Self-Efficacy Theory
Implications for the Occupational Health Nurse
A s employers come to believe
that healthy employees are
more likely to be productive employ-
ees, worksite health promotion and
disease prevention have become in-
creasingly important in occupational
health. The occupational health
nurse is often the professional who
initiates and conducts programs de-
signed to prevent occupational and
non-occupational disease. Thus it is
increasingly important that the nurse
incorporate understanding of the
complexity of behavior change into
programs designed to encourage and
promote healthy behavior.
Salazar (1991) reviewed four mod-
els developed by social and behav-
ioral scientists to explain and predict
the behavior of individuals and
groups: the Health Belief Model,
Self-Efficacy Theory, the Theory of
Reasoned Action, and the Multiat-
tribute Utility Model. These models
provide a theoretical framework for
behavior change, and Salazar (1991)
recommends that the occupational
health nurse use one of these models
as a framework for program develop-
ment.
This article describes one of these
theories, self-efficacy, in greater de-
tail and reviews research studies that
demonstrate its usefulness in pre-
dicting behavior change. Methods to
enhance self-efficacy and to assist
552
by Sheila T Fitzgerald, MSN, PhD, RNC
It is increasingly important
that the nurse incorporate
understanding of the
complexity of behavior
change into programs
designed to encourage and
promote healthy behavior.
employees to modify behavior also
are discussed.
SELF-EFFICACY THEORY
Self-efficacy, a concept derived
from Social Learning Theory, has
gained increasing recognition as a
predictor of health behavior change
and maintenance (Bandura, 1977a).
Social learning theory encompasses
several types of learning theory:
operant, classical, and vicarious.
Voluntary responses are the only
concern of operant conditioning, a
psychological learning theory
founded by Thorndike and devel-
oped and popularized by Skinner.
This theory focuses on reward and
reinforcement as a necessary compo-
nent of learning. The other major
approach to learning theory,
Pavlovian or classical conditioning, is
AAOHN JOURNAL, DECEMBER 1991, VOL. 39, NO. 12
concerned with responses that are
not voluntary. Finally, vicarious
learning is concerned with learning
the performance of a specific re-
sponse after the learner observes
someone else perform the response
(Bandura, 1963).
Figure 1 outlines the role of self
efficacy in a person performing a
behavior that will have a consequent
outcome (Bandura, 1977b; 1982).
Principal components of Bandura's
self-efficacy theory are efficacy ex-
pectation or individuals' perception
of confidence in their ability to per-
form a specific behavior, such as the
level of confidence in ability to walk
or jog after a myocardial infarction;
and outcome expectation, or a belief
that performing the behavior will
lead to a specific outcome for the
individual, such as believing that
exercise will promote cardiovascular
conditioning. Since minimal research
has been done on outcome expecta-
tion, the focus of this paper is on the
efficacy expectation component of
self-efficacy theory.
According to Bandura (1977b;
1982), self perceptions of ability are
specific: confidence in one's ability
to engage in jogging does not neces-
sarily generalize to confidence in
one's ability to lift weights (Ewart,
1986). Bandura postulates that once
efficacy information is received, it
must be cognitively processed and is
used by individuals to judge their
capabilities.
If persons judge themselves capa-
ble of performing a behavior, they
are more likely to act. Self-efficacy
judgments, whether accurate or
faulty, influence persons' choices of
activities. Individuals avoid activities
that they believe exceed their capa-
bilities and they undertake and per-
form more confidently those activi-
ties they judge themselves capable
of managing (Bandura, 1977b).
Judgments of self-efficacy also de-
termine how much effort individuals
will expend and how long they will
persist in the face of obstacles or
aversive experiences. Studies con-
ducted primarily in laboratory set-
tings have shown that when con-
fronted with difficulties, people who
have a strong sense of efficacy exert
greater effort to master challenges
when compared to those who have
doubts about their capabilities (Ban-
dura, 1981; Brown, 1978).
SOURCES OF EFFICACY
INFORMATION
Bandura (1977b) identified four
major sources of information that in-
fluence self-efficacy. The first, per-
formance accomplishment, refers to
learning through personal experience
where one achieves mastery over a
difficult or previously feared task. Per-
formance accomplishments are the
most powerful source of efficacy ex-
pectations. For example, returning to
work after coronary angioplasty is
more likely if an individual has been
successfully employed prior to the
procedure. Repeated failures in per-
forming a behavior will reduce per-
ceived self efficacy, while success will
increase it.
