Journal of Gerontological Nursing

EFFICACY BELIEFS IN GERIATRIC REHABILITATION

Barbara Resnick, PhD, CRNP

Abstract

ABSTRACT

Motivation is an important variable in older adults' ability to recover from any disabling event. The theory of self-efficacy states that efficacy beliefs affect behavior, motivational level, thought patterns, and emotional reactions in response to any situation. This study explored the impact of efficacy beliefs on older adults in a rehabilitation program and tested interventions to strengthen efficacy beliefs related to participation in rehabilitation and functional performance.

An experimental ? retest- posttest design was used. Participants were randomly assigned to: the usual care control group or the treatment group. The study was completed on an inpatient geriatric rehabilitation unit. The sample consisted of 77 participants, 55 women and 22 men with a mean age of 78 ± 7.2. Individuals in the treatment group received three efficacy enhancing interventions: role modeling, verbal persuasion, and physiological feedback. Baseline data were collected within 48 hours of admission and included four investigator-developed efficacy measures: Functional Inventory Measure, Participation Index, Numeric Rating Scale for pain, amount of analgesic used for pain, and Health Status. With the exception of Health Status, these measures were again completed within 48 hours of discharge.

Admission performance was the only statistically significant predictor of efficacy beliefs. All efficacy beliefs increased over time and were significantly correlated with performance behaviors and length of stay. The treatment group had stronger efficacy beliefs regarding participation, higher participation at discharge, and less pain than the control group.

Efficacy beliefs, both self-efficacy and outcome expectations, are related to participation, functional performance, and length of stay. Interventions to strengthen these beliefs improved participation in rehabilitation and decreased pain. Consideration of motivation can facilitate rehabilitation and help older adults obtain and maintain their highest functional level.

Abstract

ABSTRACT

Motivation is an important variable in older adults' ability to recover from any disabling event. The theory of self-efficacy states that efficacy beliefs affect behavior, motivational level, thought patterns, and emotional reactions in response to any situation. This study explored the impact of efficacy beliefs on older adults in a rehabilitation program and tested interventions to strengthen efficacy beliefs related to participation in rehabilitation and functional performance.

An experimental ? retest- posttest design was used. Participants were randomly assigned to: the usual care control group or the treatment group. The study was completed on an inpatient geriatric rehabilitation unit. The sample consisted of 77 participants, 55 women and 22 men with a mean age of 78 ± 7.2. Individuals in the treatment group received three efficacy enhancing interventions: role modeling, verbal persuasion, and physiological feedback. Baseline data were collected within 48 hours of admission and included four investigator-developed efficacy measures: Functional Inventory Measure, Participation Index, Numeric Rating Scale for pain, amount of analgesic used for pain, and Health Status. With the exception of Health Status, these measures were again completed within 48 hours of discharge.

Admission performance was the only statistically significant predictor of efficacy beliefs. All efficacy beliefs increased over time and were significantly correlated with performance behaviors and length of stay. The treatment group had stronger efficacy beliefs regarding participation, higher participation at discharge, and less pain than the control group.

Efficacy beliefs, both self-efficacy and outcome expectations, are related to participation, functional performance, and length of stay. Interventions to strengthen these beliefs improved participation in rehabilitation and decreased pain. Consideration of motivation can facilitate rehabilitation and help older adults obtain and maintain their highest functional level.

By the year 2030, there will be 65.6 million individuals older than age 65. There is evidence that disabilityincreases with age and that multiple impairments increase significantly after the age of 75 (United States Department of Health and Human Services Public Health Service, 1991). Additionally, lower extremity fractures and joint replacements are common problems that afflict older adults and alter functional ability (Perez, 1994). It is often because of these functional changes that older individuals are admitted to nursing homes. Expenditures for nursing home care now exceed $30 billion per year, of which approximately half are public funds (Ouslander, Osterweil, & Morley, 1997). Aggressive interventions, such as inpatient rehabilitation services, help older adults regain functional skills (Harris, O'Hara, & Harper, 1995; Kane, Chen, Blewett, & Sangl, 1996; Resnick & Daly, 1998), have the potential to increase quality of life (Rejeski & Shumaker, 1994), and decrease the demand for health care resources (Fiatarone & Evans, 1993).

