most commonly used to infl uence exercise and diet behaviors. Self-effi cacy expectations have generally been positively associ- ated with exercise (Chase, 2011; Der Ananian, Churan, & Adams, 2015; Flora et al., 2015; Grim et al., 2011; Nahm et al., 2010; Quicke et al., 2016; Scarapicchia et al., 2015; van Stralen et al., 2011). Specifi cally, fi ndings noted that self-effi cacy was signifi cantly associated with the adoption and maintenance of exercise behavior across the life span including adolescents (Elkins, Nabors, King, & Vidourek, 2015), adults (Irvine et al., 2011; Pretzer-Aboff et al., 2011; Qi et al.,
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2011), and those with chronic illness (Blanchard et al., 2015; Der Ananian et al., 2015; Flora et al., 2015; Quicke et al., 2016; Simons et al., 2015; Suh, Joshi, Olsen, & Motl, 2014). Expected outcomes in the form of perceived benefi ts from exercise were likewise associated with exercise behavior among older adults (Blanchard et al., 2015; J. Y. Choi, Chang, & Choi, 2015; Elkins et al., 2015; Muzaffar et al., 2014; Quicke et al., 2016; Resnick, Nahm, et al., 2014; Scarapicchia et al., 2015; Short, Vandelanotte, Rebar, & Duncan, 2014).
Using the Theory of Self-Effi cacy, interventions have been developed and tested to increase exercise behavior in healthy community-dwelling adults (Resnick, Hammersla, et al., 2014; Scarapicchia et al., 2015; Short et al., 2014; Stephens, Resinicow, Latimer-Sport, & Walker, 2015) as well as those who have sustained a hip fracture or orthopedic event or have osteoporosis (Hays et al., 2010; Orwig et al., 2011; Resnick, Nahm, et al., 2014), or among those who have cardiac disease (Blanchard et al., 2015; Duncan, Pozehl, Norman, & Hertzog, 2011; Flora et al., 2015; Grant, 2014; Yaping et al., 2013), in cancer survivors (Bennett et al., 2011; Cox et al., 2015; Henriksson, Arving, Johansson, Igelstrom, & Nordin, 2016; Lee, Von Ah, Szuck, & Yiu-Keung, 2016; McCorkle et al., 2011), in patients with chronic obstructive pulmonary disease (Donesky et al., 2011; Hospes, Bossenbroek, Ten Hacken, van Hengel, & de Greef, 2009), in patients with diabetes (Collins et al., 2011; Muzaffar et al., 2014), and to help manage pain and anxiety associated with childbirth (Byrne, Hauck, Fisher, Bayes, & Schutze, 2014; Gau et al., 2011), to help young adults cope with life events (Simons et al., 2015), to manage childhood obesity (Bagherniya, Sharma, Mostafavi, Firoozeh, & Seyed, 2015; Webber, 2014), to manage multiple sclerosis (Suh, Joshi, Olsen, & Motl, 2014), to manage depression (Kramer et al., 2014), and for those under- going dialysis (Patterson, Meyer, Beaujean, & Bowden, 2014).
Innovative examples of how to strengthen self-effi cacy for exercise include such things as using social media; for instance, a social marketing campaign as was done in the MoveU study (Scarapicchia et al., 2015). Likewise, the Healthy Outcome for Teens Project (HOT) also used an online educational interven- tion for middle school children to prevent diabetes and obesity by balancing food intake with physical activity (Muzaffar et al., 2014). For older adults, face- to-face interventions continue to be those most successfully implemented. An example of such a program was a 24-month intervention that included exer- cise classes and motivational techniques (verbal encouragement, self and role modeling, and elimination of unpleasant sensations associated with exercise; Resnick, Hammersla, et al., 2014). These interventions led to some improve- ment in time spent in physical activity.
Dietary interventions have also been developed and tested to improve the quality of dietary intake and maintain or facilitate weight loss (Bagherniya et al., 2015; Huang, Yeh, & Tsai, 2011; Oberg et al., 2011; Rejeski, Mihalko, Ambrosius, Bearon, & McClelland, 2011; Rosal et al., 2011; Stephens et al., 2015). For exam- ple, a group-mediated intervention for weight loss among older, obese adults was tested to determine if it resulted in changes in self-regulatory self-effi cacy
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for eating behavior and weight loss (Rejeski et al., 2011). A signifi cant treat- ment effect was observed for self-effi cacy for weight loss as well as weight among those who were exposed to both the diet intervention and physical activity. Similarly, a dietary intervention that was not focused on weight loss but rather on improving dietary intake for individuals with diabetes was noted to be effective. This intervention resulted in strengthening self-effi cacy around healthy eating and improved hemoglobin A1c levels among those exposed to the intervention (Oberg et al., 2011).