The second source of self-efficacy
is vicarious experiences or opportu-
nities to observe others similar to
oneself performing the behavior in
question, e.g., participating in a car-
diac rehabilitation program where in-
dividuals report successful work re-
sumption or smoking cessation after
a myocardial infarction. Observing
another individual master situations
AAOHN JOURNAL, DECEMBER 1991, VOL. 39, NO. 12
PERSON---~)o BEHAVIOR---)o OUTCOME
Efficacy
Expectations
Figure 1: Diagram of self-efficacy concepts (Bandura, 1977b). Reprinted with permission
of the American Psychological Association.
that have been feared or seen as
difficult can enhance one's own ex-
pectations of mastery.
For modeling to affect an ob-
server's self-efficacy positively, how-
ever, the model must be viewed as
overcoming difficulties through de-
termined effort rather than with ease,
and the model must be similar to the
observer with respect to other char-
acteristics (e.g., age, sex). In addi-
tion, modelled behaviors with clearly
rewarding outcomes are more effec-
tive, e.g., increased endurance with
smoking cessation.
Verbal persuasion is the third
source of efficacy information. Ex-
amples related to health behavior
change include persuasion by a re-
spected authority, e.g., a nurse or
physician verbalizes that they are
confident in the individual's ability
to stop smoking or modify a diet to
control cholesterol.
Finally, physiological arousal or
the physical feedback that individu-
als rely on to judge their capabilities,
such as anxiety, fatigue, or pain, may
be perceived as signs of physical
inefficacy. Assisting the individual to
realistically interpret symptoms and
use relaxation training to reduce anx-
iety can improve efficacy expecta-
tions and performance.
Figure 2 summarizes a modified
self-efficacy model as a predictor of
behavior (Fitzgerald, 1988). This
model incorporates the sources of
self-efficacy that influence perceived
self-efficacy which then mediates
behavior outcomes.
It is important to understand that
the concept of self-efficacy relates to
beliefs about the ability to perform
specific behaviors in particular situa-
tions; self-efficacy does not refer to a
personality characteristic or a global
Outcome
Expectations
trait. Efficacy expectations are dy-
namic and will vary over time de-
pending on the particular task and
context which confront the individual.
MEASURING EFFICACY
EXPECTATION
Banduras approach to measuring
efficacy expectation has influenced
development of numerous scales.
Measurement consists of a two step
process. In step one, respondents
indicate whether they can perform
each activity indicated on the scale.
The second step is the individu-
als' ratings of their perceived confi-
dence in performing the activity.
The activities are listed in order of
increasing difficulty, e.g., walking 1
block, 2 blocks, 3 blocks, 1 mile, etc.
Respondents then rate their confi-
dence in performing the specific be-
havior (e.g., 90% confidence in abil-
ity to walk 2 blocks, 20% confidence
in ability to walk 1 mile). Numerical
ratings for each activity on the scale
are summed and divided by the
number of activities to reflect the
strength of the efficacy expectation.
REVIEW OF RESEARCH
Numerous research studies focus-
ing on behavior change demonstrate
that self-efficacy theory predicts
modification and maintenance of be-
havior.
Initial research involving self-
efficacy theory occurred in laboratory
settings to explain behavior in sub-
jects having various types of phobias
(e.g., snakes). The scope of research
has broadened considerably and has
been extended to include selected
aspects of health behavior (e.g., ciga-
rette smoking, weight control, exer-
cise and cardiac rehabilitation, func-
tional status, and work resumption).
553
Self-Efficacy Theory
Sources of Self
Efficacy
1. Performance
attainment
2. Vicarious
experience ~Perceived
Self Efficacy
3. Verbal
persuasion
4. Physiologic
arousal
Figure 2: Modified self efficacy model as a predictor of behavior.
Cigarette Smoking
Individual lifestyle behaviors are
the cause of many of today's health
problems. Various strategies have
been developed and studied to mod-
ify one of these behaviors-cigarette
smoking-which plays a major role
in heart disease and cancer. Inter-
ventions designed to achieve perma-
nent smoking cessation have been
evaluated in well designed clinical
trials and observational studies. Re-
lapse remains a major problem, and
an individual's self-efficacy has been
demonstrated to be a major source of
relapse prevention.
In a prospective research study,
Condiotte (1981) recruited subjects
from two smoking cessation pro-
grams and found increased self effi-
cacy appraisals as a result of complet-
ing either program. Low ratings of
self-efficacy following treatment
with respect to avoidance of smoking
was highly predictive of relapse and
the length of time to relapse.
In another study, DiClemente
(1981) measured perceived self effi-
cacy in study subjects a short time
after they had stopped smoking and
were still abstinent. The perceived
self-efficacy of subjects who had
maintained abstinence at a 5 month
posttreatment follow up was signifi-
cantly higher than for those subjects
who had relapsed. Study subjects
who had higher self-efficacy ratings
also were able to maintain abstinence
longer than were those with low self
554
Behavior
1. Decision
to perform
2. Effort
~ expended
3. Persistence
efficacy ratings; study subjects also
reported less difficulty maintaining
abstinence.