Age (Mossey, Mutran, Knott, & Craik, 1989), evidence of social support (Cummings et al., 1988; Magaziner, Simonsick, Kashner, Hebel, & Kenzora, 1990), admission function (Resnick & Daly, 1998), and interruptions in the rehabilitation process (Heinemann, Linacre, Wright, Hamilton, & Granger, 1994) are statistically significant predictors of function following rehabilitation. Specifically, those that are younger, have higher admission function, and are able to complete their course of rehabilitation without interruptions due to acute illness, surgery, or financial problems, are more likely to have higher function at discharge. In addition, cognitive status and depression are the major psychological variables considered and are significandy correlated with lower levels of functional ability at the time of discharge from rehabilitation (Harris et al., 1995; Resnick & Daly, 1997).

Although motivation is recognized as an important variable in older adults' ability to recover from any disabling event (Glickstein, 1991; Sharma et al., 1996), the major research focus is on the physical and/or medical factors that impact recovery. Much less attention is given to older adults' psychosocial behavior. However, in the contemporary political economy, where efforts to contain health care costs are overriding imperatives, it is essential to consider motivation to facilitate the rehabilitation process and help older adults maximize their rehabilitation capacity.

THE THEORY OF SELFEFFICACY

The theory of self-efficacy states that specific efficacy beliefs affect behavior, motivational level, thought patterns, and emotional reactions in response to any situation (Bandura, 1977, 1986, 1995). Bandura differentiated between two components of self-efficacy theory: self-efficacy which is individuals' belief in their ability to execute a course of action; and outcome expectancy which is a judgment of the consequences that a certain behavior will produce. Ideally, behavior would be best predicted by considering both self-efficacy and outcome expectancy beliefs. Moreover, efficacy beliefs are dynamic and are both appraised and enhanced by four mechanisms:

* Performance of the activity.

* Verbal encouragement.

* Role models, or seeing like individuals perform a specific activity.

* Physiological feedback such as pain, fatigue, or anxiety associated with a given activity.

EFFICACY BELIEFS IN OLDER ADULTS

Research with older adults demonstrates that efficacy beliefs predict: recovery following a cardiac (Carroll, 1995; Gönner, Rankin, & Wolfe, 1988; Schuster, Wright, & Tomich, 1995) or orthopedic event (Ruiz, 1992; Sharma et al., 1996); short-term memory ability (McDougall, 1993); and physical competence and exercise activities (Abler & Fretz, 1988; Gecht, Connell, Sinacore, & Prohaska, 1996; Schuster, Petosa, & Petosa, 1995). Because of normal age changes, as well as older adults' vulnerability to the maladaptive effects of self-doubting and failure (Kemp, 1988; Meichenbaum, 1974), consideration of efficacy beliefs in older adults is especially important.

RELATIONSHIP OF DEMOGRAPHIC VARIABLES AND EFFICACY BELIEFS

The relationship between race, gender, and age on efficacy beliefs is inconsistent. In some studies, older men demonstrate stronger efficacy beliefs than women (Bosscher, Laurijssen, & DeBoer, 1993; Gecas, 1989; Schuster & Waldron, 1991), and in others, there is no significant difference with regard to gender (Schuster, Wright, & Tomich, 1995). Similarly, in some studies increased age is associated with a decrease in efficacy beliefs (Gecas, 1989; Woodward & Wallston, 1987), and in others, there is no consistent relationship between age and efficacy beliefs (Grembowski et al., 1993; Ruiz, 1992; Schuster & Waldron, 1991). To explore the relationship between demographic variables and efficacy beliefs in older adults, age, race, and gender were included as predictors of efficacy beliefs in this study.

