Evidence-based practice involves the rigorous use of evidence from quality studies, clinicians proficiency, and patients preferences to resolve clinical problems (Fineout-Overholt, Melnyk, Schultz, 2005). Several studies have identified noncompliance as a major problem in health care, especially in the management of chronic diseases (Hailey and Moss, 2000; Hansen, 2001; Polaschek, 2003). About 20% of dialysis patients fail to comply with prescribed regimen because they doubt their ability to, continuously, endure the discomforts they experience while on dialysis (Martchev, 2008). The theory of self-efficacy by Bandura (1977) explains that psychological procedures can predict changes in behaviour under such circumstances.
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This essay, therefore, describes and critically analyses the self-efficacy theory as well as how the theory could be applied to my area of practice as a nurse. The essay is in three sections. The first section begins with a critical reflection, using the Fundamental Patterns of Knowing by Carper (1978) as a guide, on a clinical incident where Mr. M. failed to show up for haemodialysis sessions because he could not accept having to depend on haemodialysis for survival and had resorted to herbal concoctions (description of the incident has been provided in appendix 1). Three concepts are identified from the incident but patient compliance, among the three, is chosen as the concept of importance and further description of it has been provided. Self-efficacy theory by Bandura (1977) is introduced as the most promising theory that, when applied to practice, would promote patient compliance with prescribed regimen.
Section two describes and analyses the self-efficacy theory. The theory has been analysed based on the internal and external criticisms as suggested by Barnum (1990 cited by Bredow, 2009). The section ends with some limitations of the theory.
The last section explains how I intend to apply the theory to my practice. The limitations, as well as other studies using the self-efficacy theory, have assisted me to identify factors to take into consideration in order to achieve the utmost from the theory.
Reflection on the Incident using the Fundamental Patterns of Knowing by Carper (1978)
I have come across patients who were discharged from the hospital against medical advice. Others have, also, failed to show up for review after discharge. Consequently, patient education has become an aspect of nursing care that I take seriously.
I knew I had to talk to Mr. M. after I was informed that he failed to show up for scheduled haemodialysis sessions. Redman (1993) suggests that patient education begins when the need for patients to know something or how to do something is identified. I had to educate Mr. M. on the importance of the haemodialysis sessions that had been prescribed for him. Therefore, it was my responsibility to explain issues in terms that Mr. M. could understand best to make an informed decision. Carper (1978) describes empathy as essential in aesthetic knowing. What would I have done if I was told I had a chronic disease? Honestly, although I would visit the hospital, I would rely more on my spiritual beliefs than what doctors or nurses might tell me. This act of empathy changed my perspective and might have contributed to the fruitful conversation I had with him.
I remember how easily he confided in me and genuinely revealed the main reasons why he did not show up for the procedure. I guess my communication skills might have been better, or that he needed somebody to express his fears to. He had started using some herbal concoctions for his disease. He believed that could cure him and not the haemodialysis. Potter and Perry (2005) identify cultural background as one external variable that influences an individual’s beliefs on causes of illness and the practices that may restore health. He could not accept depending on haemodialysis for survival.
I must admit that I was provoked upon hearing that Mr. M. had, one way or the other, made his condition worse. What would have happened if he had lost his life soon after being brought into the unit? Anytime a patient dies under my care, I spend a lot of time thinking about what could have been done to save his/her life. This is always a difficult moment for me, especially if I had some form of emotional attachment with the patient. However, the patients’ charter of the Ghana Health Service (2009) expects all health personnel to respect the patient as an individual with a right of choice in decisions of his/her health care plans.
The initial decision to educate Mr. M, I felt, was just an obligation. However, I imagined myself in his position. Genuinely, he thought he was making the right decision by resorting to herbal treatment because that is what he was used to. Moreover, only a few people with chronic diseases may decide to avoid treatments that would prolong their lives. Mr. M. asked a lot of questions and, to ensure accuracy, I asked for his permission and invited the nurse-in-charge who also provided more explanations to the questions he asked.
As I consider the whole incident now, I realise that I learnt a lot about empathy in nursing from that. I have, also, come to understand why health personnel should make all current information on a patient’s condition available to them in terms that they (patients) are reasonably expected to understand (Redman, 1993).