O'Leary (1985) reported that re-
lapse with respect to smoking cessa-
tion occurred in high risk situations
where effective coping strategies
that increased perceived self-efficacy
were absent. This relapse may be
avoided if one of two conditions
exists: 1) the individual's self-
efficacy to resist cigarette use is high
enough so that sufficient effort is
mobilized to resist smoking, or 2) the
individual's self-efficacy to recover
from a slip is high, so that self control
is reinstated after a slip.
Taylor (1989), using an adaptation
of the scale developed by Condiotte
(1981), designed a study to measure
confidence in ability to resist urges to
start smoking. Clients with a self
efficacy score of less than 70% on any
item on the scale were at risk of
relapse and may need help with that
area. For example, if clients reported
a 50% confidence level that they
would be able to resist smoking
when friends offered them ciga-
rettes, these individuals might be
assisted by a strategy that encourages
them to practice saying no.
In a review of several research
studies using self-efficacy theory as a
predictor of smoking cessation, Stre-
cher (1986) concluded that ratings of
self-efficacy were found to discrimi-
nate active quitters from continued
smokers, joiners of smoking cessa-
AAOHN JOURNAL, DECEMBER 1991, VOL. 39, NO. 12
tion programs from non-joiners, and
successful short term and long term
quitters who had participated in
smoking cessation programs. Self-
efficacy enhancement techniques
that reduce the strength of urges to
smoke and increase confidence in
ability to quit smoking, such as nico-
tine fading, relaxation techniques,
stress management, and social sup-
port, are suggested in the literature.
These studies provide consistent
evidence that perceived self-efficacy
reliably predicts who will remain ab-
stinent and who will relapse. Occu-
pational health nurses can use scales
to evaluate self-efficacy to resist
smoking to identify employees
whose self-efficacy with respect to
resisting smoking is low: They can
provide education and counseling to
enhance coping skills and self beliefs
of efficacy to resist smoking in cer-
tain situations.
The American Heart Association
published a booklet titled Relapse
Prevention (1990) designed to assist
current or former smokers with
smoking cessation and to develop
strategies to prevent relapse and to
enhance self-efficacy. Strategies are
based on a self-efficacy scale that
identifies for individuals potential
areas for relapse and provides recom-
mendations and suggestions of
methods to resist urges to relapse.
Weight Control
Weight control, like smoking ces-
sation, is a desirable goal with respect
to a healthy lifestyle. To date, most
self efficacy research in the area of
eating behavior concerns its relation-
ship to obesity. Chambliss (1979)
manipulated self-efficacy to increase
the weight loss by persons in their
behavioral treatment program. They
gave the participants in the study a
placebo, which was described as a
drug affecting metabolism to assist in
weight reduction. After 2 weeks of
treatment, some participants were
told that the drug was inert, encour-
aging self attributions for their suc-
cess, while others in the study were
not.
Self-efficacy attributions for

weight loss increased ability to lose
weight in persons with an internal
locus of control, but not in those who
viewed their behavior as externally
controlled. The latter persons may
have continued to attribute their
weight loss to environmental or so-
cial factors despite the efficacy attri-
bution given them.
Jeffrey (1984) conducted a pro-
spective study to identify factors re-
lated to weight loss 1 and 2 years
following a behavior modification
treatment program for weight loss. In
this study, self-efficacy was divided
into two categories, "emotion state"
efficacy, which described ratings of
confidence in ability to refrain from
eating during various emotional
states, and "situational" efficacy,
which reflected confidence in ability
to abstain in various situations such
as visiting friends or watching televi-
sion.
High pretreatment levels of emo-
tional state and situational efficacy
with respect to avoidance of eating
were significantly associated with in-
itial and long term weight loss at both
1 and 2 years posttreatment.
Like smoking, self-efficacy scales
are needed to identify an individ-
ual's efficacy for avoiding foods that
are high in calories, saturated fats,
cholesterol, or sodium. These scales
could identify individuals with low
self-efficacy with respect to modify-
ing the behaviors required to lose
weight or comply with cholesterol
lowering or low sodium diets. Self-
efficacy enhancing strategies could
then be developed to assist with
dietary compliance.