EFFICACY BELIEFS AND RECOVERY

Descriptive studies of the relationship between efficacy beliefs and recovery following a cardiac event have repeatedly shown that efficacy beliefs predict recovery behavior including walking, lifting, climbing, doing household chores, and adhering to a cardiac diet (Allen, Becker, & Swank, 1990; Carroll, 1995; Gortner & Jenkins, 1990; Gillis et al., 1993; Gulanick, 1991; Schuster, Wright, & Tomich, 1995). Efficacy beliefs similarly predict recovery following an orthopedic event (Ruiz, 1992; Sharma et al., 1996) and participation in outpatient rehabilitation and exercise programs (Gecht et al., 1996; McAuley, 1993; Scherer & Schmieder, 1996).

INTERVENTIONS THAT STRENGTHEN EFFICACY BELIEFS

Actual performance of the activity of interest is the most common intervention used to strengthen efficacy beliefs in older adults (Downs, Rosenthal, & Lichtenstein, 1992; McAuley, 1993; McCartney & McKelvie, 1996; Scherer & Schmieder, 1996). Counseling alone, and with performance behavior, strengthens efficacy beliefs related to recovery following a cardiac event (Ewart, Taylor, Reese, & DeBusk, 1983). Counseling strengthened efficacy beliefs for behavior the patient could not perform in the hospital (e.g., sexual activity). In patients following cardiac surgery, supplemental inhospital education (i.e., verbal encouragement) significantly increased efficacy beliefs related to walking, as well as recovery behaviors (Gillis et al., 1993).

Role modeling was used to strengthen efficacy beliefs related to tolerating a hydropool bath in a small study of 24 institutionalized older adults (Downs et al., 1992). Role modeling in this study involved watching a movie of bathing. The findings demonstrated that performance of bathing was more effective in strengthening efficacy beliefs than watching the role modeling movie of bathing. None of these studies used all four sources of efficacy-enhancing information (i.e., performance, verbal encouragement, role modeling, and physiological feedback) to strengthen efficacy beliefs.

Building on prior relevant research, the purposes of this study were to:

Table

TABLE 1Description of Interventions

TABLE 1

Description of Interventions

* Determine older adults' admission of self-efficacy and outcome expectancy beliefs for both participation in rehabilitation and functional performance in a geriatric rehabilitation program, and the demographic and personal factors that impact these beliefs.

* Evaluate the impact of self-efficacy-based interventions on older adults' self-efficacy beliefs, functional performance, and the extent of their active participation in an inpatient geriatric rehabilitation program.

METHODS

Design

This study used an experimental pretest-posttest design to assess the impact of self-efficacy-enhancing interventions on self-efficacy beliefs and functional outcomes of participants in a geriatric rehabilitation program. At the time of admission into the rehabilitation program, patients were randomly assigned to a hospital room, and all the rehabilitation rooms were randomly assigned to one of two treatment groups, either the usual care or efficacyintervention treatment group. This was done to decrease the chance of control group participants being exposed to the treatment group interventions.

Sample

The study was conducted on a short-stay inpatient geriatric rehabilitation unit in Baltimore, Maryland. Older adults, age 65 and older, were eligible to participate in the study if they were admitted to the rehabilitation program following an orthopedic event and did not:

* Score below 20 on the MiniMental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975).

* Have evidence of receptive and/or expressive aphasia (David, 1991).

* Score 5 or greater on the Geriatric Depression Scale (GDS) (Yesavage et al., 1983).

* Score 40 or greater on the Spielberger's Trait Anxiety Scale (Spielberger, 1983).

* Have fewer than 2 individuals in their core social network (Cummings et al., 1988).