Self-Effi cacy Interventions for Symptom and Disease Management
In addition to using self-effi cacy–based interventions to increase adherence to healthy behaviors, such as exercise and healthy diets, self-effi cacy interven- tions have been developed and tested to manage symptoms across a variety of areas. Most commonly these focus on symptoms, such as pain manage- ment (Bennett et al., 2011; Damusch et al., 2016), fear of falling (Yoo, Jun, & Hawkins, 2010; Zijlstra et al., 2011), and memory changes (McDougall, Becker, Acee, Vaughan, & Delville, 2011; Williams, 2011). For example, a multicom- ponent cognitive behavioral group intervention was tested with a sample of 540 community-dwelling adults aged 70 years or older who reported a fear of falling and avoided physical activity (Zijlstra et al., 2011). Testing showed that the multicomponent cognitive behavioral intervention improved control beliefs, self-effi cacy, outcome expectations, and social interactions. Moreover, these variables mediated the association between the intervention and con- cerns about falling or daily activity in community-dwelling older adults.
Another example of symptom-focused interventions recently reported was focused on memory in cancer survivors 65 years of age and older who experience treatment-induced memory impairments. This study compared a memory versus health training intervention in a convenience sample of older adults (McDougall et al., 2011). The memory training was designed to increase cognitive performance, reduce anxiety, decrease negative attributions, promote health, and increase memory self-effi cacy. Moderate-to-large effects were revealed in everyday and verbal memory performance scores, memory self-effi cacy, strategy use, and memory complaints. There were also moder- ate effects for group-by-time interactions on the visual memory performance, memory self-effi cacy, depression, trait anxiety, and complaints. The memory intervention group tended to improve more than the health training group, although this was not always consistent.
Management of symptoms associated with atopic dermatitis (Mitchella, Fraser, Ramsbotham, Morawska, & Yates, 2015) have also been addressed using self-effi cacy approaches to help parents of children with the disease. Likewise, apathy associated with depression has been addressed with self- effi cacy–based interventions (Kramer et al., 2014). Self-effi cacy approaches are also used to help improve adherence to medication and treatments for diseases.
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For example, self-effi cacy approaches have been used to increase adherence to osteoporosis-related medications (Nahm et al., 2015) and adherence to use of glaucoma medication (Sleath et al., 2014).
Self-Effi cacy Interventions for Education of Healthcare Providers
In addition to a clinical focus, self-effi cacy–based research has also guided the exploration of education techniques for nurses and other healthcare providers. Studies of undergraduates have focused on self-effi cacy expecta- tions related to academic performance (McVicar, Andrew, & Kemble, 2015; Phillips, Phillips, Lalonde, & Tormohlen, 2015) and clinical skills (Adelman et al., 2014; Darkwah, Ross, Williams, & Madill, 2011; Jeffries et al., 2011; Sherriff, Burston, & Wallis, 2011; Sung, Huey-Hwa, Ru-Rong, & Chao, 2016). For example, one study focused on undergraduate education (Sherriff et al., 2011) and evaluated the effect of an online, medication calculation education and testing program. The outcome measures used with the nursing students included medication calculation profi ciency and self-effi cacy expectations associated with medication calculation. Participants were registered nurses and nursing students. Outcome measures included number of test attempts, self-effi cacy, medication calculation error rates, and satisfaction with the program. Medication calculation scores at the fi rst test attempt showed improvement following 1 year of access to the program. Two of the self-effi - cacy subscales improved over time and nurses reported satisfaction with the online program.
One example of the type of self-effi cacy–based interventions used with advanced practice nurses includes a simulation-based cardiovascular assess- ment curriculum (Jeffries et al., 2011). The educational interventions included faculty-led, simulation-based case presentations using the Harvey® cardiopul- monary patient simulator (CPS), and independent learning sessions using the CPS and a multimedia, computer-based CD-ROM program. Outcome mea- sures included a cognitive written exam, a skills checklist, learner self-effi cacy, and a satisfaction survey. The 36 students who received the simulation-based training showed statistically signifi cant pre- to posttest improvement in cogni- tive knowledge and cardiovascular assessment skills.