Exercise and Cardiac
Rehabilitation
Ewart (1983) examined the effect
of efficacy expectations on compli-
ance with exercise regimens in men
recovering from clinically uncompli-
cated myocardial infarction. The re-
searchers demonstrated that changes
in efficacy scores following treadmill
exercise testing predicted both the
duration and intensity of subsequent
home activity. Self-efficacy expecta-
tions correlated with subsequent per-
AAOHN JOURNAL, DECEMBER 1991, VOL. 39, NO. 12
If persons judge
themselves capable of
performing a behavior,
they are more likely to act.
formance on treadmill exercise tests,
which in turn predicted subsequent
changes in self-efficacy. Counseling
by a nurse or physician (verbal per-
suasion) about the results of exercise
testing was useful in generalizing
self-efficacy from areas specifically
related to exercise testing (running,
walking, climbing stairs) to less re-
lated activities (e.g., lifting, sexual
intercourse).
Taylor (1985) demonstrated the
importance of raising the spouse's
perceptions of the client's capabili-
ties following uncomplicated myo-
cardial infarction. When the client's
wife also walked on the treadmill,
her judgment and her husband's
judgment of his cardiac and his phys-
ical capabilities increased signifi-
cantly.
This study demonstrated the psy-
chosocial implications of recovery
from acute physical conditions. It
emphasized the important role that
the occupational health nurse can
play in assessing physical and psy-
chological job demands in the work
setting. Communication with the
employee's health care provider
about exercise tolerance and job de-
mands will allow job accommoda-
tions, if needed, to facilitate the em-
ployee's return to work.
Functional Status in Clients With
Cardiovascular Disease
Allen (1990), in a prospective
study of persons undergoing coro-
nary artery bypass surgery, demon-
strated that self-efficacy expectations
consistently predicted activities of
daily living and physical, social, and
leisure functional status 1 and 6
months after surgery. These relation-
ships were independent of demo-
graphic and medical factors.
Fitzgerald
In clients recovering from myocar-
dial infarction, Jenkins (1987) found
that strength of efficacy expectations
for selected psychomotor (walking
and lifting) and non psychomotor
(resting after a meal, following a
dietary restriction and tolerating a
disagreement with a spouse/signifi-
cant other) behaviors increased sig-
nificantly during the first month of
recovery.
These two studies have implica-
tions for the occupational health
nurse, particularly in the area of cli-
ent education. Shortly after the car-
diac event, the occupational health
nurse can contact the individual to
determine plans for recovery and
rehabilitation and eventual return to
work. The nurse also can serve as a
liaison between the home, health
care provider, and the workplace to
implement needed accommodations.
Return to Work
Fitzgerald (1989) prospectively
studied clinical, demographic, occu-
pational, and behavioral factors that
influenced work return in individu-
als who had a percutaneous translu-
minal coronary angioplasty (PTCA).
Findings from this study indicated
that self-efficacy for work resump-
tion was the primary predictor of
work return, independent of clinical,
demographic, occupational, and
behavioral factors. Self-efficacy for
work return was assessed by two
questions:
1. Based on everything you know
now; when do you think you will
return to work after your angioplasty
(in weeks)?
2. How confident are you that you
will return to work at the time you
indicated (completely confident,
very confident, moderately confi-
dent, somewhat confident, or not at
all confident)?
A self-efficacy score, generated
from question one, was assessed at
the time of hospitalization but prior
to PTCA. High self-efficacy was
determined to be a work return esti-
mate of ~2 weeks. Low self-efficacy
for work return was determined to be
a work return estimate of >2 weeks.
555
Self-Efficacy Theory

High self-efficacy for work return health care provider to coordinate tional health nurses in developing
was significantly associated with time to return to work, as well as to educational programs and designing
being employed 1 month after provide information about the physi- interventions to optimize employee
PTCA. cal and psychological demands of the outcomes.
Eighty-six percent of the subjects job, may promote earlier time to For example, assessment of effi-
in this study who were categorized as return to work. cacy expectations may be used in
having high self-efficacy by their In addition, the occupational monitoring an individual's confi-
response to question one responded health nurse can encourage early in- dence to return to work and in assess-
to question two as being completely stitution of cardiac rehabilitation, ing behaviors that need reinforce-
confident in their estimate of time to which may promote return to work in ment to assist an employee's
resume work. Sixty-one percent of several ways: by demonstrating to decision making about positive
the individuals with low self-efficacy the individuals that they can perform health behaviors. Awareness of the
estimates about work return were physically demanding exercise in a sources of self-efficacy also can assist
also confident in those estimates. controlled environment without the occupational health nurse to de-
This demonstrates the association threatening their lives; by health pro- velop interventions that enhance ef-
between individuals' capacity to per- fessionals encouraging them about ficacy expectation and lead to even-
form a behavior and their confidence their progress; and by observing oth- tual behavior change.
in that estimate. ers who have coronary heart disease
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ABOUT THE AUTHOR: Dr. Fitz-
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The Johns Hopkins University
School of Hygiene and Public
Health, Baltimore, MD.
557