A total of 80 eligible people were invited to participate. One individual refused, and two participants were removed from the study because of acute medical problems. Therefore, the study sample included 77 participants. This sample size was sufficient to support the recommended ratio of 15 subjects to 1 predictor, for a reliable prediction equation (see Data Analysis section) and sufficient power (84% to 99%) for the repeated measures analyses (Stevens, 1992).

Interventions

Usual care consisted of 90 minutes of physical therapy provided by a licensed physical therapist (PT), and 90 minutes of occupational therapy provided by a licensed occupational therapist (OT), 5 days per week. In addition to usual care, the treatment group received three selfefficacy enhancing interventions: role modeling, verbal persuasion, and physiological feedback.

Table

TABLE 2Overview of Data Collection Points

TABLE 2

Overview of Data Collection Points

The role modeling intervention involved watching a videotape within 72 hours of admission. The verbal persuasion and physiological feedback interventions were provided five times per week during daily visits of 5 to 15 minutes each. Table 1 describes the details of each intervention. In this study, the interventions were developed to meet the needs of the individuals. Although this may raise issues regarding the consistency and replicability of the intervention, this type of intervention is consistent with the theoretical framework which focuses on individual self-efficacy beliefs.

To control for an attentional effect, patients in the control group were visited on a daily basis and viewed a videotape within 72 hours of admission. However, for subjects in the control group, the visit was purely social, and the videotape was about the history of the rehabilitation facility. Interventions were all completed privately, and the rehabilitation staff were blind to the participants' treatment group status.

Measures

Baseline measures included:

* Four investigator-developed efficacy measures (Resnick, 1996a).

* The adapted Functional Inventory Measure (FIM) (Ottenbacher et al., 1994).

* The Participation Index (Resnick, 1996a).

* Pain measures using both the Numeric Rating Scale (NRS) (Herr & Mobily, 1991) and the amount of analgesic taken (converted to morphine equivalents) (Beebe, 1989).

* A subjective measure of health status (Fillenbaum & Smyer, 1981), Data collection time points and method of administration are described in Table 2. All efficacy measures were completed privately in the participants' rooms and were completed prior to the performance measures (FIM and Participation Index). Demographic information included admission diagnosis, age, race, gender, admission and discharge living location and situation, and length of stay in rehabilitation.

Efficacy Measures

The self-efficacy measures presented in Tables 3 to 6 (Resnick, 1996a) included the:

* Self-Efficacy for Functional Ability (SEFA) scale (Table 3), a 9item measure that asks participants to rate their confidence in performing baking, dressing, transferring, toileting, ambulation, and stair climbing activities.

Table

TABLE 3Self-Efficacy for Functional Ability (SEFA) Scale*

TABLE 3

Self-Efficacy for Functional Ability (SEFA) Scale*

Table

TABLE 4Self-Efficacy for Participation in Rehabilitation (SEPR) Scale*

TABLE 4

Self-Efficacy for Participation in Rehabilitation (SEPR) Scale*

* Self-Efficacy for Participation in Rehabilitation (SEPR) scale (Table 4), a 9-item measure that focuses on individuals' confidence in their ability to participate in rehabilitation when challenged by previously identified factors that decrease willingness to participate (Resnick, 1994; 1996b).

For each item, response ranges vary from Q to 10, with 0 = inability to perform the task and 10 = definitely can perform the task. The scales are scored by summing the numerical ratings and dividing by the number of activities. Higher scores indicate stronger efficacy beliefs.

The outcome expectancy measures included:

* Outcome Expectancy for Functional Ability (OEFA) scale (Table 5), a 6-item measure that focuses on the strength of individuals' beliefs that performance will result in a certain outcome.

* Outcome Expectancy for Participation in Rehabilitation (OEPR) scale (Table 6), a 3-item measure that focuses on beliefs regarding the outcomes that will occur following participation in rehabilitation.

For each item there is a scale ranging from 1 = not at all to 5 = a great deal. Scoring is the same as described for the self-efficacy measures. In this study, efficacy measures demonstrated evidence of internal consistency (alpha coefficients .87 to .98) and validity (Resnick, 1996a).

