Because patient outcomes are increasingly being used as outcomes measures to determine the success or failure of certain treatment regimens, health behavior modifications, and compliance issues, rheumatology nurses are becoming increasingly more important in developing constructive relationships with patients with chronic diseases such as rheumatoid arthritis (RA).

This issue of Rheumatology Nurse Practice concentrates on the intersection between RA and cardiovascular disease, providing you with evidence-based information to serve as a basic educational resource. The concept of self-efficacy fits quite nicely with this topic.

To best serve your patients, you should understand the core attributes of self-efficacy, their clinical significance, and the positive and negative consequences associated with the concept.1

Self-efficacy, later coined “social cognitive theory,” was first identified as a major concept in social learning theory by psychologist Albert Bandura.”2 The concept behind this theory is that the more positive or higher self-efficacy coping behaviors or beliefs a patient demonstrates, the more likely they are to apply and adhere to certain regimens to achieve specific goals. In other words, if they believe what they do can make a difference, then it will make a difference.

Theoretically, it makes sense. But how can we as rheumatology nurses assess or measure self-efficacy in our patients and, most importantly, move individual patients from negative to positive self-efficacy?

In 2003, a study by Mueller et al found that a fibromyalgia patient’s initially low rated self-efficacy can be positively affected when that patient joins a group based on a physiotherapeutic regimen and a psychological focus.3 This can perhaps in part be attributed to the Hawthorne effect, when those being watched know they are being watched and therefore show the desired effect. We do know that the process of joining a group of others with similar or the same chronic issues sometimes becomes validating to patients and can have an antidepressant effect all to itself. In this scenario, self-efficacy can be thought of as both a process and outcome. In any case, it shows that some learned behavior can result in a positive skew toward self-efficacy.3,4 A 2011 study by Knittle et al examined the effects of physical activity goals and self-efficacy beliefs on RA-related pain and quality of life. Data from several measurement scales were collected on 106 participants in the Netherlands. Not surprisingly, patients demonstrating higher self-efficacy at baseline were more likely to achieve physical fitness goals.4 The takeaway from the study is simple—higher levels of self-efficacy predict higher levels of self-selected goal achievement. Moreover, promoting self-efficacy and helping patients with RA select small, attainable goals can have a positive effect on overall outcomes.

Nurses can have a significant impact on a patient’s self-efficacy by spending more focused time helping set short‑term, realistic, achievable, and mutually‑determined goals. Setting a detailed action plan, creating provisions for accountability and feedback, and having a contingency plan to cope with any barriers that may arise to prevent success is a smart and highly beneficial use of time with patients, especially those with low levels of self-efficacy.

Rheumatology nurses have the ability to serve as the authority on health issues to our patients by providing education, highlighting risk factors for comorbid conditions, encouraging lifestyle and behavioral changes, and referring to self-help groups.

My challenge to you today is to actively evaluate your patients’ level of self-efficacy. There are formal instruments such as the arthritis self-efficacy scale (ASES), the generalized self-efficacy scale (GSES), the Swedish exercise self-efficacy scale (ESES-S), and the rheumatoid arthritis self-efficacy scale (RASE) that may help.3-8 There are also more focused instruments such as the joint protection self-efficacy scale (JP-SES) or the Marcus and Resnick self-efficacy exercise behavior scale (SEEB).9,10 ASES and RASE have been more prominently used in clinical trials. Eight of the questions used in ASES are included in Table 1.3

Please note that any formal data collection for potential use in publication or a research trial must follow proper institutional review board requirements and adhere to good clinical practice guidelines and regulations. You must obtain informed consent from patients if you see an opportunity for use of this scale in a future publication. For individual use of the scale for patient-provider communication, however, consent is not required.

Each question on the ASES scale is scored on a simple 1-to-10 range, just like a global assessment rating. These eight questions can be used with patients to assess self-efficacy at a particular point in time. Ask these questions of patients not only for the visit at hand, but also find out how might they have rated themselves in the last week or last month. You may receive valuable assessment information and gain insight on the individualized approach needed. In the end, these tools may assist you in maximizing time with your patients and increase their chances of a successful and positive outcome.

AUTHOR PROFILE:
Sheree C. Carter, PhD, RN, is an Assistant Professor at The University of Alabama Capstone College of Nursing, Tuscaloosa, Alabama, and Former President of the Rheumatology Nurses Society.

References

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4. Knittle KP, De Gucht V, Hurkmans EJ, et al. Effect of self-efficacy and physical activity goal achievement on arthritis pain and quality of life in patients with rheumatoid arthritis. Arthritis Care Res (Hoboken). 2011;63(11):1613-1619.
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8. Nessen T, Demmelmaier I, Nordgren B, Opava CH. The Swedish Exercise Self-Efficacy Scale (ESES-S): reliability and validity in a rheumatoid arthritis population. Disabil Rehabil. 2015;37(22):2130-2134.
9. Garnefski N, Kraaij V, Benoist M, Bout Z, Karels E, Smit A. Effect of a cognitive behavioral self-help intervention on depression, anxiety, and coping self-efficacy in people with rheumatic disease. Arthritis Care Res (Hoboken). 2013;65(7):1077-1084.
10. Mäkeläinen P, Vehviläinen-Julkunen K, Pietil A. Change in knowledge and self-efficacy of patients with rheumatoid arthritis: a six-month follow-up study. Int J Nursing Practice. 2009;15(5):368-375.