Self-Efficacy
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Self-Efficacy

Thought Control Of Action

Ralf Schwarzer, Ralf Schwarzer

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eBook - ePub

Self-Efficacy

Thought Control Of Action

Ralf Schwarzer, Ralf Schwarzer

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About This Book

The goal of this book is to illustrate the change in emphasis during the 1980s from one dominated by a behaviouristic perspective to one much more congnitive in its emphasis. It is aimed at research psychologists and graduate-level psychology students.

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Year
2014
ISBN
9781317763697
V

SELF-EFFICACY, PHYSICAL SYMPTOMS, AND REHABILITATION OF CHRONIC DISEASE
ROLE OF PHYSICAL SELF-EFFICACY IN RECOVERY FROM HEART ATTACK
Craig K. Ewart
Large numbers of heart attack survivors experience unnecessary distress and put themselves at significant medical risk due to excessive fear of physical activity. Self-efficacy theory has improved our ability to identify and alleviate these inappropriate fears. Research reviewed in this chapter suggests that self-efficacy appraisals influence patient involvement in exercise regimens and mediate beneficial effects of exercise participation. The development of scales to measure self-efficacy makes it possible to identify individuals who may be at risk of dangerous overexertion due to unrealistically optimistic appraisals of their physical capabilities. Research on affect and self-appraisal suggests that self-efficacy can be strengthened by mood-dependent memories of past successes, and that self-efficacy gains foster positive affect. Factors affecting self-evaluative and affective responses to rehabilitative exercise are reviewed. Behavioral interventions to modify these influences and enhance self-efficacy enable patients to cope more effectively with the many challenges posed by heart attack.
Heart attack, or acute myocardial infarction, is a frightening experience that severely disrupts the lives of patients and their families. The fact that the heart attack is sudden, unexpected, and beyond personal control leaves deep feelings of uncertainty and dread. Bodily sensations that would have gone unnoticed before the illness now cause alarm; states of fatigue that might have been ignored are anxiously scrutinized. Unsure of what these events may signify, and fearful of triggering another attack, patients refrain from work and leisure activities that formerly provided security and pleasure. Feelings of frustration and loss intermingle with worry and self-doubt. Attempts to alter diet, avoid tobacco, or reduce alcohol consumption may exacerbate these feelings, as may the behaviors of family members who try to protect the patient by discouraging physical exertion or communication about topics that could arouse strong emotion. Paradoxically, efforts like these undermine recovery by prolonging the patient’s inactivity and social isolation, while placing a heavy burden on those who would be supportive (Croog & Levine, 1982). In a large proportion of acute myocardial infarction survivors, these behavioral, psychological, and social sequelae have the potential to retard recovery, impair adjustment, and even increase risk of recurrent.
Self-efficacy theory clarifies the role of self-appraisal processes in shaping behavioral and emotional responses to acute myocardial infarction and suggests ways to identify and alter them. This chapter will examine three of the theory’s major contributions. These include an improved understanding of how self-appraisals determine the patient’s return to normal physical activities, how they mediate the impact of physical exertion on emotional adjustment, and how they influence the ways family members react to the illness. The first part of the chapter summarizes current medical guidelines for managing the patient’s physical recovery and return to normal activities after and explains the importance of routine exercise in speeding recovery. I then review self-efficacy research that I have conducted during the past decade with colleagues in the cardiology divisions of Stanford University and Johns Hopkins University. This work indicates how self-efficacy judgments guide patients’ reactions to acute myocardial infarction and suggests the value of social-cognitive intervention in promoting health-protective exercise during recovery. Next, I examine ways in which self-efficacy may influence—and be influenced by—mood states and emotions patients experience as they try to resume their lives. Finally, I argue that perceptions of self-efficacy are affected by other persons in the patient’s immediate interpersonal milieu, and by the patient’s valued personal projects and self-strivings. Personal projects and interpersonal transactions moderate the degree to which efforts to enhance self-efficacy will lead to effective behavioral coping and lifestyle change.