Functional Status

Functional status was measured by direct observation using the functional component of the FIM, which was adapted so that ambulation distances were more appropriate for the sample (Ottenbacher et al., 1994; Resnick, 1996a). The FIM assesses self-care abilities including eating; grooming; bathing; dressing; toileting; bowel and bladder management; transfer ability to bed, chair, or wheelchair; locomotion, including either walking or wheelchair propulsion; and stair climbing. For the purposes of this study the items relating to bowel and bladder management were removed as efficacy interventions did not directly focus on these tasks. In this study, there was evidence of reliability and validity of the internal consistency of the FIM (Resnick, 1996a).

Perceived Health Status and Pain

Perceived health status was measured using the Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire (OMPAQ) question, "How would you rate your overall health?" Prior research provided evidence of reliability and validity (Fillenbaum & Smyer, 1981). Pain was measured using the O to 10 Numeric Rating Scale (NRS) (Herr & Mobily, 1991). Use of the NRS with older adults has been noted to significantly correlate with other pain measures and to have a low incidence of error.

Participation Index

The Participation Index (Resnick, 1996a; Resnick, Zimmerman, Adelman, & Magaziner, 1998) is a general measure of individuals' participation in rehabilitation based on the subjective evaluations of the PT, OT, and primary nurse. Each subscale (PT, OT, and primary nurse evaluations) of the measure includes 5 questions which focus on the patients' efforts in therapy, their willingness to arrive at therapy on time, and their willingness to carryover what was learned in therapy to the nursing unit. Responses range from 1 = not characteristic to 4 = a lot characteristic. The three subscales are summed to create a Participation Index score. Scores can range from 15 to 60, with high scores indicative of greater participation. In this study, there was evidence of reliability and validity (Resnick, 1996a).

Data Analysis

Descriptive statistics were used to characterize the sample. Paired i-tests, and chi-square were used to determine the adequacy of the randomization procedure, and four stepwise multiple regression analyses were performed to explore the predictors of admission efficacy beliefs. Five predictors for each equation were included in each model: age, race, gender, health status, and admission behavior (function or participation as appropriate for each equation). The four criteria were the specific self-efficacy and outcome expectancy beliefs (SEFA, SEPR, OEFA, OEPR). To determine whether there were differences in efficacy beliefs and outcomes between the treatment and control groups, a series of eight different 2 (time) X 2 (treatment group status) repeated measures analyses were performed.

Table

TABLE 5Outcome Expectation For Functional Ability (OEFA) Scale*

TABLE 5

Outcome Expectation For Functional Ability (OEFA) Scale*

Table

TABLE 6Outcome Expectation for Participation in Rehabilitation (OEPR) Scale*

TABLE 6

Outcome Expectation for Participation in Rehabilitation (OEPR) Scale*

RESULTS

Participant Characteristics

There were 37 participants in the control group and 40 in the treatment group. There were no statistically significant differences between the groups on admission with regard to demographics (Table 7), length of stay, or outcome variables, with the exception of pain being slightly higher in the treatment group (F = 6.5; ? <. 012) (Table 8).

Predictors of Efficacy Beliefs

Admission function was the only variable to significantly predict admission SEFA (R2 adjusted = .34;/? < .05) and OEFA (R2 adjusted = .13; ? < .05). Similarly, admission participation was the only variable that significantly predicted SEPR (R2 adjusted = .07; ? < .05). Age, race, gender, and health did not significantly add to these prediction equations. None of the hypothesized predictors significandy accounted for admission OEPR.

