Use of Self-Efficacy and Dyspnea Perceptions to Predict Functional Performance in People with COPD

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<ul><li><p>Use of Self-Efficacy and Dyspnea Perceptions to Predict Functional Performance in People with COPD </p><p>Debra Siela, DNSc RN CCNS APRN-BC CCRN RRT </p><p>Key words COPD, dyspnea, functional performance, </p><p>gender differences, self-efficacy, perceptions </p><p>This correlational and cotnparative study explored whether self-reports of self-efJicacy and dyspnea perceptions predict the perceived level of functional performance in adults who have chronic obstructive pulmonary disease (COPD). The convenience sample included 97 Caucasian men (52) and women (45). Participants had to have a forced expiratory volume in I second (FEVi) of less than 70% predicted, and a FEViJorced vital capacity (FVC) of less than 70%. Par- ticipants were recruited froin pulmonary function Iaborato- ries and from better breather support groups in a Midwest- ern state. Three standardized, self-report instruments, COPD Self-EfJicacy Scale (CSES), the Piiltnonary Func- tional Status and Dyspnea Questionnaire (PFSDQ), and Functional Performance Inventory (FPI) were used to tnea- sure the participants self-report of their perceptions of self- efJicacy, dyspnea, and functional performance. Dyspnea predicted 38. I % of the variance in fiinctional performance, with self-efJicacy Contributing an additional 6.5% to the variance in the total sample. Self-efJicacy predicted 36.5% of the variance in functional performance in men, with </p><p>dyspnea contributing an additional 7.2% to the variance. Howevec in wotnen, only dyspnea was a signijkant predic- tor of functional performance, at 48.5% when both dyspnea and self-efJicacy were entered as independent variables. To improve patients perceptions of functional performance, nurses can use methods such as breathing techniques and upper- and lower-body exercises that increase optimal man- agement of dyspnea. Nurses may increase the self-eficacy of managing dyspnea by helping patients master breathing techniques and exercise through coaching and providing vi- carious experiences through patient support groups or pul- monary rehabilitation programs. </p><p>Debra Siela is an assistant professor at the School of Nurs- ing at Ball State University and is an ICU clinical nurse specialist at Ball Memorial Hospital in Muncie, IN. Her progratn of research is focused on dyspnea, fiinctional per- formance, and weaning from mechanical ventilation. Ad- dress correspondence to Debra Siela, 3935 E. Elm Grove Road, Blufton, IN 46714 or e-mail </p><p>Approximately 16 million people in the United States have chronic obstructive pulmonary disease (COPD), which is the na- tions fourth leading cause of death (National Heat and Lung Blood Institute [NHLBI], 2000) and the second leading cause of disabil- ity (Higgins, 1993). In addition, the costs associated with COPD were approximately $23.9 billion in 1993 in the United States, pri- marily because of frequent hospitalizations and physician office visits (Benson &amp; Marano, 1998; NHLBI, 2000). It is predicted that by 2020 COPD will rank fifth in conditions that affect the worlds total socioeconomic burden (Murray &amp; Lopes, 1996). </p><p>A main factor that contributes to high levels of disability and morbidity in people with COPD is the incapacitating sen- sation of dyspnea, which affects functional performance and quality of life (Heffner, 2002; Pauwels, Buist, Calverley, Jenk- ins, &amp; Hurd, 2001). Nurses must examine physiological mea- sures, psychosocial responses, and psychosocial resources of people with COPD to help them manage their dyspnea. Self- efficacy is an extremely important element of a persons psy- chosocial resources. Self-effcacy is the amount of confidence with which a person can perform a specific behavior in a spe- cific situation (Bandura, 1986). A high level of self-efficacy implies a high level of confidence that people with COPD have </p><p>in their abilities to manage dyspnea and functional performance for their optimal health and wellness. </p><p>More information is needed about the perceptions of self-ef- ficacy, dyspnea, and functional performance in people with COPD, and about the differences between men and women in their perceptions of their performances. They must be helped to adapt to and manage the effects of COPD. This study explored whether the self-reports of self-efficacy and dyspnea percep- tions can predict the perceived level of functional performance in adults with COPD. </p><p>Literature review Functional status and performance , </p><p>Functional status is a key element of healthcare practice and must be incorporated as an outcome criterion. As defined by Lei- dy (1994), functional status is a multidimensional concept that characterizes a persons ability to provide for the necessities of life, that is, those activities people do in the normal course of their lives to meet basic needs, fulfill usual roles, and maintain health and well-being. The four dimensions of functional status include functional performance, functional capacity, functional