Physical Recovery From Acute Myocardial Infarction

Fears evoked by acute myocardial infarction often lead to prolonged physical inactivity with adverse psychological, social, and economic consequences for patients. Moreover, lack of exercise may prove medically harmful to the large proportion of patients in whom the likelihood of recurrent acute myocardial infarction in the near future is relatively low. From 33% to 50% of patients fall into this low-risk category, as do approximately 75% of patients who have undergone coronary artery bypass graft (CABG) surgery (DeBusk, et al., 1986). Low-risk patients are those who have not developed severe exercise-induced ischemia or severe left ventricular dysfunction; their annual mortality is less than 2%. These patients need less medical intervention and can return to work sooner than those at higher risk. Functional capacity of low-risk patients increases rapidly in the first six months after acute myocardial infarction even without physical exercise training, and within three to six months after acute myocardial infarction, they enjoy a functional exercise capacity similar to that of healthy men in their 50’s (DeBusk et al., 1986).
Physical training. Recovery of functional capacity is enhanced by having the patient engage in progressive exercise training (e.g., walking, jogging, cycling, swimming) beginning three weeks after acute myocardial infarction. Patients are encouraged to exercise at intensities within a range of 70% to 85% of peak heart rate (as determined by symptom-limited exercise test) for 20 to 30 minutes per day, three to five days per week. Low-risk patients can exercise safely at home (Miller, Haskell, Berra, & DeBusk, 1984). Safety is increased by having patients wear a portable monitor to help them maintain their heart rate within prescribed limits.
Coronary Artery Bypass Graft (CABG). Patients who have undergone CABG can exercise safely without disrupting the wound or the vascular anastomosis after three weeks of healing; leg discomfort (from removal of vein for grafting) rarely persists beyond four weeks. These patients are often advised to engage in walking and, later, in stationary cycling as this activity is less likely to cause nonunion of the sternum than is jogging. Exercise is particularly important during recovery from CABG because bed rest following surgery causes decondi-tioning that contributes to fatigue—a condition patients often inaccurately construe as a sign of cardiac illness. Even a program of moderate walking can prevent this fatigue. Patients who have undergone CABG tend to interpret chest wall pain as ischemic; they may abandon prescribed exercises unless they are counseled on how to interpret those exercise-induced sensations that are without cardiac importance.
Return to work. Low-risk patients can resume most of their pre-illness activities, including returning to work, within three to six months after acute myocardial infarction. The occupational work environment is thought to be more stressful than the home environment but acute myocardial infarction occurs no more frequently in one setting than in the other (DeBusk et al., 1986). Only 5% of patients in the United States now perform “heavy” occupational work, so only a very small percentage of patients are advised to seek assignment to less demanding jobs. By three months after acute myocardial infarction, low-risk patients are capable of exercising at intensities that are much higher than the levels they encounter at work. Considering that not working creates significant stress or hardship for many patients, after three months low-risk individuals generally are not advised to delay their return to work on medical grounds.
Exercise program. In the first few months after acute myocardial infarction, exercise helps patients feel less tired and more vigorous, enhances recovery of functional capacity, and accelerates return to normal activities. Maintenance of regular exercise over longer periods in a cardiac rehabilitation program appears to reduce risk; meta-analysis of 22 randomized trials of rehabilitation with exercise indicates that participation in rehabilitation is associated with a 20% reduction in overall mortality over the first three years after acute myocardial infarction (O’Connor et al., 1989). While the independent effects of physical exercise are difficult to determine due to the fact that rehabilitation programs usually include diet, smoking cessation, stress reduction, or other interventions, meta-analysis of all available studies suggests that patients who shun exercise after acute myocardial infarction would appear to be at somewhat greater risk of reinfarction during the first three years and of sudden death during the first year after acute myocardial infarction.

Enhancing Physical Self-Efficacy

From a social-cognitive perspective, many problematic behavioral and emotional reactions to acute myocardial infarction stem from uncertainties about one’s physical capabilities. Self-efficacy theory provides methods to identify and measure these uncertainties, and to increase patient participation in healthful exercise by altering self-appraisal. The theory asserts that the most effective way to help patients overcome inappropriate fear of exertion is to have them perform feared activities in gradually increasing intensities (mastery experiences), permit them to observe other patients like themselves performing the activity (vicarious mastery), have physicians and nurses provide reassurance and encouragement (persuasion), and prevent the “pathologizing” of innocuous bodily sensations or states by suggesting more benign interpretations (physiologic feedback). These interventions are, in fact, key components of well-designed cardiac rehabilitation programs and may constitute the most important benefit these programs provide.
My own investigation of self-appraisal processes in recovery from acute myocardial infarction began with an attempt to construct and validate physical self-efficacy scales for cardiac patients. Interviews with patients and review of relevant literature revealed significant concerns about walking, climbing stairs, jogging, lifting heavy objects, and engaging in sexual activity; initial findings led to the creation of scales that asked patients to indicate their level of confidence (on a scale ranging from 0 = not at all confident, to 100 = completely confident) that they could walk or jog various distances, climb flights of stairs, lift various amounts of weight, and engage in sexual activity for various time periods (as the sample available to us consisted of heterosexual married men, sexual activity was defined as “sexual intercourse”).1 In the initial validation study, patients completed these scales before their three-week treadmill test, immediately after the test, and again after the results and implications of the test had been explained by a cardiologist and nurse.
As predicted by self-efficacy theory, results showed that the experience of mastery, persuasion, and internal feedback provided during this evaluation increased physical self-efficacy in patients tested three weeks after acute myocardial infarction. The treadmill exercise test protocol required the patient to exercise at gradually increasing intensities while a physician and nurse offered encouragement and suggested appropriate interpretations of internal physical states. After the...

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