Self-effi cacy–based interventions have been used with other healthcare professionals as well (Salerno, Delaney, Swartwout, & Tsui-Sui, 2015). For example, a self-effi cacy–based approach was used to strengthen self-effi cacy and outcome expectations related to being involved in research for social workers. This was an intervention that focused on adolescent-focused moti- vational interviewing training to improve health professionals’ knowl- edge, skills, and confi dence in risk reduction counseling with adolescents. Following the intervention there was a signifi cant improvement in knowl- edge, skills, and confi dence associated with implementing motivational interviewing.
10 . THEORY OF SELF -EFF ICACY 227
Self-Effi cacy Expectations, Outcome Expectations, and Behavior
Bandura postulates that self-effi cacy and outcome expectations increase fol- lowing self-effi cacy–based interventions, particularly performance of the behavior of interest (Bandura, 1995). However, the theory is not always sup- ported. There have been multiple studies in which older adults have been exposed to self-effi cacy–based interventions for exercise and there was no change in effi cacy expectations, even though there were improvements in behavior (Flora et al., 2015; Muzaffar et al., 2014; Orwig et al., 2011; Resnick, Gruber-Baldini, Zimmerman, et al., 2009). These fi ndings may, in part, be due to measurement issues in that the individuals who volunteered for these intervention studies generally had strong self-effi cacy and outcome expec- tations at baseline and thus there was a ceiling effect. In addition, the mea- sures used may not have been specifi c enough for the behavior of interest. For example, in many of these studies self-effi cacy and outcome expectations were measured in light of the challenges that can infl uence engaging in an exercise activity rather than simply asking about confi dence in, for example, walking 10 feet, 20 feet, and so on. It is also possible that the intervention was not strong enough to result in a change in self-effi cacy and outcome expectations.
Alternative explanations for a lack of signifi cant increase in self-effi cacy or outcome expectations following an intervention have been proposed by McAuley (McAuley et al., 2006). Specifi cally, he suggested that a decline in self-effi cacy following exposure to an exercise intervention can also occur when there is a decrease in exposure to exercise classes, when exposed to a new exercise that is challenging, when there is a change in clinical condition or ability so that the exercise program is perceived to be more diffi cult, or when the exercise program is progressively more challenging. Therefore, it is critical to consider these aspects when implementing exercise intervention studies.
■ USE OF THE THEORY IN NURSING PRACTICE
Translation of research fi ndings into practice is not often done in a timely fash- ion. This is particularly true of research fi ndings that focus on behavior change. However, there is evidence to demonstrate that the Theory of Self-Effi cacy can help direct nursing care. The theory has been particularly helpful with regard to motivating individuals to participate in health-promoting activities, such as regular exercise, smoking cessation, weight loss, and going for recommended cancer screenings. For example, Resnick and her research teams (Nahm et al., 2010; Orwig et al., 2011; Qi et al., 2011; Resnick, Gruber-Baldini, Zimmerman, et al., 2009; Resnick, Galik, Vigne, & Payne, 2016; Shaughnessy & Resnick, 2009) have used the Self-Effi cacy Theory as a foundation for programs that
228 I I . M IDDLE RANGE THEOR IES READY FOR APPL ICAT ION
encourage exercise and physical activity in older adults. Among these inter- ventions, the function-focused care (FFC) approach has been tested the most extensively and is described as an exemplar.
Function-Focused Care
Function-focused care (FFC), also referred to as restorative care, is a philoso- phy of care that focuses on evaluating the older adult’s underlying capability with regard to function and physical activity and helping him or her to opti- mize and maintain abilities and continually increase time spent in physical activity. Implementation of FFC is guided overall by a social ecological model. This model provides an overarching framework for understanding the inter- relations among diverse personal and environmental factors that can infl uence behavior change and specifi cally addresses intrapersonal, interpersonal, envi- ronmental, and policy factors. At the interpersonal level, self-effi cacy–based interventions are used to facilitate an FFC approach and change behavior among caregivers as well as older individuals. The ultimate goal is to optimize function and physical activity among older adults.