Potter and Perry (2005) note that assessment provides a database on the needs and health problems of patients as well as how they respond to these problems. Protocol for the unit also requires that vital signs (blood pressure, temperature, pulse and respiratory rates) and weight of patients should be monitored before and after haemodialysis. Monitoring the weight of the patient before and after the procedure determines the fluid loss (Silvestri, 2002). Knowledge of these, as well as various positions used in nursing, came to play in the management of Mr. M.
Ignoring my initial feelings of anger and carrying out my duties is one act that always makes me happy whenever I think about this incident. Mr. M. felt respected. I noticed this from his expression of gratitude to the nurses and the complement he made about me – “you are very respectful”. Since that incident, I have come to understand that upholding the patient’s charter, mostly, promotes satisfaction for the nurse as well as the patient.
Asking for his permission before inviting the nurse-in-charge to join our conversation is something I considered as trivial. However, Potter and Perry (2005) describe autonomy as respect for the client’s right to determine the course of an action. Allowing me to invite the nurse-in-charge proved to me that Mr. M. trusted my judgements at that time – I had respected his autonomy and he had trusted my judgements.
Three concepts may be identified from the above – patient education, patient compliance, and patient rights and responsibilities. However, the concept of importance to me in relation to the above is patient compliance which is, usually, the expected outcome of patient education.
Involving patients in their care is vital. However, majority of patients diagnosed with chronic kidney disease may have little or no knowledge on the condition as well as its management. Moreover, patients spend less time on admission than previously and tend to perform a lot of procedures that would have been performed in the hospitals by nurses (Babcock and Miller, 1994). Patient compliance to prescribed regimen, then, becomes a necessity if the goals of management are to be realised fully.
Patient compliance refers to patients’ observation of prescribed regimen (Potter and Perry, 2005). Falvo (2004) states that proper treatment or control of diseases is a key health benefit of patient compliance while noncompliance, explained by Rankin and Stallings (2001) as failure of patients to follow advice recommended to them by health personnel, not only affects the health of these patients but, also, the appropriate use of resources (Falvo, 2004). Concerns have been raised over the use of the term ‘compliance’ in healthcare because of its authoritative meaning and words such as ‘concordance’ or ‘collaboration’ (Falvo, 2004) and ‘concurrence’ or ‘cooperation’ (Rankin and Stallings, 2001) have been suggested. Nevertheless, it seems that compliance is the popular term in all health care settings.
Various forms of patient compliance are essential in the management of chronic kidney disease (Tsay, 2003). These may include appointment keeping, compliance to medications, dietary and lifestyle changes (Falvo, 2004). A lot of behavioural change is, therefore, a necessity and these do not depend on a single decision, making the whole process a difficult one for the patient (Rankin and Stallings, 2001). Several studies have identified noncompliance as a major problem in health care, especially in the management of chronic diseases (Hailey and Moss, 2000; Hansen, 2001; Polaschek, 2003). Martchev (2008) identifies that about 20% of patients on dialysis do not comply with the prescribed course of therapy and reasons given include discomforts experienced by patients while undergoing dialysis.
Potter and Perry (2005) suggest that the nurse should assess what patients need to know in order to comply with the regimen that is prescribed for them. These should, then, be incorporated into the teaching process to encourage learning and positive behaviour changes. Babcock and Miller (1994) suggest that trust and communication are key to achieving patient compliance and encourage nurses to listen and avoid being judgemental in order to win the trust of patients.
Factors that may diminish patient compliance should, also, be assessed and addressed. Kloeppel and Henry (1987 cited by Babcock and Miller, 1994) listed denial, complexity of regimen, comprehension, side effects, differing cultural beliefs and cost as factors that can diminish compliance. The nurse should, therefore, be able to motivate the patient to recognise their capabilities in managing their conditions, and self-efficacy theory by Bandura (1977) appears promising to achieving such goals.
Development of the theory
Albert Bandura introduced the social learning theory in the 1970s in order to underscore the benefits of learning by observation, maintaining that most human behaviour is learnt by modelling. However, the scope of the theory expanded to include cognitive processes that influence human behaviour. Therefore, Bandura renamed it ‘the social cognitive theory’ (Miwa, 2005). Self-efficacy theory developed from the social cognitive theory (Resnick, 2009).
The self-efficacy theory states that “psychological procedures, whatever their form, alter the level and strength of self-efficacy” (Bandura, 1977, p. 191). The theory recognises the diverse forms of human capabilities and proposes that people’s thoughts, beliefs and emotions influence their behaviour (Bandura, 1997; Resnick, 2009). Musser and Leone (1992) add that the theory places an emphasis on a person’s key role in influencing what they think, feel and do.