Table

TABLE 7Demographic Characteristics of Sample by Group

TABLE 7

Demographic Characteristics of Sample by Group

Impact of Intervention

Based on repeated measures analyses (Table 8), with the exception of amount of analgesic used, there was a statistically significant effect of time for all study variables. Participants demonstrated an increase in efficacy beliefs, participation, functional performance, and a decrease in pain following rehabilitation. There was a time X treatment group interaction with regard to SEPR (F = 6.6; ? < .025), OEPR (F = 10.4;/> < .025), participation (F = 6.9; p < .05), and pain based on the NRS (F = 20.6; ? < .05). At discharge, those in the treatment group had stronger efficacy beliefs related to participation, greater participation, and less pain than those in the control group. There was no statistically significant effect of the treatment on SEFA (F= 1.75; ? > .05), OEFA (F = 2.6; ? > .05), function (F = .33; ? > .05), amount of medication used (F = .22; p > .05), or length of stay (F = .66;p>.05).

Predictors of Discharge Outcomes

Based on exploratory regression analyses, admission function and admission OEFA accounted for 44% of the variance in discharge function, with OEFA adding a statistically significant increase in the amount of variance accounted for in discharge function (R2 change = .06; F = 4.28; ? < .05). The SEFA, SEPR, OEPR, age, and experimental group status did not add to the equation.

Admission function and admission SEFA accounted for 31 % of the variance in length of stay, with the addition of SEFA demonstrating a statistically significant increase in the amount of variance accounted for (R2 change = .05; F = 3.1; ? < .05). This indicates that self-efficacy beliefs related to function may be important predictors of length of stay. Admission participation and experimental treatment group status accounted for 51 % of the variance in discharge participation. Experimental treatment group status showed a statistically significant increase in the amount of variance accounted for, beyond the effects of admission participation (R2 change = .10; F = 5.2; p < .05).

DISCUSSION

Predictors of Efficacy Beliefs

The demographic variables of age, race, and gender did not significantly predict any of the four efficacy beliefs. This supports prior studies of older adults in which gender, age, and/or race were not related to efficacy beliefs with regard to health behavior (Carroll, 1995; Clark, 1996; Grembowski et al., 1993; Rejeski, Craven, Ettinger, McFarlane, & Shumaker, 1996; Schuster, Wright, & Tomich, 1995). Based on this study and prior findings, demographic variables have little impact on the efficacy beliefs of older adults.

There was no relationship between health status and efficacy beliefs or functional performance in this study. This may be explained in part by the lack of variance in health status. In addition, the relationship between health and functional status, which served as the rationale for the inclusion of this variable, was based on studies of community-dwelling older adults (Seeman et al., 1994). In contrast, the participants in this study were hospitalized and admitted for rehabilitation because of functional impairment, regardless of their health status.

Table

TABLE 8Mean Scores for Study Variables by Experimental Group and Results o1 Repeated Measures Analyses

TABLE 8

Mean Scores for Study Variables by Experimental Group and Results o1 Repeated Measures Analyses

Admission function was the only statistically significant predictor of efficacy beliefs for functional ability (SEFA and OEFA), and admission participation was the only statistically significant predictor of admission SEPR. While self-efficacy theory suggests that efficacy beliefs have an impact on behavior (i.e., functional performance and participation in rehabilitation), it is likely that behavior in turn has an impact on efficacy beliefs. This reciprocal relationship is supported by Social Cognitive Theory (Bandura, 1977) from which the theory of self-efficacy is derived. Social Cognitive Theory suggests there is an interrelationship between behavior, the individual, and the environment, with any of them having a major impact on motivation and behavior at any given point.

Impact of Outcome Expectations on Behavior

Bandura (1977, 1986, 1995) theorized that self-efficacy beliefs were better predictors of behavior than outcome expectations (Bandura, 1995; Jenkins, 1985). Conversely, the current study, as well as prior research (Grembowski et al., 1993; Schuster, Petosa, & Petosa, 1995; Schwarzer & Fuchs, 1995), suggest that outcome expectations may have an independent effect on behavior. It is possible that for older adults the outcomes of performing an activity are more important than beliefs in their ability to perform the activity (Resnick, 1996a).