FFC is implemented using the following four components: (a) environment and policy/procedure assessments; (b) education; (c) developing function- focused goals; and (d) mentoring and motivating. Component a involves completing assessments of the environment and policies/procedures relevant to function and physical activity within the settings. The fi ndings from these assessments guide environmental and policy/procedure change, such as mak- ing pleasant walking areas on units or in facilities, establishing transporta- tion policies that allow patients/residents to ambulate to tests or procedures, or allowing residents to walk in outside areas when living in long-term care settings.
Component b involves teaching nursing staff, other members of the inter- disciplinary team (e.g., social work, physical therapy), patients, and families about the philosophy of FFC. Teaching is done both formally and informally in small groups or one on one and incorporates self-effi cacy techniques includ- ing verbal encouragement, use of role models, and actual performance of skills and activities (e.g., use of demonstrations by caregivers for how to interact with older individuals using an FFC approach).
Component c involves establishing individualized goals for older individu- als geared toward increasing their function and time spent in physical activity. Goals are established after evaluating the older adult’s underlying function and ability (e.g., ability to follow a one-, two-, or three-step command, ability to get up from a chair). Individualized goals provide important encourage- ment as they indicate to the older individual that the goal established is some- thing that the healthcare team or family in the home setting believes he or she is capable of achieving.
10 . THEORY OF SELF -EFF ICACY 229
Component d is implemented using all four sources of self-effi cacy–based information for both the caregivers being exposed to FFC and the patient/ resident. Building off the initial education done with caregivers (this includes nurses, nursing assistants, home healthcare workers, and family caregivers, and other members of the interdisciplinary team including physicians, social workers, physical therapists, etc.), an identifi ed champion in a facility or home setting will provide the ongoing verbal encouragement, support, recognition, and positive reinforcement around performing FFC with the older individual. For example, this might be a simple “it was terrifi c that you worked with Mrs. Jones to have her walk to the dining room today”; or “that was great this morn- ing when you led the residents in a few minutes of dance prior to eating break- fast.” The champion also can provide one-on-one mentoring and role modeling as needed. This might include intervening in a situation in which FFC is not occurring. For example, a nursing assistant or a family might be pushing Mrs. Jones to the dining room in a wheelchair because she wanted to get a ride. The champion might interrupt and role-model FFC interactions by indicating to Mrs. Jones that she did a great job walking to the dining room this morn- ing and encourage her to “show Jane [the caregiver] how well you can walk!” Other formalized activities the champion might do include: (a) observing per- formance of caregivers within a setting and providing one-on-one mentoring of ways in which to incorporate FFC into routine care, (b) providing caregivers with positive reinforcement for doing FFC interactions, (c) meeting in groups or informally with caregivers to address their beliefs about physical activity and feelings and experiences associated with providing FFC, (d) reinforcing the benefi ts associated with FFC for both caregivers and older adults as a way to strengthen outcome expectations, (e) highlighting role models (other care- givers who successfully implemented the program), and (f) identifying change aides and positive opinion leaders to help with dissemination and implemen- tation of FFC and eliminate the infl uence of negative opinion leaders.
In addition, caregivers are taught to implement self-effi cacy–based approaches to motivate older adults to engage in function and physical activ- ity. As with all types of behaviors, actual performance is the best way to strengthen self-effi cacy and outcome expectations. Therefore, caregivers are taught to engage the resident in an activity he or she is capable of performing well and without uncomfortable sensations such as fear or pain. Once perfor- mance occurs, the caregivers are encouraged to provide critically important positive reinforcement to older individuals for engaging in the activity. This might be a hug, a smile, or a round of applause! Goals are set with the older individual. The individual, particularly those with cognitive impairment may need help to establish realistic and benefi cial goals. The best way to establish these goals is to talk with the individual and identify what is important to them in terms of quality of life and what they want to be able to do functionally and physically. This might be working toward going out on a trip or going to a
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granddaughter’s wedding. Activities and goals are individualized and should refl ect what the person has done and enjoyed throughout his or her lifetime. Walking, shopping, delivering televisions, or working on a nursing unit can all be used to motivate the older individual to engage in those well-known activi- ties yet again.
Role modeling is very useful as is self-modeling as a way to motivate older individuals. The role model may be the caregiver, a relative, or a peer and may be as simple as showing the older individual what to do at any given moment. For example, with older adults with signifi cant cognitive impairment sitting next to them and getting up from a chair will cue (i.e., model for) them to do likewise. Likewise, reminding the older individual that he or she was able to walk to the bathroom successfully yesterday and thus can do so today is a form of self-modeling that is often effective.