reserve, and functional capacity utilization (Leidy, 1994). </p><p>Rehabilitation Nursing Volume 28, Number 6 NovembedDecember 2003 197 </p></li><li><p>Self-Efficacy, Dyspnea, and Functional Performance in COPD </p><p>In 1995, Leidy defined functional performance as the extent to which people execute certain activities or behaviors in their normal activities of daily living (ADL). Leidy suggests that most studies that claim to measure functional status are actually at- tempting to measure functional performance. </p><p>Dyspnea and functional performance There has been limited research on functional performance and </p><p>dyspnea in people with COPD (Graydon, Ross, Webster, Gold- stein, &amp; Avendano, 1995; Lee, Graydon, &amp; Ross, 1991; Leidy &amp; Knebel, 1999; Moody, McCormick, &amp; Williams, 1990; Moody, McCormick, &amp; Williams, 1991; Reardon, Patel, &amp; ZuWallack, 1993; Weaver &amp; Narsavage, 1992; Wijkstra et al., 1994; Williams &amp;Bury, 1989). Descriptions of the sample com- position in these studies varied. Three studies (Graydon et al., 1995; Lee et al., 1991; Leidy &amp; Knebel, 1999) reported num- bers of both genders in their samples; men outnumbered wom- en in all three. The other six referenced studies did not report differences in gender numbers, and none of the studies reported any sample ethnicity characteristics. </p><p>Data from these studies indicate that the degree of dyspnea per- ceived by people directly affects their functional performances. The studies found that high levels of dyspnea decrease func- tional performance, however, more than one aspect of dyspnea was measured in many different ways. </p><p>McCord and Cronin-Stubbs (1992) presented an operational model of dyspnea based on its many different aspects and its measurement. The model suggests four dimensions of dysp- nea-physiologic antecedents, mediators, reactions, and con- sequences or outcomes. In this study, all four dimensions were examined. The presence of obstructive pulmonary disease as de- termined by spirometry parameters was used for the phsyiolog- ic antecedents. Self-efficacy was considered to be a mediator, and reactions were reflected by levels of dyspnea reported with activities. Lastly, outcomes or consequences were demonstrat- ed by the level of functional performance. </p><p>Self-efficacy Many people with COPD have high levels of dyspnea that </p><p>affect their functional performance and they have little or no confidence in their ability to manage or control the effects of that dyspnea. Thus, they have overall low self-efficacy, which is defined as peoples beliefs about their capabilities to control the events that affect their lives (Bandum, 1989). Bandura (1989) maintains that behavior change and maintenance of that change are functions of efficacy and outcome expectations. Efficacy ex- pectations are beliefs about a persons ability to engage in a be- havior that will result in an expected outcome. Outcome expec- tations are the beliefs that engaging in a certain behavior or behaviors will result in a specific outcome. In judging their ca- pabilities in performing a behavior, people must use four sources of efficacy information-mastery, vicarious experience, verbal persuasion;and physiological state. </p><p>. Self-efficacy has been examined for its ability to predict and explain changes in health behaviors. This concept also has been ex- plored in relation to health behavior change in ill populations. Self- efficacy has been examined in the COPD population in terms of </p><p>managing dyspnea, cigarette smoking cessation, and participa- tion in exercise and pulmonary rehabilitation (Carrieri-Kohlman, Douglas, Gormley, &amp; Stulbarg, 1993; Scherer &amp; Schmieder, 1997). </p><p>Many people with COPD and dyspnea have low efficacy ex- pectations because they lack mastery and vicarious experiences. In addition, they also may have dyspnea because of their aversive physiological states, which perpetuate their low efficacy expec- tations, and subsequently, low self-efficacy. The relation of dys- pnea and self-efficacy to functional performance in COPD pa- tients has not yet been examined. Although dyspnea is a significant predictor of functional performance, the addition of self-efficacy may predict even more of the variance in functional performance. </p><p>Gender differences in COPD Finally, the prevalence of women with COPD has increased </p><p>significantly in the past 15 years (NHLBI, 2000; Benson &amp; Man- no, 1998). However, research has been limited on gender dif- ferences in people with COPD and dyspnea. Most likely, men and women have different experiences. Researchers have re-. ported gender differences in how people experience cardiovas- cular disease, as well as in other illness and disease states. While gender differences have been examined in self-efficacy research, such differences in dyspnea and the functional performance of people with COPD have not been specifically described. </p><p>Hypotheses The following hypotheses were proposed for this study: (a) </p><p>there are significant relationships among self-efficacy, dyspnea, and functional performance in people