The initial work in the development of the theory was undertaken to determine whether psychological procedures could influence a person’s self-efficacy expectations and, ultimately, lead to a change in behaviour (Resnick, 2009). Adult snake phobics were assigned to either participant modelling (direct contact with a snake), modelling (observing others touch a snake) or no treatment groups for equivalent periods of time. It was identified that self-efficacy, assessed at different times of the treatment period, predicted behaviour change in 92% of the total assessment tasks, although different treatments produced different strengths of self-efficacy (Bandura, 1977; Resnick, 2009)
Major theoretical concepts
Human/personal agency refers to deliberate actions of an individual and is vital in the behaviour that is portrayed by people (Resnick, 2009). It evolves across one’s entire life span, accounts for developmental changes in perceived self-efficacy and is influenced by “imposed”, “selected” or “created” environment (Bandura, 1997, p.163).
Self-efficacy refers to an individual’s belief in their ability to perform specific tasks (Bandura, 1997). Efficacy beliefs are significant in the development of human competence because they regulate a person’s thoughts, feelings, source of motivation and actions (Bandura, 1995). Bandura (1982) affirms that self-efficacy is, therefore, a major predictor of behaviour and whether that behaviour would persist in adverse times.
Four major sources influence self-efficacy expectations and these are:
Performance accomplishments/Enactive mastery experience – current or previous performance
Vicarious experiences – modelling by other similar people
Social/verbal persuasion – exhortation on an individual’s capabilities from another source
Any one of the sources, at some time, may utilise one or more of the other sources of efficacy information. In addition, each of these sources may produce different strengths of self-efficacy. Nevertheless, performance accomplishments, generally, produce higher self efficacy expectations (Bandura, 1977, 1995, 1997; Resnick, 2009). Once efficacy beliefs are established, they regulate human functioning through four major processes and these are cognitive, motivational, affective and selection processes (Bandura, 1995). Bandura (1997) terms these as mediating processes/efficacy-activated events and adds that they, mostly, interact with each other to regulate human functioning.
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Analysis and Evaluation of the Theory
Theory analysis involves a methodological approach that examines all aspects of a theory as has been written by the theorist (Bredow, 2009). An underlying assumption that led to the development of the self-efficacy theory was that personal efficacy influences the initiation, persistence as well as the effort applied for a specific behavioural change (Bandura, 1977). Findings from several studies have supported this assumption (examples include Bandura, 1977; Tsay, 2003; Sarkar, Fisher and Schillinger, 2006). Barnum (1990 cited by Bredow, 2009) suggests that theory analysis should comprise of its internal and external criticisms. Therefore, the self-efficacy theory has been analysed by considering its internal and external criticisms.
Clarity: Major concepts of the theory (human agency and self-efficacy) have been clearly stated and explained. Explanation of these components has been made in simple terms such that, although the theory was developed from the field of psychology, one does not necessarily need a sound knowledge in psychology to interpret and understand them.
Logical Development: The theory originated from the social cognitive theory (Resnick, 2009) and has been developed in a logical manner. Its major concepts have been developed and explained systematically to highlight the unique role that individuals play in changing their negative health behaviours (Bandura, 2004). The sources of self-efficacy as well as their unique degrees of influence have been well explained. Tools for measuring self-efficacy have also been developed with Bandura (1977) developing the first one. Conclusions have also been very logical. According to Bandura (1977), a person’s efficacy expectations always influence them to put up behaviour that, in turn, yields an outcome.
Adequacy: The theory clearly states that individuals have unique roles in producing behavioural change and has concluded that self-efficacy plays a central role, both directly and via its influences on the other determinants, in predicting change in behaviour (Bandura, 2004). A meta-analysis by Lewis, LaRose, Rifon et al. (2007) to manipulate self-efficacy in protection motivation research identified that education and age may influence self-efficacy. However, they suggested that these findings may be speculative and recommended that further analysis should be done.
It has been stated earlier that the concept of human agency in the theory develops through the various stages of life and that the stage of its development may influence self-efficacy (Bandura, 1997). It, therefore, appears that the findings of Lewis et al. (2007) do not suggest that the theory of self-efficacy is inadequate.