Impact of Treatment on Efficacy Beliefs

In this study, there was a statistically significant difference between the treatment and control groups in efficacy beliefs related to participation and actual participation in rehabilitation, but there was no difference in efficacy beliefs related to function or actual functional performance. The lack of difference between the treatment groups in these areas may be because of the fact that both groups participated in rehabilitation and performed functional skills. Bandura (1977, 1986) stated that performing a specific activity is likely to have the greatest impact on efficacy beliefs.

Based on the design of this study, the individual impact of performing the activity of interest, verbal encouragement, role modeling, and decreasing unpleasant physiological feedback cannot be determined. Moreover, there was no control of the participants' exposure to extraneous sources of efficacy information such as seeing others in rehabilitation and receiving verbal encouragement from staff. Future research must explore the impact of single versus multiple sources of efficacyenhancing information.

Relationship of Pain and Length of Stay With Efficacy Beliefs and Performance

The overall lack of a significant relationship among pain, efficacy beliefs, and function in this study was likely due to the way in which pain was measured. Specifically, there was no consideration given to the meaning of the pain for the individual. Theoretically it is the individuals' interpretations of pain, rather than actual pain, that has an impact on efficacy beliefs and ultimately performance (Bandura, 1977).

The relationship between function and length of stay was anticipated because reimbursement for rehabilitation was based on functional ability, and the date of discharge was determined when individuals reached their established functional goals. More important, after controlling for admission function, self-efficacy related to function predicted length of stay. This suggests that the belief in one's abilities, which is presumably the motivation to perform those activities, has an important impact on length of stay.

CONCLUSION AND IMPLICATIONS FOR NURSING

This study demonstrates that selfefficacy and outcome expectancy beliefs are related to performance, and efficacy-enhancing interventions strengthen efficacy beliefs and performance with regard to participation in rehabilitation. Interventions to strengthen these beliefs can be used to improve participation in rehabilitation. This can have a major impact on older adults' recovery process and may be instrumental in decreasing rehabilitation time and improving functional performance.

In a managed care environment, there is little time allowed for motivating the unmotivated patient. The opportunity to participate in a rehabilitation program may be denied the patient who is labeled unmotivated, i.e., not willing to participate or perform. To begin to consider the motivation of older adults in rehabilitation, nurses should focus on older adults' efficacy beliefs. While it is not realistic to provide the intensive interventions suggested in this study for all older adults, the efficacy scales can be used to identify individuals with overall low efficacy beliefs and specific problem areas. For example, older adults may respond that they cannot participate in rehabilitation when tired or in pain. To prevent problems with participation, interventions can be implemented to decrease these sensations, such as regular administration of analgesics or ice packs to an affected area. For older adults who have low self-efficacy beliefs related to function, nurses should focus on strengthening efficacy beliefs by:

* Providing ambulation opportunities such as walking the individual to the bathroom.

* Providing verbal encouragement regarding their ability to ambulate a short distance.

* Setting small realistic goals and providing positive reinforcement for the progress they are making toward goal attainment.

* Exposing the individual to similar older adults who have successfully regained functional skills.

The use of individualized assessment and treatment plans can strengthen efficacy beliefs in older adults and thereby improve participation in rehabilitation, improve functional performance, and decrease length of stay.

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TABLE 1

Description of Interventions

TABLE 2

Overview of Data Collection Points

TABLE 3

Self-Efficacy for Functional Ability (SEFA) Scale*

TABLE 4

Self-Efficacy for Participation in Rehabilitation (SEPR) Scale*

TABLE 5

Outcome Expectation For Functional Ability (OEFA) Scale*

TABLE 6

Outcome Expectation for Participation in Rehabilitation (OEPR) Scale*

TABLE 7

Demographic Characteristics of Sample by Group

TABLE 8

Mean Scores for Study Variables by Experimental Group and Results o1 Repeated Measures Analyses

10.3928/0098-9134-19980701-08

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