For older adults, the experience of engaging in functional and physical activ- ity must occur free of uncomfortable physiological feedback. Due to multi- morbidities, there is a high prevalence of symptoms associated with physical activity such as pain, fatigue, and fear of exacerbating underlying disease or falling. These symptoms need to be anticipated, acknowledged, and addressed. It is extremely challenging to eliminate these sensations and yet maintain func- tion and physical activity; thus, acknowledging the sensations, talking about them, and assuring the individual that we “won’t let them fall” or “won’t have them do anything that will cause them more pain” are important. Pain medica- tions and use of ice or heat to a joint are other ways to manage the pain before ambulation or a given activity.
In addition to addressing the uncomfortable sensations associated with an activity, the positive and pleasant outcomes and sensations can be highlighted. Making function and physical activity fun is important—music, dance, and the use of humor through what may be slower and more tedious personal care activities are useful interventions. Associating exercise activities with improve- ments in blood pressure readings, blood sugars, and weight loss is another way to demonstrate the benefi ts of activity.
■ CONCLUSION
The studies that nurse researchers have done using the Theory of Self-Effi cacy provide support for the importance of self-effi cacy and outcome expectations with regard to behavior change. The studies also provide support for the effec- tiveness of specifi c interventions that have been tested to strengthen both self- effi cacy and outcome expectations and thereby improve behavior. However, it is important to note that studies have also demonstrated that self-effi cacy and outcome expectations may not be the only predictors of behavior. Other vari- ables, such as genetic predispositions, tension/anxiety, barriers to behavior,
10 . THEORY OF SELF -EFF ICACY 231
and other psychosocial experiences, impact behavior. Bandura (1986) recog- nized that expectations alone would not result in behavior change if there were no incentives to perform or if there were inadequate resources or external con- straints. Certainly, an individual may believe that he or she can participate in a rehabilitation program but may not have the resources (i.e., transportation or money) to do so. In addition, when considered over time, it is possible that self-effi cacy and outcome expectations will not get stronger. Rather, the indi- vidual may recognize that it is not as easy to perform a given behavior, and self-effi cacy and outcome expectations may actually weaken.
Self-Effi cacy Theory is situation-specifi c. Therefore, it is diffi cult to general- ize an individual’s self-effi cacy from one type of behavior to the other. If an individual has high self-effi cacy with regard to diet management, this may or may not generalize to persistence in an exercise program. Future nursing research needs to focus on the degree to which specifi c self-effi cacy behaviors can be generalized. To what degree is self-effi cacy, a dimension of individual humanness, distinct for each person but consistent across a range of related behaviors for one person? Future consideration should also be given to the relationship between self-effi cacy and resilience, particularly with regard to specifi c areas. Resilience refers to the capacity to spring back from a physical, emotional, fi nancial, or social challenge. Self-effi cacy is an important compo- nent of resilience. Future research should also begin to consider the genetic variability in individuals and how this may impact self-effi cacy. Resilient individuals will tend to have stronger self-effi cacy and thus are more likely to engage in an activity on a regular basis.
Measurement of self-effi cacy and outcome expectations requires the devel- opment of situation-specifi c scales with a series of activities listed of increas- ing diffi culty or by a contextual arrangement in nonpsychomotor skills such as dietary modifi cation (Bandura, 1997). It is important to carefully construct these scales and establish evidence of reliability and validity. Behavior-specifi c scales can be used as the foundation for assessing an individual’s self-care abil- ities in a particular area. Interventions can then be developed that are relevant for that individual.
Increasingly, outcome expectations are being included along with self-effi - cacy beliefs. This is critically important as there is evidence that some inter- ventions may strengthen outcome expectations (e.g., education) but have no impact on self-effi cacy beliefs (Flora et al., 2015). There may also be differences in response to an intervention in terms of impact on self-effi cacy versus out- come expectations based on gender. In a study of sex differences in physical activity among Korean college students (J. Y. Choi et al., 2015), for example, it was noted that only self-effi cacy was associated with physical activity for males while only outcome expectations were associated with physical activity for females. The infl uence of self-effi cacy expectations and outcome expecta- tions as they relate to initiation versus long-term adherence to behaviors is
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currently not well understood and ongoing research in this area is needed. Social Cognitive Theory and the Theory of Self-Effi cacy have helped guide nursing research related to behavior change. Ongoing studies are needed to continue to build and utilize this work to improve the health of individuals in this country and globally.
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