with COPD; (b) there are significant gender differences in self-efficacy, dyspnea, and func- tional performance in people with COPD; and (c) self-efficacy and dyspnea are significant predictors of the level of functional performance in adults with COPD. </p><p>Methods Sample </p><p>The study included 97 subjects, 52 men and 45 women, with COPD who participated by completing questionnaires. Data, collected over a 2-year period, were used from all 97 subjects. Eligible participants had moderate to severe COPD, as verified by FEVi% predicted and FEVI/FVC% predicted using the Amer- ican Thoracic Society (ATS) spirometry interpretation guide- lines (American Thoracic Society, 1991). ATS criteria classify obstructive pulmonary disease as follows: moderate, a FEVi% predicted of less than 70% but greater than 60%; moderately se- vere, a FEVi% predicted of less than 60% but greater than 50%; severe, a FEVi% predicted of less than 50% but greater than 34%; and very severe, a FEVI% predicted of less than 34%. </p><p>Pulmonary function tests provided spirometry results. Sub- jects had performed the tests within 6 months before the study. The following spirometry values were examined: forced expi- ratory volume in one second (FEVI), FEVi% predicted, forced vital capacity (FVC), FVC% predicted, and forced expiratory volume in one second over foced vital capacity (FEVl/FVC). </p><p>Other criteria for inclusion included self-reported dyspnea and the ability to read, write, and understand English. In this study, COPD refers to the entities of emphysema and chronic bronchi- </p><p>198 Rehabilitation Nursing * Volume 28, Number 6 * NovembedDecember 2003 </p></li><li><p>tis, or both. Excluded were subjects with asthma only, as deter- mined by spirometry, and no significant increase, defined as 12% or greater in spirometry parameters after bronchodilation. Other subjects excluded were those with heart failure, pulmonary ede- ma, renal failure, neuromuscular disease, and pulmonary diseases other than COPD. No criteria were set regarding age, smoking history, use of oxygen, or functional performance. </p><p>Variables and instruments Descriptive and demographic data were collected about age, </p><p>gender, ethnicity, educational level, employment status, and in- come source. Clinical data collected included pulmonary rehabil- itation completion, support group membership, disability status, oxygen use, smoking history, medication use, and disease history. </p><p>Self-efficacy variable and measurement Self-efficacy is defined as peoples beliefs about their capa- </p><p>bilities to exercise control over events that affect their lives (Ban- dura, 1989). Efficacy expectations are beliefs about ones abil- ity to engage or execute the behavior that will result in an expected outcome. We measured efficacy expectation as the component of self-efficacy. The operational definition of effi- cacy expectation was self-report of the strength of the partici- pants confidence in their ability to manage or avoid dyspnea in various situations. Participants rate their efficacy expectations on the COPD Self-Efficacy Scale (CSES) developed by Wigal, Creer, and Kotses (1991). The CSES was also used to measure self-efficacy as a mediator of dyspnea based on the operational model of dyspnea (McCord &amp; Cronin-Stubbs, 1992). </p><p>The CSES is a self-administered tool that assesses self-effi- cacy in managing dyspnea. It consists of 34 items with a five- point response scale. Respondents rate the strength of their con- victions of how confident they are that they can manage their dyspnea in various situations, including emotional, weatheden- vironment, and physical exertion. The five points range from very confident (1) to not at all confident (5). </p><p>The CSES was both reliable and valid in its initial pilot test and second test administration (Wigal, Creer, &amp; Kotses, 1991). It was chosen for this study because of its specificity for indi- viduals with COPD in managing dyspnea. For our purposes, the overall scale mean score was used as a study variable rather than any of the five factor scores. </p><p>Dyspnea variable and measurement The operational definition of dyspnea in this study is self-re- </p><p>port of dyspnea ratings with various activities. The Pulmonary Functional Status and Dyspnea Questionnaire (PFSDQ) (Lareau, Carrieri-Kohlman, Janson-Bjerklie, &amp; Roos, 1994) is a self-ad- ministered tool that has both dyspnea and activity assessment components. The dyspnea component assesses the intensity of dyspnea with activities. It has a total of 85 items, six of which are general questions about dyspnea. The other 79 items have an 11- point response scale ranging from 0 (no dyspnea) to 10 (very se- vere dyspnea). Participants rate their dyspnea for each item based on the response scale. Six categories of activities are included: (1) self-care (15 items), (2) mobility (14 items), (3) eating (8 items), (4) home management (22 items), (5) recreation (10 </p><p>items), and (6) social (10 items). Sample items include brushhomb hair, raise arms overhead, and g...</p></li></ul>


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