Consistency: Definitions of the major concepts are maintained throughout the explanation of the theory. It appears that outcome expectancy as a concept has been included and applied to the theory by other writers. Efficacy expectations and outcome expectations have been related in testing the self-efficacy theory (Resnick, Shaughnessy, Macko et al., 2007; Resnick, 2009). However, Bandura (1997) states that the two are different. Outcome expectancy and self-efficacy are both vital in the social cognitive theory but self-efficacy was developed into a theory to highlight its central role in the social cognitive theory (Bandura, 2004). Association of outcome expectations to efficacy in the self-efficacy theory is, therefore, not consistent with Bandura’s explanation of the theory.
Level of theory: Self-efficacy theory is a middle range theory because it has fewer concepts and can be generalised across different backgrounds (McEwen, 2007b).
Complexity: Two major concepts – human agency and self-efficacy beliefs – have been used to explain the theory, making its description simple. Concept of self-efficacy has been further explained. Consequently, the theory can be understood without lengthy explanations once the concepts have been grasped.
Discrimination: McEwen (2007b) identifies that cognitive behavioural theories, including the social cognitive theory, have been used more often in the nursing management of chronic diseases because of their effectiveness in changing target behaviours. Self-efficacy theory originated from the social cognitive theory and has been very vital in various aspects of nursing, predominantly in the management of chronic diseases, as has been stated above.
Reality convergence: It has been stated earlier that the underlying assumption of self-efficacy theory is that perceived personal efficacy influences the initiation, persistence as well as the effort to apply to produce behaviour. Therefore, in the face of difficulties, individuals who doubt their capabilities (low self-efficacy) tend to give up on their attempts while those with a strong sense of self-efficacy would put in more effort until they are able to overcome those challenges and achieve their target (Bandura, 1982). These observations are true and may explain why a lot of successful people tell stories of difficult moments they might have overcome to attain their status. A study undertaken by Tsay (2003) confirms that self-efficacy theory is very applicable in achieving some nursing goals.
Pragmatism: A theory is of major importance to the health profession when it proves useful in changing conditions to improve patient outcomes (Nicoll, 1997). Application of the self-efficacy theory in real-life and clinical settings have been successful. Bandura (1977) used it to treat snake phobics while Sarkar et al. (2006) have also used it to promote self-management of diabetes among limited health literates across different races.
Significance: After Bandura developed efficacy measurement tool in 1977, several others have been developed for efficacies for different tasks (Oetker-Black, 1996; Corbett, 1999; Perraud, 2000). This is because different studies, mostly, require different measurement tools (Resnick, 2009). Consequently, nurses caring for different patients with different diagnosis may have to adopt different but appropriate efficacy measures in order to effectively apply the theory to practice. In addition, the theory emphasises on the individuality of patients by positing that different people have different levels of efficacy for different tasks (Bandura, 1977). Therefore, nurses using the theory provide individualistic care based on their unique efficacy, making the theory very significant in nursing.
Utility: Nurses in different care settings have used the theory both in research and practice and have found it practicable (Buchmann, 1997; Tsay, 2003; Sarkar et al., 2006). Gortner and Jenkins (1990) used the theory to test the role of self-efficacy in rehabilitation of patients following cardiac surgery. These and other studies imply that the theory of self-efficacy generates hypotheses that are researchable by nurses.
Scope: The focus of the self-efficacy theory is narrow, making it more applicable in nursing practice.
Eastman and Marzillier (1984a) state that differentiating efficacy expectation and outcome expectation is not practicable. They believe that outcome expectations have a major influence on self-efficacy. Bandura (1977) used adult snake phobics to develop the self-efficacy theory. Eastman and Marzillier (1984a), however, ask whether a non-phobic of snakes would have the same efficacy expectations in procedures that involve lifting poisonous and non poisonous snakes. They explain that efficacy expectations for lifting a poisonous snake would be low because of a dreadful outcome expectation should the snake bite. Eastman and Marzillier (1984b) conclude that defining self-efficacy without referring to outcome expectations is difficult, if not impossible. This might explain the reason why Resnick (2009; Resnick et al., 2007) explain the theory with reference to both efficacy and outcome expectations.
Biglan (1987) also criticises that the role of the environment has been neglected in the self-efficacy theory and suggests that behaviour could be well analysed and effective treatment methods developed when the effect of the environment on behaviour is clearly understood.
Application of the Theory to Practice
Application of theories to nursing practice assists nurses to identify important data and how they are related, make predictions based on the observed relationship and, then, choose appropriate interventions to solve specific nursing problems (McEwen, 2007a). Many patients on dialysis fail to comply due to discomforts experienced during dialysis (Martchev, 2008). They end up doubting their ability to continue with the treatment. Reassuring such patients of their ability to continue with the treatment would, therefore, be a very appropriate intervention and Bandura (1977) provides a means to achieving this.
Analysis of the theory has revealed to me some limitations of the theory (Eastman and Marzillier, 1984a, 1984b; Biglan, 1987) and assisted me to identify other issues I could consider in applying the self-efficacy theory to practice. Reviewing other studies that have been undertaken using the self-efficacy theory has also exposed some more issues that I might take into consideration whenever I want to apply the theory to practice. For example, Tsay (2003) used the theory to achieve fluid compliance but believes other factors, apart from self-efficacy, might have contributed to the observed change in behaviour. Sarkar et al. (2006) used the theory to encourage self-management of diabetes but suggest that the patient’s environment should be considered. Buchmann (1997) used self-efficacy, but with expert power, to achieve medication compliance.
Therefore, when I encounter any noncompliant patient again, my first responsibility would be to identify reasons for noncompliance. When it is identified that they doubt their ability to continue with the treatment, then application of self-efficacy theory would be the next step: other dialysis patients who have been successful on treatment would be encouraged to share their experiences with them (vicarious experience). I could also coax them to believe in their capabilities of undergoing the treatment irrespective of whatever their perceived impediments are (verbal persuasion). Environmental factors that might influence their behaviour would be addressed. They would, also, be made to appreciate the outcomes should they continue or abate the prescribed regimen (outcome expectancy). Figure 1 in appendix 2 gives an illustration of the factors that would be taken into consideration in applying the theory. The same approach could be used in other departments apart from the dialysis unit for patient care.
Rosenstock (1990 cited by Kuhn, 2007) added self-efficacy to the Health Belief Model to meet the difficulties associated with changing unhealthy behaviours that are habitual. This implies that, when necessary, self-efficacy could be combined with other theories or models to achieve the ultimate target.
Nurses are able to perfect their actions when they examine their experiences through reflection in order to be conscious of how different elements of nursing care inform total professional practice in nursing (Durgahee, 1996). A reflection on a clinical incident where patient compliance was identified as a concept of concern led me to search for a theory that could be applied should I face a similar problem again in my practice. Self-efficacy theory by Bandura (1977) was identified as the most appropriate because it emphasises on the unique role that individuals play in changing their own behaviour. The theory was described and critically analysed, paying attention to its internal and external criticisms. Some limitations of the theory were also discussed.
In times like these, when evidence-based practice is being advocated for in nursing (McEwen, 2007a), application of theory to practice would be a step in the right direction. This essay has given me the opportunity to reflect on a clinical incident and ways to improve my practice. In addition, identification of relevant theories that are applicable to specific clinical problems is an intellectual skill that I have gained from this reflective writing. This is an academic experience that I can always draw on later in my practice as a nurse. I believe that this experience would also guide me in my bid for continuous professional and personal development. This is more than a personal gain as I can transfer the knowledge and skills to influence the professional development of my colleagues in Ghana.
Description of the incident
I had graduated from the university and was preparing to write the licensing exams of the Nursing and Midwifery Council (NMC) of Ghana. I had been assigned to the dialysis unit for two weeks. On my fourth day in the unit, Mr. M., a 43-year old man with end stage renal disease (ESRD) was brought into the unit. He presented with oedema, tachycardia, and respiratory distress. He looked pale and was sweating profusely. He needed urgent haemodialysis. His vital signs and weight were monitored before the procedure began. He was also given humidified oxygen as prescribed. Throughout the procedure, he was kept in the Fowler’s position.
According to the nurse-in-charge of the unit, Mr. M had been to the unit for the first time the previous week. He had been advised to come to the unit for haemodialysis, at least, thrice every week. However, he had failed to show up when he was expected to.
Throughout the procedure, the nurses keenly monitored his vital signs and general condition in order to detect any complication and manage earlier. When his condition had stabilised, I initiated a conversation with him in an attempt to know his reasons for not showing up when his time was due. I gathered that he had superstitious beliefs on the cause of his condition and had resorted to herbal preparations for his cure.
I explained the disease process and the reasons why he needed haemodialysis to survive to him. I allowed him to ask questions and answers were provided in terms he understood best. During the entire moment, all that I was considering was ‘only if this man had paid heed to the advice given him previously, he wouldn’t have gone through all this stress, even to the point of almost losing his life’.
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